Assessing Potentially Inappropriate Prescribing in Community-Dwelling Older Patients Using the Updated Version of STOPP-START Criteria: A Comparison of Profiles and Prevalences with Respect to the Original Version

Comparing AGS Beers 2019, STOPP version 2, and EU(7)-PIM list in Portuguese older adults in primary health care

PURPOSE

This study aims to identify PIM prevalence in older adults according to the 2019 Beers criteria, Screening Tool of Older Person's Prescriptions version 2 (STOPP v2) criteria, and the Portuguese EU(7)-PIM list and also to analyze the concordance between these criteria.

METHODS

A retrospective study was conducted among 1200 Portuguese older adults (≥ 65 years old), users of primary health care. Demographic, clinical, and pharmacological data were collected concerning the period between April 2021 and August 2022. A comparative analysis was performed between the three PIM identification criteria, and the concordance was determined according to the Lin concordance correlation coefficient.

RESULTS

The mean age was 76.3 (SD 7.7) years old and 57.6% of the older adults were females. Our findings indicate varying prevalence rates among these criteria with 63.8% (95% CI 61.0-66.6%), 66.8% (95% CI 64.1-69.5%), and 50.1% (95% CI 47.2-53.0%) of the older adults take at least one PIM according to the EU(7)-PIM list, Beers 2019, and STOPP v2 criteria, respectively. The highest prevalence observed was for proton pump inhibitors according to EU(7)-PIM list (30.1%, 95% CI 27.6-32.9) and Beers criteria (30.1%, 95% CI 27.6-32.9) and alprazolam according to STOPP v2 criteria (10.1%, 95% CI 8.4-11.9%). A poor concordance between criteria was observed (< 0.834). The highest concordance coefficient was found between the EU(7)-PIM list and the Beers criteria (0.833), and the lowest between the EU(7)-PIM list and STOPP criteria (0.735).

CONCLUSION

This study reveals varying prevalence rates of PIM in older adults, as assessed by different criteria, and highlights the need for targeted interventions and improved prescribing practices. In the future, studies should focus on the occurrence of negative outcomes in older adults associated with PIM consumption.

Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions

BACKGROUND

This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital.

METHODS

Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy).

RESULTS

In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission.

CONCLUSION

There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.

Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand

BACKGROUND

Older inpatients, particularly those with frailty, have increased exposure to complex medication regimens. It is not known whether frailty and complexity of medication regimens influence attitudes toward deprescribing. This study aimed to investigate (1) older inpatients' attitudes toward deprescribing; (2) if frailty and complexity of medication regimen influence attitudes and willingness to deprescribe - a relationship that has not been investigated in previous studies.

METHODS

In this cross-sectional study, older adults (≥ 65 years) recruited from general medicine and geriatric services in a New Zealand hospital completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Hospital frailty risk score (HFRS) was calculated using diagnostic codes and other relevant information present at the time of index hospital admission; higher scores indicate higher frailty risk. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI); higher scores indicate greater complexity. Logistic regression analysis was used to identify predictors of attitudes and willingness to deprescribe.

RESULTS

A total of 222 patients were included in the study, the median age was 83 years and 63% were female. One in two patients reported feeling they were taking too many medications, and 1 in 5 considered their medications burdensome. Almost 3 in 4 (73%) wanted to be involved in decision-making about their medications, and 4 in 5 (84%) were willing to stop one or more of their medications if their prescriber said it was possible. Patients with higher MRCI had increased self-reported medication burden (adjusted odds ratio (AOR) 2.6, 95% CI 1.29, 5.29) and were more interested in being involved in decision-making about their medications (AOR 1.8, CI 0.99, 3.42) than those with lower MRCI. Patients with moderate HFRS had lower odds of willingness to deprescribe (AOR 0.45, CI 0.22,0.92) compared to the low-risk group. Female patients had a lower desire to be involved in decision-making. The oldest old age group( > 80 years) had lower self-reported medication burden and were less likely to want to try stopping their medications.

CONCLUSION

Most older inpatients wanted to be involved in decision-making about their medications and were willing to stop one or more medications if proposed by their prescriber. Medication complexity and frailty status influence patients' attitudes toward deprescribing and thus should be taken into consideration when making deprescribing decisions. Further research is needed to investigate the relationship between frailty and the complexity of medication regimens.

The MGPIDP-L project: Potentially inappropriate drug prescribing and its associated factors

OBJECTIVE

The aim of this study was to identify the prevalence of potentially inappropriate drug prescribing¹ (PIDP) using a combination of explicit and implicit criteria in a sample of Lebanese older adults taking 5 or more chronic medications per day in ambulatory care settings and to identify which factors were associated with PIDP. The explicit criteria included five different lists: Beers, Laroche, European Union (EU(7)-PIM list), STOPP/ START, STOPP Frail, and Alert and Mastering of Iatrogenesis issued by the French High Authority of Health. We also performed a sensitivity analysis to compare the potentially inappropriate medications according to each criterion.

