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Int J Clin Pharm (2013) 35:805812

DOI 10.1007/s11096-013-9811-y

RESEARCH ARTICLE

Potentially inappropriate prescribing and drugdrug interactions


among elderly Chinese nursing home residents in Macao
Cheng Kin Lao Sao Chan Ho Ka Kit Chan
Chon Fai Tou Henry Hoi Yee Tong
Alexandre Chan

Received: 15 March 2013 / Accepted: 14 June 2013 / Published online: 28 June 2013
 Springer Science+Business Media Dordrecht 2013

Abstract Background The ageing of the population has


become a concern all over the world, including Macao. In
general, older people are more prone to adverse drug events
which can result from potentially inappropriate medication
(PIM) use and drugdrug interactions (DDIs). Objective
This study was designed to evaluate the prevalence of PIM
use and DDIs among elderly nursing home residents in
Macao, and to find out the factors associated with these
drug-related problems. Setting This study was conducted in
the largest nursing home in Macao, with a bed capacity of
168. Method All data of this cross-sectional study were
collected from medical charts and medication administration records. PIM use was determined by the screening tool
of older persons prescription (STOPP) criteria and potential DDIs were detected using the preset criteria of two
compendia, Drug-Reax and Lexi-Interact. Multivariate
logistic regression analysis was performed to identify the
independent factors associated with each drug-related
problem. Main outcome measures The proportions of
elderly nursing home residents who regularly used PIMs
and who were exposed to DDIs. Results A total of 114
elderly residents were eligible for PIM analysis. They
consumed an average of 6.9 3.1 different medications.
About 46.5 % of them regularly used one or more PIMs.
The prevalence of DDIs was 37.8 % among the 111 elderly
residents who consumed at least two different medications.

An increased number of drugs used was identified as the


independent factor associated with PIM use and DDIs
(p \ 0.05). However, the use of STOPP-related PIMs did
not appear to raise the likelihood of DDIs among the study
population. Conclusion Both PIM use and DDIs are common among elderly nursing home residents in Macao.
Further studies should be conducted to evaluate the clinical
outcomes of pharmacist-led interventions for elderly residents in the local nursing home setting.
Keywords Drug interactions  Elderly  Macao  Nursing
home  Potentially inappropriate medication  STOPP

Impacts on practice

Potentially inappropriate medication use and potential


drug-drug interactions are highly prevalent among
elderly nursing home residents in Macao.
The number of medications used is found to be
significantly associated with potentially inappropriate
prescribing and drug-drug interactions.
Elderly nursing home residents with hypertension or a
history of stroke are more likely to experience potential
drugdrug interactions.
There is room for improvement in detection and
prevention of drugrelated problems among the nursing
home residents in Macao.

C. K. Lao (&)  S. C. Ho  K. K. Chan 


C. F. Tou  H. H. Y. Tong
School of Health Sciences, Macao Polytechnic Institute, Rua de
Lus Gonzaga Gomes, Macao, Peoples Republic of China
e-mail: cklao@ipm.edu.mo

