Potentially Harmful Drug-Disease Interactions in Older Adults (DDE)

The percentage of persons 67 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a potentially harmful medication, concurrent with or after the diagnosis. Three rates are reported: 

1. 1. A history of falls and a prescription for anticholinergic agents, antiepileptics, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics or antidepressants (SSRIs, tricyclic antidepressants and SNRIs). 
   2. Dementia and a prescription for antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants or anticholinergic agents.
   3. Chronic kidney disease and prescription for Cox-2 selective NSAIDs or nonaspirin NSAIDs. 

Why It Matters?

In older adults, certain medications are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. Use of potentially inappropriate medications (PIM) in older adults can lead to poor health outcomes, including adverse drug events, confusion, falls, hospitalizations and death. 

Older adults, commonly prescribed multiple prescription drugs due to complex medical problems, are increasingly at risk of PIM use. One study found that each additional drug an individual used during the year was associated with a 5.2 percentage point increase in their probability of using a PIM¹. PIM use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs², as well as to increased risk of death³. Use of specific PIMs such as hypnotics, including benzodiazepine receptor agonists and nonsteroidal anti‐inflammatory drugs (NSAIDS) can also result in increased risk of delirium, falls, fractures, gastrointestinal bleeding and acute kidney injury⁴. 

The DDE and DAE measures are based on recommendations in the American Geriatrics Society (AGS) 2023 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults⁵. The AGS Beers Criteria are one of the most widely used sources about the safety of medication prescribing in older adults. They include evidence-based recommendations on medications that are potentially harmful in all older adults and those with specific diseases or conditions. The development of the 2023 Updated Beers Criteria was based on a systematic literature review and discussion by a panel of experts in geriatric care and pharmacotherapy. NCQA’s measurement advisory panels also provide guidance on the specific conditions and medications included in the DDE and DAE measures. 

Preventing poor health effects from use of PIMs is a growing concern with the increasing population of adults over 65 and rising prescription medication use, particularly as the hospitalization rate for adverse drug events among adults 65 or older is 7 times higher than that of adults younger than 65^{6 7}. 

Interventions focused on reducing the use of PIMs can lower the incidence of these poor health outcomes. Prescription benefit plans often require preauthorization of specific medications, to limit the use of PIMs in older adults. Additional interventions have included direct patient education⁸ and the use of computer-based reminder systems. Computerized prescribing, combined with clinical decision support systems, can alert a physician when they are attempting to prescribe a PIM to an older adult. 

Studies have found these systems to be effective in reducing prescribing of PIMs^{9 10 11}. Studies have also shown that integration of the Beers Criteria (which list PIMs) in electronic health records can provide instant feedback and medication alternatives when PIMs are originally selected12. 

Reducing use of PIMs in older adults also represents an opportunity to lower the costs associated with harm from medications (e.g., hospitalizations for drug toxicity) and encourages clinicians to consider safer alternatives. Adverse drug events (ADE) occur often in hospitals and contribute to longer length of stay and increased risk of mortality. Older adults make up approximately 35% of all inpatient stays but contribute to approximately 53% of inpatient stays complicated by ADEs13. The impact and the management of ADEs is complex and, as one study found, may cost up to $30.1B annually in the United States14. Preventable medication errors are estimated to impact more than 7 million patients, contribute to 7,000 deaths and, as another study found, cost almost $21B in direct medical costs across all care settings annually in the U.S15. 

Historical Results – National Averages