The use of STOPP/START criteria as a screening tool for assessing the appropriateness of medications in the elderly population

Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy

BACKGROUND

Polypharmacy is associated with poorer health outcomes in older adults. Other than the associated multimorbidity, factors contributing to this association could include medication adverse effects and interactions, difficulties in managing complicated medication regimes, and reduced medication adherence. It is unknown how reversible these negative associations may be if polypharmacy is reduced. The purpose of this study was to determine the feasibility of implementing an operationalized clinical pathway aimed to reduce polypharmacy in primary care and to pilot measurement tools suitable for assessing change in health outcomes in a larger randomized controlled trial (RCT).

METHODS

We randomized consenting patients ≥ 70 years old on ≥ 5 long-term medications into intervention or control groups. We collected baseline demographic information and research outcome measures at baseline and 6 months. We assessed four categories of feasibility outcomes: process, resource, management, and scientific. The intervention group received TAPER (team approach to polypharmacy evaluation and reduction), a clinical pathway for reducing polypharmacy using "pause and monitor" drug holiday approach. TAPER integrates patients' goals, priorities, and preferences with an evidence-based "machine screen" to identify potentially problematic medications and support a tapering and monitoring process, all supported by a web-based system, TaperMD. Patients met with a clinical pharmacist and then with their family physician to finalize a plan for optimization of medications using TaperMD. The control group received usual care and were offered TAPER after follow-up at 6 months.

RESULTS

All 9 criteria for feasibility were met across the 4 feasibility outcome domains. Of 85 patients screened for eligibility, 39 eligible patients were recruited and randomized; two were excluded post hoc for not meeting the age requirement. Withdrawals (2) and losses to follow-up (3) were small and evenly distributed between arms. Areas for intervention and research process improvement were identified. In general, outcome measures performed well and appeared suitable for assessing change in a larger RCT.

CONCLUSIONS

Results from this feasibility study indicate that TAPER as a clinical pathway is feasible to implement in a primary care team setting and in an RCT research framework. Outcome trends suggest effectiveness. A large-scale RCT will be conducted to investigate the effectiveness of TAPER on reducing polypharmacy and improving health outcomes.

TRIAL REGISTRATION

clinicaltrials.gov NCT02562352 , Registered September 29, 2015.

Inappropriate Prescriptions in Older People-Translation and Adaptation to Portuguese of the STOPP/START Screening Tool

Inappropriate prescribing, which encompasses the prescription of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), is a common problem for older people. The STOPP/START tool enables general practitioners, who are the main prescribers, to identify and reduce the incidence of PIMs and PPOs and appraise an older patient’s prescribed drugs during the diagnosis process to improve the clinical care quality. This study aimed to translate and validate the STOPP/START screening tool to enable its use by Portuguese physicians. A translation-back translation method including the validation of the obtained Portuguese version was used. Intra- and inter-rater reliability and agreement analyses were used in the validation process. A dataset containing the information of 334 patients was analyzed by one GP twice within a 2-week interval, while a dataset containing the information of 205 patients was independently analyzed by three GPs. Intra-rater reliability assessment led to a Kappa coefficient (κ) of 0.70 (0.65−0.74) for the STOPP criteria and 0.60 (0.52−0.68) for the START criteria, considered to be substantial and moderate values, respectively. The results of the inter-rater reliability rating were almost perfect for all combinations of raters (κ > 0.93). The version of the STOPP/START criteria translated into Portuguese represents an improvement in managing the medications prescribed to the elderly. It provides clinicians with a screening tool for detecting potentially inappropriate prescribing in patients older than 65 years old that is reliable and easy to use.

Evaluation of the reliability of the criteria for assessing prescription quality in Chinese hospitals among pharmacists in China

BACKGROUND

The reliability of Criteria for Assessing Prescription Quality in Chinese Hospitals (CAPQCH) has never been rigorously verified. This study was designed to verify the reliability of the CAPQCH among pharmacists in China.

METHODS

Fourteen pharmacists, 5 from hospitals and 9 from the communities were recruited. We randomly selected 200 prescriptions, and made the testing prescriptions including appropriate and inappropriate testing prescriptions. Pharmacists assessed these testing prescriptions according to criteria in CAPQCH. Three test sets (Set 1, Set 2, and Set 3) were evaluated at 6-month intervals. Before administration of Set 3, pharmacists were informed that achievement on Set 3 would be reflected in their performance appraisal. We also evaluated the performance based on prescription comments before and after combining several confusing criteria. Cohen's Kappa statistic, Fleiss' Kappa statistic, and accuracy were employed to evaluate reliability among pharmacists.

RESULTS

Median values of Cohen's Kappa were 0.61 in Set 1, 0.66 in Set 2, and 0.80 in Set 3; reliability is thus substantial. Our data indicate no significant differences between Set 1 and Set 2, whereas Set 3 indicates significantly improved performance. Moreover, combinations of confusing criteria contributed little to improvement of performance in prescription comments.

CONCLUSION

Our results verified the reliability of CAPQCH application by working pharmacists. Adding performance based on prescription comments to personal appraisals was effective in improving the quality of prescription comments. These findings may be useful when future modification of the CAPQCH is considered. Moreover, this study contributes to improving the understanding of the prescription assessment situation in China.

Geriatrics on beers criteria medications at risk of adverse drug events using real-world data

OBJECTIVES

The established Beers Criteria consider side effects and safety concerns when prescribing drugs to the elderly. As the criteria suggest that attention should be paid toward prescriptions rather than prescription prohibition lists, these Beers Criteria medications (BCMs) are used appropriately under unavoidable circumstances.

METHODS

Patients aged ≥ 65 years and with an experience of being prescribed inappropriate medications at Konyang University Hospital, South Korea, were selected. We analyzed data from the Korea Adverse Event Reporting System (KAERS) and the Food and Drug Administration Adverse Event Reporting System (FAERS) of the United States to identify medication-induced adverse drug events (ADEs). The actual incidence was predicted by multiplying the incidence and number of BCMs prescribed to the patients. The proportional reporting ratio (PRR) and reporting odds ratio (ROR) were calculated using KAERS and FAERS data.