Introduction

A. Chan
Department of Pharmacy, Faculty of Science, National
University of Singapore, Singapore, Singapore

With its Chinese and Portuguese heritage, Macao is a small


but well-developed gaming city in Southern China. Similar

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806

to other developed regions, Macao faces the problem of


population ageing. The official statistical agency estimates
that the elderly population, defined as 65 years of age or
older, will rise from 7.3 % of total population as in 2011 to
19.2 % by 2036 [1]. Population ageing poses an increasing
burden to health care systems all over the world including
Macao. As the elderly often suffer from multiple chronic
diseases [2], they commonly experience polypharmacy
[35]. The complexity of drug regimens, in addition to agerelated physiological changes, renders geriatric patients
vulnerable to drug-related problems including potentially
inappropriate medication (PIM) use and potential drug
drug interactions (DDIs).
Potentially inappropriate medication use in the elderly is
frequently observed in the nursing home setting. According
to the studies conducted among different countries,
23.770 % of elderly nursing home residents were prescribed with at least one PIM [58]. Similarly, potential
DDIs are also highly prevalent among the elderly. In Taiwan, 25.1 % of nursing home residents experienced DDIs,
among which 72 % were of moderate or major severity [9].
Potential DDIs are among the recognized causes of adverse
drug events. A recent study found that the incidence of
DDI-related adverse drug events was 6 % in elderly outpatients. About 37 % of the cases led to hospital admission
[10]. Moreover, according to a Finnish nursing home study,
PIMs were consumed by 47.9 % of residents exposed to
DDIs while only 34.2 % of those without DDIs were
identified as PIM users. This significant difference suggested the association between PIM use and potential DDIs
[6].
Over the years, the Macao government has invested
considerable financial resources in health care, with the
elderly as one of the main beneficiary groups. The government-run hospital and outpatient health centers provide
a wide range of free medical services to all elderly permanent residents, including prescription medications and
vaccinations [11]. Nonetheless, there is room for
improvement in the long-term care facility sector. Currently, there are 19 long-term care facilities in Macao, with
only one providing regular medical and nursing care to
residents, while most of the others offer limited to no
nursing care [12]. As health care professionals with
expertise in drug management, pharmacists play a prominent role in optimizing medication use in this setting in
many western countries [13]. On the contrary, pharmacists
routine involvement in medication reviews for nursing
home residents is lacking in Macao.
Ensuring the appropriateness of prescribing and avoiding DDIs are essential for minimizing the occurrence of
adverse drug events among the elderly. With the rapid
growth of the ageing population, more emphasis should be
placed on the quality and safety of drug use for geriatric

123

Int J Clin Pharm (2013) 35:805812

patients. However, there is a lack of published data on


medication usage among the elderly residing in nursing
homes in Macao.

Aim of the study


This study was designed to assess the prevalence of PIM
use and potential DDIs among the elderly residents in a
Macao nursing home, and to identify the factors associated
with each problem. It will serve as the first step for further
investigation on how to enhance pharmacists contribution
to preventing drug-related problems in the local long-term
care facilities.

Method
Study design and setting
This was a cross-sectional study conducted in the private,
non-profit Caritas Meng Fai Nursing Home in Macao. The
study protocol was approved by the review committee at
the Macao Polytechnic Institute. All data were de-identified
and a waiver for informed consent was obtained. Caritas
Meng Fai Nursing Home is currently the largest long-term
care facility in Macao, with a bed capacity of 168 [12]. It is
also the only skilled nursing facility with an in-house
medical team consisting of a physician, nurses, a physical
therapist, and an occupational therapist. The medical team
provides around-the-clock care to the residents who are
mostly of poor health or disabled, although the residents
are also managed by other specialized physicians outside of
the nursing home. All medications and supplements are
required to be stored in the in-house pharmacy and dispensed by nurses. Residents are not allowed to keep any
drug or supplement in their own rooms.
Inclusion and exclusion criteria
The study population comprised all residents who were
65 years or older, and consumed at least one scheduled
prescription or over-the-counter medication. All medications consumed on an as-needed basis, vitamin or mineral
supplements, drugs for topical use, and herbal medicines
were not counted in this study. The residents were excluded
if their medication administration records were unavailable
or incomplete.
Data collection
Eligibility screening and data collection were performed on
a single day (1 August 2011). All data were obtained from

806

to other developed regions, Macao faces the problem of


population ageing. The official statistical agency estimates
that the elderly population, defined as 65 years of age or
older, will rise from 7.3 % of total population as in 2011 to
19.2 % by 2036 [1]. Population ageing poses an increasing
burden to health care systems all over the world including
Macao. As the elderly often suffer from multiple chronic
diseases [2], they commonly experience polypharmacy
[35]. The complexity of drug regimens, in addition to agerelated physiological changes, renders geriatric patients
vulnerable to drug-related problems including potentially
inappropriate medication (PIM) use and potential drug
drug interactions (DDIs).
Potentially inappropriate medication use in the elderly is
frequently observed in the nursing home setting. According
to the studies conducted among different countries,
23.770 % of elderly nursing home residents were prescribed with at least one PIM [58]. Similarly, potential
DDIs are also highly prevalent among the elderly. In Taiwan, 25.1 % of nursing home residents experienced DDIs,
among which 72 % were of moderate or major severity [9].
Potential DDIs are among the recognized causes of adverse
drug events. A recent study found that the incidence of
DDI-related adverse drug events was 6 % in elderly outpatients. About 37 % of the cases led to hospital admission
[10]. Moreover, according to a Finnish nursing home study,
PIMs were consumed by 47.9 % of residents exposed to
DDIs while only 34.2 % of those without DDIs were
identified as PIM users. This significant difference suggested the association between PIM use and potential DDIs
[6].
Over the years, the Macao government has invested
considerable financial resources in health care, with the
elderly as one of the main beneficiary groups. The government-run hospital and outpatient health centers provide
a wide range of free medical services to all elderly permanent residents, including prescription medications and
vaccinations [11]. Nonetheless, there is room for
improvement in the long-term care facility sector. Currently, there are 19 long-term care facilities in Macao, with
only one providing regular medical and nursing care to
residents, while most of the others offer limited to no
nursing care [12]. As health care professionals with
expertise in drug management, pharmacists play a prominent role in optimizing medication use in this setting in
many western countries [13]. On the contrary, pharmacists
routine involvement in medication reviews for nursing
home residents is lacking in Macao.
Ensuring the appropriateness of prescribing and avoiding DDIs are essential for minimizing the occurrence of
adverse drug events among the elderly. With the rapid
growth of the ageing population, more emphasis should be
placed on the quality and safety of drug use for geriatric

