Analysis of Potentially Inappropriate Medication Use in 372 Old Adult Inpatients

Background: In 2017, China published the "Criteria for Potentially Inappropriate Medications use for the old adults in China". There is no medical institution in Huainan that has conducted investigations on PIMs for the old adults until now. The survey investigated the PIMs for the old adults in our hospital, and also tested the applicability and practicability of the 72 drugs included in the "Criteria for Potentially Inappropriate Medications use for the old adults in China". Methods: According to the Criteria for Potentially Inappropriate Medications use for the old adults in China (2017 Edition), a retrospective analysis of the medications in 372 old adult inpatients aged 65 years and above was performed to evaluate the occurrence of their PIMs use. Results: The average age of the 372 inpatients was (74.67±6.95) years old, the average Inpatient days was (11.96±8.5) days, and the average number of illnesses per person was (4.92±2.55). Of 372 inpatients, 62.63% (233) inpatients had PIMs in the China-PIM list for the old adults , and 17.20% (64) inpatients had PIMs related to their diseases. Conclusion: The proportion of PIMs among old adult inpatients in our hospital is relatively high. The hospital should pay attention to it and actively take measures to reduce the risk of PIMs for the old adults and ensure rational drug use in clinical medicine.


Background
Potentially inappropriate medications(PIMs) refer to that the potential adverse risks of using certain drugs which belong to the high-risk drug class [1] may exceed the predicted bene ts.As old adults suffer from multiple diseases at the same time, they need to take a variety of drugs.There are potential risks in the interaction both between drugs and between drugs and the body.The use of scienti c criteria to evaluate the PIMs in old adults patients can prevent adverse drug events(ADEs), and guide rational drug use in clinical medicine.In 1991, American geriatric expert Beers and others rst published the PIM criteria for the old adults mainly for outpatients and long-term care patients, called the Beers Criteria [2], and is currently widely used internationally [3].China has now entered an aging society.From 2014 to 2016, Xuanwu Hospital of Capital Medical University took the lead to initially develop the Preliminary Judgment Criteria for Potentially Inappropriate Use of Drugs in the Disease State of the old adults in China by referring to the medication data of a large number of old adult patients over 60 years old [4] And the China PIM List for old adults [5], and tested the applicability and practicality of the China PIM List for old adults, and jointly issued the Judgement criteria of PIM for old adults in China in Beijing in 2017.
PIMs can increase the risk of adverse drug reactions/events and other risks in the old adults, leading to increased rehospitalization and increased case fatality rate.Therefore, for the drugs listed in the Judgement criteria of PIM for old adults in China, measures should be taken to avoid the drug use, reduce the dose or increase monitoring in the treatment of old adults patients or under certain disease states.

Materials And Methods
Use the HIS of our hospital to retrieve information and medication records of all patients checking into our hospital from June 2019 to June 2020.The inclusion criteria: age ≧ 65 years old; time of hospitalization ≧ 48 h.Exclusion criteria: Age < 65 years; time of hospitalization < 48 h; Those who have been repeatedly hospitalized 2 times or more within a month; No drugs were used during hospitalization; Death during hospitalization; Case data are incomplete.According to the average value of the index assignment of expert evaluation in the Judgement criteria of PIM for old adults in China, the risk intensities of the drugs are classi ed: (1) High-risk drugs, the old adults should avoid using them; (2) Low-risk drugs, the old adult should use with caution.Class A warning drugs are recommended for drug adjustment and intervention; the rest are classi ed as Class B warning drugs.According to the Judgement criteria of PIM for old adults in China, based on the frequency of medication, they are classi ed into Class A and Class B warning drugs.Class A warning drugs are recommended to clinicians and clinical pharmacists for priority warning.SPSS 22.0 statistical software was used to process the data.Count data is represented by the number of cases and percentage (%), and dose data is represented by X ± s.

Basic materials
Of the 372 inpatints, the average age is (74.67 ± 6.95) years old,average inpaint days are (11.96 ± 8.5) days average number of disease per person is (4.92 ± 2.55) Within them, the incidence rate of PIM among female patients is higher than that of male patients.The incidence rate of PIM among old adult patients ≥ 80 years old is higher than that of old adult patients aged 65 to 79.The incidence rate of PIM among patients with Inpatient days ≥ 10 is higher than that of the patients with inpatient days of 2-9 days.The incidence rate of PIM among patients with ≥ 4 disease is higher than that of the patients with 1 to 3 diseases.See Table 1 for details.2.2 Occurrence of PIM Among them, 233 (62.63%) patients used the drugs in the China-PIM list for the old adults.The top three drugs with higher incidence were spironolactone (15.21%), clopidogrel (11.22%) and insulin (11.22%).
Among them, 219 (54.29%) cases used A-level warning drugs, but did not use high-risk-intensity drugs; 182 (45.71%) cases used B-level warning drugs, and 93 (23.19%) cases used drugs of high risk intensity.See Table 2 for details.Among them, 64 (17.20%) patients have 90 PIMs related to the disease state, all of which are A-level warning drugs.The highest incidence took place when taking clopidogrel or nonsteroidal anti-in ammatory drugs during coagulation disorders or anticoagulation theatment.See Table 3 for details.

