Inappropriate prescribing common in AD patients


Three European studies have reported that elderly patients – notably those with Alzheimer’s disease – are highly likely to receive inappropriately prescribed medications both in the community and in the nursing home setting.

Inappropriate prescribing generally includes medications with an unfavourable risk-benefit when a safer alternative exists; inappropriate dose or duration; drugs with significant drug-drug or drug-disease interactions; and potentially beneficial medications that are underused (Spinewine et al. Lancet 2007;370:173-184). The Beers criteria for inappropriate medications were initially developed for nursing home residents (Beers et al. Arch Intern Med 1991;151:1825-1832) and subsequently modified (Zhan et al. JAMA 2001;286:2823-2829). The Beers criteria have been expanded for use in all older patients (Beers MH. Arch Intern Med 1997;157:1531-1536), but do not consider drug-drug interactions or underprescribing.

More recent are the STOPP (Screening Tool of Older People’s potentially inappropriate Prescriptions) criteria (Gallagher & O’Mahoney. Age Ageing 2008;37:673-679; free full text at, and the START (Screening Tool to Alert doctors to the Right Treatment) criteria (Barry et al. Age Ageing 2007;36:632-638; free full text at

In France, the REAL.FR group is conducting a prospective four-year study of potentially inappropriate medication (PIM) use in 684 patients with mild-to-moderate AD living in the community (Montastruc et al. Eur J Clin Pharmacol 2013;69:1589-1597). Overall, 46.8% of subjects had received at least one PIM. The most common PIMs were cerebral vasodilators (24% of all prescriptions), atropinic drugs (17%) and long half-life benzodiazepines (8.5%). In 16% of cases, atropinic agents were given in conjunction with cholinesterase inhibitors. At risk of PIMs were females (OR 1.5) and AD patients taking five or more prescribed drugs.

In Ireland, a retrospective analysis of six nursing homes found that 46.2% of patients were prescribed one or more PIMs (Parsons et al. Drugs Aging 2012;29:143-155). The most frequent PIMs were long-term neuroleptics, NSAIDs prescribed for >3 months, high-dose proton pump inhibitors for >2 months, tricyclic antidepressants in patients with dementia, and long-term use of long-acting benzodiazepines.

Inappropriate benzodiazepine prescribing was also identified as a problem in a 2006 survey in Quebec (Enquête sur la Santé des Aînés/Survey on the Health of the Elderly), in which one-third of elderly individuals living in the community had received a benzodiazepine prescription (Dionne et al. Psychiatr Serv 2013;64:331-338).

Germany has produced its PRISCUS list of inappropriate medications (Holt et al. Dtsch Arztebl Int 2010;107: 543-551; free full text at A study at the University of Cologne has used PRISCUS to examine the PIM prevalence in community-living elderly based on health claims data (Schubert et al. Pharmacoepidemiol Drug Saf 2013; epublished April 12, 2013).

An estimated 22% of the elderly population received at least one PIM. The most common medications used inappropriately were antidepressants (6.5%), antihypertensives (3.8%) and antiarrhythmics (3.5%). Those at greater risk were women (OR 1.39) and patients with “extreme polypharmacy” (>10 medications; OR 5.16).

Dr. Yves Bacher: Patients with dementia are at particular risk of medication side effects. The chronicity of the disease, their old age, frequent comorbidities and the often vagueness of their symptoms could result in multiple medications added to the drug regimen. Medication regimens should be reassessed regularly and carefully.

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