METHODS

Data were collected from each patient via a face-to-face interview. Logistic regressions were conducted to evaluate both objectives.

RESULTS

Many factors were positively associated with PIDP. The risk of PIDP was positively associated with age (OR =4.692, 95% CI [1.889-11.655]). Treatment for insomnia doubled the odds of PIDP (P<0.05). Participants who picked their medications from the pharmacy and had excess stock of drugs were at higher risk of having PIDP by 2.042 (95% CI [1.199-3.478]) and 2.965(95% CI [1.133-7.762]) respectively. However, patients with a perception of being heavily medicated and patients with a missed dose in the last two weeks had lower odds of PIDP.

CONCLUSION

Our study showed a high prevalence of PIDP in Lebanon, which is associated with various correlates. Selecting the appropriate tools to assess PIDP and providing patient education regarding the risks associated with potentially inappropriate medications are issues to be addressed among older adults.

Potentially Inappropriate Medication and Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

Inappropriate prescribing in the elderly is a risk factor for higher adverse drugs reactions, hospitalisation, and mortality rates. Therefore, it is necessary to identify irrational prescriptions and implement interventions to improve geriatric clinical practices in nursing homes. This study aimed to examine and compare the prevalence of potentially inappropriate medications in nursing home residents using three different updated criteria: 2019 Beers criteria, PRISCUS list, and v2 STOPP criteria, and to determine the prevalence of potential prescribing omissions according to v2 START criteria. A descriptive, observational, and cross-sectional study design was used. A total of 218 residents were involved in this study. Data on drug use were collected from medical charts. Information was screened with the software CheckTheMeds. Potentially inappropriate medications were present in 96.3%, 90.8%, and 35.3% of residents, according to the STOPP, Beers, and PRISCUS criteria or list, respectively. Inappropriate medication was found to be significantly associated with polypharmacy and severe or moderate drug–drug interactions with the three tools and with pathologies and unnecessary drugs only for STOPP criteria. The most frequent inappropriate medications were benzodiazepines and proton pump inhibitors. A regular use of software to review medications in nursing home residents would help to reduce the risk of these drug-related problems.

Comparison of the prevalence and nature of potentially inappropriate medication use in geriatric outpatients between tertiary and community healthcare settings: a multicenter cross-sectional study

Background Geriatric outpatients with polypharmacy have a high risk of potentially inappropriate medication (PIM) use. Aim To identify differences in both prevalence and patterns of PIMs and drug-related problems (DRPs) in older outpatients who visited the tertiary hospitals (THs) and community health centers (CHCs) and analyze associated factors. Method A prospective cross-sectional study was conducted in five THs and five CHCs from September 2018 to November 2019 in Beijing, China. Data were collected from outpatients aged ≥ 65 years with chronic diseases and polypharmacy. PIMs were evaluated using the 2015 and 2019 Beers Criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria. DRPs were classified using the Helper-Strand DRP Classification. The prevalence and types of PIMs and DRPs were compared, and relevant factors were analyzed. Results The prevalence of PIMs based on the 2015 Beers Criteria was higher in patients from the THs, while PIMs based on the 2019 Beers Criteria did not show a significant difference. PIM prevalence based on STOPP Criteria and DRPs was higher in patients from CHCs. Visiting CHCs was an independent factor of PIMs based on the 2015 Beers Criteria (OR 0.774, 95% CI 0.604-0.992) and the STOPP Criteria (OR 2.427, 95% CI 1.883-3.128), and DRPs (OR 3.612, 95% CI 2.682-4.865). Conclusion Differences in PIM and DRP might be due to the patients and settings. Specific measures to improve the appropriateness of medications in both settings should be used.

Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases

Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.

Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP: A cross-sectional study

Background

Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria.

Objective

To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria^® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care.

Methods

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model.

Results

A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores.

Conclusions

The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.

Potentially inappropriate medications and potentially prescribing omissions in Chinese older patients: Comparison of two versions of STOPP/START

WHAT IS KNOWN AND OBJECTIVE

The aim of this study was to compare the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in elderly Chinese patients identified by the Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) version 2 (v2) and version 1 (v1). The secondary objective was to analyse the risk factors associated with the PIMs/PPOs.

