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Use of potentially inappropriate medications among elderly common in some European countries

The JAMA Network Journals

There are substantial differences between European countries in the potentially inappropriate use of medications among elderly home care patients, according to a study in the March 16 issue of JAMA.

Use of potentially inappropriate medications in elderly patients is a major health care concern, according to background information in the article. It is likely to increase the risk of adverse drug events, which are estimated to be the fifth most common cause of death among hospitalized patients and which account for a large number of hospital admissions and a substantial increase in health care costs.

In the United States and Canada, epidemiological studies have documented widespread use of potentially inappropriate medications among nursing home residents (up to 40 percent) and community-dwelling elderly persons (14 percent-37 percent). In contrast, in Europe little information has been available about potentially inappropriate medication use and is based on small studies with uncertain generalizability.

Daniela Fialová, Pharm.D., of Charles University, Prague, Czech Republic, and colleagues conducted a study to determine from a large sample of European home care elderly patients the prevalence of potentially inappropriate medication use. The study included 2,707 elderly patients receiving home care (average age, 82.2 years) in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were assessed between September 2001 and January 2002.

Combining 3 sets of expert panels criteria, the researchers found that 19.8 percent of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8 percent to 10.9 percent. Substantial differences were documented between Eastern Europe (41.1 percent in the Czech Republic) and Western Europe (average 15.8 percent, ranging from 5.8 percent in Denmark to 26.5 percent in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (nearly two times increased risk), polypharmacy (the administration of many drugs at the same time, nearly twice the risk), anxiolytic (medication used to reduce anxiety or agitation) drug use (1.8 times increased risk), and depression (1.3 times increased risk). The odds of potentially inappropriate medication use significantly increased with the number of associated factors.

Individuals aged 85 years or older and those living alone were less likely to receive inappropriate medications.

"In Europe, use of potentially inappropriate medications among frail community-dwelling elderly persons appears to be common, with substantial regional variations. The differences likely reflect country-specific drug policies, care provision differences, inequalities in socioeconomic background, differences in overall health conditions, and specific regulatory measures. While regional preferences for some inappropriate medications need a more in-depth evaluation, these variations indicate amenability to intervention, particularly in Eastern Europe. Future efforts should be targeted to modifiable correlates of inappropriate medication use and research should focus on outcomes and intervention strategies," the authors write.

"Despite previous criticism of the expert panels' criteria for their simplicity, these tools increase clinicians' awareness about potentially inappropriate medications for older patients. Thoughtful adoption of these criteria by regulatory institutions, national guidelines, and computerized alert systems might improve prescribing. Because one of the current principal aims of the European Union is to improve practice, rules, and regulations throughout Europe, harmonizing drug policy and regulatory measures with respect to potentially inappropriate medication use should be a major focus (e.g., withdraw ineffective and/or harmful medications, establish prescribing limits for the elderly, approve safer alternatives, harmonize prescribing guidelines). These strategies could help ensure that prescribing for older patients in Europe is improved and consistent across countries," the researchers conclude.


(JAMA. 2005;293:1348-1358. Available post-embargo at

Editor's Note: This study is an ancillary study of the European AdHOC (Aged in Home Care) project, supported by the EU Commission under the Vth Framework Programme.

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