Potentially inappropriate medications use in a psychiatric elderly care hospital: A cross‐sectional study using Beers criteria

Abstract Background and Aims Potentially inappropriate medications (PIMs) carry risks that outweigh any potential benefits when compared to safer or more effective alternative treatments. Adverse drug events are more likely to occur in older adults with psychiatric diseases due to multimorbidity, polypharmacy, and age‐related changes in drug pharmacokinetics and pharmacodynamics. The aim of this study was to assess the prevalence and risk factors of PIM use in an aged care hospital's psychogeriatric division, using the American Geriatrics Society Beers criteria 2019. Methods This cross‐sectional study was conducted on all current inpatients, having a mental disorder and aged ≥65 years, in one elderly care hospital in Beirut, from March to May 2022. Medications, sociodemographic and clinical characteristics were collected from patients' medical records. PIMs were evaluated based on Beers criteria 2019. Independent variables were described using descriptive statistics. Factors associated with PIM use were identified by bivariate analysis followed by binary logistic regression. A two‐sided p value <0.05 was considered statistically significant. Results The study included 147 patients, with a mean age of 76.3 years, 46.9% of them having schizophrenia, 68.7% using 5 or more drugs and 90.5% taking at least 1 PIM. The most prescribed PIMs were antipsychotics (40.2%), anticholinergics (16%), and antidepressants (7.8%). PIM use was significantly associated with polypharmacy (AOR = 20.88, 95% CI: 1.22−357.87, p = 0.04) and anticholinergic cognitive burden (ACB) score (AOR = 7.25, 95% CI: 1.13−46.52, p = 0.04). Conclusion PIMs were highly prevalent among hospitalized Lebanese psychiatric elderly. Polypharmacy and ACB score were the determinants of PIM use. A multidisciplinary medication review led by a clinical pharmacist could reduce PIM use.


| INTRODUCTION
Mental disorders are disturbances in a person's cognition, emotional control, or behavior that cause distress or functional impairment in one or more major life domains. Mental disorders, including dementia and substance use disorders, are very common among older adults, 65 years and over, with a worldwide estimated prevalence of 21.4%, according to Global Burden of Disease Study 2019 results. 1 In Lebanon, their prevalence is even higher reaching 23.2% of older adults who represent 9.7% of the population. 1,2 Older adults in general and those with psychiatric illnesses in particular are at greater risk of adverse drug events (ADEs) due to multimorbidity, polypharmacy, and age-related changes in drug pharmacokinetics and pharmacodynamics, notably increased sensitivity to the central nervous system (CNS) and anticholinergic effects of drugs. 3 Moreover, older adults with psychiatric illnesses are more exposed 4 to PIM use which is defined as the intake of drugs with ineffectiveness or a high risk-benefit ratio, compared with more effective and safer alternative treatment options. 5 Numerous studies have found polypharmacy, which is commonly reported as the daily use of 5 or more drugs, 6 to be a predictor of PIM use. 7,8 The latter is a major health concern associated with increased healthcare costs and poor clinical outcomes, such as hospitalizations, emergency department visits, outpatient provider visits, prolonged length of stay, functional decline, cognitive impairment, many other geriatric syndromes, ADEs, and even mortality. [8][9][10] Several criteria have been developed in different countries to evaluate the appropriateness of medications use in older adults. 11 The American Geriatrics Society (AGS) Beers criteria are the most utilized and the longest-running criteria in all settings of care, except for the hospice and palliative care settings. 12 The latest AGS Beers criteria update was the 2019 version 12 In addition to identifying medications for which the risks of use outweigh the benefits, the AGS Beers criteria also highlight the subgroups of older adults who should be exempt from or to whom they apply. 12 Moreover, they draw attention of clinicians to potential problems and interactions when considering the use of these medications. 12 However, they are only a starting point for improving medication appropriateness since they don't cover underuse and overuse of drugs. The AGS recommends clinicians to use clinical judgment and common sense when prescribing medications, knowing that full adherence to the criteria is not always practicable. Nevertheless, the designation of the medication as potentially inappropriate can serve as a reminder for close monitoring if a clinician is unable to find an alternative and decides to continue using a PIM in a specific patient. This will allow the possibility of prevention or early detection of an ADE.
The prevalence of potentially inappropriate medications (PIMs) varied widely depending on the study settings, the patient characteristics, the version of the Beers criteria and the countryspecific market regulations that affect how identical criteria are applied. It ranged from 18.5% to 82.6% in residential long-term care facilities for older adults, 13 while it varied from 20.6% to 80.5% among older inpatients when cognitive impairment was reported. 14 Several studies showed that anxiolytics were the most common PIMs in psychiatric older adults, followed by antidepressants and antipsychotics. 7 Although several studies in various countries have used different assessment tools to examine the prevalence, predictors, and impact of PIM use in older adults in a range of settings, 15  years and older, diagnosed with a mental disorder, taking at least one chronic medication and having received a comprehensive geriatric assessment by a trained physician. Patients with incomplete medical records were excluded. The sample size included all patients who met the eligibility criteria during the study period. Therefore, the sample size was not calculated a priori.
The study protocol was approved by the Institutional Review Board (2022RC-006-LIUSOP) and was in compliance with the Declaration of Helsinki. The collection and processing of the data in this study complied with data protection and privacy. A written informed consent from the patients or their caregivers was not required since this study was observational in nature and did not have any physiologic, psychological, or social risks on the participants. Antiepileptics, antipsychotics, benzodiazepines, nonbenzodiazepine, benzodiazepine receptor agonist hypnotics, and antidepressants were considered CNS-active drugs, according to the AGS Beers criteria 2019. 12 In addition, the anticholinergic burden of medications, prescribed for more than 6 months, was assessed using the 2012 update of the anticholinergic cognitive burden (ACB) scale. 24 This scale classify drugs with anticholinergic properties according to their adverse cognitive effects. The total ACB score of each patient was calculated by adding the score of each possible (score 1) and definite (score 2 or 3) anticholinergic drug identified. It was then divided into four groups: 0, 1, 2, and ≥3 due to the increased risk of cognitive impairment and mortality with an ACB score ≥3. 25 Every medication included in the patient's medical record was assessed for PIM use based on the updated 2019 AGS Beers criteria. 12 The dependent variable was the use of at least one PIM by the psychiatric older adults. The medication was deemed to be PIM if it was listed in any of the five tables included in the Beers criteria

| Statistical analysis
All data analyses were performed using IBM ® SPSS ® Statistics software, version 25. Descriptive statistics were used to describe the demographic and clinical characteristics of psychiatric older adults. Categorical variables were reported using numbers and percentages, whereas continuous variables were presented using means (M) and standard deviations (SD).

| RESULTS
A total of 147 psychiatric patients met the inclusion criteria. Table 1 summarized the demographic and clinical characteristics of the study

| CONCLUSION
This study showed that PIM use, as identified by Beers criteria 2019, was highly prevalent among psychiatric older adults. It also revealed that PIM use was associated with polypharmacy and ACB score. The involvement of a clinical pharmacist as part of a multidisciplinary healthcare team in elderly care hospitals as well as raising physicians' awareness of PIMs lists and increasing the use of nonpharmacological interventions will improve medication appropriateness and lessen drug related problems. Future research should investigate the impact of PIM use on patient-centered outcomes, such as functional and cognitive status.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

TRANSPARENCY STATEMENT
The lead author Bahia Chahine affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.