METHODS

This was a retrospective cross-sectional study, and all patients were aged ≥65 years and discharged from internal medical wards of Beijing Chaoyang Hospital in December 2018. STOPP/START v2 and STOPP/START v1 were used to detect PIMs/PPOs. The concordance between the two versions was calculated using kappa tests. A logistic regression analysis was carried out to determine variables independently associated with PIM/PPO use.

RESULTS AND DISCUSSION

In the 662 patients included, the median age was 73 years and 361 were male (54.53%). PIMs were present in 36.1% and 47.7% of participants according to the STOPP v1 and STOPP v2, respectively. The prevalence of PPOs was 42.0% and 64.2% according to the START v1 and START v2, respectively. Drug prescribed without indication was the most common item in PIMs, whereas ACEIs were the drugs most frequently involved with PPOs according to the STOPP/START v2. Two versions of the STOPP criteria indicated a moderate coherence, whereas two versions of the START criteria showed poor accordance. Age (OR 1.029, 1.004-1.054), gender (OR 1.536, 1.103-2.138) and the number of prescribed medications (<5: OR 1; 5-9: OR 2.503, 1.173-5.342; ≥10: OR 4.324, 2.204-9.235) were associated factors with PIMs identified by the STOPP v2, whereas PPOs identified by the START v2 were independently associated with age (OR 1.039, 1.012-1.066), activities of daily living (ADL) score (OR 2.713, 1.818-4.048), the number of prescribed medications (<5: OR 1; 5-9: OR 2.704, 1.524-4.795; ≥10: OR 3.075, 1.704-5.549) and Charlson Comorbidity Index (OR 1.302, 1.110-1.529).

WHAT IS NEW AND CONCLUSION

This study showed a high prevalence of PIMs/PPOs in aged internal medical ward inpatients in China, which was associated with various correlates. The STOPP/START v2 had a higher detection rate than v1.

Efficacy of pharmacists’ assessment and intervention based on Screening Tool for Older Persons’ Appropriate Prescriptions for Japanese compared with Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria version 2 in older patients with cardiovascular disease

AIM

This study aimed to evaluate the efficacy of pharmacists' assessment and intervention using the Screening Tool for Older Persons' Appropriate Prescriptions for Japanese (STOPP-J) to detect and correct potentially inappropriate medications (PIM) compared with the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria version 2.

METHODS

A prospective observational study was carried out at a medical unit of Cardiovascular Surgery and Cardiovascular Internal Medicine in a Japanese university hospital involving new inpatients aged ≥65 years prescribed one or more daily medication. Pharmacists detected PIM based on STOPP-J and STOPP criteria version 2, and corrected them with physicians. The number of patients with PIM, the content and changes in PIM were compared between both criteria.

RESULTS

Overall, 230 patients were included (mean age 75.4 years, 162 men, mean number of medications 8.3). STOPP-J detected significantly more patients with PIM than STOPP criteria version 2 (122 [53%] vs 75 [33%], P < 0.001). The number of PIM based on STOPP-J was 232, the physicians were recommended to change 61 (26%) and 50 (22%) were changed. Meanwhile, the number of PIM based on STOPP criteria version 2 was 133, the physicians were recommended to change 61 (46%) and 54 (41%) were changed. Several medications detected as PIM using STOPP-J were not detected using STOPP criteria version 2.

CONCLUSIONS

STOPP-J detected significantly more patients with PIM than STOPP criteria version 2, and pharmacists' assessment and intervention based on STOPP-J were suggested to be effective for detecting and correcting PIM. Geriatr Gerontol Int 2019; 19: 1101-1107.

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-sectional Study

BACKGROUND

Multimorbidity is a global health problem that is usually associated with polypharmacy, which increases the risk of potentially inappropriate prescribing (PIP). PIP entails higher hospitalization rates and mortality and increased usage of services provided by the health system. Tools exist to improve prescription practices and decrease PIP, including screening tools and explicit criteria that can be applied in an automated manner.

OBJECTIVE

This study aimed to describe the prevalence of PIP in primary care consultations among patients aged 65-75 years with multimorbidity and polypharmacy, detected by an electronic clinical decision support system (ECDSS) following the 2015 American Geriatrics Society Beers Criteria, the European Screening Tool of Older Person's Prescription (STOPP), and the Screening Tool to Alert doctors to Right Treatment (START).

METHODS

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling adults aged 65-75 years (henceforth called young seniors), with multimorbidity (≥3 diseases) and polypharmacy (≥5 medications), who had visited their primary care doctor at least once over the last year at 1 of the 38 health care centers participating in the Multimorbidity and Polypharmacy in Primary Care (Multi-PAP) trial. Sociodemographic data, clinical and pharmacological treatment variables, and PIP, as detected by 1 ECDSS, were recorded. A multivariate logistic regression model with robust estimators was built to assess the factors affecting PIP according to the STOPP criteria.

