Discussion
To our interpretation, this is the first analysis to determine the prevalence of PIP medication in older adults attending the outpatient psychiatry department using Beers criteria 2019 and STOPP criteria 2015. According to Beers criteria 2019, 91.2% (416 out of 456) of older adults have prescribed at least one PIP medication. Whereas STOPP criteria 2015 identifies 73.3% (336 out of 456) older adults prescribed with at least one PIP medication. Results show that recommendations of Beers criteria have relatively more trespassed for PIMs than STOPP criteria. In other words, Beer criteria seem to have more comprehensive and sturdy recommendations for use of psychotropic drugs as compared to STOPP criteria.
The prevalence of PIP medication reported in our study by using both sets of criteria is significantly higher than the findings of another research conducted based on older Beer and STOPP guidelines.24,25 The difference might be due to differences in data collection of sample population or difference in criteria used as this study uses the updated and latest version of both the criteria.
Out of a total of 456 patients, the Antianxiety agents were prescribed in nearly 82% (n=378) of the older adults. Out of 378 patients, potentially inappropriate antianxiety agents were prescribed in 97.3% (n=362) and 74.6% (n= 282) older adults as per Beers criteria and STOPP criteria. Beers criteria include a higher proportion of potentially inappropriate antianxiety agents as compared to STOPP criteria. Beers criteria 2019 mention to avoid short/intermediate/long-acting benzodiazepines in all older adults, whereas the STOPP criteria mention only LABZD, but the literature shows that all the benzodiazepines including short/intermediate/Long-acting can cause harmful adverse events (e.g. falls, fractures, cognitive impairment) if use in older adults.26,27 Beers criteria and STOPP criteria identify clonazepam as the most common PIP medication irrespective of any condition. Whereas LABZDs are used in older adults with dementia, cognitive impairment, history of fall, and delirium are considered potentially inappropriate.12 The potential risks of using long-acting agents must be considered while choosing pharmacotherapy for anxiety in older people.
The present study also examined the predictors of PIP medication prescribing with bivariate analysis. The most important predictors of PIP medication prescribing were the rural background of living, ≥4 psychotropic medication prescribed, TCA use, SNRI use, LABZD use, short-acting benzodiazepine use, atypical antipsychotic use according to Beers criteria 2019. On the other hand, alcohol addiction, rural region of living, TCA use, SSRI use, long-acting benzodiazepine, and atypical antipsychotic use came out to be the predictor for PIP medication use according to STOPP criteria 2015.
Our study found that antidepressants were the second most frequently prescribed psychotropic drug as almost 68.8% of the older adults were prescribed with at least one antidepressant either TCA, SSRI, SNRI. Previous studies have reported the same findings on community-dwelling older adults.25 Although SSRIs are preferred agents to treat depression in older adults, TCA is still prescribed in older adults and is considered potentially inappropriate psychotropic medication according to STOPP criteria.28 The use of TCA and SNRI has been associated with substantial anticholinergic effects, sedation effects. Moreover, SNRI users are more prone to cerebrovascular events as compared to SSRI users.4Beers criteria recommend all TCA, SSRI, and SNRI in older adults with syncope, and only TCA should be avoided in older adults with a history of falls or fractures due to its associated strong anticholinergic adverse effects such as confusion, dry mouth, sedation, and orthostatic hypotension. However, STOPP criteria only mention TCA that it should not be used as a first-line treatment in older adults with depression.
Atypical Antipsychotics were the third most prescribed psychotropic drug in older adults. Beers criteria have given the list of conventional and atypical antipsychotic list, irrespective of diagnosis/conditions that should be avoided in older adults. Among Atypical antipsychotics medication class quetiapine, olanzapine, risperidone is the most common PIP medication prescribed in older adults. Beers criteria recommend avoiding antipsychotics in older adults with dementia, cognitive impairment, history of falls or fractures, delirium due to its strong anticholinergic effects, and extrapyramidal side effects. Whereas STOPP criteria only recommend avoiding antipsychotics in older adults with dementia, delirium. In our study, 132 older adults out of 456 patients were prescribed with at least three or more CNS active drug combinations that are considered potentially clinically important drug-drug interactions as mentions in Beers criteria 2019. Thirty-four clinically important drug-drug interactions were identified in older adults by using Beers criteria. In contrast, STOPP criteria don’t recommend any guidelines on clinically important drug-drug interaction.
It was observed that most of the countries have developed their own criteria or guidelines to identify PIM in the geriatric population. However, there is a major number of developed as well as developing countries where no guideline/criteria have been chalked out. Healthcare professionals from all over the world use Beers criteria or STOPP criteria to identify PIM in older adults, but there has always been a state of confusion in most countries for uniform use of these guidelines. Hence there is a need that all geriatric societies of the world should come together to make a unified guideline for identifying PIM in the geriatric population.
The present study highlight that the prevalence of PIP medication as determined by the use of Beers criteria and STOPP criteria in older adults is very high that demands immediate attention. The study also reflects a more comprehensive and sturdy nature of AGS Beer criteria as the Beers criteria detect significantly more PIMs than STOPP criteria due to the inclusion of clinically important drug-drug interaction and more conditions in drug-disease interaction. TCA, long-acting benzodiazepine, and atypical antipsychotic use were some of the risk factors for potentially inappropriate psychotropic medication use in older adults. Although this study gives a greater understanding of PIP medication prescribing in older adults attending the psychiatry outpatient department, there are some drawbacks in the present study that need to be recognized. The study’s findings are focused on older adults attending the outpatient psychiatry department, so extrapolation of results to inpatients older adults will not be feasible. Finally, the study did not evaluate the Adverse drug reactions/outcomes resulting from the use of PIP medication detected by Beers criteria and STOPP criteria.