123

Int J Clin Pharm (2013) 35:805812

patients. However, there is a lack of published data on


medication usage among the elderly residing in nursing
homes in Macao.

Aim of the study


This study was designed to assess the prevalence of PIM
use and potential DDIs among the elderly residents in a
Macao nursing home, and to identify the factors associated
with each problem. It will serve as the first step for further
investigation on how to enhance pharmacists contribution
to preventing drug-related problems in the local long-term
care facilities.

Method
Study design and setting
This was a cross-sectional study conducted in the private,
non-profit Caritas Meng Fai Nursing Home in Macao. The
study protocol was approved by the review committee at
the Macao Polytechnic Institute. All data were de-identified
and a waiver for informed consent was obtained. Caritas
Meng Fai Nursing Home is currently the largest long-term
care facility in Macao, with a bed capacity of 168 [12]. It is
also the only skilled nursing facility with an in-house
medical team consisting of a physician, nurses, a physical
therapist, and an occupational therapist. The medical team
provides around-the-clock care to the residents who are
mostly of poor health or disabled, although the residents
are also managed by other specialized physicians outside of
the nursing home. All medications and supplements are
required to be stored in the in-house pharmacy and dispensed by nurses. Residents are not allowed to keep any
drug or supplement in their own rooms.
Inclusion and exclusion criteria
The study population comprised all residents who were
65 years or older, and consumed at least one scheduled
prescription or over-the-counter medication. All medications consumed on an as-needed basis, vitamin or mineral
supplements, drugs for topical use, and herbal medicines
were not counted in this study. The residents were excluded
if their medication administration records were unavailable
or incomplete.
Data collection
Eligibility screening and data collection were performed on
a single day (1 August 2011). All data were obtained from

Int J Clin Pharm (2013) 35:805812

807

the eligible subjects medical charts. Data collection


parameters included basic demographic information,
diagnoses, certain vital signs and laboratory results such as
serum creatinine, etc. Furthermore, each subjects medications (on the day of study) were captured and recorded.
All medications were categorized based on the WHO
anatomical therapeutic chemical (ATC) classification system [14]. To ensure the accuracy of data collection, the
data were counterchecked by other investigators in the
research team.

required sample size was estimated to be at least 108


subjects, based on the prevalence of PIM use and DDIs
from the Finnish nursing home study conducted by HosiaRandell et al. [6]. All statistical analyses were performed
by using SPSS for Windows, version 17.0.

Endpoints

A total of 156 residents were screened for eligibility.


Following exclusion of the residents who were younger
than 65 years and/or took no medications, 114 (73.1 %)
residents were eligible for the evaluation of PIM use
(Fig. 1). The mean age of eligible subjects was
86.6 8.4 years and two-thirds were females. The subjects consumed an average of 6.9 3.1 different medications by ATC code, ranging from 1 to 15 (Fig. 2). Among
them, 31 subjects (27.2 %) consumed at least 9 medications, a cutoff point that has been used to define polypharmacy in previous literature [22].