RESULTS

PIP was detected in 57.0% (338/593; 95% CI 53-61) and 72.8% (432/593; 95% CI 69.3-76.4) of the patients according to the STOPP criteria and the Beers Criteria, respectively, whereas 42.8% (254/593; 95% CI 38.9-46.8) of the patients partially met the START criteria. The most frequently detected PIPs were benzodiazepines (BZD) intake for more than 4 weeks (217/593, 36.6%) using the STOPP version 2 and the prolonged use of proton pump inhibitors (269/593, 45.4%) using the 2015 Beers Criteria. Being a woman (odds ratio [OR] 1.43, 95% CI 1.01-2.01; P=.04), taking a greater number of medicines (OR 1.25, 95% CI 1.14-1.37; P<.001), working in the primary sector (OR 1.91, 95% CI 1.25-2.93; P=.003), and being prescribed drugs for the central nervous system (OR 3.75, 95% CI 2.45-5.76; P<.001) were related to a higher frequency of PIP.

CONCLUSIONS

There is a high prevalence of PIP in primary care as detected by an ECDSS in community-dwelling young seniors with comorbidity and polypharmacy. The specific PIP criteria defined by this study are consistent with the current literature. This ECDSS can be useful for supervising prescriptions in primary health care consultations.

[Pharmaceutical care for older adults. Application of STOPP-START criteria]

INTRODUCTION

Drug-related problems can be caused by potentially inappropriate prescribing (PIP), one of the most used tools for its identification are the STOPP (Older Persons' potentially inappropriate Prescriptions) - START (Screening Tool to Alert doctors to Right Treatment) criteria. The objective of this study is to determine PIP in older adults who receive pharmaceutical care in the Pharmacotherapy Optimization Unit (POU)-Rosario.

MATERIALS AND METHODS

Pharmacoepidemiological observational study, which evaluates the quality of medication use. Workplace: POU-Rosario. Population under study: adults over 60 years of age, who received pharmacotherapy follow-up during the period March 2017 to February 2018. PIPs were identified using the STOPP-START criteria, 2014 version; selecting the most appropriate criteria to assess outpatient pharmacotherapy. Prevalence of PIP and amount of PIP per active principle were estimated.

RESULTS

50 patients older than 60 years received pharmacotherapy follow-up in the POU; 47 patients (94.0%) had at least one PIP corresponding to a STOPP criterion; 17 STOPP criteria were found among the 41 initially selected, leading to 145 PIPs identified. And 7 START criteria among the 11 initially selected, leading to 50 PIPs identified. Medications with a higher amount of PIPs: benzodiazepines and proton pump inhibitors.

CONCLUSIONS

This study allowed the identification of a high prevalence of PIP. The data obtained show the usefulness of these criteria. The STOPP-START criteria have been included to support decision making during pharmacotherapy follow-up to propose pharmaceutical interventions, in order to enhance pharmacotherapy. These activities contribute to patient safety, a dimension of health quality.

Potentially Inappropriate Prescribing and Related Hospital Admissions in Geriatric Patients: A Comparative Analysis between the STOPP and START Criteria Versions 1 and 2

BACKGROUND

Older persons are at significant risk of drug-related admissions (DRAs). We previously demonstrated that 27% of hospitalizations in geriatric patients were associated with potentially inappropriate medicines (PIMs) and/or potential prescribing omissions (PPOs) identified by the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 1 (v₁). The updated STOPP/START criteria version 2 (v₂) comprised a 31% increase in prescribing criteria.

OBJECTIVE

As a secondary analysis of our study conducted in 2008, we aimed to compare the prevalence and types of DRAs identified by STOPP/START.v₁ and STOPP/START.v₂.

METHODS

We applied the STOPP/START.v₂ criteria to a subset of 100 consecutively admitted geriatric patients selected from our original cross-sectional study of 302 patients. A geriatrician and a pharmacist adjudicated whether the identified PIMs and PPOs were related to acute hospitalization. Admissions were defined as DRAs if the identified PIM(s) and/or PPO(s) were related to the main cause of admission or played a significant contributory role in the admission.

RESULTS

The median patient age was 83 years and the median number of medications at home was 8. Compared with STOPP/START.v₁, STOPP/START.v₂ not only yielded more instances of inappropriate prescribing but also targeted significantly more PIMs and PPOs associated with preventable DRAs (23% vs. 40% of all admissions, p < 0.001). PIMs of fall-risk-increasing drugs, and PPOs of musculoskeletal and cardiovascular system drugs, were most frequently associated with DRAs.

CONCLUSION

The latter instances of inappropriate prescribing with major clinical relevance warrant particular attention during medication review in older persons.

