Objective.—To estimate the incidence of serious and fatal adverse drug reactions
(ADR) in hospital patients.Data Sources.—Four electronic databases were searched from 1966 to 1996.Study Selection.—Of 153, we selected 39 prospective studies from US hospitals.Data Extraction.—Data extracted independently by 2 investigators were analyzed by a random-effects
model. To obtain the overall incidence of ADRs in hospitalized patients, we
combined the incidence of ADRs occurring while in the hospital plus the incidence
of ADRs causing admission to hospital. We excluded errors in drug administration,
noncompliance, overdose, drug abuse, therapeutic failures, and possible ADRs.
Serious ADRs were defined as those that required hospitalization, were permanently
disabling, or resulted in death.Data Synthesis.—The overall incidence of serious ADRs was 6.7% (95% confidence interval
[CI], 5.2%-8.2%) and of fatal ADRs was 0.32% (95% CI, 0.23%-0.41%) of hospitalized
patients. We estimated that in 1994 overall 2216000 (1721000-2711000) hospitalized
patients had serious ADRs and 106000 (76000-137000) had fatal ADRs, making
these reactions between the fourth and sixth leading cause of death.Conclusions.—The incidence of serious and fatal ADRs in US hospitals was found to
be extremely high. While our results must be viewed with circumspection because
of heterogeneity among studies and small biases in the samples, these data
nevertheless suggest that ADRs represent an important clinical issue.

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Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies

Background Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. Methods This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes thatshould generally be avoidedin persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to havespecific medical conditions. Results This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. Conclusions This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/757456/ioi20821.pdf

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.

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American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults

The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug–drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13‐member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence‐based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults.

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Results On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations. Conclusions Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

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Emergency Hospitalizations for Adverse Drug Events in Older Americans

BACKGROUND:Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents.OBJECTIVE:To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome.METHODS:A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data.RESULTS:A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1....

Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes

Elderly patients use more medications than younger patients and the trend of increasing drug use continues through 80 years of age. Studies conducted in a variety of settings have shown that patients over 65 years of age use an average of 2 to 6 prescribed medications and 1 to 3.4 non-prescribed medications. Success of pharmaceutical and medical research has resulted in an abundance of effective drugs to treat acute and chronic conditions. Most research resulting in the development and marketing of these medications has been directed at proving the efficacy and safety of single drug products. Little research has been directed to determine the safety and efficacy of combining multiple medications to treat concurrent conditions in a single patient. It is known that the use of multiple medications increases the risks of adverse drug reactions, drug-drug interactions, and makes compliance with medication regimens more difficult. Numerous studies have been conducted to better understand factors that are associated with increased drug use in elderly people. Studies also have been conducted to identify interventions that can improve drug treatment for the elderly, and reduce polypharmacy. Multiple drug use is common in older people, and may give rise to drug related problems. Methods to reduce the risks of polypharmacy include patient education, physician education, such as education and feedback systems, and regulatory intervention. Continual drug and disease monitoring is essential.

Polypharmacy in the aged. Practical solutions.

OBJECTIVE: To quantitate probable adverse drug reactions (ADRs) in a geriatric nursing homes population.



DESIGN: A repeated measures prospective study.



SETTING: Two nursing home populations in rural Georgia.



PATIENTS: All 332 residents present for 30 or more days over a 4-year period.



MEASUREMENT: Admission and monthly drug regimen review for each resident, Naranjo algorithm assessment of each ADR, with monthly reports to attending physicians and follow-up within the next month.



RESULTS: There were 444 probable ADRs in 217 of 332 residents (67.4%) during this period. The 217 residents had a mean 1.9 ± 1.3 probable adverse drug reactions (range, 1–9). The ADR group differed statistically from the rest of the population only in the number of drugs per patient (7.8 ± 2.6 vs 3.3 ± 1.3), which was almost twice the number of active problems present in both the ADR (4.0 ± 0.9) and non-ADR populations (3.8 ± 1.4). The organ systems most commonly involved in the 444 ADRs observed were cardiovascular (188), central nervous system (129), gastrointestinal (82), endocrine (41), immune (17), hematologic (7), pulmonary (6), and renal (5). The drugs most commonly implicated in ADRs were, in decreasing order, diuretics, antipsychotics, anxiolytics, potassium supplements, digoxin, NSAIDs, insulin, theophylline, H2-receptor antagonists, antiinfectives, anticonvulsants, and thyroid supplements. There were 39 multiple drug ADRs in 34 patients. In decreasing order the drug classes in multiple ADRs were CNS depressants, antihypertensives, potassium-altering therapy, and NSAIDs. Numerous patients had repetitions of the same ADR, especially with antipsychotics, NSAIDs, and insulin.



CONCLUSIONS: ADRs are a common occurrence in a geriatric nursing home population, and may be related to inadequate attention to the patients history as well as to unrealistic therapeutic endpoints. J Am Geriatr Soc 44:194–197, 1996.

James W. Cooper

Papers

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes

Polypharmacy in the aged. Practical solutions.

Probable adverse drug reactions in a rural geriatric nursing home population: a four-year study.

Solubility and Ionization Characteristics of Phenytoin