438 Patterns and appropriateness of prescribing for people with dementia in ambulatory care in Saudi Arabia: A cross-sectional study
Authors: Alageel N A , Hughes C M , Alwhaibi M , Alkeridy W , Barry H E 
Published: April 2023

Abstract

Introduction
People with dementia (PwD) often have several comorbidities for which medications are prescribed. Consequently, polypharmacy and potentially inappropriate prescribing (PIP) are highly prevalent amongst PwD and have been linked with negative health outcomes (1). To date, no studies have been conducted in Saudi Arabia which describe current prescribing practices, polypharmacy or appropriateness of medications prescribed for PwD.

Aim
To explore prescribing trends, estimate the prevalence of polypharmacy and PIP, and investigate associations between PIP and polypharmacy, age and gender among PwD in ambulatory care in Saudi Arabia.

Methods
A cross-sectional, retrospective study was conducted using data from electronic health records in a large tertiary hospital in Saudi Arabia. Patients were eligible to be included if they were aged ≥65 years, had a dementia diagnosis, and had visited the ambulatory care clinic during the study period 01/01/2019 – 31/12/2021. Patients who died during the study period were excluded. Polypharmacy was indicated by use of ≥5 chronic medications. Prescribing appropriateness was assessed by applying a subset of the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria, comprising 78 indicators (2). Descriptive statistics were used to describe the study population. Overall prevalence of PIP and the prevalence per each STOPP criterion were calculated as a proportion of all eligible persons in the dataset. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and gender; adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Data extraction and analysis were conducted using SPSS v27.

Results
The study population included 287 PwD. The majority were female (n=161, 56.0%) and the mean age was 78.8 [standard deviation (SD) ±8.0) years. The mean number of medications prescribed was 9.0 (±4.2) and polypharmacy was observed in 82.6% (n=237) of patients. The overall PIP prevalence during the study period was 61.0% (n=175). The most common instances of PIP were drugs prescribed beyond the recommended duration (n=90, 31.4%), drugs prescribed without an evidence-based clinical indication (n=78, 27.2%), proton pump inhibitors (PPIs) at full therapeutic dosage for &gt;8 weeks (n=75, 26.0%), acetylcholinesterase inhibitors with concurrent treatment with drugs that reduce heart rate (n=60, 21.0%), and anticholinergic/antimuscarinic drug use (n=28, 9.8%). Whilst polypharmacy was found to be strongly associated with PIP (OR 21.9, 95% CI 8.3 – 57.5), no association was observed between PIP and age or gender after adjustments for polypharmacy.

Conclusion
To our knowledge, this is the first study to evaluate polypharmacy, prescribing appropriateness, and factors associated with PIP for PwD in Saudi Arabia. Findings have revealed a high prevalence of PIP among PwD that is strongly associated with polypharmacy. However, our focus was on PwD in one tertiary care hospital and thus findings may not be generalisable beyond this setting. Future research should involve PwD and other key stakeholders to develop practical interventions to decrease the burden of polypharmacy and PIP and optimise medication use for this vulnerable patient population.

References
1. Delgado J, Jones L, Bradley MC, Allan LM, Ballard C, Clare L, Fortinsky RH, Hughes CM, Melzer D. Potentially inappropriate prescribing in dementia, multi-morbidity and incidence of adverse health outcomes. Age and Ageing. 2021;50(2): 457-464.
2. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age and Ageing. 2015; 44(2): 213–218.