RESULTS

We predicted that the incidence of ADEs would be higher for metoclopramide, chlorpheniramine, and amitriptyline in patients using medications for more than 1 day and metoclopramide, chlorpheniramine, and ketoprofen in patients using medications only for 1 day. Among the ADEs reported to KAERS and FAERS, significant ROR and PRR values were noted for clonazepam (drowsiness), nortriptyline (sleepiness), and zolpidem (amnesia, somnambulism, agitation, dependence, nightmare, and dysgeusia).

CONCLUSION

This study highlighted the actual status of BCM prescriptions in clinical institutions and predicted the incidence of ADEs. We concluded that greater care must be taken while prescribing BCMs to the elderly and indicators, such as PRR and ROR should be monitored regularly.

Potentially inappropriate prescribing according to STOPP-2 criteria among elderly patients in an acute medical department: An observational study of prevalence and predictive factors

OBJECTIVE

The aim of the study was to assess the prevalence and factors associated with potentially inappropriate medication use in elderly patients hospitalized in an acute medical unit.

METHODS

It is a prospective observational study carried out in the acute medical unit of Ibn Sina University Hospital located in Rabat, Morocco. The study sample consisted of all hospitalized patients aged ≥65years. Data collection was performed by a clinical pharmacist during an interview with the patient, at the multidisciplinary team meeting and from the patient's medical records. Medication use was assessed everyday from admission to discharge. The frequency of potentially inappropriate medication (PIM) was evaluated using The Screening Tool of Older Person's Prescriptions (STOPP) criteria version 2.

RESULTS

The study involved 123 elderly inpatients aged 75±7 years old. In total, 55 patients (44.7%) used≥1 PIM. The highest prevalence of PIMs was in relation with concomitant use of two or more drugs with anticholinergic properties (16%). In adjusted multivariate analysis, the following parameters were independently associated with PIM use: length of stay at the acute medical unit (OR 1.12; 95% CI 1.00-1.20), and number of pre-admission drugs (OR 1.30; 95% CI 1.00-1.60).

CONCLUSION

Half of the elderly population received at least one PIM identified by the STOPP criteria. Inadequacy of prescription was associated with the number of pre-admission drugs and the length of stay. Assessing medication during conciliation and enhanced drugs monitoring at discharge especially for patients with a longer stay can be an important strategy for minimizing PIM use.

Study of pharmacist intervention in polypharmacy among older patients: Non-randomized, controlled trial

AIM

We investigated the outcomes of interdisciplinary drug therapy interventions by pharmacists among older residents of special elderly nursing homes.

METHODS

The study was designed as a non-randomized, parallel-group, controlled study. Four nursing homes were allocated in a 1:1 ratio to an intervention group (IG) or control group (CG). The participants of the study were residents taking five or more medications. The nursing homes in the IG were each visited by one pharmacist, who was charged with looking for potential problems in drug therapy. Activities in the CG were carried out as usual. The intervention period was 6 months. The primary end-points were the incidences of potentially inappropriate medication (PIM) and falls. The mean difference and proportion of participants were compared between groups.

RESULTS

Data from 28 participants in the IG and 27 participants in the CG were analyzed. The number of PIM decreased from 2.64 at baseline to 2.39 after 6 months in the IG (P = 0.032). The proportion of participants in whom the use of PIM was reduced without problems was 17.9% in the IG and 3.7% in the CG (P = 0.094). The mean number of falls was 0.04 in the IG and 0.41 in the CG (P = 0.033). Falls occurred in 3.6% of participants in the IG and 22.2% of participants in the CG (P = 0.043).

CONCLUSIONS

The results suggested a trend toward fewer PIM and falls in the IG. Geriatr Gerontol Int 2019; ••: ••-••.

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study

Objectives

To provide baseline information on inappropriate prescribing (IP), and to evaluate whether potentially inappropriate medications (PIMs), as defined by STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, were associated with preventable adverse drug events (ADEs) and/or hospitalization.

Methods

We prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.

Results

IP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1–1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20–25.3).

Conclusion

The majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.

The Care Home Independent Prescribing Pharmacist Study (CHIPPS)-a non-randomised feasibility study of independent pharmacist prescribing in care homes

BACKGROUND

Residents in care homes are often very frail, have complex medicine regimens and are at high risk of adverse drug events. It has been recommended that one healthcare professional should assume responsibility for their medicines management. We propose that this could be a pharmacist independent prescriber (PIP). This feasibility study aimed to test and refine the service specification and proposed study processes to inform the design and outcome measures of a definitive randomised controlled trial to examine the clinical and cost effectiveness of PIPs working in care homes compared to usual care. Specific objectives included testing processes for participant identification, recruitment and consent and assessing retention rates; determining suitability of outcome measures and data collection processes from care homes and GP practices to inform selection of a primary outcome measure; assessing service and research acceptability; and testing and refining the service specification.

METHODS

Mixed methods (routine data, questionnaires and focus groups/interviews) were used in this non-randomised open feasibility study of a 3-month PIP intervention in care homes for older people. Data were collected at baseline and 3 months. One PIP, trained in service delivery, one GP practice and up to three care homes were recruited at each of four UK locations. For ten eligible residents (≥ 65 years, on at least one regular medication) in each home, the PIP undertook management of medicines, repeat prescription authorisation, referral to other healthcare professionals and staff training. Outcomes (falls, medications, resident's quality of life and activities of daily living, mental state and adverse events) were described at baseline and follow-up and assessed for inclusion in the main study. Participants' views post-intervention were captured in audio-recorded focus groups and semi-structured interviews. Transcripts were thematically analysed.

RESULTS

Across the four locations, 44 GP practices and 16 PIPs expressed interest in taking part; all care homes invited agreed to take part. Two thirds of residents approached consented to participate (53/86). Forty residents were recruited (mean age 84 years; 61% (24) were female), and 38 participants remained at 3 months (two died). All GP practices, PIPs and care homes were retained. The number of falls per participating resident was selected as the primary outcome, following assessment of the different outcome measures against predetermined criteria. The chosen secondary outcomes/outcome measures include total falls, drug burden index (DBI), hospitalisations, mortality, activities of daily living (Barthel (proxy)) and quality of life (ED-5Q-5 L (face-to-face and proxy)) and selected items from the STOPP/START guidance that could be assessed without need for clinical judgement. No adverse drug events were reported. The PIP service was generally well received by the majority of stakeholders (care home staff, GPS, residents, relatives and other health care professionals). PIPs reported feeling more confident implementing change following the training but reported challenges accommodating the new service within their existing workload.

