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Abstract

Background: Although several previous studies have examined the prevalence and risk factors associated with inappropriate prescribing (IP) among elderly patients, as identified by the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, no research has been conducted among elderly home care patients. Objective: This study aimed to explore the prevalence of IP and its risk factors as identified by the STOPP/START criteria among elderly home care patients in Japan. Study Design: Cross-sectional study. Setting: Home care settings in Japan. Participants: Eighty-nine patients aged 65 years or older who received regular home visiting services from Yamato Clinic between May 2013 and June 2013. Main Outcome Measure: The prevalence of IP and its risk factors as identified by the STOPP/START criteria. Results: Of the study population, 40.4% had at least one potentially inappropriate medication and 60.7% had at least one incidence of underprescribing. Risk factors for potentially inappropriate medications were hypertension, constipation, and polypharmacy, while those for underprescription were osteoporosis and polypharmacy. Conclusion: The prevalence of IP among elderly home care patients is high, with risk factors that include not only polypharmacy but also several specific underlying medical conditions.

Keywords

polypharmacy home care setting elderly patients prevalence risk factor

Introduction

Inappropriate prescribing (IP) occurs when pharmacotherapy does not meet accepted medical standards.¹ IP has been correlated with poor compliance, increased risk of drug–drug interactions and adverse drug reactions, and increased economic burden.^2-10 As a result, IP among elderly people has become an important public health issue worldwide.²

There are several definitions of IP. O’Connor et al¹¹ defined it as having 3 major domains: (a) misprescribing, (b) overprescribing, and (c) underprescribing. Several recent studies concluded that the prevalence of IP and its risk factors vary with population characteristics, study settings, drug policies, and the definitions used.^12-15

There are several tools used to detect IP in elderly people,¹⁶ such as Beers’ criteria,¹⁷ the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START),^18,19 and the Improved Prescribing in the Elderly Tool (IPET).²⁰

A recent study showed that the STOPP/START criteria have high sensitivity for detecting potential drug-related problems²¹ and are more sensitive in detecting IP than Beers’ criteria.²²

Since the prevalence of IP has been correlated with patient age,¹⁴ and the need for home medical care for elderly people in developed countries such as Japan is predicted to continue increasing in the future, IP among elderly home care patients is an important issue for developed countries with aging societies.

To the best of our knowledge, while several previous studies have assessed the prevalence and risk factors associated with IP as identified by the STOPP/START criteria²² among elderly patients, no study has yet been conducted among elderly home care patients.²² This study aims to address these issues among elderly home care patients in Japan.

Methods

This cross-sectional study enrolled all patients aged 65 years or older who received regular home visiting services from Yamato Clinic between May 2013 and June 2013. Yamato Clinic provides ambulatory care and home visiting services for community residents, with five doctors specialized in family medicine. None of the 5 doctors was familiar with the STOPP/START criteria.

Ethics Statement

The study was approved by the ethics committee of the Mito Kyodo General Hospital and was conducted according to the principles expressed in the Declaration of Helsinki.

Data Collection

We included all patients who were 65 years or older and who satisfied the inclusion criteria. Our inclusion criteria were as follows: (a) patients received home visiting services regularly for at least 1 month and (b) patients had been regularly prescribed medications from Yamato Clinic, excluding topical drugs.

We used electronic medical records to collect patients’ background information, which included age, sex, estimated glomerular filtration rate (eGFR; mL/min), serum albumin (mg/dl), availability of oversight regarding ambulation and drug use, underlying medical conditions, whether they lived with or without family, and whether or not they utilized a home visiting pharmacist or nurse. We verified prescriptions that had been regularly prescribed by Yamato Clinic between May 2013 and June 2013.

Statistical Analysis

We defined the polypharmacy as the concurrent use of 6 or more prescriptions,¹² and the IP as having 2 domains: (a) potentially inappropriate medications (PIMs), which include misprescribing and overprescribing and (b) underprescribing. A PIM was defined as having occurred when at least 1 of the 65 original STOPP criteria (Table 1) was met, while underprescribing was designated by the occurrence of at least 1 of the 22 original START criteria (Table 1). Differences in variable distributions between patients who experienced PIMs or underprescribing and those who did not were compared using Student’s t test for continuous variables and Pearson’s χ² test or Fisher’s exact test for categorical variables.

