Use of High-Risk Medications in Older Adults (DAE)

The percentage of persons 67 years of age and older who had at least two dispensing events for the same high-risk medication. Three rates are reported:  

  1. The percentage of persons 67 years of age and older who had at least two dispensing events for high-risk medications to avoid from the same drug class. 
  2. The percentage of persons 67 years of age and older who had at least two dispensing events for high-risk medications to avoid from the same drug class, except for appropriate diagnoses. 
  3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for persons in both numerators). 

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 death1. 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 injury3. 

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 Adults4. 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 655 6. 

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 education7 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 PIMs8 9 10. 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 selected11. 

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 ADEs12. The impact and the management of ADEs is complex and, as one study found, may cost up to $30.1B annually in the United States13. 

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 United States14. 

Historical Results – National Averages

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References

  1. CDC, National Center for Health Statistics. 2022. Wide-Ranging Online data for Epidemiologic Research (WONDER). Atlanta, GA. Available at http://wonder.cdc.gov
  2. Lahue, B.J., B. Pyenson, K. Iwasaki, H.E. Blumen, S. Forray, and J.M. Rothschild. 2012. “National Burden of Preventable Adverse Drug Events Associated with Inpatient Injectable Medications: Healthcare And Medical Professional Liability Costs.” American Health & Drug Benefits 5(7), 1.
  3. Food and Drug Administration (FDA). 2011. XANAX Prescription Label. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018276s045lbl.pdf
  4. Donnelly, K., R. Bracchi, J. Hewitt, P.A. Routledge, & B. Carter. 2017. “Benzodiazepines, Z-Drugs and the Risk of Hip Fracture: A Systematic Review and Meta-Analysis.” PLOS ONE 12(4), e0174730. https://doi.org/10.1371/journal.pone.0174730
  5. Bakken, M.S., A. Engeland, L.B. Engesæter, A.H. Ranhoff, S. Hunskaar, & S. Ruths. 2014. “Risk of Hip Fracture Among Older People Using Anxiolytic and Hypnotic Drugs: A Nationwide Prospective Cohort Study.” European Journal of Clinical Pharmacology 70(7), 873–880. https://doi.org/10.1007/s00228-014-1684-z
  6. de Vries, O.J., G. Peeters, P. Elders, C. Sonnenberg, M. Muller, D.J.H. Deeg, & P. Lips. 2013. “The Elimination Half-Life of Benzodiazepines and Fall Risk: Two Prospective Observational Studies.” Age and Ageing 42(6), 764–770. https://doi.org/10.1093/ageing/aft089
  7. Woolcott, J.C., K.J. Richardson, M.O. Wiens, B. Patel, J. Marin, K.M. Khan, & C.A. Marra. 2009. “Meta-Analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons.” Archives of Internal Medicine 169(21), 1952–1960. https://doi.org/10.1001/archinternmed.2009.357
  8. Xing, D., X.L. Ma, J.X. Ma, J. Wang, Y. Yang, & Y. Chen. 2014. “Association Between Use of Benzodiazepines and Risk of Fractures: A Meta-Analysis. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 25(1), 105–20. https://doi.org/10.1007/s00198-013-2446-y
  9. Davidson, J.R. 2001. “Pharmacotherapy of Generalized Anxiety Disorder.” The Journal of Clinical Psychiatry.
  10. Gorman, J.M. 2003. “Treating Generalized Anxiety Disorder.” Journal of Clinical psychiatry 64(1), 24-29.
  11. Lydiard, R.B., K. Rickels, B. Herman, & D.E. Feltner. 2010. “Comparative Efficacy of Pregabalin and Benzodiazepines in Treating the Psychic and Somatic Symptoms of Generalized Anxiety Disorder.” International Journal of Neuropsychopharmacology 13(2), 229-241.
  12. Paquin, A.M., K. Zimmerman, & J.L. Rudolph. 2014. “Risk Versus Risk: A Review of Benzodiazepine Reduction in Older Adults.” Expert Opinion on Drug Safety 13(7), 919–934. https://doi.org/10.1517/14740338.2014.925444
  13. Sivertsen, B., S. Omvik, S. Pallesen, B. Bjorvatn, O.E. Havik, G. Kvale, et al. 2006. “Cognitive Behavioral Therapy vs Zopiclone for Treatment of Chronic Primary Insomnia in Older Adults: A Randomized Controlled Trial.” JAMA 295(24):2851-8.
  14. He, Q., X. Chen, T. Wu, L. Li, & X. Fei. 2019. “Risk of Dementia in Long-Term Benzodiazepine Users: Evidence from a Meta-Analysis of Observational Studies.” Journal of Clinical Neurology (Seoul, Korea) 15(1), 9–19. https://doi.org/10.3988/jcn.2019.15.1.9

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