Potential prescribing omissions in patients with cardiovascular disease

Aims Potential prescribing omissions (PPOs) of medications are a frequent form of inadequate prescription drug practices. The objective of this study was to identify PPOs in a sample of elderly patients with cardiovascular disease. Methods Quasi-experimental study. Data were collected from a population database. We included patients who were older than 65 years and had a diagnosis of hypertension, dyslipidaemia, diabetes mellitus, coronary heart disease, heart failure or atrial fibrillation in Colombia. PPOs were determined in a random sample of patients by the START-2 (Screening Tool to Alert doctors to Right Treatment) criteria. The impact of the PPO was determined after an educational intervention with the doctors who were responsible for treating said patients. Results A total of 630 patients, with a median age of 72 years (interquartile range: 68-78 years), were included; 56.2% were women. The most frequent diagnoses were arterial hypertension (94.1%, n = 593) and dyslipidaemia (56.5%, n = 356). We identified 100 patients (15.9%) with omissions equalling 139 PPOs, and the most common PPOs were due to a lack of angiotensin-converting enzyme inhibitors in patients associated with heart failure or coronary heart disease (n = 23, 16.5%) and a lack of statins (n = 20; 14.4%) and aspirin (n = 20; 14.4%) in coronary heart disease. Prescription adjustments were achieved in 35 patients (25.2%). Conclusions Potential prescribing omissions are common in elderly patients with cardiovascular disease. Educational interventions may contribute to a reduced PPO frequency and improve the quality of prescription drug administration.

Potentially inappropriate medications among the elderly in primary care in Thailand from three different sets of criteria

Objective:

The primary objective was to examine potentially inappropriate medications (or PIMs) in the elderly using three different criteria: Beers 2015, STOPP version 2, and Winit-Watjana (for Thai elderly patients). The secondary objective was to examine PIM-related factors.

Methods:

This is a retrospective cross-sectional study. Eligible patients were aged ≥65 years in a primary care unit. Demographic data, medical prescriptions in the past year, clinical data and diagnoses were collected from electronic medical records. PIMs, including the use of ≥2 medications, were identified using the three criteria. Descriptive and analytical statistics were conducted. The type I error was 0.05. Multiple logistic regression analysis was used to examine associations between PIMs and other factors.

Results:

A total of 400 patients were recruited, and 1,640 prescriptions were reviewed. The median age was 70.5 years, and the median numbers of diseases, medications, and prescriptions were 3 (interquartile range or IQR=2), 11 (IQR=20), and 3 (IQR=4), respectively. Of all the patients, 213 (53.3%) showed a use of ≥5 medications, and 301 (75.3%) were prescribed PIMs. Of the 1,640 prescriptions, 60% had at least one PIM. The Winit-Watjana criteria, Beers 2015 criteria and STOPP version 2 identified 66.8%, 59.0% and 40.3% of the patients receiving PIMs, respectively. Approximately 16% of the patients showed at least one potential drug-drug interaction. The use of duplicate drug classes accounted for the highest proportion of potential drug-drug interactions (41.3%). Polypharmacy (odds ratio or OR 3.93, 95% confidence interval or 95%CI 2.17-71.2) and the presence of ≥4 diseases (OR 2.78, 95%CI 1.39-5.56) were associated with PIMs.

Conclusions:

PIMs are common among the elderly patients in primary care in Thailand. Prescriptions of the elderly with polypharmacy or multiple concurrent diagnoses should be reviewed for PIMs because they have a high chance of receiving PIMs.

The impact of medication review with version 2 STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria in a French nursing home: a 3-month follow-up study

Background:

Improving medication appropriateness is a priority of French national campaigns in nursing homes. A pilot study was conducted to evaluate the impact of a medication review in a French nursing home with a 3-month follow up.

Method:

A medication review was conducted in 2015 using version 2 STOPP and START criteria. The number and type of drugs meeting a STOPP that were reintroduced and the number and type of drug meeting a START that were stopped during follow up were measured. An expert committee adjudicated whether 3-month hospitalizations and deaths were related to medication review. The impact of medication review on the cost related to drug consumption was calculated for 3 months.

Results:

The 52 residents (age 84 ± 9 years, 83% female) fulfilled, on average, 2 ± 1.4 of the STOPP criteria and 0.7 ± 0.6 of the START criteria. A total of 101 drugs were stopped and 34 drugs were started. Five deaths occurred during follow up and were judged as not related to medication review. Five drugs stopped were reintroduced in five residents for a rebound effect or a symptom occurrence and one resident had stopped a START medication (aspirin) for a minor adverse drug reaction. At 3 months, a gain of 20.21 ± 31.34 euros per resident was observed.