The PIM analysis included all subjects who were eligible


for this study. The screening tool of older persons prescription (STOPP) was utilized for investigating the prevalence of PIM use. STOPP is a relatively new explicit tool
including 65 criteria, which are organized based on physiological systems [15] and display good inter-rater reliability among physicians and pharmacists [16, 17].
The elderly subjects were deemed eligible for the
evaluation of potential DDIs if they regularly used at least
two different medications. The DDI analysis was conducted using two drug compendia: Drug-Reax from Micromedex 2.0 [18] and Lexi-Interact [19], both of which
are commonly used in clinical settings. However, their
inclusion and severity grading of DDIs are largely inconsistent [20]. For the purpose of this study, the potential
DDIs were only included if they were listed in both compendia and considered clinically relevant, defined as
meeting the following two criteria: (1) a severity rating of
contraindicated, major, or moderate and an evidence rating
of excellent, good or fair in Drug-Reax, and (2) a severity
rating of major or moderate and a reliability rating of
excellent, good, or fair in Lexi-Interact. These criteria were
derived and modified based on a previous DDI study that
also utilized two compendia as references [21].
In order to minimize interpretation bias, three raters
were trained to use STOPP and the two DDI compendia.
Each rater evaluated the data set individually and all disagreements were resolved through discussion.
Statistical analysis
Descriptive statistics were utilized to report the prevalence
of PIM use and potential DDIs. Inferential statistics
including Chi Square test and/or Fishers Exact test were
used to compare categorical data and all continuous data
were compared using the Students t test. In order to
identify the independent factors associated with PIM use
and potential DDIs, multivariate logistic regression analysis was performed on the subject characteristics and/or
comorbidities with p \ 0.05 in the bivariate analysis. The

Results
Demographics

PIM use
Fifty-three subjects used at least one PIM, accounting for
46.5 % of the study population. Among these subjects, 21
(40 %) consumed two or more PIMs. The most common
PIMs, as determined by STOPP, were duplicate drug
classes, the use of benzodiazepines in patients with a fall
history, and the use of dipyridamole as monotherapy for
cardiovascular secondary prevention (Table 1).
Factors associated with PIM use
Among the subject characteristics, an increased number of
drugs used (p \ 0.001) and the use of psychotropic drugs
(p = 0.025) were significantly associated with the use of
PIMs. No associations were found between PIM use and
age, gender, or certain chronic medical conditions such as
hypertension, diabetes, dementia, Parkinson disease, and
stroke history (all with p [ 0.05). The multivariate logistic
regression analysis demonstrated that the more medications
an elderly subject consumed, the more likely the subject
would use PIMs (OR 1.28, 95 % CI 1.111.47) (Table 2).
DDIs
One hundred and eleven elderly subjects were eligible for
the DDI analysis (Fig. 1). Considerable variations were
observed in the results between the two compendia. Based
on the preset criteria of Lexi-Interact, 488 potential DDIs
were recognized. In contrast, 168 potential DDIs were

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Int J Clin Pharm (2013) 35:805812

Fig. 1 Flow diagram of the


study population and the
number of residents with or
without PIMs or DDIs. DDI
drugdrug interaction, PIM
potentially inappropriate
medication

Total number
of residents
n=156

65 years of
age
n=118

< 65 years of
age
n=38

Medication
users
n=114

Medication
non-users
n=4

Taking 1
medication
n=114

With PIM(s)
n=53

Taking 2
medications
n=111

Without PIMs
n=61

With DDI(s)
n=42

Without DDIs
n=69

DDI = drug-drug interaction; PIM = potentially inappropriate medication.


14.0%

Percentage of study population

Fig. 2 Distribution of study


subjects by the number of
regularly used medications
(n = 114)

12.3% (14)

13.2% (15)

12.3% (14)
11.4% (13)

12.0%

12.3% (14)

% of study population
(number of residents)

10.0%
8.0%

7.0% (8)
6.1% (7)

6.0%

4.4% (5)
4.4% (5)

6.1% (7)

4.4% (5)

4.0%
2.6% (3)
0.9% (1)

1.8% (2)
0.9% (1)

2.0%
0.0%
1

10

11

12

13

14

15

Number of regularly used medications

detected by using the preset criteria of Drug-Reax. In


overall, 77 potential DDIs were listed in both compendia
and met all the preset criteria. Only 8 of them were listed
as of major severity by both compendia. Of the 111
subjects, 42 (37.8 %) were exposed to one or more
potential DDIs. The number of potential DDIs per subject
ranged from 1 to 7. Seventeen subjects (40.5 %) experienced two or more potential DDIs. The most frequently
encountered DDI was the concomitant use of clopidogrel
and amlodipine (Table 3).

