title: Minimizing inappropriate medications in older populations: a 10-step conceptual framework.
abstract: The increasing burden of harm resulting from the use of multiple drugs in older patient populations represents a major health problem in developed countries. Approximately 1 in 4 older patients admitted to hospitals are prescribed at least 1 inappropriate medication, and up to 20% of all inpatient deaths are attributable to potentially preventable adverse drug reactions. To minimize this drug-related iatrogenesis, we propose a quality use of medicine framework that comprises 10 sequential steps: 1) ascertain all current medications; 2) identify patients at high risk of or experiencing adverse drug reactions; 3) estimate life expectancy in high-risk patients; 4) define overall care goals in the context of life expectancy; 5) define and confirm current indications for ongoing treatment; 6) determine the time until benefit for disease-modifying medications; 7) estimate the magnitude of benefit versus harm in relation to each medication; 8) review the relative utility of different drugs; 9) identify drugs that may be discontinued; and 10) implement and monitor a drug minimization plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. The framework aims to reduce drug use in older patients to the minimum number of essential drugs, and its utility is demonstrated in reference to a hypothetic case study. Further studies are warranted in validating this framework as a means for assisting clinicians to make more appropriate prescribing decisions in at-risk older patients.
authors.affiliation: Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Australia. ian_scott@health.qld.gov.au
authors.forename: Ian A
authors.initials: IA
authors.lastname: Scott
authors.forename: Leonard C
authors.initials: LC
authors.lastname: Gray
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Martin
authors.forename: Charles A
authors.initials: CA
authors.lastname: Mitchell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004334:Drug Administration Schedule; D064420:Drug-Related Side Effects and Adverse Reactions / Q000517:prevention & control*; D005260:Female; D006040:Goals; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control*; D008017:Life Expectancy; D019338:Polypharmacy