Potentially Inappropriate Antihypertensive Prescriptions to Elderly Patients: Results of a Prospective, Observational Study

Abstract

Introduction

Previous studies of antihypertensive treatment of older patients have focused on blood pressure control, cardiovascular risk or adherence, whereas data on inappropriate antihypertensive prescriptions to older patients are scarce.

Objectives

The aim of the study was to assess inappropriate antihypertensive prescriptions to older patients.

Methods

An observational, prospective multicentric study was conducted to assess potentially inappropriate prescription of antihypertensive drugs, in patients aged 75 years and older with arterial hypertension (HTN), in the month prior to hospital admission, using four instruments: Beers, Screening Tool of Older Person’s Prescriptions (STOPP), Screening Tool to Alert Doctors to the Right Treatment (START) and Assessing Care of Vulnerable Elders 3 (ACOVE-3). Primary care and hospital electronic records were reviewed for HTN diagnoses, antihypertensive treatment and blood pressure readings.

Results

Of 672 patients, 532 (median age 85 years, 56% female) had HTN. 21.6% received antihypertensive monotherapy, 4.7% received no hypertensive treatment, and the remainder received a combination of antihypertensive therapies. The most frequently prescribed antihypertensive drugs were diuretics (53.5%), angiotensin-converting enzyme inhibitors (ACEIs) (41%), calcium antagonists (32.2%), angiotensin receptor blockers (29.7%) and beta-blockers (29.7%). Potentially inappropriate prescription was observed in 51.3% of patients (27.8% overprescription and 35% underprescription). The most frequent inappropriately prescribed drugs were calcium antagonists (overprescribed), ACEIs and beta-blockers (underprescribed). ACEI and beta-blocker underprescriptions were independently associated with heart failure admissions [beta-blockers odds ratio (OR) 0.53, 95% confidence interval (CI) 0.39–0.71, p < 0.001; ACEIs OR 0.50, 95% CI 0.36–0.70, p < 0.001].

Conclusion

Potentially inappropriate prescription was detected in more than half of patients receiving antihypertensive treatment. Underprescription was more frequent than overprescription. ACEIs and beta-blockers were frequently underprescribed and were associated with heart failure admissions.

Appendices

Appendix 1: Pharmacological Anamnesis

See Fig. 1 for the questionnaire used for pharmacological anamnesis.

Fig. 1

Pharmacological anamnesis questionnaire

Appendix 2: Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

For the Beers criteria for potentially inappropriate medication use in older adults, see Tables 7 and 8.

Table 7 Independent of diagnoses or conditions

Table 8 Considering diagnoses or conditions

Appendix 3: Screening Tool of Older People’s Potentially Inappropriate Prescriptions (STOPP)

The following drug prescriptions are potentially inappropriate in persons aged >65 years of age (see reference [12] for individual references below):

A. Cardiovascular system

Item 3. Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available) [Williams et al. 2004]

Item 4. Thiazide diuretic with a history of gout (may exacerbate gout) [Dougall and McLay 1996].

Item 5. Non-cardioselective beta-blocker with chronic obstructive pulmonary disease (risk of increased bronchospasm) [van der Woulde et al. 2005, Salpeter et al. 2005]

Item 6. Beta-blocker in combination with verapamil (risk of symptomatic heart block) [BNF 2006]

Item 7. Use of diltiazem or verapamil with NYHA class III or IV heart failure (may worsen heart failure) [BNF 2006]

Item 8. Calcium channel blockers with chronic constipation (may exacerbate constipation) [Dougall and McLay 1996]

G. Endocrine system

Item 2. Beta-blockers in those with diabetes mellitus and frequent hypoglycaemia

H. Drugs that adversely affect fallers

Item 4. Vasodilator drugs with persistent postural hypotension, i.e. recurrent >20 mmHg drop in systolic blood pressure (risk of syncope, falls) [Leipzig et al. 1999]

Appendix 4 Screening Tool to Alert Doctors to Right Treatments (START)

