Potentially inappropriate prescriptions in acutely admitted older patients: a development study to create a clinical...

Older patients admitted with acute illness face a high risk of adverse drug events (ADEs), yet no clinical decision support (CDS) tool currently exists to guide pharmacotherapy in this population during the early phase of hospitalization. This development study aimed to establish expert consensus on drugs that should be used with caution or avoided in acutely admitted older patients in specific clinical situations.

A three-round Delphi study was conducted among 26 experienced physicians in Clinical Pharmacology, Emergency Medicine, and Geriatric Medicine. Panel members rated statements on potentially inappropriate prescriptions (PIPs) across nine clinical situations (e.g., hypotension, hypoglycemia, dehydration). Statements were rated on a five-point Likert scale; consensus was defined as ≥ 75% agreement for or ≥ 50% agreement against. Questionnaires were administered via REDCap.

Consensus was reached on 127 of 138 statements (81 accepted and 46 rejected, total 92%) across three Delphi rounds. An additional 8 statements were accepted following author review, resulting in a final list of 89 PIP-situation combinations. Drugs, such as ACE inhibitors, insulin, diuretics, and sedatives, were frequently identified as problematic across multiple situations. Common concerns among the experts included abrupt withdrawal of potentially inappropriate medications in situations, where this could be detrimental to the patient, and it was underscored, that other courses of action would often be better (e.g., increasing observations or reducing dose).

We developed a CDS tool to identify PIPs in acutely admitted older adults. Based on expert consensus, it addresses a key gap in acute geriatric care. Future studies will aim to validate the tool.