Skip to main content
SpringerLink
Log in

Changes in Under-Treatment after Comprehensive Geriatric Assessment

An Observational Study

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background Under-treatment is frequently present in geriatric patients. Because this patient group often suffer from multiple diseases, polypharmacy (defined as the concomitant chronic use of five or more drugs) and contraindications to indicated drugs may also frequently be present.

Objective To describe the prevalence of under-treatment with respect to frequently indicated medications before and after comprehensive geriatric assessment (CGA) and the prevalence of contraindications to these medications.

Patients and Methods The geriatric outpatients evaluated in this study had previously been included in a prospective descriptive study conducted in 2004. Demographic data, medical history, co-morbidity and medication use and changes were documented. The absence of drugs indicated for frequently under-treated conditions before and after CGA was compared. Under-treatment was defined as omission of drug therapy indicated for the treatment or prevention of 13 established diseases or conditions known to be frequently under-treated. Co-morbid conditions were independently classified by two geriatricians, who determined whether or not a condition represented a contraindication to use of these drugs.

Results In 2004, 807 geriatric outpatients were referred for CGA. Of these, 548 patients had at least one of the 13 selected diseases or conditions. Thirty-two of these patients were excluded from the analysis, leaving 516 patients. Before CGA, 170 of these patients were under-treated (32.9%); after CGA, 115 patients (22.3%) were under-treated. Contraindications were present in 102 of the patients (19.8%) and were more frequent in under-treated patients. After CGA, mean drug use and the prevalence of polypharmacy increased. Although 393 drugs were discontinued after CGA, the overall number of drugs used increased from 3177 before CGA to 3424 after CGA. Five times more drugs were initiated for a new diagnosis than for correction of under-treatment.

Conclusions Under-treatment is significantly reduced after CGA. Patients with contraindications to indicated medicines are more frequently under-treated. CGA leads to an increase in polypharmacy, mainly because of new conditions being diagnosed and despite frequent discontinuation of medications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I
Table II
Table III
Table IV

Similar content being viewed by others

References

  1. Rochon PA, Gurwitz JH. Prescribing for seniors: neither too much nor too little. JAMA 1999; 281(2): 113–5

    Article  Google Scholar 

  2. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006; 54: 1516–23

    Article  PubMed  Google Scholar 

  3. Denneboom W, Dautzenberg MGH, Grol R, et al. Analysis of polypharmacy in older patients in primary care using a multidisciplinary expert panel. Br J Gen Pract 2006; 56: 504–10

    PubMed  Google Scholar 

  4. Kuijpers MA, van Marum RJ, Egberts AC, et al. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol 2008; 65(1): 130–3

    Article  PubMed  Google Scholar 

  5. Ko DT, Mamdani M, Alter DA. Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox. JAMA 2004; 291: 1864–70

    Article  PubMed  CAS  Google Scholar 

  6. Havranek EP, Abrams F, Stevens E, et al. Determinants of mortality in elderly patients with heart failure: the role of angiotensin-converting enzyme inhibitors. Arch Intern Med 1998; 158: 2024–8

    Article  PubMed  CAS  Google Scholar 

  7. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997; 277: 115–21

    Article  PubMed  CAS  Google Scholar 

  8. Kuzuya M, Masuda Y, Hirakawa Y, et al. Underuse of medications for chronic disease in the oldest of community-dwelling older frail Japanese. J Am Geriatr Soc 2006; 54: 598–05

    Article  PubMed  Google Scholar 

  9. Komajda M, Follath F, Swedberg K, et al., on behalf of the Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The EuroHeart Failure Survey programme: a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J 2003; 24: 464–74

    Article  PubMed  CAS  Google Scholar 

  10. Boyles PJ, Peterson GM, Bleasel MD, et al. Undertreatment of congestive heart failure in an Australian setting. J Clin Pharm Ther 2004; 29: 15–22

    Article  PubMed  CAS  Google Scholar 

  11. Tran CT, Laupacis A, Mamdani MM, et al. Effect of age on the use of evidence-based therapies for acute myocardial infarction. Am Heart J 2004; 148(5): 834–41

    Article  PubMed  Google Scholar 

  12. Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacological care for vulnerable older patients. Ann Intern Med 2004; 140: 714–20

    PubMed  Google Scholar 

  13. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid conditions: implications for pay for performance. JAMA 2005; 294: 716–24