CONCLUSION

Implementing a PIP service in care homes is feasible and acceptable to care home residents, staff and clinicians. Findings have informed refinements to the service specification, PIP training, recruitment to the future RCT and the choice of outcomes and outcome measures. The full RCT with internal pilot started in February 2016 and results are expected to be available in mid late 2020.

The Care Home Independent Prescribing Pharmacist Study (CHIPPS)-a non-randomised feasibility study of independent pharmacist prescribing in care homes

BACKGROUND

Residents in care homes are often very frail, have complex medicine regimens and are at high risk of adverse drug events. It has been recommended that one healthcare professional should assume responsibility for their medicines management. We propose that this could be a pharmacist independent prescriber (PIP). This feasibility study aimed to test and refine the service specification and proposed study processes to inform the design and outcome measures of a definitive randomised controlled trial to examine the clinical and cost effectiveness of PIPs working in care homes compared to usual care. Specific objectives included testing processes for participant identification, recruitment and consent and assessing retention rates; determining suitability of outcome measures and data collection processes from care homes and GP practices to inform selection of a primary outcome measure; assessing service and research acceptability; and testing and refining the service specification.

METHODS

Mixed methods (routine data, questionnaires and focus groups/interviews) were used in this non-randomised open feasibility study of a 3-month PIP intervention in care homes for older people. Data were collected at baseline and 3 months. One PIP, trained in service delivery, one GP practice and up to three care homes were recruited at each of four UK locations. For ten eligible residents (≥ 65 years, on at least one regular medication) in each home, the PIP undertook management of medicines, repeat prescription authorisation, referral to other healthcare professionals and staff training. Outcomes (falls, medications, resident's quality of life and activities of daily living, mental state and adverse events) were described at baseline and follow-up and assessed for inclusion in the main study. Participants' views post-intervention were captured in audio-recorded focus groups and semi-structured interviews. Transcripts were thematically analysed.

RESULTS

Across the four locations, 44 GP practices and 16 PIPs expressed interest in taking part; all care homes invited agreed to take part. Two thirds of residents approached consented to participate (53/86). Forty residents were recruited (mean age 84 years; 61% (24) were female), and 38 participants remained at 3 months (two died). All GP practices, PIPs and care homes were retained. The number of falls per participating resident was selected as the primary outcome, following assessment of the different outcome measures against predetermined criteria. The chosen secondary outcomes/outcome measures include total falls, drug burden index (DBI), hospitalisations, mortality, activities of daily living (Barthel (proxy)) and quality of life (ED-5Q-5 L (face-to-face and proxy)) and selected items from the STOPP/START guidance that could be assessed without need for clinical judgement. No adverse drug events were reported. The PIP service was generally well received by the majority of stakeholders (care home staff, GPS, residents, relatives and other health care professionals). PIPs reported feeling more confident implementing change following the training but reported challenges accommodating the new service within their existing workload.

CONCLUSION

Implementing a PIP service in care homes is feasible and acceptable to care home residents, staff and clinicians. Findings have informed refinements to the service specification, PIP training, recruitment to the future RCT and the choice of outcomes and outcome measures. The full RCT with internal pilot started in February 2016 and results are expected to be available in mid late 2020.

Pharmacist intervention acceptance for the reduction of potentially inappropriate drug prescribing in acute psychiatry

Background Prescribing for the elderly is challenging. A previous observational study conducted in our geriatric psychiatry admission unit (GPAU) using STOPP/START criteria showed a high number of potentially inappropriate drug prescriptions (PIDPs). A clinical pharmacist was added to our GPAU as a strategy to reduce PIDPs. Objective The objective of the present study was to assess the impact of a clinical pharmacist on PIDPs by measuring acceptance rates of pharmacist interventions (PhIs). Setting This study was conducted at the GPAU of Lausanne University Hospital. Method The clinical pharmacist attended four GPAU meetings weekly. Complete medication reviews were performed daily. The clinical pharmacist conducted standard analyses based on clinical judgment and STOPP/START criteria assessment. A PhI was generated when a PIDP was detected. When a PhI was accepted, the PIDP was considered as eliminated. Acceptance rate of PhI was calculated (number of PhI accepted/total number of PhI). Main outcome measure PhIs acceptance rates. Results In a cohort of 102 patients seen between July 2013 and February 2014, a total of 697 PhIs (average 6.8/patient) were made based on standard evaluation (n = 479) and STOPP/START criteria (n = 243). The global acceptance rate was 68% (standard, 78%; STOPP/START, 47%). Conclusion Good PhIs acceptance rates demonstrated that a clinical pharmacist can reduce PIDPs in a GPAU. PhIs based on standard evaluation had a higher acceptance than those based on STOPP/START criteria, probably because they are better adapted to individual patients. However, these two evaluation approaches can be used in a complementary manner.

Prevalence and predictors of potentially inappropriate prescribing of central nervous system and psychotropic drugs among elderly patients: A national population study in Korea

OBJECTIVES

To investigate the prevalence of potentially inappropriate prescribing (PIP) of central nervous system and psychotropic (CNS-PS) drugs to the Korean elderly population, and to identify PIP-associated factors.

METHODS

Ambulatory care visits were identified from the 2013 National Aged Patient Sample (HIRA-APS-2013) data, composed of 20% random samples of all enrollees in the universal health security program aged ≥65 years. The CNS-PS section of Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) criteria version 2 was used to identify PIP at these visits.

RESULTS

A total of 24,427,069 prescription claims records and 1,122,080 patients were included in the study; 10.73% of the claims and 53.64% of the patients satisfied at least one STOPP criterion in the prescription of CNS-PS drugs. The highest prevalence of PIP was observed for the criteria of "first-generation antihistamines" (FGAH), followed by tricyclic antidepressants (TCA) in patients with prostatism and TCA in patients with dementia. The generalized estimating equation logistic regression analysis showed that the PIP of FGAH was significantly associated with polypharmacy (5-9 drugs: odds ratio (OR) 4.965, 95% confidence interval (CI) 4.936-4.994; ≥10 drugs: OR 5.704, 95% CI 5.604-5.807), less severe health conditions (Charlson Comorbidity Index (CCI)=2: OR 0.852, 95% CI 0.842-0.862; CCI=1: OR 0.975, 95% CI 0.964-0.986), prescriptions from clinics (OR>1.0), and outpatient care by general practitioners (OR>1.0).

