Article Navigation
Article Contents
-
Key Points
-
Declaration of Conflicts of Interest:
-
Declaration of Sources of Funding:
-
REFERENCES
- < Previous
- Next >
Journal Article
, Rafael Hernandez-Palacios Osakidetza Basque Health Service, Araba Mental Health Network, Araba Psychiatric Hospital, Internal Medicine Department , Vitoria-Gasteiz , Spain Search for other works by this author on: Oxford Academic Sharon Pfleger Public Health Directorate, Pharmaceutical Public Health, NHS Highland , UK School of Pharmacy and Life Sciences, The Robert Gordon University , Aberdeen , UK Environmental Research Institute, University of the Highlands and Islands , Thurso , UK Search for other works by this author on: Oxford Academic Juan Medrano Osakidetza Basque Health Service, Araba Mental Health Network, Araba Psychiatric Hospital, Psychiatry , Vitoria-Gasteiz , Spain Search for other works by this author on: Oxford Academic Gorka Orive NanoBioCel Group , Laboratory of Pharmaceutics, School of Pharmacy, University of the Basque Country UPV/EHU , Paseo de la Universidad 7, Vitoria-Gasteiz 01006 , Spain Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN) . Vitoria-Gasteiz , Spain University Institute for Regenerative Medicine and Oral Implantology - UIRMI (UPV/EHU-Fundación Eduardo Anitua) , Vitoria , Spain Bioaraba, NanoBioCel Research Group , Vitoria-Gasteiz , Spain Search for other works by this author on: Oxford Academic Unax Lertxundi Bioaraba Health Research Institute; Osakidetza Basque Health Service, Araba Mental Health Network, Araba Psychiatric Hospital, Pharmacy Service , Vitoria-Gasteiz , Spain Address correspondence to: Unax Lertxundi, Bioaraba Health Research Institute; Osakidetza Basque Health Service, Araba Mental Health Network, Araba Psychiatric Hospital, Pharmacy Service, Vitoria-Gasteiz, Spain. c/Alava 43, 01006 Vitoria-Gasteiz, Alava, Spain. Email: unax.lertxundietxebarria@osakidetza.net Search for other works by this author on: Oxford Academic
Age and Ageing, Volume 53, Issue 6, June 2024, afae119, https://doi.org/10.1093/ageing/afae119
Published:
26 June 2024
Article history
Received:
24 April 2024
Revision requested:
10 June 2024
Published:
26 June 2024
- Split View
- Views
- Article contents
- Figures & tables
- Video
- Audio
- Supplementary Data
-
Cite
Cite
Rafael Hernandez-Palacios, Sharon Pfleger, Juan Medrano, Gorka Orive, Unax Lertxundi, Inappropriate prescribing in older people: not only a patient safety issue but an avoidable source of environmental harm, Age and Ageing, Volume 53, Issue 6, June 2024, afae119, https://doi.org/10.1093/ageing/afae119
Close
Search
Close
Search
Advanced Search
Search Menu
inappropriate prescribing, older people, safety, environment, ageing population
Key Points
Humans are consuming more pharmaceuticals than ever.
Medicines are estimated to account for 25% of NHS carbon emissions.
Tackle inappropriate polypharmacy: good for the patient & the environment.
Humans are consuming more pharmaceuticals than ever before [1] as a result of ageing populations, and technological innovation transforming the treatment of ageing-related and chronic diseases [2]. Moreover, climate-related environmental changes are associated with a rise in the incidence of certain chronic diseases [3], which ultimately will lead to further medicines use. Healthcare is a key contributor to the climate crisis emitting 4.4% of global net emissions [4]. Medicines are estimated to account for 25% of NHS carbon emissions in the UK [5] so any increase in their use may worsen atmospheric warming [6].
Medicines also adversely affect the water and soil compartments of the environment through effluent from wastewater treatment plants, application of contaminated sludge to crops or inappropriate disposal via domestic waste to landfill. The Global Monitoring of Pharmaceuticals project studied 258 rivers across 104 countries and showed the presence of pharmaceuticals in the environment at concentrations of concern to human and/or environmental health in over 25% of the rivers sampled [7].