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Factors associated with DDIs


Subjects with hypertension (p \ 0.001), diabetes
(p = 0.001), and a history of stroke (p = 0.034) were more
likely to have potential DDIs. The number of drugs used
was also significantly higher among the DDI users
(p \ 0.001). No significant differences between the presence and absence of DDIs were observed in relation to age,
gender, dementia, Parkinson disease, and the use of psychotropic drugs (all with p [ 0.05). It was also found that

Int J Clin Pharm (2013) 35:805812


Table 1 Most common PIMs
based on the STOPP criteria

809

Rank

Criterion (concern)

Frequency
(% total PIMs)

1st

Duplicate drug classes (optimization of monotherapy within a single drug class


should be observed prior to considering a new class of drug)

22 (25.3)

2nd

Benzodiazepines in patients who are prone to falls (sedative, may cause reduced
sensorium and impair balance)

11 (12.6)

Dipyridamole as monotherapy for cardiovascular secondary prevention (no


evidence for efficacy)

11 (12.6)

3rd

First-generation antihistamines in patients who are prone to falls (sedative and


may impair sensorium)

9 (10.3)

4th

Prolonged use ([1 week) of first-generation antihistamines (risk of sedation and


anti-cholinergic side effects)

8 (9.2)

Neuroleptic drugs in patients who are prone to falls (may cause gait dyspraxia
and parkinsonism)

8 (9.2)

Proton pump inhibitors for peptic ulcer disease at full therapeutic dosage for
[8 weeks (earlier discontinuation or dose reduction for maintenance/
prophylactic treatment of peptic ulcer disease, esophagitis or gastroesophageal
reflux disease as indicated)

3 (3.4)

NSAID with heart failure (risk of exacerbation of heart failure)

3 (3.4)

5th
Total PIMs identified = 87
PIM potentially inappropriate
medication

Table 2 Bivariate analysis and multivariate logistic regression analysis to identify the independent factors associated with PIM use
Characteristic

Bivariate analysis

Age [mean (SD)]a

Multivariate analysis

Without PIMs (n = 61)

With PIMs (n = 53)

81.7 (9.4)

81.4 (7.2)

Gender

p value

OR (95 %CI)

p value

0.887
0.507

Males [No. (%)]

22 (36.1)

Females [No. (%)]

39 (63.9)

16 (30.2)
37 (69.8)

Stroke history [No. (%)]

38 (62.3)

30 (56.6)

0.537

Hypertension [No. (%)]

41 (67.2)

41 (77.4)

0.229

Diabetes [No. (%)]


Dementia [No. (%)]

17 (27.9)
18 (29.5)

20 (37.7)
16 (30.2)

0.262
0.937

Parkinson disease [No. (%)]b

2 (3.3)

3 (5.7)

0.662

Taking psychotropic drugs [No. (%)]

24 (39.3)

32 (60.4)

0.025c

2.20 (0.994.90)

0.052

Number of drugs used [mean (SD)]a

5.9 (3.1)

8.0 (2.8)

\0.001c

1.28 (1.111.47)

0.001c

CI confidence interval, OR odd ratio, PIM potentially inappropriate medication, SD standard deviation
a

Students t test;

Fishers Exact test;

statistically significant; all of the others were done by using Chi Square test

STOPP-related PIM use did not increase the likelihood of


potential DDIs (p [ 0.05). An increased number of drugs
used (OR 1.53, 95 % CI 1.251.86), stroke history (OR
4.26, 95 % CI 1.3913.05), and hypertension (OR 5.03,
95 % CI 1.1222.66) were shown to be the independent
factors associated with potential DDIs (Table 4).

Discussion
This is the first study that evaluated the prevalence of drugrelated problems among elderly nursing home residents in
Macao. Our findings suggested that 46.5 % of elderly nursing home residents used PIMs and 37.8 % were exposed to

potential DDIs. Polypharmacy appeared to be an alarming


issue because 27.2 % of the study population regularly
consumed 9 or more medications. For every one additional
medication prescribed to an elderly resident, the risks for
PIM use and DDIs rose by 27.7 and 52.6 %, respectively.
The high prevalence of PIM use in the Macao nursing
home was consistent with that in the other countries [7, 8].
One of the most commonly encountered PIMs in this study
was benzodiazepine use in patients who were prone to falls.
PIM use involving benzodiazepines was also identified in an
Irish nursing home study [8]. Along with their sedating
effect, long-term use of high doses of benzodiazepines is
associated with an increased fracture risk in the elderly [23].
A recent study has also established a strong relationship

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Int J Clin Pharm (2013) 35:805812