CONCLUSIONS

Appropriate interventions to reduce PIP should be made, especially for the criteria that indicate a high PIP prevalence. Targeted strategies are necessary to modify the risk factors of PIP identified from this study.

Impact of hospitalization in an acute geriatric unit on polypharmacy and potentially inappropriate prescriptions: A retrospective study

AIM

Polypharmacy is a highly prevalent geriatric syndrome, and hospitalizations can worsen it. The aim of the present study was to analyze the influence of hospitalization on polypharmacy and indicators of quality of prescribing, and their possible association with health outcomes.

METHODS

A retrospective study of 200 patients discharged from an acute geriatric unit was carried out. Indicators of quality of prescription were registered at admission and discharge: polypharmacy defined as ≥5 medications, hyperpolypharmacy (≥10), potentially inappropriate prescribing by Beers and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, potentially prescribing omissions by Screening Tool to Alert doctors to the Right Treatment (START) criteria, drug interactions and anticholinergic burden measured with the Anticholinergic Risk Scale. Mortality, emergency room visits and hospital admissions occurring during 6 months after discharge were also registered.

RESULTS

The total number of drugs increased at discharge (9.1 vs 10.1, P < 0.001), without increasing chronic medications (8.5 vs 8.3, P = 0.699). No significant variations were observed in the prevalence of polypharmacy (86.5% vs 82.2%), potentially inappropriate prescribing (68.5% vs 71.5%), potential prescribing omissions (58% vs 58%) or drug interactions (82.5% vs 83.5%). Patients with anticholinergic drugs tended to increase, not reaching statistical significance (39.5% vs 44.5%; P = 0.064). Polypharmacy was associated with emergency room visits (OR 2.62, 95% CI 1.07-6.40; P = 0.034), and hyperpolypharmacy with hospitalizations (OR 2.49, 95% CI 1.25-4.93; P = 0.009).

CONCLUSIONS

After hospitalization in an acute geriatric unit, the prevalence of polypharmacy, potentially inappropriate prescribing, potential prescribing omissions, interactions or anticholinergic drugs is still very high. Polypharmacy is a risk factor for hospitalization and emergency room visits. Measuring indicators of quality of prescription might be useful to design interventions to optimize pharmacotherapy and improve health outcomes in elderly acute patients. Geriatr Gerontol Int 2017; 17: 2354-2361.

Drug prescription appropriateness in the elderly: an Italian study

Purpose

Correct drug prescription in the elderly is a difficult task that requires careful survey of the current pharmacological therapies. In this article, we reviewed the drug prescriptions provided to 860 persons aged 65 years or over, residing in a small city of Lombardy, Italy.

Methods

Subjects were recruited from a local nursing home, the Pavia and Vigevano Neuropsychological Center for Alzheimer’s Disease, general practitioners’ offices, and the local University of the Third Age. For each patient, the amount of potentially inappropriate prescriptions (PIPs), sedative and anticholinergic load (SL and AL, respectively), and drug–drug interactions were evaluated.

Results

Widespread polypharmacy, giving rise to 10.06% of PIPs in the whole collection of prescriptions, was observed. In particular, PIPs mainly concern drugs acting at the central nervous system level, mostly benzodiazepines and antipsychotics. Moreover, approximately one-fourth of the subjects had an elevated SL and approximately one-tenth a high AL. Drug–drug interactions were frequent (266 requiring medical attention), up to five for each single patient. Of concern was the underuse of antidementia drugs: only 20 patients received a cholinesterase inhibitor or memantine, although 183 patients were potentially suitable for this treatment.

Conclusion

These results demonstrate the need to develop novel strategies aimed at improving the quality of drug prescription.

Patients Aged 80 Years or Older are Encountered More Potentially Inappropriate Medication Use

Background:

Polypharmacy and potentially inappropriate medications (PIMs) are prominent prescribing issues in elderly patients. This study was to investigate the different prevalence of PIM use in elderly inpatients between 65–79 years of age and 80 years or older, who were discharged from Geriatric Department in West China Hospital.

Methods:

A large-scale cohort of 1796 inpatients aged 65 years or over was recruited. Respectively, 618 patients were 65–79 years and 1178 patients were 80 years or older. Updated 2012 Beers Criteria by the American Geriatric Society was applied to assess the use of PIM among the investigated samples.

Results:

A review of the prescribed medications identified 686 patients aged 80 years or older consumed at least one PIM giving a rate of 58.2%. Conversely, 268 (43.4%) patients aged 65–79 years consumed at least one PIM (χ² = 40.18, P < 0.001). Patients aged 80 years or older had higher hospitalization expenses, length of stay, co-morbidities, medical prescription, and mortality than patients aged 65–79 years (all with P < 0.001). Patients aged 80 years or older were prescribed with more benzodiazepines, drugs with strong anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin. In multiple regression analysis, PIM use was significantly associated with female gender, age, number of diagnostic disease, and number of prescribed medication.

Conclusions:

The finding from this study revealed that inpatients aged 80 years or older encountered more PIM use than those aged 65–79 years. Anticholinergic properties, megestrol, antipsychotics, theophylline, and aspirin are medications that often prescribed to inpatients aged 80 years or older. Doctors should carefully choose drugs for the elderly, especially the elderly aged 80 years or older.

Monitoring Polypharmacy in Healthcare Systems Through a Multi-Setting Survey: Should We Put More Attention on Long Term Care Facilities?

Background

Polypharmacy is a main issue of patient safety in all healthcare settings (i.e. increase adverse drug reactions and incidence of drug-drug interactions, etc.). The main object of the study was to evaluate the prevalence of polypharmacy and the appropriateness of drugs prescriptions in the regional health system (RHS) of Friuli Venezia-Giulia Region, Italy.

Design and methods

We carried out a point prevalence study in May 2014; 1582 patients ≥65 years were included from: 14 acute hospitals, 46 Long Term Care Facilities (LTCFs) and 42 general practitioners’ (GPs) clinics. Data analysis included the evaluation of potentially inappropriate prescriptions (PIPs) taking Beers criteria as a reference.

