Why do family doctors prescribe potentially inappropriate medication to elderly patients?

Abstract

BackgroundBased on changes in pharmacokinetics and –dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited.MethodsThis mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs’ medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed.ResultsContent analysis of 1846 patients’ records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics.ConclusionsIt is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs’ experiences in daily practice, FPs’ knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs’ daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs’ advanced training.

General practitioners’ views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients—A qualitative interview study with GPs (CIM-TRIAD study)

“…For example GPs reported—despite being aware of the potential harmfulness of some medication—to have no potent alternatives for the PIM and justify the use of these medications with constant monitoring and the non-occurrence of side effects. Other studies report similar accounts on unavailability of alternatives [15, 16] and monitoring [15]. Voigt et al’s [15] results also support our finding that a patient’s distress might sometimes justify the use of PIM.…”

“…Other studies report similar accounts on unavailability of alternatives [15, 16] and monitoring [15]. Voigt et al’s [15] results also support our finding that a patient’s distress might sometimes justify the use of PIM. Anderson et al [14] and Cullinan et al [16] also found that rating a drug as potentially harmful in general did not always keep GPs from prescribing it to an individual patient and that the drug appearing to work without side effects perpetuates the prescription.…”

“…GPs mentioned that trying to discontinue psychoactive drugs, especially benzodiazepines, leads to patients switching to another GP who is more willing to prescribe these drugs [32]. Other GPs from Germany [15, 17] and other countries [14, 16] reported the same concerns. Another study by Dalleur et al [33] supported that GPs fear reluctance of patients to change their treatment as there might be a high psychological or physical attachment to certain drugs deemed potentially inappropriate.…”

“…With Voigt et al’s study [15] being the only and a also small-sampled study interviewing German GPs about PIM (from the PRISCUS list), a comprehensive study of German GPs’ views on problematic medication/PIM, the PL, as well as on (long-term) prescriptions of PIM (according to the PL) is to our knowledge still missing. Therefore, in the present study, the following research questions were addressed:

What do German GPs think about PIM, problematic medication and the PL?

What affects (long-term) use of PIM/problematic medication from the GPs’ point of view?

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Physician Factors Associated with Polypharmacy and Potentially Inappropriate Medication Use

“…A lack of evidence for the benefit/risk of deprescribing is known to be a common reason for prescribing PIMs 26 or as a barrier to deprescribing. 18,19 Medication optimization criteria, such as the Beers List, can be a resource for clinicians as a summary of the current best evidence regarding PIMs.…”