Table 1.

STOPP/START Screening Criteria.¹⁸

	STOPP Criteria
A. Cardiovascular system
1.	Digoxin at a long-term dose >125 µg/d with impaired renal function
2.	Loop diuretic as first-line monotherapy for hypertension or for dependent ankle edema only
3.	Thiazide diuretic with a history of gout
4.	Noncardioselective β-blocker with chronic obstructive pulmonary disease
5.	β-blocker in combination with verapamil
6.	Use of diltiazem or verapamil with New York Heart Association class 3 or 4 heart failure
7.	Calcium-channel blockers with chronic constipation
8.	Use of aspirin and warfarin in combination without histamine H2 receptor antagonist (except cimetidine) or proton pump inhibitor
9.	Dipyridamole as monotherapy for cardiovascular secondary prevention
10.	Aspirin with no history of coronary, cerebral or peripheral vascular symptoms or occlusive arterial event or with a past history of peptic ulcer disease without histamine H2 receptor antagonist or proton pump inhibitor or at dose >150 mg/d or to treat dizziness not clearly attributed to cerebrovascular disease
11.	Warfarin for first, uncomplicated deep venous thrombosis for longer than 6-month duration or for first, uncomplicated pulmonary embolus for longer than 12-month duration
12.	Aspirin, clopidogrel, dipyridamole, or warfarin with concurrent bleeding disorder
B. CNS and psychotropic drugs
1.	Tricyclic antidepressants with dementia or with glaucoma or with cardiac conductive abnormalities or with constipation or with prostatism or prior history of urinary retention or with an opiate or calcium-channel blocker
2.	Long-term (ie, >1 month), long-acting benzodiazepines, and those with long-acting metabolites
3.	Long-term (ie, >1 month) neuroleptics as long-term hypnotics or in those with parkinsonism
4.	Phenothiazines in patients with epilepsy
5.	Anticholinergics to treat extrapyramidal side effects of neuroleptic medications
6.	Selective serotonin reuptake inhibitors with a history of clinically significant hyponatremia (noniatrogenic hyponatremia <130 mmol/L within the previous 2 months)
7.	Prolonged use (>1 week) of first-generation antihistamines
C. Gastrointestinal system
1.	Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhea of unknown cause or severe infective gastroenteritis
2.	Prochlorperazine or metoclopramide with parkinsonism
3.	Proton pump inhibitors for peptic ulcer disease at full therapeutic dosage for >8 weeks
4.	Anticholinergic antispasmodic drugs with chronic constipation
D. Respiratory system
1.	Theophylline as monotherapy for chronic obstructive pulmonary disease
2.	Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-to-severe chronic obstructive pulmonary disease
3.	Nebulized ipratropium with glaucoma
E. Musculoskeletal system
1.	NSAID with history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent histamine H2 receptor antagonist, proton pump inhibitor, or misoprostol
2.	NSAID with moderate-to-severe hypertension or with heart failure
3.	Long-term use of NSAID (>3 months) for relief of mild joint pain in osteoarthtitis
4.	Warfarin and NSAID together
5.	NSAID with chronic renal failure
6.	Long-term corticosteroids (>3 months) as monotherapy for rheumatoid arthritis or osteoarthritis
7.	Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to allopurinol
F. Urogenital system
