Skip to main content
SpringerLink
Log in

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background and objectives

Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality.

Methods

This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald’s method.

Results

This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index.

Conclusions

Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Ageing Europe - statistics on population developments [cited 2023 Oct 31]. https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Ageing_Europe_-_statistics_on_population_developments#Older_people_.E2.80.94_population_overview.

  2. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146-156. https://doi.org/10.1093/gerona/56.3.M146.

    Article  CAS  PubMed  Google Scholar 

  3. Rockwood K, Stadnyk K, MacKnight C, McDowell I, Hébert R, Hogan DB. A brief clinical instrument to classify frailty in elderly people. Lancet. 1999;353:205–6. https://doi.org/10.1016/S0140-6736(98)04402-X.

    Article  CAS  PubMed  Google Scholar 

  4. Eckerblad J, Theander K, Ekdahl A, Unosson M, Wirehn A-B, Milberg A, et al. Symptom burden in community-dwelling older people with multimorbidity: a cross-sectional study. BMC Geriatr. 2015;15:1. https://doi.org/10.1186/1471-2318-15-1.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol. 2007;63:187–95. https://doi.org/10.1111/j.1365-2125.2006.02744.x.

    Article  PubMed  Google Scholar 

  6. Lövheim H, Sandman P-O, Kallin K, Karlsson S, Gustafson Y. Relationship between antipsychotic drug use and behavioral and psychological symptoms of dementia in old people with cognitive impairment living in geriatric care. Int Psychogeriatr. 2006;18:713–26. https://doi.org/10.1017/S1041610206003930.

    Article  PubMed  Google Scholar 

  7. Weich S, Pearce HL, Croft P, Singh S, Crome I, Bashford J, et al. Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. BMJ. 2014;348: g1996. https://doi.org/10.1136/bmj.g1996.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Dedhiya SD, Hancock E, Craig BA, Doebbeling CC, Thomas J. Incident use and outcomes associated with potentially inappropriate medication use in older adults. Am J Geriatr Pharmacother. 2010;8:562–70. https://doi.org/10.1016/S1543-5946(10)80005-4.

    Article  PubMed  Google Scholar 

  9. Rogowska M, Thornton M, Creese B, Velayudhan L, Aarsland D, Ballard C, et al. Implications of adverse outcomes associated with antipsychotics in older patients with dementia: a 2011–2022 update. Drugs Aging. 2023;40:21–32. https://doi.org/10.1007/s40266-022-00992-5.

    Article  PubMed  Google Scholar 

  10. Yunusa I, Alsumali A, Garba AE, Regestein QR, Eguale T. Assessment of reported comparative effectiveness and safety of atypical antipsychotics in the treatment of behavioral and psychological symptoms of dementia. JAMA Netw Open. 2019;2: e190828. https://doi.org/10.1001/jamanetworkopen.2019.0828.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Yunusa I, Rashid N, Demos GN, Mahadik BS, Abler VC, Rajagopalan K. Comparative outcomes of commonly used off-label atypical antipsychotics in the treatment of dementia-related psychosis: a network meta-analysis. Adv Ther. 2022;39:1993–2008. https://doi.org/10.1007/s12325-022-02075-8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Schmucker DL. Aging and the liver: an update. J Gerontol A Biol Sci Med Sci. 1998;53:B315-320. https://doi.org/10.1093/gerona/53A.5.B315.

    Article  CAS  PubMed  Google Scholar 

  13. Drenth-van Maanen AC, van Marum RJ, Knol W, van der Linden CMJ, Jansen PAF. Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy: results of application to case histories by general practitioners. Drugs Aging. 2009;26:687–701. https://doi.org/10.2165/11316400-000000000-00000.

    Article  PubMed  Google Scholar 

  14. Hutchison LC, O’Brien CE. Changes in pharmacokinetics and pharmacodynamics in the elderly patient. J Pharm Pract. 2007;20:4–12. https://doi.org/10.1177/0897190007304657.

    Article  Google Scholar 

  15. Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010. BMC Med. 2015;13:74. https://doi.org/10.1186/s12916-015-0322-7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38:360–72. https://doi.org/10.1111/jcpt.12059.

    Article  CAS  PubMed  Google Scholar 

  17. Curtin D, Gallagher PF, O’Mahony D. Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences. Ther Adv Drug Saf. 2019;10:204209861982943. https://doi.org/10.1177/2042098619829431.

    Article  Google Scholar 

  18. Pazan F, Weiss C, Wehling M, FORTA, Bauer JM, Berthold HK, et al. The FORTA (Fit fOR The Aged) List 2021: Fourth Version of a Validated Clinical Aid for Improved Pharmacotherapy in Older Adults. Drugs Aging. 2022;39:245–7. https://doi.org/10.1007/s40266-022-00922-5.

    Article  PubMed  PubMed Central  Google Scholar 

  19. ICD-9-CM: International Classification of Diseases 9th Revision Clinical Modification. 5th ed. Medicode; 1997.

  20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Arlington; American Psychiatric Association; 1994

  21. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults: 2019 AGS BEERS Criteria® Update Expert Panel. J Am Geriatr Soc. 2019;67:674–94.https://doi.org/10.1111/jgs.15767

  22. Pasina L, Astuto S, Cortesi L, Tettamanti M, Franchi C, Marengoni A, et al. Therapeutic duplicates in a cohort of hospitalized elderly patients: results from the REPOSI study. Drugs Aging. 2016;33:647–54. https://doi.org/10.1007/s40266-016-0395-9.