The United Nations states that one in six people in the world will be over the age of 65 by 2050 [8]. Multimorbidity and the associated use of multiple medicines are common in the older population. Combined with this demographic transition, if prescription patterns are maintained, global medicine use will increase.
Polypharmacy has often been defined as the use of five or more prescribed medicines [9]. It is now suggested that it is the concurrent use of two or more medicines and that the emphasis should be on whether the prescribing is evidence based and appropriate [10, 11]. It is estimated that around one-third prescriptions for older people living at home are potentially inappropriate added to which around half of all medicines for chronic conditions are not taken as intended [12]. This coupled with the fact that medication- related harm is a serious problem, causing severe or life-threatening outcomes in over a quarter of all preventable harm cases [13] and that such inappropriate use is impacting our environment strengthens the case for appropriate polypharmacy to keep both our patients and our planet safe.
Efforts to limit the harm caused by inappropriate prescriptions led to the development of explicit criteria for clinically important prescribing problems to reduce older people’s exposure to inappropriate medicines, such as the AGS Beers and the STOPP/START criteria [14, 15]. Recently the iSIMPATHY European project has proposed a 7-step process to appropriate polypharmacy based on patient centred medication appropriateness index [16]. The findings from the project demonstrated that implementing the 7-step medication review to appropriate polypharmacy resulted in 82% of interventions being clinically significant, with 4% potentially preventing major organ failure or adverse drug reactions of similar clinical importance. There were 9800 potentially avoided admissions. Overall, patients reported better understanding of their medicines, improved adherence and experienced less harm [16].
Medicine reviews, apart from achieving the best outcomes for patients’ health and wellbeing, are also cost-effective in terms of reduced medication costs, health and social care utilisation costs.
The more sustainable use of medicines is gaining attention among health care professionals. In Scotland, doctors and pharmacists issued a joint statement on reducing the environmental impact of medicines calling on national guidance developers to include information about the environmental impact of medicines [17].
There remain many data gaps with regard to carbon footprints, life cycle assessments and the impact of water and soil based pharmaceuticals. However, the National Institute for Health and Care Excellence estimated that implementing its medicine optimisation guideline [18] to prevent avoidable medicine-related hospital admissions could reduce greenhouse gas emissions by 202 tonnes, save 0.3 million m3 of fresh water and prevent the creation of 24 tonnes of waste in hospitals per 100 000 population [18].
Tackling inappropriate polypharmacy in older people not only improves the quality of their life, but will also help mitigating environmental effects of medicines with the added consequence that harm to human health will be reduced and will help achieving the goal set in the Third Global Patient Safety Challenge, Medication Without Harm [19]. Considering the environmental harm caused by pharmaceuticals (including their carbon footprint) is just another reason to use them rationally.
We believe that including environmental aspects as explicit criteria for appropriate prescribing in older people could help clinicians to make better decisions, which will benefit both patients and the environment.
Declaration of Conflicts of Interest:
None.
Declaration of Sources of Funding:
None.
REFERENCES
1.
Orive G Lertxundi U Brodin T Manning P
Greening the pharmacy
.
Science
2022
;
377
:
259
–
60
.
2.
GBD 2019 Demographics Collaborators
Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019: a comprehensive demographic analysis for the global burden of disease study 2019
.
Lancet
2020
;
396
:
1160
–
203
.
3.
OECD
Available at:
Accessed March 8, 2024
.
4.
Health Care Without Harm
Available at:
Accessed March 8, 2024
.
5.
Greener NHS
Delivering a ‘Net Zero’ National Health Service
. NHS England,
2020
.
Available at:
https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/,
Accessed March 5, 2024
.
6.
Redshaw CH Stahl-Timmins WM Fleming LE Davidson I Depledge MH
Potential changes in disease patterns and pharmaceutical use in response to climate change
.