Conclusion:

The medication review using version 2 STOPP and START criteria and involving the physician in charge seems useful for detecting and correcting inappropriate prescribing in a nursing home.

Polypharmacy in older patients at primary care units in Brazil

Background Despite extensive studies of polypharmacy in older patients, no consensus regarding the definition of this practice exists in the literature. Several studies have defined polypharmacy as problematic when considering only the numbers of medications used by patients. Objective This study aimed to assess the prevalence of polypharmacy prescribing by comparing two different definitions (quantitative and qualitative) and evaluating factors associated with this practice in older patients. Setting Twenty-three basic health units. Method A cross-sectional study involving 386 older adults who received a prescription after a medical consultation. Multivariate analyses were conducted using a Poisson regression with robust variance. Main outcome measure The main outcome measures included patients with a prescription of five or more medications (quantitative polypharmacy) and those with a prescription of five or more medications including at least one drug considered potentially inappropriate for older adults (qualitative polypharmacy). Results The frequency of quantitative polypharmacy was 20.5%. The results of an adjusted analysis showed that the frequency of quantitative polypharmacy was associated with a higher number of self-reported morbidities and the prescription of potentially inappropriate drugs. The prevalence of qualitative polypharmacy was 10.4%, and after adjustment, this outcome remained significantly associated with the presence of three or more self-reported morbidities. Conclusions The presence of multiple comorbidities was identified as the main factor associated with the prescription of both quantitative and qualitative polypharmacy.

Medication use in older patients and age-blind approach: narrative literature review (insufficient evidence on the efficacy and safety of drugs in older age, frequent use of PIMs and polypharmacy, and underuse of highly beneficial nonpharmacological strategies)

INTRODUCTION

The importance of rational drug therapy is increasing with the aging of the population. Since one of the main reasons for inappropriate drug prescribing is also the "age-blind" approach, which results in ageist practices, this narrative literature review focuses on the description of the main barriers related to insufficient individualization of drug regimens associated with such age-blind approaches.

METHODOLOGY

A narrative literature review using the PubMed, WoS, Embase, and Scopus databases was conducted by the EU COST Action IS1402. Experts in different scientific fields from six countries (the Czech Republic, Spain, Portugal, Hungary, Serbia, and Turkey) worked in four specific areas: (1) underrepresentation of older adults in clinical trials and clinical and ethical consequences; (2) insufficient consideration of age-related changes and geriatric frailty in the evaluation of the therapeutic value of drugs; (3) frequent prescribing of potentially inappropriate medications (PIMs); and (4) frequent underuse of highly beneficial nonpharmacological strategies (e.g., exercise).

RESULTS

Older patients are underrepresented in clinical trials. Therefore, rigorous observational geriatric research is needed in order to obtain evidence on the real efficacy and safety of frequently used drugs, and e.g. developed geriatric scales and frailty indexes for claims databases should help to stimulate such research. The use of PIMs, unfortunately, is still highly prevalent in Europe: 22.6% in community-dwelling older patients and 49.0% in institutionalized older adults. Specific tests to detect the majority of age-related pharmacological changes are usually not available in everyday clinical practice, which limits the estimation of drug risks and possibilities to individualize drug therapy in geriatric patients before drug prescription. Moreover, the role of some nonpharmacological  strategies is highly underestimated in older adults in contrast to frequent use of polypharmacy. Among nonpharmacological strategies, particularly physical exercise was highly effective in reducing functional decline, frailty, and the risk of falls in the majority of clinical studies.

CONCLUSION

Several regulatory and clinical barriers contribute to insufficient knowledge on the therapeutic value of drugs in older patients, age-blind approach, and inappropriate prescribing. New clinical and observational research is needed, including data on comprehensive geriatric assessment and frailty, to document the real efficacy and safety of frequently used medications.

A Systematic Review of Studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years

BACKGROUND

Polypharmacy remains problematic for individuals ≥65.

OBJECTIVE

To summarise the percentages of patients meeting 2015 STOPP criteria for Potentially Inappropriate Prescriptions (PIPs), 2015 Beers criteria for Potentially Inappropriate Medications (PIMs), and START criteria Potential Prescribing Omissions (PPOs).

METHODS

Searches conducted on 2 January 2019 in Medline, Embase, and PubMed identified 562 studies and 62 studies were retained for review. Data were abstracted independently.