Results

Patients in therapy with 10 drugs or more were 13.5%: 15.2% in hospitals, 9.7% in GPs’ clinics and 15.6% in LTCFs. According to Beers criteria we identified 1152 PIPs that involved globally almost half of patients (46.0%): 41.9% in hospitals, 59.6% in LTCFs and 37.0% in GP’s clinics. The 53.9% of patients received at least one mainly kidney excreted drug; for these patients the evaluation of serum creatinine was overall present in the 87.7% (747/852): 96.4% in hospital ones, 87.5% in GPs’ clinics and 77.8% in LTCFs. LTCFs residents were significantly (P<0.05) more exposed to PIPs and less monitored for the renal function.

Conclusions

A reliable estimation of the phenomenon in all the main healthcare settings is a necessary prerequisite to set tailored policies for facing polypharmacy within a RHS; the results showed the necessity to put a special attention on LTCFs.

Long-Term Outcomes of Medication Intervention Using the Screening Tool of Older Persons Potentially Inappropriate Prescriptions Screening Tool to Alert Doctors to Right Treatment Criteria

OBJECTIVES

To compare 24-month outcomes of participants of a prospective randomized controlled trial (RCT) assigned to undergo a medication intervention of orally communicated recommendations based on Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) (intervention group) with outcomes of those assigned to undergo written medication review (control group).

DESIGN

Retrospective cohort study.

SETTING

Chronic care geriatric facility.

PARTICIPANTS

Of 359 participants from a prospective RCT conducted between April 2012 and September 2013, 306 were evaluable for another 12-month follow-up.

MEASUREMENTS

Outcomes at 24-month follow-up included quality of prescribing (assessed according to STOPP/START), hospitalizations, falls, costs of medications, and all-cause mortality. Outcomes were compared with those reported at the beginning (baseline) and end (12-month follow-up) of the RCT.

RESULTS

There was a significant rise in potentially inappropriate prescriptions (PIPs) (P = .01) and potentially prescriptions omissions (PPOs) (P < .001) in the intervention group between 12 and 24 months, although the prevalence of PIPs was significantly lower in the intervention group (33.3%) than the control group (48.4%) at 24-month follow-up (P = .02). Costs of medications were significantly lower in the intervention group than the control group (P < .001) at 24-month follow-up. The average number of falls in both groups dropped significantly between baseline and study closure (P = .04 and P = .008, respectively). There was no significant difference in hospitalizations and mortality between the two groups at 24-month follow-up.

CONCLUSION

The effect of an orally communicated medication intervention with the STOPP/START criteria on falls was maintained over time. Direct communication between pharmacists and prescribing physicians is more efficient than written medication review and is recommended every 6 months in geriatric facilities.

Potentially inappropriate prescribing according to the STOPP/START criteria for older adults

BACKGROUND

The aim of this study was to demonstrate the prevalence and possible predictors of potentially inappropriate medications (PIMs) and potentially prescription omissions (PPOs) according to the Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria in geriatric patients.

METHODS

A total of 374 patients (140 male, 234 female) aged ≥65 years were included. Comprehensive demographic and clinical data including age, gender, current diagnoses/medications, comorbid diseases and medical problems were noted.

RESULTS

There were 154 (41.2 %) patients with at least one PIM. Most common PIMs were proton pump inhibitors for peptic ulcer disease (9.6 %), calcium-channel blockers (6.4 %) and anticholinergic/antispasmodic drugs (5.9 %) in chronic constipation. There were 274 (73.3 %) patients with at least one PPO. Most common PPOs were calcium-vitamin D supplement in osteoporosis (OP) (39.6 %), statin (22.5 %) and antiplatelet therapies (16.0 %) in diabetes mellitus (DM) with cardiovascular risk factors. PIM was independently associated with female gender (OR = 2.21, p = 0.003), number of medications (OR = 1.35, p < 0.001), Katz scores of daily life activities (OR = 0.87, p = 0.013) and OP (OR = 0.29, p < 0.001). PPO was independently associated with age (OR = 1.06, p = 0.009), Geriatric Depression Scale score (OR = 1.20, p = 0.007), DM (OR = 6.50, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 5.29, p = 0.010), number of medications (OR = 0.88, p = 0.019), and incontinence (OR = 0.39, p = 0.043).

CONCLUSION

High prevalence of PIMs and PPOs were found in geriatric patients. Number of medications, female gender, and dependency were associated with PIM. Age, higher scores of Geriatric Depression Scale, DM, and COPD were related with PPOs.

Risk Factors Associated with the Requirement for Pharmaceutical Intervention in the Hospital Setting: A Systematic Review of the Literature

Background

A number of methods exist for the risk assessment of hospital inpatients to determine the likelihood of patients experiencing drug-related problems (DRPs), including manual review of a patient’s medication (medication reviews) and more complex electronic assessment using decision support alerts in electronic prescribing systems. A systematic review was conducted to determine the evidence base for potential risks associated with adult hospital inpatients that could not only lead to medication-related issues but might also be directly associated with pharmacist intervention.

Objectives

The aims were to perform a systematic review of the literature in order to (1) identify all measurable risk factors associated with adult hospital inpatients that potentially lead to a pharmaceutical intervention; (2) critically evaluate the quality of the identified research; and (3) further subcategorise potential risk factors, so that pharmaceutical services may be targeted to patients “at risk” by identifying potential risk factors in a patient’s electronic hospital record.

Methods

A systematic review, conducted in June 2013, searched ten medical literature databases for all papers identifying risks leading to pharmacist interventions or DRPs, adverse drug events (ADEs), adverse drug reactions, drug errors (where not included in the definition of an ADE), and medication-related problems. The search identified 7720 titles, from which 120 papers were sourced. A hand search of a further 11 journals was also performed. No date restrictions were imposed. All primary research and literature reviews were included. Summary articles were excluded with the exception of literature reviews. The inclusion of search outputs was validated by a third party pharmacy research graduate.