1.	Bladder antimuscarinic drugs with dementia or with chronic glaucoma or with chronic constipation or with chronic prostatism
2.	α-blockers in males with frequent incontinence
3.	α-blockers with long-term urinary catheter in situ (ie, for more than 2 months)
G. Endocrine system
1.	Glibenclamide or chlorpropamide with type 2 diabetes mellitus
2.	β-blockers in those with diabetes mellitus and frequent hypoglycemic episodes
3.	Estrogens with a history of breast cancer or venous thromboembolism
4.	Estrogens without progestogen in patients with intact uterus
H. Drugs that adversely affect those prone to falls (≥1 fall in past 3 months)
1.	Benzodiazepines
2.	Neuroleptic drugs
3.	First-generation antihistamines
4.	Vasodilator drugs known to cause hypotension in those with persistent postural hypotension
5.	Long-term opiates in those with recurrent falls
I. Analgesic drugs
1.	Use of long-term powerful opiates as first-line therapy for mild-to-moderate pain
2.	Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives
3.	Long-term opiates in those with dementia unless indicted for palliative care or management of moderate-to-severe chronic pain syndrome
J. Duplicate drug classes
1.	Any regular duplicate drug class prescription, such as two concurrent opiates, NSAIDs, serotonin-specific reuptake inhibitors, loop diuretics, and ACE inhibitors
	START Criteria
A. Cardiovascular system
1.	Warfarin in the presence of chronic atrial fibrillation
2.	Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated, but not aspirin
3.	Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral, or peripheral vascular disease in patients with sinus rhythm
4.	Antihypertensive therapy where systolic blood pressure is consistently >160 mm Hg
5.	Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease
6.	ACE inhibitor with chronic heart failure or following acute myocardial infarction
7.	β-blocker with chronic stable angina
B. Respiratory system
1.	Regular inhaled β₂-agonist or anticholinergic agent for mild-to-moderate asthma or chronic obstructive pulmonary disease
2.	Regular inhaled corticosteroid for moderate-to-severe asthma or chronic obstructive pulmonary disease, where predicted FEV₁ <50%
3.	Home continuous oxygen with documented chronic type 1 respiratory failure or type 2 respiratory failure
C. CNS
1.	l-DOPA in idiopathic Parkinson’s disease with definite functional impairment and resultant disability
2.	Antidepressant drug in the presence of moderate-to-severe depressive symptoms lasting for at least 3 months
D. Gastrointestinal system
1.	Proton pump inhibitor with severe gastroesophageal acid reflux disease or peptic stricture requiring dilation
2.	Fiber supplement for chronic, symptomatic diverticular disease with constipation
E. Musculoskeletal system
1.	DMARD with active moderate-to-severe rheumatoid disease lasting >12 weeks
2.	Bisphosphonates in patients taking maintenance oral corticosteroid therapy
3.	Calcium and vitamin D supplement in patients with known osteoporosis
F. Endocrine system
1.	Metformin with type 2 diabetes ± metabolic syndrome (in the absence of renal impairment)
2.	ACE inhibitor or angiotensin-receptor blocker in diabetes with nephropathy
3.	Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors
4.	Statin therapy in diabetes mellitus with coexisting major cardiovascular risk factors present

