IN RECENT weeks, a team of experts at Cork University Hospital (CUH) has moved a step closer to revolutionising a key aspect of medical care of the elderly in Ireland.

And a major part of the team's plans involves merging the best in up-to-date technology with their own pioneering medical research, which has pinpointed worrying new trends in elderly care.

Dr Denis O'Mahony, a senior lecturer at CUH's department of medicine and a consultant in geriatric medicine, is enthusiastic when he talks about the hospital's seminal research into inappropriate prescribing for the elderly.

The expert team at the hospital's department of geriatric medicine were not sure that the tools being used to assess prescribing practices here for some time were sufficient for Irish needs. So they went about devising one of their own, and uncovered worrying results in the prescribing of medicines to the elderly.

"We were applying screening tools [critiques of appropriate prescription] here that were devised in North America. They were full of lists of drugs not prescribed any more and the challenge was to devise tools appropriate to the specific needs of Irish users, " O'Mahony told the Sunday Tribune.

Stopp and Start approach What the team arrived at was the breakthrough 'Stopp' (screening tools for older persons' prescriptions) and 'Start' (screening tools to action right treatment) models. Stopp is aimed at designating inappropriate medication that had negative effects when prescribed for older people.

The Start method, used alongside Stopp, indicates which medications are considered best practice internationally for prescribing in cases of complex medical need.

The findings of an as-yet unpublished study recently conducted by O'Mahony and his colleagues are remarkable. Just over half of the 600 geriatric patients whose cases were studied . . . 52% in total . . . were found to have been given inappropriate prescriptions as part of their treatment.

"These instances varied in severity from instances that might be appropriately described as minor in some cases and major in others.

The cases of highest severity include instances of inappropriate prescription that may result in patient fatality, " O'Mahony said.

The research teams also identified another area where medical care was dramatically below par. In 57% of cases, patients were not receiving a prescription for at least one medicine that, by international best-practice standards, they should have been given.

The Cork team's study, to be published in the UK's Journal of Clinical Pharmacy and Therapeutics, describes inappropriate prescribing as the use of medicines that introduce a significant risk of an adverse drug reaction (ADR) where there is evidence of an equally effective but lower-risk therapy to treat the same condition.

People over the age of 65 have a higher incidence of chronic illness, disability and dependence than those under 65. They are more likely to be on medication than younger people, and are often taking several drugs at once to treat different conditions. Prescribing for older people is challenging as any new medication must be considered in the context of its psychological and physical effects, and age-related changes in physiology.

Adverse drug reactions can also be difficult to detect in elderly people, as many geriatric patients frequently suffer non-specific symptoms such as lethargy, confusion, light-headedness, falling and constipation.

Added to the mix is the issue of polypharmacy . . . the use of a range of different drugs concurrently . . . a requirement in the treatment of multiple chronic diseases. Polypharmacy is recognised as being a factor in the dramatic increase of ADRs. Doctors have claimed that patients taking two drugs face a 13% risk of ADR, rising to 38% when taking four drugs and 82% in the use of seven or more drugs. One of the major issues arising from polypharmacy, in the context of inappropriate prescribing, is the treatment of symptoms related to ADRs with even more medication.

"Patients who are inappropriately prescribed the wrong medication are mostly persons who are chronically ill. The risk of adverse drug interaction is significant in such a case. It is correct to say that there is a considerable danger for an older patient who is prescribed the wrong medicine, " O'Mahony says.

Lack of training for GPs The Cork expert is certain about where the problem lies when it comes to inappropriate prescribing among elderly Irish patients.

"For the most part, it is coming from the primary care sector: general practitioners. It is the great majority of cases, perhaps 85% to 90%.

One of the principal factors behind this trend is the lack of education and training in good prescribing practice for geriatric patients, " he says.

O'Mahony says the new research should lead to more emphasis on prescription awareness, relevant to older patients, in the training of doctors and nurses. The Cork hospital could play a leading role in this. The Health Research Board (HRB) is currently funding Dr Paul Gallagher at Cork's Department of Geriatric Medicine to lead research into 'Appropriate prescribing in late life'.

"Ultimately, it is hoped that we can develop Stopp and Start into software packages. We are having discussions with the department of computer sciences at the university regarding the possible development of a computer-based tool that GPs may access easily to check their prescriptions against the tools available through Stopp and Start."

The mortality rate as a result of inappropriate prescribing is difficult to determine.

"It is not possible at this time to say with certainty what percentage of patients died as a specific consequence of inappropriate prescription, " says O'Mahony.

"A further stage of our work will be to set down an agreed framework of what exactly constitutes the different ranges within a spectrum of consequences . . . what we mean when we speak about minor consequences and major consequences in relation to inappropriate prescribing in the elderly."