Results

From the 7720 titles, 38 publications met the inclusion criteria for the review. The ten most frequently reported risk factors associated with medication-related issues that may potentially lead to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): prescription of certain drugs or classes of drugs, polypharmacy, elderly patients (defined as over 65 years), female gender, poor renal function, the presence of multiple comorbidities, length of patient stay, history of drug allergy or sensitivity, patient compliance issues, and poor liver function. The ten classes of drugs most frequently reported to be associated with medication-related issues leading to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): intravenous antimicrobials, thrombolytics/anticoagulants, cardiovascular agents, central nervous system agents, corticosteroids, diuretics, chemotherapy, insulin/hypoglycaemics, opiates, and anti-epileptics.

Conclusion

Review of the literature identified 38 papers, from which the ten most frequently reported risk factors linked with factors that are potentially associated with hospital pharmaceutical interventions (all definitions included) were identified. No papers were identified that demonstrated a direct causal relationship between a potential risk factor and hospital pharmaceutical interventions. All of the potential risk factors associated with problems with the use of medicines can be identified from patient records on admission to hospital. These risk factors may be used to identify patients at risk, with a view to targeting pharmaceutical intervention in order to minimise risks of problems with medicines and improve efficiency of clinical pharmacy services.

Polytherapy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in three different settings (hospital, community, long-term care facilities) of the Friuli Venezia Giulia region, Italy: are the very elderly at higher risk of PIPs?

PURPOSE

The aim of this point-prevalence study was to assess the occurrence of polypharmacy and hyperpolypharmacy and the risk of potentially inappropriate prescriptions (PIPs) among elderly and very elderly patients in different health-care settings of the Friuli-Venezia Giulia region in the North-East of Italy.

METHODS

Prescription pattern of elderly (65-79 years) and very elderly (>79 years) patients in three different health-care settings [hospitals, general practitioners, and long-term care facilities (LTCFs)] was assessed in March 2014, and PIPs were assessed according to the Beers criteria. Other situations at potentially high risk were checked.

RESULTS

A total of 1582 patients (hospital, n = 528; outpatients, n = 527; nursing homes, n = 527) were included. Very elderly were more represented in hospitals (60.4%) and LTCFs (77.1%) than among general practitioners (37.6%). Polypharmacy and hyperpolypharmacy rates ranged 57.7-73.7% and 9.7-15.6%, respectively. The most frequently prescribed drugs were the proton pump inhibitors, whereas the most common PIPs resulted the benzodiazepines. Multinomial regression analysis showed that female sex, age > 79 years, hyperpolypharmacy, and chronic kidney disease were associated with the risk of having ≥2 PIPs. Two situations at high risk of PIPs not contemplated by the Beers criteria were recurrent in the study population and concerned the statins and metformin.

CONCLUSIONS

Polypharmacy and hyperpolypharmacy among elderly and very elderly are strictly associated with the risk of multiple PIPs. The findings offer the opportunity to remark that improvement of the knowledge of safe drug use is generally needed in aging societies and may become of utmost relevance among health-care workers operating in LTCFs. Copyright © 2016 John Wiley & Sons, Ltd.

[Interventions to optimize pharmacologic treatment in hospitalized older adults: a systematic review]

OBJECTIVE

To summarise the evidence on interventions aimed at optimising the drug treatment of hospitalised elderly patients.

MATERIAL AND METHODS

We conducted a search in the main medical literature databases, selecting prospective studies of hospitalised patients older than 65 years who underwent interventions aimed at optimising drug treatment, decreasing polypharmacy and improving the medication appropriateness, health outcomes and exploitation of the healthcare system.

RESULTS

We selected 18 studies whose interventions consisted of medication reviews, detection of predefined drugs as potentially inappropriate for the elderly, counselling from a specialised geriatric team, the use of a computer support system for prescriptions and specific training for the nursing team. Up to 14 studies assessed the medication appropriateness, 13 of which showed an improvement in one or more of the parameters. Seven studies measured the impact of the intervention on polypharmacy, but only one improved the outcomes compared with the control. Seven other studies analysed mortality, but none of them showed a reduction in that rate. Only 1 of 6 studies showed a reduction in the number of hospital readmissions, and 1 of 4 studies showed a reduction in the number of emergency department visits.

CONCLUSIONS

Despite the heterogeneity of the analysed interventions and variables, we obtained better results in the process variables (especially in medication appropriateness) than in those that measured health outcomes, which had greater variability.

Detection of potentially inappropriate prescribing in the very old: cross-sectional analysis of the data from the BELFRAIL observational cohort study

BACKGROUND

Little is known about the prevalence and clinical importance of potentially inappropriate prescribing instances (PIPs) in the very old (>80 years). The main objective was to describe the prevalence of PIPs according to START (Screening Tool to Alert doctors to Right Treatment; omissions) and,STOPP (Screening Tool of Older Person's Prescriptions; over/misuse) and the Beers list (over/misuse). Secondary objectives were to identify determinants if PIPs and to assess the clinical importance to modify the treatment in case of PIPs.

METHODS

Cross-sectional analysis of baseline data of the BELFRAIL cohort, which included 567 Belgian patients aged 80 and older in primary care. Two independent researchers applied the screening tools to the study population to detect PIPs. Next, a multidisciplinary panel of experts rated the clinical importance of the PIPs on a subsample of 50 patients.

RESULTS

In this very old population (median age 84 years, 63 % female), the screening detected START-PIPs in 59 % of patients, STOPP-PIPs in 41 % and Beers-PIPs in 32 %. Assessment of the clinical importance revealed that the most frequent PIPs were of moderate or major importance. In 28 % of the subsample, the relevance of the PIP was challenged by the global medical, functional and social background of the patient hence the validity of some criteria was questioned.

CONCLUSION

Potentially inappropriate prescribing is highly prevalent in the very old. A good understanding of the patients' medical, functional and social context is crucial to assess the actual appropriateness of drug treatment.

[Improving drug prescribing in the elderly: a new edition of STOPP/START criteria]

Inappropriate use of drugs in older patients may have an adverse impact on several individual health outcomes, such as increasing the prevalence of adverse drug reactions, morbidity and mortality, and geriatric syndromes, as well as on health care systems, such as increased costs and longer hospital stays. Explicit criteria of drug appropriateness are increasingly used to detect and prevent inappropriate use of drugs, either within a comprehensive geriatric assessment or as tool used by different multidisciplinary geriatric teams. STOPP-START criteria, first published in 2008 (in Spanish in 2009), are being adopted as reference criteria throughout Europe. The Spanish version of the new 2014 edition (recently published in English) of the STOPP-START criteria is presented here. A review of all the papers published in Spain using the former version of these criteria is also presented, with the intention of promoting their use and for research in different health care levels.