    Article  PubMed  CAS  Google Scholar 

  14. Baker DW, Hayes RP, Massie BM, et al. Variations in family physicians’ and cardiologists’ care for patients with heart failure. Am Heart J 1999; 138: 826–34

    Article  PubMed  CAS  Google Scholar 

  15. Lipton HL, Bero LA, Bird JA, et al. Undermedication among geriatric outpatients: results of a randomized controlled trial. Ann Rev Gerontol Ger 1992; 12: 95–108

    Google Scholar 

  16. Lee DS, Tu JV, Juurlink DN, et al. Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA 2005; 294: 1240–7

    Article  PubMed  CAS  Google Scholar 

  17. Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 2004; 116: 394–401

    Article  PubMed  Google Scholar 

  18. Tulner LR, Frankfort SV, Gijsen GJ, et al. Drug-drug interactions in a geriatric outpatient cohort: prevalence and relevance. Drugs Aging 2008; 25(4): 343–55

    Article  PubMed  Google Scholar 

  19. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–98

    Article  PubMed  CAS  Google Scholar 

  20. Meulen EF, Schmand B, van Campen JP, et al. The seven minute screen: a neurocognitive screening test highly sensitive to various types of dementia. J Neurol Neurosurg Psychiatry 2004; 75(5): 700–5

    Article  PubMed  CAS  Google Scholar 

  21. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Maryland State Med J 1965; 14: 61–5

    CAS  Google Scholar 

  22. Fillenbaum GG. Screening the elderly: a brief instrumental activities of daily living measure. J Am Geriatr Soc 1985; 33: 698–706

    PubMed  CAS  Google Scholar 

  23. Samsa GP, Hanlon JT, Schmader KE. A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994; 47: 891–6

    Article  PubMed  CAS  Google Scholar 

  24. Charlson ME, Pompei P, Ales KA, et al. A new method of classifying prognostic comorbidity in longitudinal studies. J Chron Dis 1987; 40(5): 373–83

    Article  PubMed  CAS  Google Scholar 

  25. Dutch College of General Practitioners (Nederlands Huisartsen Genootschap). NHG-Standaarden [in Dutch; online]. Available from URL: http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden.htm [Accessed 2010 Aug 11]

  26. Dutch Institute for Health Care Improvement, Medicines Evaluation Board, Dutch Ministry of Health, Welfare and Sport (College ter Beoordeling Geneesmiddelen, ministerie VWS). Database human medicines [in Dutch/English; online]. Available from URL: http://www.cbg-meb.nl/CBG/nl/humane-geneesmiddelen/geneesmiddeleninformatiebank/default.htm [Accessed 2010 Aug 11]

  27. Limburg M, Tuut MK. CBO guideline ‘Stroke’ (revision) Dutch Institute for Healthcare Improvement [in Dutch]. Ned Tijdschr Geneeskd 2000 May 27; 144(22): 1058–62

    PubMed  CAS  Google Scholar 

  28. Williams MA, Fleg JL, Ades A, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients ≥75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2002; 105: 1735–43

    Article  PubMed  Google Scholar 

  29. Frankfort SV, Tulner CR, van Campen JPCM, et al. Evaluation of pharmacotherapy in geriatric patients after performing complete geriatric assessment (CGA) at a diagnostic day clinic. Clin Drug Invest 2006; 26: 169–74

    Article  CAS  Google Scholar 

  30. Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? JAMA 2003; 290: 2685–92

    Article  PubMed  CAS  Google Scholar 

  31. Man-Son-Hing M, Nichol G, Lau A, et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677–85

    Article  PubMed  CAS  Google Scholar 

  32. Bond AJ, Molnar FJ, Li M, et al. The risk of hemorrhagic complications in hospital in-patients who fall while receiving antithrombotic therapy. Thrombosis J 2005; 3: 1 [online]. Available from URL: http://www.thrombosisjournal.com/content/3/1/1 [Accessed 2010 Aug 24]

    Article  Google Scholar 

  33. Gage BF, Birman Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 2005; 118: 612–7

    Article  PubMed  Google Scholar 

  34. Ueno H, Ohshita T, Kondo K, et al. Association between microbleeds on T3*-weighted images and recurrent hemorrhagic stroke in patients treated with warfarin following ischemic stroke. Am J Neuroradiol 2008; 29(8): 1483–6