Abbreviations: STOPP, Screening Tool of Older Persons’ potentially inappropriate Prescriptions; START, Screening Tool to Alert doctors to Right Treatment; CNS, central nervous system; NSAID, nonsteroidal anti-inflammatory drug; ACE, angiotensin-converting enzyme; FEV₁, forced expiratory volume in 1 second; DMARD, disease-modifying antirheumatic drug.

To examine the influence of factors associated with PIMs and underprescribing, we used a multivariate logistic regression analysis. For logistic regression analysis, patient age was categorized into 3 groups: 65 to 74, 75 to 84, and ≥85 years.

Multivariate logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals after controlling simultaneously for potential confounders. Regardless of univariable association, we forced several risk factors into the fully adjusted multivariate logistic regression analysis because of known associations with PIMs or underprescribing.

All analyses were conducted using SPSS-J (version 21.0; IBM, Tokyo, Japan).

Results

Demography

Eighty-nine patients (52 females) were included in this study. Table 2 shows patient background information in detail. The mean patient age was 84.9 ± 7.9 years. The main underlying medical conditions were constipation in 56 patients (62.9%), hypertension in 51 patients (57.3%), and dementia in 41 patients (46.1%).

Table 2.

Patient Background (N = 89).

	All Patients (N = 89); n (%)
Gender
Male	37 (41.6)
Female	52 (58.4)
Mean age (years ± standard deviation)	84.9 ± 7.9
Age (years)
65-74	9 (10.0)
75-84	30 (33.7)
≥85	50 (56.2)
Estimated glomerular filtration rate <60 mL/min	38 (42.7)
Serum albumin <3.5 g/dL	30 (33.7)
Independent ambulation	40 (44.9)
Independent drug oversight	22 (24.7)
Living with family	86 (96.6)
Utilizing home visiting pharmacist	76 (85.4)
Utilizing home visiting nurse	41 (46.1)
Underlying medical conditions
Constipation	56 (62.9)
Hypertension	51 (57.3)
Dementia	41 (46.1)
Osteoporosis	21 (23.6)
Diabetes mellitus	19 (21.3)
Dyslipidemia	16 (18.0)
Cerebral infarction/transient ischemic attack	17 (19.1)
Cerebral/subarachnoid hemorrhage	14 (15.7)
Heart failure	14 (15.7)
Atrial fibrillation	13 (14.6)
Chronic obstructive pulmonary disease	10 (11.2)
Hyperuricemia/gout	7 (7.9)
Osteoarthritis	6 (6.7)
Number of prescriptions (mean ± standard deviation)	6.4 ± 3.4

Polypharmacy

The prevalence of polypharmacy was 60.7%. By the univariable analyses of the associations between patient background, underlying medical conditions and polypharmacy, significant correlations with polypharmacy were found for age (P = .039), eGFR <60 mL/min (OR = 3.894, P = .003), utilizing a home visiting pharmacist (OR = 4.327, P = .017), constipation (OR = 2.753, P = .024), dementia (OR = 0.321, P = .011), diabetes mellitus (OR = 4.491, P = .018), and hyperuricemia/gout (P = .039).

Potentially Inappropriate Medications

According to the STOPP criteria, 40.4% of the study population had at least one PIM. By the univariable analyses of the associations between patient background, underlying medical conditions and PIMs, significant correlations with PIMs were found for eGFR < 60 mL/min (OR = 3.056, P = .012), serum albumin <3.5 g/dL (OR = 0.315, P = .019), constipation (OR = 3.989, P = .005), hypertension (OR = 2.912, P = .019), heart failure (OR = 4.712, P = .01), hyperuricemia/gout (OR = 10.4, P = .016), and polypharmacy (OR = 11.273, P < .001). The most frequent STOPP criteria identified in the present study were (a) calcium-channel blockers with chronic constipation (18 patients, 20.2%); (b) long-term, long-acting benzodiazepines (9 patients, 10.1%); and (c) long-term use of nonsteroidal anti-inflammatory drugs for symptom relief of mild osteoarthritis (6 patients, 6.7%).

Underprescribing

According to the START criteria, 60.7% of the study population experienced at least one instance of underprescribing. By the univariable analyses of the associations between patient background, underlying medical conditions and underprescribing, significant correlations with underprescribing were found for eGFR <60 mL/min (OR = 3.894, P = .003), utilizing a home visiting pharmacist (OR = 6.8, P = .003), osteoporosis (OR = 5.333, P = .007), diabetes mellitus (P < .001), atrial fibrillation (OR = 9.714, P = .012), hyperuricemia/gout (P = .039), and polypharmacy (OR = 8.529, P < .001). The most frequent START criteria identified in the present study were (a) metformin with type 2 diabetes ± metabolic syndrome (15 patients, 16.9%), (b) calcium and vitamin D supplementation in patients with known osteoporosis (14 patients, 15.7%), and (c) angiotensin-converting enzyme inhibitors with chronic heart failure (8 patients, 9%).

Independent Risk Factors for PIMs and Underprescribing

Table 3 shows the logistic regression analysis examining the influence of factors associated with PIMs and underprescribing. Risk factors for PIMs were hypertension, constipation, and polypharmacy, while those for underprescribing were osteoporosis and polypharmacy.

Table 3.

Multivariate Logistic Regression Analysis of Risk Factors Associated With PIMs and Underprescribing.