These medications should be considered as appropriate and indicated for people >65 years of age with the following conditions, where no contraindication to prescription exists (see reference [12] for individual references below):

A. Cardiovascular system

Item 4. Antihypertensive therapy where systolic blood pressure consistently >160 mmHg [Williams et al. 2004, Papademetriou et al. 2004, Skoog et al. 2004, Thenkwalder et al. 2005]

Item 6. ACE inhibitor with chronic heart failure [Hunt et al. 2005]

Item 7. ACE inhibitor following acute myocardial infarction [ACE Inhibitor Myocardial infarction Collaborative Group 1998, Antman et al. 2004]

Item 8. Beta-blocker with chronic stable angina [Gibbons et al. 2003]

F. Endocrine system

Item 2. ACE inhibitor or ARB in diabetes with nephropathy, i.e. overt urinalysis proteinuria or microalbuminuria (>30 mg/24 h) ± serum biochemical renal impairment* [Sigal et al. 2005]

*Serum creatinine >150 µmol/l, or estimated glomerular filtration rate <50 ml/min [BNF 2006].

Appendix 5: Assessing Care of Vulnerable Elders-3 (ACOVE-3) Quality Indicators [41]

Abbreviations ACE angiotensin-converting enzyme, ARB angiotensin receptor blocker, BP blood pressure, HF heart failure, HTN hypertension/elevated BP, IHD ischaemic heart disease, LVEF left ventricular ejection fraction, MI myocardial infarction, NSTEMI non-ST elevation myocardial infarction, STEMI ST-segment elevation myocardial infarction, VE vulnerable elder.

5.1 Hypertension

5.1.1 Intervening for Persistent HTN

Item 9. IF a VE with HTN has persistent (on two consecutive visits) systolic BP above goal*, THEN an intervention (e.g. pharmacological, lifestyle, compliance) should occur, or there should be documentation of reversible cause or other justification for the elevation.

*Goal systolic BP (mmHg): diabetes mellitus or chronic renal disease 130 mmHg; home ambulatory monitoring 135 mmHg; all other patients 140 mmHg of other specified goal.

5.1.2 Beta-Blocker for HTN and IHD

Item 13. IF a VE with HTN has IHD, THEN treatment with a beta-blocker should be recommended or there should be documentation of why it should not be provided.

5.1.3 ACE Inhibitor for Comorbid Vascular Disease

Item 14. IF a VE with HTN has a history of HF, left ventricular hypertrophy, IHD, chronic kidney disease or cardiovascular accident, THEN he or she should be treated with an ACE inhibitor or ARB or there should be documentation of why it should not be provided.

5.2 Heart Failure

5.2.1 ACE Inhibitor

Item 1. IF a VE has LVEF less than 40%, THEN he or she should receive an ACE inhibitor (or ARB if ACE inhibitor intolerant).

5.2.2 Selective Beta-Blocker

Item 7. IF a VE has HF and LVEF less than 40%, THEN he or she should be treated with a beta-blocker known to prolong survival (carvedilol, metoprolol, or bisoprolol).

5.3 Ischaemic Heart Disease

5.3.1 Early ACE Inhibitor Therapy for MI and HF

Item 5. IF a VE has an MI (STEMI or NSTEMI) complicated by HF or LVEF less than 40%, THEN he or she should be given an ACE inhibitor or ARB within 36 h of presentation and advised to continue this treatment for 4 weeks or longer.

5.3.2 Beta-Blocker Therapy

Item 14. IF a VE has had an MI (STEMI or NSTEMI), THEN he or she should be offered a beta-blocker and advised to continue treatment for 2 years or longer after infarction.

5.3.3 ACE Inhibitor Therapy

Item 15. IF a VE has IHD, THEN he or she should be offered ACE inhibitor or ARB therapy and advised to continue the treatment indefinitely.

5.4 Diabetes Mellitus

5.4.1 Proteinuria

Item 4. IF a VE with diabetes mellitus has proteinuria, THEN an ACE inhibitor or ARB should be prescribed.