A comparison of estimated drug costs of potentially inappropriate medications between older patients receiving nurse home visit services and patients receiving pharmacist home visit services: a cross-sectional and propensity score analysis

Background

There have been no multicenter studies that estimated the relations of either nurse or pharmacist home visit program to drug costs of potentially inappropriate medications (PIMs). This study aimed to establish whether patients who used nurse or pharmacist home visit programs (nurse or pharmacist program) had lower drug costs of PIMs than those who did not use nurse or pharmacist programs for older patients living at home.

Methods

This cross-sectional study was conducted in home care settings in Japan, involving 430 patients aged 65 or older, of whom 276 were female. All received regular home visits from five clinics between May and December 2013. After the PIMs were identified with the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, we estimated the drug costs based on actual pharmaceutical prices and measured against who using nurse or pharmacist programs after a propensity score weighted adjustment.

Results

Patients who used nurse programs had lower drug cost of PIMs than those who did not use, but it was not significantly different (5.9 ± 13.1 vs 7.1 ± 13.9 USD per month, P = 0.199). The cost of PIMs for patients who used pharmacist programs also had no difference. (7.2 ± 14.5 vs 5.5 ± 11.5 USD per month, P = 0.06). In the patient groups who used nurse programs, patients who also used pharmacist programs had significantly higher costs of PIMs than those who used only nurse programs (5.5 ± 13.9 vs 2.5 ± 6.0 USD per month, P = 0.006). In patients group who did not use pharmacist programs, patients who only used nurse programs had significantly lower costs of PIMs than those who did not use nurse programs (3.6 ± 7.7 vs 5.8 ± 12.7 USD per month, P = 0.022).

Conclusions

Patients who used nurse program have a trend towards lower drug costs of PIMs than those who used nurse and pharmacist program or pharmacist program alone. Although this study tried to adjust the potential confounders as possible as we could by using propensity score analysis, further studies are needed to confirm our results.

Conceptualizing and measuring potentially inappropriate drug therapy

WHAT IS KNOWN AND OBJECTIVE

Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice.

METHODS

A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT.

RESULTS AND DISCUSSION

From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1  = 0·479) and substantial for abstracts (κ2  = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature.

WHAT IS NEW AND CONCLUSION

This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.

The impact of hospitalization on potentially inappropriate prescribing in an acute medical geriatric division

BACKGROUND

Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) have been increasingly used to evaluate potentially inappropriate prescriptions (PIPs) and potentially prescription omissions (PPOs). The impact of hospitalization on PIPs/PPOs has not been investigated in depth.

OBJECTIVE

To compare the prevalence of PIPs/PPOs in elderly patients on hospital admission and discharge and to identify associated risk factors.

SETTING

An acute medical geriatric division of the Tel Aviv Medical Center (Israel).

METHOD

This retrospective cross-sectional study included patients admitted from 12/2011 to 12/2012 aged ≥65 years. Data from patients' records included demographic details, diagnoses and medications at admission and discharge. STOPP/START criteria were applied to each patient's record.

MAIN OUTCOME MEASURE

Prevalence of PIPs/PPOs on hospital admission and discharge.

RESULTS

Three hundred patients were included (mean ± SD age 81.9 ± 7.2 years). Admission PIPs prevalence was 39.3 % (118 patients, 172 PIPs) and it increased to 46.0 % (138 patients, 209 PIPs) at discharge (P = 0.009). Admission PPOs prevalence was 41.0 % (123 patients, 153 PPOs) and it decreased to 28.3 % (85 patients, 99 PPOs) at discharge (P < 0.001). Having at least one PIP/PPO at discharge but not at admission was associated with length of hospital stay (OR 1.02, 95 % CI 1.001-1.03). History of falls increased the risk of being a "new PIP patient" (OR 2.25, 95 % CI 1.03-4.9), whereas diabetes increased the risk of being a "new PPO patient" (OR 3.86, 95 % CI 1.2-12.5).

CONCLUSION

Hospitalization in a geriatric division resulted in an increase in PIPs and a decrease in PPOs. Strategies to reduce PIPs need to be implemented, especially for patients with longer hospital stay and a history of falls.

How to implement a geriatric assessment in your clinical practice

Cancer is a disease that mostly affects older adults. Other health conditions, changes in functional status, and use of multiple medications change the risks and benefits of cancer treatment for older adults. Several international organizations, such as the International Society of Geriatric Oncology, the European Organization for Research and Treatment of Cancer, recommend the conduct of a geriatric assessment (GA) for older adults with cancer to help select the most appropriate treatment and identify any underlying undetected medical, functional, and psychosocial issues that can interfere with treatment. The aim of this review is to describe what a GA is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. We provide an overview of commonly used tools. Key considerations in performing the GA include the resources available (staff, space, and time), patient population (who will be assessed), what GA tools to use, and clinical follow-up (who will be responsible for using the GA results for developing care plans and who will provide follow-up care). Important challenges in implementing GA in clinical practice include not having easy and timely access to geriatric expertise, patient burden of the additional hospital visits, and establishing collaboration between the GA team and oncologists regarding expectations of the population referred for GA and expected outcomes of the GA. Finally, we provide some possible interventions for problems identified during the GA.

Effects of "Fit fOR The Aged" (FORTA) on pharmacotherapy and clinical endpoints--a pilot randomized controlled study

PURPOSE

The feasibility of applying the Fit fOR The Aged (FORTA) list, a drug classification combining positive and negative labeling of drugs, should be studied in geriatric patients and medication quality and clinical endpoints measured. FORTA labels range from A (indispensable), B (beneficial), C (questionable) to D (avoid).

METHODS

A prospective randomized controlled pilot trial was performed in hospitalized geriatric patients in whom the FORTA instrument or standard care was applied. Patients were randomly admitted to an intervention and a control ward. Changes of FORTA label distributions between admission and discharge, over- and under-prescription rates, clinical endpoints including the number of falls during the hospitalization, and Barthel Index (BI) at admission and discharge were measured.