Variable	PIMs (n = 89, Defined by STOPP Criteria)			Underprescribing (n = 89, Defined by START Criteria)
Variable	OR	95% CI	P Value	OR	95% CI	P Value
Gender
Male	0.39	0.12-1.30	.124	2.46	0.68-8.94	.172
Age (years)
65-74	1.00		.796	1.00		.315
75-84	1.92	0.29-12.7	.500	0.14	0.01-1.79	.130
≥85	1.13	0.32-3.95	.854	0.73	0.19-2.75	.639
Hypertension	4.86	1.36-17.4	.015	0.98	0.29-3.28	.970
Diabetes mellitus	1.14	0.26-4.42	.847	2.3 × 10⁹	0.000	.998
Dyslipidemia	1.94	0.44-8.60	.383	0.95	0.19-4.91	.953
Polypharmacy^a	8.87	2.35-33.5	.001	8.06	2.38-27.3	.001
Constipation	8.82	2.12-36.8	.003
Osteoporosis				7.77	1.58-38.3	.012

Abbreviations: PIM, potentially inappropriate medication; STOPP, Screening Tool of Older Persons’ potentially inappropriate Prescriptions; START, Screening Tool to Alert doctors to Right Treatment; OR, odds ratio; 95% CI, 95% confidence interval.

Concurrent use of 6 or more medications.

Discussion

To the best of our knowledge, the present study is the first to explore the prevalence and risk factors associated with IP, as identified by STOPP/START criteria, among elderly home care patients.

This study demonstrated 2 important findings: (a) the prevalence of PIM and underprescribing among elderly home care patients in Japan may be high and (b) risk factors for IP included not only polypharmacy but also several underlying medical conditions.

First, we found the high prevalence of PIMs among elderly home care patients in Japan. Calcium-channel blockers with chronic constipation, which is the one of the frequent STOPP criteria occurring in the present study, could contribute to the prevalence of PIMs in the present study. This result may have 2 explanations. The first is the higher incidence of coronary spasm in Japan compared with Western countries.²³ Japanese doctors may therefore tend to use calcium-channel blockers more frequently. The second reason is that practice guidelines for hypertension in Europe and the United States tend to recommend diuretics and angiotensin-converting enzyme inhibitors as first-choice treatments for hypertension,^24,25 whereas those in Japan generally recommend calcium channel blockers.²⁶

We also found the high prevalence of underprescribing among elderly home care patients in Japan. One possible reason for this result may derive from the therapeutic guidelines for type 2 diabetes in Japan. Although the several therapeutic guidelines for type 2 diabetes in the world concluded that metformin therapy should be initiated concurrently with lifestyle interventions at the time of diagnosis,²⁷ treatment guidelines for diabetes in Japan do not emphasize the use of metformin.²⁸ In addition, the product information associated with metformin in Japan states that the drug should be used very carefully in elderly diabetic patients based on the higher risk of complications in this population.

The other interesting finding of this study was that the risk factors for IP included not only polypharmacy but also several underlying medical conditions. Although polypharmacy is major risk factor for IP in previous studies in other countries and settings,^12,13,15,29 the underlying medical conditions as risk factors may reflect the local factor. In this study, the risk factors for PIMs were hypertension, constipation, and polypharmacy, whereas those for underprescribing were osteoporosis and polypharmacy. The one possible reason for several underlying medical conditions as risk factor of IP among elderly home care patients in Japan is prescribing habits of Japanese doctor.

The prescribing habits may be affected by national drug formularies, national practice guidelines, and continuing medical education. These drug formularies, practice guidelines, and medical education for several medical conditions in Japan may not catch up with the evidence and consensus included in the STOPP/START criteria. The other possible reason may be that the present study evaluated the prescribing habits of only several doctors in one institution, and therefore our results may not be fully generalizable as home care setting in Japan.

This study had 3 limitations, referred to above. First, our study may not be representative of elderly home care patients in Japan because it was carried out in only one institution. Second, the sample in this study was relatively small. Third, the number of doctors who prescribed medications to the study population was relatively small. These limitations restrict the generalizability of our results.

