1. Use of Implicit Criteria to Determine Appropriateness of Medication in Geriatric Populations Brittany Barnes Pharm.D Candidate 2013, Marilyn N. Bulloch, Pharm. D, BCPS Introduction In 2010, the U.S. Census Bureau reported that people older than the age of 65 made up thirteen percent of the total population. Though this is not the largest segment of the population, it had the second largest increase from 2000 to 2010. In addition to this rapid increase in population, the segment aged 80 and older is the fastest growing population. The projected life expectancy for the total population for the year 2015 and 2020 is 78.9 and 79.5 years respectively. With the rise in the number of geriatric patients ever increasing, a heightened focus on suboptimal medication use is emerging. Due to multiple chronic comorbidities the geriatric populations face, they have the highest number of prescriptions per person than any other age group. Higher numbers of prescriptions and prescribers leads to polypharmacy. Polypharmacy is a state where a patient is taking more medications that what is warranted, and this can expose a patient to unnecessary adverse events, harmful drug interactions, and overmedication or undermedication. The effects of polypharmacy intesify in the geriatric populationdue to age-related changes in pharmacokinetics and pharmacodynamics which causes drugs to stay in the body longer or strengthen the effects of medications. To overcome this problem, tools containing explicit and implicit criteria have been developed to avoid potentially harmful or unnecessary medications. Both types of tools were developed using evidence-based medicine. Explicit criteria are lists complied by geriatric experts of medications to avoid, where as implicit criteria guide the user to determine appropriateness based on their own clinical judgment on a patient specific basis. There are several types of implicit tools available and the content and method varies from each defined criteria. This study gives an overview of the different implicit criteria that are available for determining appropriateness of medications in elderly populations. Results Purpose Search of PubMed, MEDLINE, and Google Scholar Keywords searched: implicit, criteria, geriatric, prescribing, inappropriate, polypharmacy, medication Original studies, reviews, systemic-reviews, and commentary reviewed Inclusion criteria: studies involving patients 65 and older, English language Thirty five articles were reviewed and from this sixteen implicit tools included in this study Conclusion Disclosure: Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation Brittany Barnes: Nothing to disclose Marilyn Bulloch: Nothing to disclose References are available on request. Methods The purpose of this study was to evaluate and compare currently available implicit tools used for for the evaluation of appropriateness of medication in elderly populations (65 or older). Implicit CriteriaDesign Medication Appropriateness Index 10 criteria; each criteria linked to a weighted value to provide a score (0-18) per drug ≥10 minutes per medication Fitted for the Aged (FORTA) Grading system of medication (A- D) similar to the pregnancy category grading system Assessment time not reported Lipton’s Criteria6 criteria assigned a rating of 1,2 or 9 to determine the appropriateness of medicine Assessment time ~15 minutes; unknown if per drug or patient Assessment of Underutilization of Medication (AOU) Compares list of chronic medical conditions to list of prescribed drugs; a rating of no omission, marginal omission, or omission assigned Assessment time not reported Good Palliative- Geriatric Practice Algorithm used to determine the possibility of discontinuation of medications Assessment time not reported Criteria to Assess Appropriate Medication Use Interprets current guidelines for chronic medical conditions for patients with the pre- specified conditions Tool to Improve Medications in Elderly via Review (TIMER) Guide for pharmacist and pharmacy student when performing a medication review 4 sections using a scale ranging from strongly agree to strongly disagree Time consuming; training required Assess, Review, Minimize, Optimize, Reassess (ARMOR) Interactive tool that takes into account clinical profile and functional status Goals improvement in functional status and mobility Assessment time not reported Prescribing Optimization Method (POM) 6 open-ended questions that aid in optimizing prescribing therapy in older patients Each question associated with potential follow-up issues Time consuming; education for prescriber is recommended Anticholinergic Risk Scale (ARS) List of medications with anticholinergic potential, each given a numerical value 1,2, or 3 Total score calculated by adding the points for each drug Assessment time not reported Geriatric Medicine Algorithm Algorithm; 6 criteria are evaluated Explicit list of high risk and dose adjustment drugs are provided Assessment time not reported; author reports time demand not unreasonable Drug Burden Index (DBI) Formula used to describe anticholinergic and sedative burden Total score calculated from combination of anticholinergic and /or sedative properties and total medication number May be time consuming; scores provide by consultant Time Until BenefitModel that guides users in discontinuation of therapies Remaining life expectancy, time until benefit, goals of care, and target therapy are evaluated Assessment time not reported Minimum Data Set 2.0 (MDS) Component of the Resident Assessment Instrument (RAI) 15 sections composed of 3-9 questions; areas in red trigger Resident Assessment Protocol (RAP) Assessment time: 1-2 hours Pharmacist’s Management of Drug Related Problems A step-by-step process of 9 functions for pharmacist to evaluate medication regimens Assessment time not reported; training required Oborne et al.14 indicators to evaluate the appropriateness of prescribed medications Algorithms for ACE-Inhibitors, Benzodiazepines, digoxin, B2-agonist Assessment time not reported 16 implicit tools have been developed to evaluate the appropriateness of medications in geriatric patients There are numerous implicit criteria models and each is different in areas of design, content, and clinical application Time of assessment ranged from ten minutes per drug to one to two hours which may be a disadvantage Implicit criteria can aid in the reduction of suboptimal prescribing in geriatric patients by assessing given information on a patient specific basis