J Toxicol Environ Health B Crit Rev
2013
;
16
:
285
–
320
.
7.
Wilkinson JL Boxall ABA Kolpin DW Leung KMY Lai RWS
Pharmaceutical pollution of the world’s rivers
.
Proc Natl Acad Sci U S A
2022
;
119
:
e2113947119
.
8.
United Nations
Available at:
2022
;
Accessed March 5, 2024
.
9.
Masnoon N Shakib S Kalisch-Ellett L Caughey GE
What is polypharmacy? A systematic review of definitions
.
BMC Geriatr
2017
;
17
:
230
.
10.
Scottish Government Polypharmacy Model of Care Group
Polypharmacy Guidance: Realistic Prescribing
. 3rd edition.
Edinburgh
:
Scottish Government
,
2018
.
Available at:
Accessed March 8, 2024
. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf.
OpenURL Placeholder Text
11.
Mair A
Medication Safety in Polypharmacy, Third Global Patient Safety Challenge. Rep
.
Geneva
:
World Health Organisation
,
2019
.
Available at:
Accessed March 5, 204
. https://www.who.int/publications-detail-redirect/WHO-UHC-SDS-2019.11.
OpenURL Placeholder Text
12.
Tian F Chen Z Zeng Y Feng Q Chen X
Prevalence of use of potentially inappropriate medications among older adults worldwide: a systematic review and meta-analysis
.
JAMA Netw Open
2023
;
6
:
e2326910
.
13.
Hodkinson A Tyler N Ashcroft DM
Preventable medication harm across health care settings: a systematic review and meta-analysis
.
BMC Med
2020
;
18
:
313
.
14.
American Geriatrics Society Beers Criteria® Update Expert Panel
American Geriatrics Society 2023 updated AGS beers criteria® for potentially inappropriate medication use in older adults
.
J Am Geriatr Soc
2023
;
71
:
2052
–
81
.
15.
O'Mahony D Cherubini A Guiteras AR
STOPP/START criteria for potentially inappropriate prescribing in older people: version 3
.
Eur Geriatr Med
2023
;
14
:
625
–
32
.
16.
Mair A Kirke C Scott M
iSIMPATHY Evaluation Report, Edinburgh, iSIMPATHY Consortium
,
2023
.
Available at:
Accessed March 5, 2024
. https://www.isimpathy.eu/uploads/iSIMPATHY_Evaluation_report_ver8_online.pdf.
17.
Three organizations: Royal Pharmaceutical Society. Joint statement: Reducing the environmental impact of prescribing.
Royal College of General Practitioners
. Academy of Medical Royal Colleges and Faculties in Scotland.
Available at:
Accessed March 8, 2024
.
18.
National Institute of Clinical Excellence
Available at:
2017
;
Accessed March 5, 2024
.
19.
WHO
The Third WHO Global Patient Safety Challenge: Medication without Harm
,
2017
.
Available at:
Accessed March 5, 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/pages/standard-publication-reuse-rights)
Subject
Pharmacology and therapeutics
Issue Section:
Editorial
Download all slides
Comments
0 Comments
Comments (0)
Submit a comment
You have entered an invalid code
Thank you for submitting a comment on this article. Your comment will be reviewed and published at the journal's discretion. Please check for further notifications by email.
Advertisem*nt intended for healthcare professionals
Citations
Views
101
Altmetric
More metrics information
Metrics
Total Views 101
74 Pageviews
27 PDF Downloads
Since 6/1/2024
Month: | Total Views: |
---|---|
June 2024 | 101 |
Citations
Powered by Dimensions
Altmetrics
Email alerts
Article activity alert
Advance article alerts
New issue alert
In progress issue alert
Subject alert
Receive exclusive offers and updates from Oxford Academic
Citing articles via
Google Scholar
-
Latest
-
Most Read
-
Most Cited
More from Oxford Academic
Clinical Medicine
Geriatric Medicine
Medicine and Health
Books
Journals
Advertisem*nt intended for healthcare professionals