In conclusion, the prevalence of IP among elderly home care patients could be high, and the risk factors for IP included not only polypharmacy but also specific underlying medical conditions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research funds for this study were provided by a Clinical Research Grant from St. Luke’s Life Science Institute.

Author Biographies

Jun Hamano, MD, is Assistant Professor of Faculty of Medicine in University of Tsukuba. His reseach interest is home care and palliative care.

Yasuharu Tokuda, PhD, is Professor of Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences in University of Tsukuba.

References

Hanlon

Schmader

Ruby

Weinberger

. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49:200-209.

Spinewine

Schmader

Barber

. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370:173-184.

Ebbesen

Buajordet

Erikssen

. Drug-related deaths in a department of internal medicine. Arch Intern Med. 2001;161:2317-2323.

Routledge

O’Mahony

Woodhouse

. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004;57:121-126.

Schneeweiss

Hasford

Göttler

Hoffmann

Riethling

A-K

Avorn

. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol. 2002;58:285-291.

Bates

Spell

Cullen

. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307-311.

Classen

Pestotnik

Evans

Lloyd

Burke

. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301-306.

Lindley

Tully

Paramsothy

Tallis

. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing. 1992;21:294-300.

Chang

Liu

Yang

. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005;25:831-838.

10.

Passarelli

Jacob-Filho

Figueras

. Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause. Drugs Aging. 2005;22:767-777.

11.

O’Connor

Gallagher

O’Mahony

. Inappropriate prescribing: criteria, detection and prevention. Drugs Aging. 2012;29:437-452.

12.

Fialová

Topinková

Gambassi

. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293:1348-1358.

13.

Gallagher

Lang

Cherubini

. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol. 2011;67:1175-1188.

14.

Barry

Gallagher

Ryan

O’mahony

. START (screening tool to alert doctors to the right treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36:632-638.

15.

Ryan

O’Mahony

Kennedy

Weedle

Byrne

. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68:936-947.

16.

Kaufmann

Tremp

Hersberger

Lampert

. Inappropriate prescribing: a systematic overview of published assessment tools [published online September 10, 2013]. Eur J Clin Pharmacol. doi:10.1007/s00228-013-1575-8.

17.

American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.

18.

Gallagher

Ryan

Byrne

Kennedy

O’Mahony

. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46:72-83.

19.

Lam

Cheung

. The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly population. Expert Rev Clin Pharmacol. 2012;5:187-197.

20.

Naugler

Brymer

Stolee

Arcese

. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol. 2000;7:103-107.

21.

Curtain

Bindoff

Westbury

Peterson

. A comparison of prescribing criteria when applied to older community-based patients. Drugs Aging. 2013;30:935-943.

22.

Hill-Taylor

Sketris

Hayden

Byrne

O’Sullivan

Christie

. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38:360-372.

23.

Yasue

Nakagawa

Itoh

Harada

Mizuno

. Coronary artery spasm—clinical features, diagnosis, pathogenesis, and treatment. J Cardiol. 2008;51:2-17.

24.

Mancia

Fagard

Narkiewicz

. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159-2219.

25.

Chobanian

A V

Bakris

Black

. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572.

26.

Ogihara

Kikuchi

Matsuoka

. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2009). Hypertens Res. 2009;32:3-107.

27.

Inzucchi

Bergenstal

Buse

. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.

28.

Japan Diabetes Society, ed. Treatment Guide for Diabetes. Tokyo, Japan: Japan Diabetes Society; 2012.

29.

García-Gollarte

Baleriola-Júlvez

Ferrero-López

Cruz-Jentoft

. Inappropriate drug prescription at nursing home admission. J Am Med Dir Assoc. 2012;13:83.e9-83.e15.

Inappropriate Prescribing Among Elderly Home Care Patients in Japan

Abstract

Keywords

Introduction

Methods

Ethics Statement

Data Collection

Statistical Analysis

Results

Demography

Polypharmacy

Potentially Inappropriate Medications

Underprescribing

Independent Risk Factors for PIMs and Underprescribing

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

Author Biographies

References