Table 3 Most common potential DDIs


Rank

Potential DDI

Drug-Reax

Lexi-Interact

Severity

Evidence

Severity

Evidence

Frequency
(% total DDIs)

1st

Clopidogrel

Amlodipine

Major

Excellent

Moderate

Fair

6 (7.8)

2nd

Clopidogrel

Nifedipine

Major

Excellent

Moderate

Fair

3 (3.9)

Aspirin

Enalapril

Moderate

Excellent

Moderate

Excellent

3 (3.9)

3rd

Clopidogrel

Esomeprazole

Major

Excellent

Major

Fair

2 (2.6)

Clopidogrel

Cilostazol

Major

Fair

Moderate

Fair

2 (2.6)

Amlodipine

Simvastatin

Major

Good

Major

Fair

2 (2.6)

Amlodipine
Furosemide

Diltiazem
Captopril

Moderate
Moderate

Good
Good

Moderate
Moderate

Good
Good

2 (2.6)
2 (2.6)

Furosemide

Celecoxib

Moderate

Good

Moderate

Excellent

2 (2.6)

Furosemide

Digoxin

Moderate

Good

Moderate

Fair

2 (2.6)

Levodopa

Phenytoin

Moderate

Good

Moderate

Fair

2 (2.6)

Allopurinol

Theophylline

Moderate

Fair

Moderate

Good

2 (2.6)

Total potential DDIs that met all preset criteria = 77


DDI drugdrug interaction
Table 4 Bivariate analysis and multivariate logistic regression analysis to identify the independent factors associated with potential DDIs
Characteristic

Bivariate analysis

Age [mean (SD)]a

Multivariate analysis

Without DDIs (n = 69)

With DDIs (n = 42)

82.1 (8.2)

80.2 (8.7)

Gender

p value

OR (95 %CI)

p value

0.251
0.498

Males [No. (%)]

24 (34.8)

Females [No. (%)]

45 (65.2)

30 (71.4)

Stroke history [No. (%)]

37 (53.6)

31 (73.8)

0.034c

4.26 (1.3913.05)

0.011c

39 (92.9)

5.03 (1.1222.66)

0.035c

2.46 (0.867.01)

0.093

1.53 (1.251.86)

\0.001c

Hypertension [No. (%)]

42 (60.9)

12 (28.6)

\0.001

Diabetes [No. (%)]

15 (21.7)

22 (52.4)

0.001

Dementia [No. (%)]

19 (27.5)

14 (33.3)

0.517

Parkinson disease [No. (%)]b

2 (2.9)

3 (7.1)

0.365

Taking psychotropic drugs [No. (%)]


Number of drugs used [mean (SD)]a

39 (56.5)
5.9 (2.4)

17 (40.5)
8.8 (3.0)

0.101
\0.001c

PIM use [No. (%)]

32 (46.4)

21 (50.0)

0.711

CI confidence interval, DDI drugdrug interaction, OR odd ratio, PIM potentially inappropriate medication, SD standard deviation
a

Students t test;

Fishers Exact test;

statistically significant; all of the others were done by using Chi Square test

between fall-induced osteoporotic fractures and PIM-related


hospital admission among frail older people [24]. If a safer
alternative is not available, it is recommended that benzodiazepines should be prescribed at the lowest effective dose
for the shortest duration.
In the literature, it is known that discrepancies were
observed among various DDI compendia [20, 25, 26].
Therefore, screening DDIs using more than one reference is
common practice in clinical settings. Drug-Reax and LexiInteract were chosen for the DDI analysis because they are
widely used by healthcare professionals internationally. In
addition, their sensitivity in identifying clinically significant
DDIs is higher when compared with other compendia. Their

123

major difference is specificity, with Lexi-Interact providing


less specific DDI information [20]. In this study, 488 DDIs
were detected by Lexi-Interact, compared to 168 DDIs by
using Drug-Reax. Among them, merely 100 DDIs were
detected by both compendia. Two potential DDIs classified
as contraindicated by Drug-Reax (carbamazepine/nifedipine and phenytoin/nifedipine) were listed as of moderate
severity by Lexi-Interact. This reconfirms the inconsistency
between different DDI compendia, and also rationalizes the
approach to use two compendia as references.
Among the eligible residents, 37.8 % had a total of 77
potential DDIs that met the preset criteria. A Taiwanese
study showed that 25.1 % of nursing home residents had

