gms | German Medical Science

Background: Regarding the complexity of problems of medication in the elderly and reflecting the higher admission rates to hospitals in elderly patients because of adverse drug reaction or drug-drug reaction, expert groups in several countries developed so called black lists of drugs for elderly patients, describing potentially inappropriate medication (PIM). In Germany the first black list ‘PRISCUS’ has been consensually developed in 2010. PRISCUS includes currently 83 drugs that should be avoided or prescribed with lower dosage in elderly patients [1]. Current studies examining older patient samples showed prescription rates of PIM between 22.5-28.4 % in the primary care setting [2], [3]. Since these rates seem to be high, it would be useful to understand prescribing of PIM by family practitioners (FP) to generate feasible and need-oriented solutions for improvement of medical care in the elderly.

Materials and Methods: The study “General practitioners’ views on polypharmacy and its consequences for patient health care” (granted by Roland Ernst Foundation) was conducted by the Department of General Practice of the Technische Universität Dresden from March 2013 to June 2014. Using a mixed methods design this retrospective cross sectional study consisted on three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs including selected patient-specific case vignettes and 3) qualitative interviews with their medical assistants. Statistical analysis of data was done using SPSS 22.0 to describe characteristics of the sample and subsamples regarding morbidity and treatments. A logistic regression was conducted to identify predictors for PIM-prescription. Qualitative content analysis of interviews with FPs was done to explore and categorize contextual factors and individual reasons for PIM description from FPs point of view.

Results: 1241 records of patients > 65 years (mean age: 76 (± 6 SD), females: 56.6%) of 7 FP were analyzed regarding PIM prescription. 23.9% of these elderly patients received at least one PIM prescription. Sedatives and hypnotics were the most frequent (13.7%) prescribed PIM-agents. Significantly more female (F: 27.6% vs. M: 19.1%, p≤0.001) and more very old patients (≥80 years: 31.3 % vs. <80 years: 21.6%, p≤0.001) received a PIM prescription. Documented mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Most reported cause for PIM prescription by FP was the statement of unavoidability of PIM because having no alternatives in medication, especially in multimorbid patients. Skepticism was commonly reported regarding applicability of PRISCUS in daily practice and its benefits for individual patients within the complex context of multimorbidity as well as concerning lack of time as main barrier for appropriate prescribing.

Conclusion: It is essential to consider FPs in a complex decision making process with several influencing factors on their prescribing of PIM: patient-oriented prioritization, FPs’ individual experiences in daily practice regarding prescription of drugs, FPs’ knowledge regarding existing evidence/recommendations, the quality of interprofessional collaboration with in- and out-patient specialist and organizational characteristics in daily practice should be reflected.