Analysis of PIM in old adult inpatients in hospital
Among the 372 62.63%(233)inpatients used the drugs in China PIM List for old adults.The incidence rate of PIM was slightly higher than the retrospective analysis result (61.15%) of PIM conducted by Liu Yulong et al. [6] on 317 old adults inpatients.In the statistics of the PIM situation of old adult inpatients in our hospital, the barbiturate compound amidobarbital injection was included.This medicine is a compound preparation, and its components are aminopyrine, antipyrine and barbital.; Ophthalmic drugs in aminoglycoside antibiotics are not included such as tobramycin dexamethasone ointment and the eye drops.
The incidence rate of PIM among female inpatients in our hospital is higher than that of female inpatients, which may be related to the sample size.The incidence rate of PIM in old adult inpatients ≥ 80 years old is higher than that of old adult inpatients aged from 65 to 79, the incidence rate of PIM in patients with inpatient days ≥ 10 is higher than that inpatients with inpatient days of 2-9, and the incidence rate of PIM in inpatients with diseases ≥ 4 is higher than that of inpatients with 1 ~ 3 diseases, it may be because that old adult inpatients have more complications, more severe illness condition, and different degrees of cognitive impairment [7], and it may also be related to the adverse drug reactions and drug interactions caused by taking a variety of drugs by old adult inpatients [8-10] .
62.63%(233) patients in our hospital used the drugs in the China PIM List for old adults.The top three drugs with high incidence rate are spironolactone (15.21%), clopidogrel (11.22%) and insulin (11.22%).Spironolactone increases the risk of hyperkalemia in patients with heart failure.For old adult patients, blood potassium and electrocardiogram should be closely monitored, and using spironolactone with potassium-containing drugs such as penicillin, non-steroidal anti-in ammatory drugs, angiotensin converting anzyme inhibitior and angiotensin receptor inhibitor should better be avoided in treating old adult patients.When using clopidogrel, attention should be paid to bleeding and hematological abnormalities; If a patient is treated with aspirin, non-steroidal anti-in ammatory drugs, heparin or thrombolytic drugs, clopidogrel should be used with caution, and the patient should be monitored closely.
There are many types of insulin in our hospital, including short-acting insulin, intermediate-acting insulin, long-acting insulin and premixed insulin.The appropriate insulin should be selected according to the blood glucose monitoring of the old adults, and the blood glucose of the patient should be closely monitored.

Personal advice on the China PIM List for adults
The problem of rational use of drugs for old adult has become increasingly prominent.Now most clinical research and drug treatment guidelines focus on speci c diseases, rather than the age or physical condition of special populations.Therefore, it is necessary to develop a list of PIMs for old adult.which provides a certain guarantee for the rational use of drugs.I have some doubts and questions on calculating the PIMs of old adult inpatients in our hospital based on the China PIM List for old adults.In the disease state of peptic ulcer, the use of non-steroidal anti-in ammatory drugs will exacerbate the primary ulcer and cause new ulcers.It is recommended to add the disease state of gastrointestinal bleeding; in the disease state of gout, the use of thiazide diuretics will exacerbate or cause gout, it is recommended to add the disease state of hyperuricemia.It is recommended to add tramadol sustainedrelease tablets in the anesthetics and anesthetic adjuvants.There are more patients using tramadol sustained-release tablets in our hospital, while fewer patients use tramadol tablets and tramadol injection.In the China PIM List for old adults Chinese patent medicines can be added according to the national conditions.For example, Xiaoke Pills containing glibenclamide can also cause hypoglycemia in old adult patients; In the basic state of diabetes, long-term use of glucocorticoids will aggravate diabetes.The speci c length of long-term use is recommended to be standardized; In the case of a history of falls or fractures, the list of PIMs is dexzopiclone and zopiclone can be added.Ezopiclone is the dextrorotatory form of zopiclone, and the risk points of the two drugs are relatively similar.

Conclusion
There are no medical institutions in Huainan that have conducted investigations on PIMs in old adult, and only a few domestic medical institutions have conducted investigations and analysis based on the Judgement criteria of PIM in old adults in China.Thoroughly investigate the situation of PIMs in the old adults in our hospital, and providing suggestions for the next measures the hospital should take to improve the rational use of drugs for old adult patients in our hospital.At the same time, the applicability and practicability of 72 drugs included in the China PIM List for old adults were tested for the actual use of drugs in our hospital.

Table 2
Occurrence of PIM among old adult inpatients(n = 401) Risperidone( 1 ) Avoid the treatment of abnormal behavior in patients with dementia, and only apply when non-drug treatment fails or the patient poses a threat to themselves and others; (2) Increase the risk of cerebrovascular accidents and death in patients with dementia low 1 Olanzapine (1) Nervous system adverse reactions (prolonged sedation time, cognitive dysfunction); (2) Extravertebral system Warfarin (1) Individual differences are large, protein binding rate is high, overdose is likely to cause hemorrhage; (2) Old adults take more drugs, and their physiological state changes, possible interactions and risk of adverse reactions caused by single drugs are increased; (3) Routine monitoring of

Table 3
Old adult patients and PIM relating to disease status (n = 90)