Int J Clin Pharm (2013) 35:805812

potential DDIs including those of minor severity [9]. The


higher DDI prevalence in this study might result from the
higher average number of medications consumed by the
residents compared with that in the Taiwanese study.
This study has also established that DDIs were significantly associated with stroke history and hypertension,
which was consistent with the findings of previous studies
[6, 27]. Hypertension was diagnosed in 92.9 % of the aged
residents with DDIs in this study. The elderly residents
who had a history of hypertension were five times more
likely to experience DDIs. A follow-up evaluation showed
that the hypertensive residents consumed significantly
more medications than their normotensive counterparts,
which might be the explanation of their elevated DDI risk.
The association between antihypertensive drug use and the
occurrence of DDIs was also documented in a previous
study [28]. This reiterates the importance to raise such
awareness among prescribers for older patients, especially
those who have a history of hypertension and/or stroke.
An increased number of drugs used was strongly associated with both PIM use and potential DDIs among this study
population. Polypharmacy has long been demonstrated to
raise the likelihood of PIM use [58, 29, 30] and DDIs [6, 9,
27, 31, 32] among older people. More importantly, polypharmacy is also associated with serious PIM-related
adverse events [33]. Polypharmacy was prevalent in this
study possibly due to the involvement of multiple physicians
in disease management and a lack of pharmacist-led drug
reviews in the local nursing home setting.
Another noteworthy finding was the absence of any association between STOPP-related PIM use and clinically relevant DDIs. Contradictory to such results, a Finnish study
revealed that elderly people managed with the Beers criteriarelated PIMs were more likely to have DDIs, although its DDI
analysis was based on a different compendium [6]. The relationship between PIM use and DDIs should be further studied.
In the studied nursing home, more than 150 residents are
regularly managed by only one in-house physician. It
provides opportunities for pharmacists to enhance their
clinical role in a city where they are mainly perceived as
sole medication suppliers by the public. As drug experts,
pharmacists can apply their knowledge and collaborate
with physicians to optimize drug therapies for nursing
home residents. Based on the results of a European study,
medication reviews carried out by pharmacists of the
multidisciplinary teams can lead to fewer drugs prescribed
and higher detection and resolution rates of drug-related
problems [34]. Pharmacist-led medication reviews can also
lower the costs of mortality and morbidity associated with
pharmacotherapy [35]. Moreover, pharmacists contribution to patient care is highly appreciated by physicians and
nurses in the long-term care facility setting [34, 36]. Currently, the data on the other outcomes of pharmacist

811

services are still questionable in this setting and there is a


need for more studies on this topic [37].
Several limitations can be noted in this study. The relatively small sample size and its single-center nature seem to
adversely influence the generalizability of the results.
However, the studied nursing home is the only one of its kind
in Macao, with a strict policy of drug storage and administration that can ensure data accuracy. In addition, certain
laboratory tests such as serum sodium and creatinine levels
are required to assess several criteria of STOPP. Nonetheless, some residents did not have these laboratory records
available in their medical charts, which might influence the
PIM analysis. In fact, the prevalence of potential DDIs might
also be subject to underestimation due to the exclusion of
dietary supplements and herbal medicines which are widely
consumed by local people. A lack of evidence-based clinical
information on drug-supplement interactions or drug-herb
interactions makes it impractical to take them into consideration. Furthermore, owing to the regional variation in
medical practice, certain medications such as piracetam and
nicergoline are commonly prescribed by local physicians but
they are not listed in both Drug-Reax and Lexi-Interact.
Lastly, STOPP is an explicit tool which is criterion-based
and takes little or no clinical judgment into account. Even
with such limitation, explicit PIM screening tools are usually
more feasible in practice because the implicit approaches are
more time-consuming and may have low reliability [38].

Conclusion
STOPP-related PIM use and potential DDIs were highly
prevalent among elderly Chinese nursing home residents in
Macao. Polypharmacy was shown to be an issue for the
elderly residents in this setting, which might increase the risk
of drug-related problems. However, the use of PIMs as
determined by STOPP did not increase the likelihood of
potential DDIs. It is imperative to conduct further studies to
assess the clinical outcomes of pharmacist interventions for
the elderly residing in long-term care facilities in Macao.
Acknowledgments The authors gratefully acknowledged the medical and administrative staff of Caritas Meng Fai Nursing Home for
their assistance.
Funding This study was financially supported by the Macao Polytechnic Institute.
Conflicts of interest

No conflicts of interest to declare.

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