    Article  PubMed  CAS  Google Scholar 

  35. Lee SH, Ryu WS, Roh JK. Cerebral microbleeds are a risk factor for warfarin related intracerebral hemorrhage. Neurology 2009; 72: 171–6

    Article  PubMed  CAS  Google Scholar 

  36. Cordonnier C, van der Flier WM, Sluimer JD, et al. Prevalence and severity of microbleeds in a memory clinic setting. Neurology 2006; 66: 1356–60

    Article  PubMed  CAS  Google Scholar 

  37. van Deelen BAJ, van den Beemt PMLA, Egberts TCG, et al. Cognitive impairment as determinant for sub-optimal control of oral anticoagulation treatment in elderly patients with atrial fibrillation. Drugs Aging 2005; 22(4): 353–60

    Article  PubMed  Google Scholar 

  38. Kagansky N, Knobler H, Rimon E, et al. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med 2004; 164: 2044–50

    Article  PubMed  Google Scholar 

  39. AD 2000 Collaborative group, Bentham P, Gray R, et al. Aspirin in Alzheimer’s disease: a randomized open-label trial. Lancet Neurol 2008; 7(1): 41–9

    Article  PubMed  CAS  Google Scholar 

  40. Mant J, Hobbs R, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493–503

    Article  PubMed  CAS  Google Scholar 

  41. Goldberger JJ, Bonow RO, Cuffe M, et al. Post-myocardial infarction β-blocker therapy — the bradycardia conundrum: rationale and design for the Pacemaker and β-blocker therapy post-MI (PACE-MI) trial. Am Heart J 2008; 155: 455–64

    Article  PubMed  CAS  Google Scholar 

  42. Andrus MR, Loyed JV. Use of β-adrenoreceptor antagonists in older patients with chronic obstructive pulmonary disease and cardiovascular co-morbidity: safety issues. Drugs Aging 2008; 25(2): 131–44

    Article  PubMed  CAS  Google Scholar 

  43. Gislason GH, Rasmussen JN, Abildstrom SZ, et al. Long-term compliance with beta blockers, angiotensinconverting enzyme inhibitors, and statins after acute myocardial infarction. Eur Heart J 2006; 27: 1153–8

    Article  PubMed  CAS  Google Scholar 

  44. Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool for Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment): consensus validation. Int J Clin Pharmacol Ther 2008; 46: 72–83

    PubMed  CAS  Google Scholar 

  45. Ryan C, O’Mahony D, Kennedy J, et al. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol 2009; 68(6): 936–47

    Article  PubMed  Google Scholar 

  46. Drenth-van Maanen AC, van Marum RJ, Knol W, et al. Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy: results of application to case histories by general practitioners. Drugs Aging 2009; 26(8): 687–701

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

No sources of funding were used to conduct this study or prepare this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this study.

Author information

Authors and Affiliations

  1. Department of Geriatric Medicine, Slotervaart Hospital, Louwesweg 6, 1066, EC Amsterdam, the Netherlands

    Linda R. Tulner, Jos P. C. M. van Campen & Suzanne V. Frankfort

  2. Department of Pharmacy and Pharmacology, Slotervaart Hospital, Amsterdam, the Netherlands

    Suzanne V. Frankfort, Cornelis H. W. Koks & Jos H. Beijnen

  3. Beta Faculty, Department of Pharmaceutical Sciences, Division of Drug Toxicology, Utrecht University, Utrecht, the Netherlands

    Jos H. Beijnen

  4. Department of Internal Medicine, Slotervaart Hospital, Amsterdam, the Netherlands

    Desiderius P. M. Brandjes

  5. Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons (Ephor), University Medical Centre Utrecht, Utrecht, the Netherlands

    Paul A. F. Jansen

Authors
  1. Linda R. Tulner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jos P. C. M. van Campen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Suzanne V. Frankfort
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cornelis H. W. Koks
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jos H. Beijnen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Desiderius P. M. Brandjes
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paul A. F. Jansen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Linda R. Tulner.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tulner, L.R., van Campen, J.P.C.M., Frankfort, S.V. et al. Changes in Under-Treatment after Comprehensive Geriatric Assessment. Drugs Aging 27, 831–843 (2010). https://doi.org/10.2165/11539330-000000000-00000

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/11539330-000000000-00000

Keywords

Search

Navigation