Inappropriate Medication Prescriptions in Elderly Adults Surviving an Intensive Care Unit Hospitalization

Authors

  • Alessandro Morandi MD, MPH,

    Corresponding author
    1. Geriatric Research Group, Brescia, Italy
    2. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    • From the Rehabilitation and Aged Care Unit Hospital Ancelle, Cremona, Italy
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  • Eduard Vasilevskis MD,

    1. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    2. Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
    3. Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
    4. Department of Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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  • Pratik P. Pandharipande MD, MSCI,

    1. Division of Critical Care, Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
    2. Anesthesia Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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  • Timothy D. Girard MD, MSCI,

    1. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    2. Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
    3. Department of Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
    4. Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee
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  • Laurence M. Solberg MD,

    1. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    2. Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
    3. Department of Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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  • Erin B. Neal PharmD,

    1. Department of Pharmaceutical Services, Vanderbilt University, Nashville, Tennessee
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  • Tyler Koestner MS,

    1. College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
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  • Renee E. Torres MS,

    1. Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
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  • Jennifer L. Thompson MPH,

    1. Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
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  • Ayumi K. Shintani PhD, MPH,

    1. Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
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  • Jin H. Han MD, MSc,

    1. Department of Emergency Medicine, School of Medicine, Vanderbilt University, Nashville, Tennessee
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  • John F. Schnelle PhD,

    1. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    2. Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
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  • Donna M. Fick PhD,

    1. School of Nursing, Pennsylvania State University, University Park, Pennsylvania
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  • E. Wesley Ely MD, MPH,

    1. Center for Quality Aging, Vanderbilt University, Nashville, Tennessee
    2. Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
    3. Department of Veterans Affairs Medical Center, Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
    4. Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee
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  • Sunil Kripalani MD, MSc

    1. Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
    2. Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Address correspondence to Alessandro Morandi, Rehabilitation and Aged Care Unit Hospital Ancelle, Via Aselli, 14, 26100 Cremona, Italy. E-mail: morandi.alessandro@gmail.com

Abstract

Objectives

To determine types of potentially (PIMs) and actually inappropriate medications (AIMs), which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly intensive care unit (ICU) survivors.

Design

Prospective cohort study.

Setting

Tertiary care, academic medical center.

Participants

One hundred twenty individuals aged 60 and older who survived an ICU hospitalization.

Measurements

Potentially inappropriate medications were defined according to published criteria; a multidisciplinary panel adjudicated AIMs. Medications from before admission, ward admission, ICU admission, ICU discharge, and hospital discharge were abstracted. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs.

Results

Of 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), nonbenzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied according to drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs, 55% of anticholinergics, 71% of atypical antipyschotics, 67% of nonbenzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs. The majority of PIMs and AIMs were first prescribed in the ICU. Preadmission PIMs, discharge to somewhere other than home, and discharge from a surgical service predicted number of discharge PIMs, but none of the factors predicted AIMs at discharge.

Conclusion

Certain types of PIMs, which are commonly initiated in the ICU, are more frequently considered inappropriate upon clinical review. Efforts to reduce AIMs in elderly ICU survivors should target these specific classes of medications.

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