RESULTS

62 studies (n=1,854,698) included two RCTs and 60 non-randomised studies. For thirty STOPP/START studies (n=1,245,974) average percentages for ≥1 PIP weighted by study size were 42.8% for 1,242,010 community patients and 51.8% for 3,964 hospitalised patients. For nineteen Beers studies (n = 595,811) the average percentages for ≥1 PIM were 58% for 593,389 community patients and 55.5% for 2,422 hospitalised patients. For thirteen studies (n=12,913) assessing both STOPP/START and Beers criteria the average percentages for ≥1 STOPP PIP were 33.9% and Beers PIMs 46.8% for 8,238 community patients, and for ≥ 1 STOPP PIP were 42.4% and for ≥1 Beers PIM 60.5% for 4,675 hospitalised patients. Only ten studies assessed changes over time and eight found positive changes.

CONCLUSION

PIP/PIM/PPO rates are high in community and hospitalised patients in many countries. RCTs are needed for interventions to: reduce new/existing PIPs/PIMs/PPO prescriptions, reduce prescriptions causing adverse effects, and enable regulatory authorities to monitor and reduce inappropriate prescriptions in real time. Substantial differences between Beers and STOPP/START assessments need to be investigated whether they are due to the criteria, differential medication availability between countries, or data availability to assess the criteria.

Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study

OBJECTIVE

To determine whether hospital admission is associated with potentially inappropriate prescribing among older primary care patients (aged ≥65 years) and whether such prescribing was more likely after hospital admission than before.

DESIGN

Longitudinal study of retrospectively extracted data from general practice records.

SETTING

44 general practices in Ireland in 2012-15.

PARTICIPANTS

Adults aged 65 years or over attending participating practices.

EXPOSURE

Admission to hospital (any hospital admission versus none, and post-admission versus pre-admission).

MAIN OUTCOME MEASURES

Prevalence of potentially inappropriate prescribing assessed using 45 criteria from the Screening Tool for Older Persons' Prescription (STOPP) version 2, analysed both as rate of distinct potentially inappropriate prescribing criteria met (stratified Cox regression) and binary presence of potentially inappropriate prescribing (logistic regression) and adjusted for patients' characteristics. A sensitivity analysis used matching with propensity scores based on patients' characteristics and diagnoses.

RESULTS

Overall 38 229 patients were included, and during 2012 the mean age was 76.8 (SD 8.2) years and 43% (13 212) were male. Each year, 10.4-15.0% (3015/29 077 in 2015 to 4537/30 231 in 2014) of patients had at least one hospital admission. The overall prevalence of potentially inappropriate prescribing ranged from 45.3% (13 940/30 789) of patients in 2012 to 51.0% (14 823/29 077) in 2015. Independently of age, sex, number of prescription items, comorbidity, and health cover, hospital admission was associated with a higher rate of distinct potentially inappropriate prescribing criteria met; the adjusted hazard ratio for hospital admission was 1.24 (95% confidence interval 1.20 to 1.28). Among participants who were admitted to hospital, the likelihood of potentially inappropriate prescribing after admission was higher than before admission, independent of patients' characteristics; the adjusted odds ratio for after hospital admission was 1.72 (1.63 to 1.84). Analysis of propensity score matched pairs showed a slight reduction in the hazard ratio for hospital admission to 1.22 (1.18 to 1.25).

CONCLUSION

Hospital admission was independently associated with potentially inappropriate prescribing. It is important to determine how hospital admission may affect appropriateness of prescribing for older people and how potential adverse consequences of admission can be minimised.

Hospital readmissions, mortality and potentially inappropriate prescribing: a retrospective study of older adults discharged from hospital

AIMS

Applying version 2 of the STOPP/START criteria to discharge prescriptions of older adults discharged from a general medical unit, the aim of this study is to assess potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) and their association with hospital readmission and mortality.

METHODS

Discharge medications, co-morbidities and patient demographics were recorded over an 8-month period for consecutive emergency admissions of patients aged ≥65 years. PIMs and PPOs were identified using version 2 of the STOPP/START criteria. Multivariate analysis for association of PIMs and PPOs with re-admissions and mortality during the follow-up period were assessed using binary logistic regression.

RESULTS

Data for 259 patients with a mean age of 77 (65-99, 51% female) were analysed. At discharge, the mean number of co-morbidities and medications per patient were 5.4 (SD: 2.1 range: 0-14) and 9.3 (SD: 4.0 range: 1-31) respectively. During the follow-up period (mean 41.5 months, SD: 2.0 range: 38-46 months), 50.2% of patients had died and the median number of readmissions was two (IQR: 1-4 range: 0-33). Prescription of more than five medications was significantly associated with PIMs and PPOs (OR: 2.75, 95% CI: 1.34-5.62 and OR 3.20, 95% CI: 1.57-6.54 respectively). Presence of a PIM was associated with three or more readmissions (OR: 2.43 95% CI: 1.19-4.98) and PPOs with mortality (OR: 1.88, 95% CI: 1.09-3.27).