    Article  PubMed  Google Scholar 

  23. Eggermont LHP, de Vries K, Scherder EJA. Psychotropic medication use and cognition in institutionalized older adults with mild to moderate dementia. Int Psychogeriatr. 2009;21:286–94. https://doi.org/10.1017/S1041610209008552.

    Article  PubMed  Google Scholar 

  24. Wetzels RB, Zuidema SU, de Jonghe JFM, Verhey FRJ, Koopmans RTCM. Prescribing pattern of psychotropic drugs in nursing home residents with dementia. Int Psychogeriatr. 2011;23:1249–59. https://doi.org/10.1017/S1041610211000755.

    Article  CAS  PubMed  Google Scholar 

  25. Nijk RM, Zuidema SU, Koopmans RTCM. Prevalence and correlates of psychotropic drug use in Dutch nursing-home patients with dementia. Int Psychogeriatr. 2009;21:485–93. https://doi.org/10.1002/gps.5116.

    Article  PubMed  Google Scholar 

  26. Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89:845–54. https://doi.org/10.1038/clpt.2011.44.

    Article  CAS  PubMed  Google Scholar 

  27. Dalleur O, Boland B, Losseau C, Henrard S, Wouters D, Speybroeck N, et al. Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled study. Drugs Aging. 2014;31:291–8. https://doi.org/10.1007/s40266-014-0157-5.

    Article  CAS  PubMed  Google Scholar 

  28. Frankenthal D, Lerman Y, Kalendaryev E, Lerman Y. Intervention with the screening tool of older persons potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatr Soc. 2014;62:1658–65. https://doi.org/10.1111/jgs.12993.

    Article  PubMed  Google Scholar 

  29. Wehling M, Burkhardt H, Kuhn-Thiel A, Pazan F, Throm C, Weiss C, et al. VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification. Age Ageing. 2016;45:262–7. https://doi.org/10.1093/ageing/afv200.

    Article  PubMed  Google Scholar 

  30. Awad A, Hanna O. Potentially inappropriate medication use among geriatric patients in primary care setting: a cross-sectional study using the Beers, STOPP, FORTA and MAI criteria. PLoS ONE. 2019;14: e0218174. https://doi.org/10.1371/journal.pone.0218174.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Pazan F, Weiss C, Wehling M, Wehling M, Burkhardt H, Schwarz S, et al. The FORTA (Fit fOR The Aged) list 2018: third version of a validated clinical tool for improved drug treatment in older people. Drugs Aging. 2019;36:481–4. https://doi.org/10.1007/s40266-019-00669-6.

    Article  PubMed  Google Scholar 

  32. Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32:113–21. https://doi.org/10.1111/j.1365-2710.2007.00793.x.

    Article  CAS  PubMed  Google Scholar 

  33. O’Connor MN, O’Sullivan D, Gallagher PF, Eustace J, Byrne S, O’Mahony D. Prevention of hospital-acquired adverse drug reactions in older people using screening tool of older persons’ prescriptions and screening tool to alert to right treatment criteria: a cluster randomized controlled trial. J Am Geriatr Soc. 2016;64:1558–66. https://doi.org/10.1111/jgs.14312.

    Article  PubMed  Google Scholar 

  34. Maust DT, Kim HM, Seyfried LS, Chiang C, Kavanagh J, Schneider LS, et al. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm. JAMA Psychiat. 2015;72:438–45. https://doi.org/10.1001/jamapsychiatry.2014.3018.

    Article  Google Scholar 

  35. Pasina L, Novella A, Cortesi L, Nobili A, Tettamanti M, Ianes A. Drug prescriptions in nursing home residents: an Italian multicenter observational study. Eur J Clin Pharmacol. 2020;76:1011–9. https://doi.org/10.1007/s00228-020-02871-7.

    Article  PubMed  Google Scholar 

  36. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213–8. https://doi.org/10.1093/ageing/afu145.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors are very grateful to Korian Italy for the opportunity to conduct the study. Korian Italy had no role in the conception and design of the study, data analysis and interpretation, preparation and writing of the report, or the decision to submit the manuscript for publication. The authors are grateful to J.D. Baggott for language editing.

Author information

Authors and Affiliations

  1. Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy

    Marina Azab, Alessio Novella & Luca Pasina

  2. Over SRL, Milan, Italy

    Aladar Ianes

Authors
  1. Marina Azab
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alessio Novella
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Aladar Ianes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Luca Pasina
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marina Azab.

Ethics declarations

Funding

No sources of funding were used to assist in the conduct of this study or the preparation of this article.

Conflict of interest

Marina Azab, Alessio Novella, Aladar Ianes and Luca Pasina have no conflicts of interest that are directly relevant to the contents of this article.

Ethical approval

This study was approved by the Ethics Committee of the IRCCS Carlo Besta Foundation (ethics approval number 60_2019).

Consent to participate

This was a retrospective study and data collection complied fully with Italian law on personal data protection. All data were anonymous and informed consent was not required for the purpose of this study.

Consent for publication

Not applicable.

Data availability statement

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Code availability

The codes that support the findings of this study are available on request from the corresponding author.

Author contributions

All authors participated in drafting of the manuscript or critical revision for important intellectual content. Individual contributions were as follows: MA and LP designed the study, interpreted the data, and wrote the manuscript; AN interpreted the statistical analyses, and AI undertook the final critical revision for important intellectual content. All authors read and approved the final version of the paper and agree to be accountable for this work.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 148 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Azab, M., Novella, A., Ianes, A. et al. Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study. Drugs Aging 41, 187–197 (2024). https://doi.org/10.1007/s40266-023-01083-9

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-023-01083-9

Search

Navigation