CONCLUSIONS

Using version 2 of the STOPP/START criteria, the presence of PIMs and/or PPOs in older adults discharged from hospital is significantly associated with repeated hospital admissions and mortality respectively.

Prevalence of potentially inappropriate prescribing in a subpopulation of older European clinical trial participants: a cross-sectional study

OBJECTIVES

To estimate and compare the prevalence and type of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) among community-dwelling older adults (≥65 years) enrolled to a clinical trial in three European countries.

DESIGN

A secondary analysis of the Thyroid Hormone Replacement for Subclinical Hypothyroidism Trial dataset.

PARTICIPANTS

A subset of 48/80 PIP and 22/34 PPOs indicators from the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) V2 criteria were applied to prescribed medication data for 532/737 trial participants in Ireland, Switzerland and the Netherlands.

RESULTS

The overall prevalence of PIP was lower in the Irish participants (8.7%) compared with the Swiss (16.7%) and Dutch (12.5%) participants (P=0.15) and was not statistically significant. The overall prevalence of PPOs was approximately one-quarter in the Swiss (25.3%) and Dutch (24%) participants and lower in the Irish (14%) participants (P=0.04) and the difference was statistically significant. The hypnotic Z-drugs were the most frequent PIP in Irish participants, (3.5%, n=4), while it was non-steroidal anti-inflammatory drug and oral anticoagulant combination, sulfonylureas with a long duration of action, and benzodiazepines (all 4.3%, n=7) in Swiss, and benzodiazepines (7.1%, n=18) in Dutch participants. The most frequent PPOs in Irish participants were vitamin D and calcium in osteoporosis (3.5%, n=4). In the Swiss and Dutch participants, they were bone antiresorptive/anabolic therapy in osteoporosis (9.9%, n=16, 8.6%, n=22) respectively. The odds of any PIP after adjusting for age, sex, multimorbidity and polypharmacy were (adjusted OR (aOR)) 3.04 (95% CI 1.33 to 6.95, P<0.01) for Swiss participants and aOR 1.74 (95% CI 0.79 to 3.85, P=0.17) for Dutch participants compared with Irish participants. The odds of any PPOs were aOR 2.48 (95% CI 1.27 to 4.85, P<0.01) for Swiss participants and aOR 2.10 (95% CI 1.11 to 3.96, P=0.02) for Dutch participants compared with Irish participants.

CONCLUSIONS

This study has estimated and compared the prevalence and type of PIP and PPOs among this cohort of community-dwelling older people. It demonstrated a significant difference in the prevalence of PPOs between the three populations. Further research is urgently needed into the impact of system level factors as this has important implications for patient safety, healthcare provision and economic costs.

Potentially Inappropriate Prescribing in Older Adults with Hypertension or Diabetes Mellitus and Hypertension in a Primary Care Setting in Bahrain

OBJECTIVES

The aims of this study were to evaluate: (1) the prevalence and types of potentially inappropriate prescribing in older adults with hypertension or diabetes mellitus and hypertension, and (2) whether or not differences in the training of primary care physicians were associated with potentially inappropriate prescribing.

MATERIALS AND METHODS

Primary care prescriptions issued by family physicians and general practitioners were audited using Screening Tool of Older Persons' Prescriptions criteria (version 1), with 18 out of 65 applicable criteria. Descriptive statistics were used to test the difference between proportions, and two-tailed t test was used for continuous variables.

RESULTS

A total of 2,090 outpatient prescriptions were written during the study period; of these, 712 (34.1%) were potentially inappropriate. The mean number of drugs per patient was 6.03 (±2.5). Of the 712 prescriptions, 543 (76.3%) were used for the treatment of acute medical illnesses. The most common examples of potentially inappropriate prescribing were: orphenadrine (n = 174; 8.33%), long-term nonsteroidal anti-inflammatory drugs for > 3 months (n = 150; 7.18%), proton pump inhibitors for > 8 weeks (n = 135; 6.46%), antihypertensive therapy duplication (n = 59; 2.82%), long-acting glyburide (n = 48; 2.29%), and chlordiazepoxide for > 1 month (n = 44; 2.11%). Family physicians showed a greater tendency toward potentially inappropriate prescribing compared to general practitioners, but the difference was nonsignificant (n = 514 [34.75%] vs. n = 162 [31.3%]; p = 0.16).

CONCLUSIONS

The prevalence of potentially inappropriate prescribing (i.e., 34.1%) was within the spectrum reported worldwide and unrelated to the training backgrounds of physicians. Most of the identified potentially inappropriate prescribing (76.3%) in older adults was associated with medications for acute medical illnesses and hence inappropriate polypharmacy should be discouraged.