RESULTS

Polypharmacy persisted in both groups. At discharge, a higher rate of A drugs was prescribed in the intervention group (58 patients, median age 84 years) vs. standard care (56 patients, median age 83 years, p < 0.02), and both over- and under-prescriptions were significantly lower in the FORTA than in the control group (p < 0.03). Two (3.4%) intervention, but 12 (21.4%) control, patients fell at least once (p < 0.001). The fall rate per 1,000 patient years was 1.5 ± 8.3 in the intervention and 10.6 ± 25.4 in the control group (p < 0.004).

CONCLUSIONS

This pilot study shows that the application of the FORTA list is feasible in geriatric patients. In this small study, the medication quality improved in the intervention group, but polypharmacy persisted in both groups. The fall rate was significantly lower in the intervention group. These encouraging results must be interpreted carefully.

Views of general practitioners on the use of STOPP&START in primary care: a qualitative study

BACKGROUND AND OBJECTIVE

STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria aim at detecting potentially inappropriate prescribing in older people. The objective was to explore general practitioners' (GPs) perceptions regarding the use of the STOPP&START tool in their practice.

DESIGN

We conducted three focus groups which were conveniently sampled. Vignettes with clinical cases were provided for discussion as well as a full version of the STOPP&START tool. Knowledge, strengths and weaknesses of the tool and its implementation were discussed. Two researchers independently performed content analysis, classifying quotes and creating new categories for emerging themes.

RESULTS

Discussions highlighted incentives (e.g. systematic procedure for medication review) and barriers (e.g. time-consuming application) influencing the use of STOPP&START in primary care. Usefulness, comprehensiveness, and relevance of the tool were also questioned. Another important category emerging from the content analysis was the projected use of the tool. The GPs imagined key elements for the implementation in daily practice: computerized clinical decision support system, education, and multidisciplinary collaborations, especially at care transitions and in nursing homes.

CONCLUSION

Despite variables views on the usefulness, comprehensiveness, and relevance of STOPP&START, GPs suggest the implementation of this tool in primary care within computerized clinical decision support systems, through education, and used as part of multidisciplinary collaborations.

Potentially inappropriate prescribing in older primary care patients

OBJECTIVES

The aim of the study was to determine the rate of Potentially Inappropriate Medicines (PIM) and Potential Prescription Omissions (PPO) according to Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria.

STUDY DESIGN

A cross-sectional survey in community pharmacy.

METHOD

A prospective cross-sectional study was performed, during March-May 2012, in five community pharmacies. Patients aged ≥65 years, who collected one or more prescribed medications, were asked to participate in the study, and an interview was scheduled. Patients were asked to provide their complete medical and biochemical record from their general practitioner.

RESULTS

509 patients, mean age 74.8±6.5 years, 57.4% female, participated in the study. 164 PIM were identified in 139 patients (27.3%). The most common were: long-term use of long-acting benzodiazepines (20.7%), use of non-steroidal antiinflammatory drugs (NSAID) in patients with moderate-severe hypertension (20.1%), use of theophylline as monotherapy for chronic obstructive pulmonary disease (COPD, 15.9%) and use of aspirin without appropriate indication (15.2%). Patients with more than four prescpritions had a higher risk for PIM (OR 2.85, 95% CI 1.97-4.14, p<0.001). There were 439 PPO, identified in 257, (50.5%) patients. Predictors for PPO were older age, presence of diabetes, myocardial infarction, osteoporosis, stroke, COPD and/or angina pectoris.

CONCLUSION

STOPP/START criteria may be useful in identifying inappropriate prescribing and improving the current prescribing practices. Pharmacists should focus more on patients with more than four medications and/or patients with gout or pain accompanied with arterial hypertension because those patient may be at higher risk of PIM. Additionlly, patients older than 74 years with diabetes, osteoporosis, myocardial infarction, stroke, angina pectoris and/or COPD may have an increased risk of PPO.

Frequency of potentially inappropriate prescriptions in older people at discharge according to Beers and STOPP criteria

BACKGROUND

Potentially inappropriate prescriptions (PIP) are frequent, generate negative outcomes, and are to a great extent avoidable. Although there is general agreement about the definition of PIP, how to measure them is a matter of debate.

OBJECTIVE

Our aim was to measure the frequency of PIP in older people at hospital discharge using two sets of criteria--Beers (2012 update) and STOPP.

SETTING

A university hospital in southern Spain.

METHOD

This cross sectional study involved a random sample of patients 65 years or more discharged from the University Hospital San Cecilio (Granada, Spain), from July 1, 2011 to June 30, 2012. Age, gender, length of hospital stay, type of hospital service, drugs prescribed and pathologies were obtained from discharge reports.

MAIN OUTCOME MEASURE

The main outcome measures were: (1) the prevalence of PIP according to each set of criteria (Beers and STOPP) and its 95 % confidence interval, globally and stratified for different categories of the study variables; (2) the degree of agreement between the two criteria using Kappa statistics; and (3) the drugs most commonly involved in PIP according to both criteria.

RESULTS

There were 624 patients (median age 78) included in our study. According to Beers criteria, 22.9 % (19.6-26.2 %) of the patients had at least one PIP. This figure was 38.4 % (34.6-42.2 %) for STOPP criteria. Just 13.6 % of the patients had prescriptions simultaneously inappropriate for both criteria. Higher PIP frequency was observed in patients discharged from internal medicine. PIP increased with the Charlson Index and with the number of drugs prescribed, but not with gender, age or length of hospital stay.

CONCLUSION

A very high frequency of PIP at discharge was observed. By intervening in five drug groups, about 80 % of PIP might be avoided according to either of the two criteria.

Inappropriate prescribing according to the STOPP/START criteria in older people from a primary care setting

BACKGROUND

STOPP (screening tool of older persons' prescriptions)/START (screening tool to alert doctors to right treatment) criteria aim to identify potentially inappropriate medication (PIM) due to mis-, over- and under-prescription in older patients. Initially developed by Irish experts, their applicability has been demonstrated in primary health care (PHC).

OBJECTIVE

To quantify and identify the most frequent PIM at PHC level using STOPP/START criteria. To identify factors that may modulate the onset of PIM.

METHODS

Audit of a random sample of 272 electronic health records (including prescription, diagnosis and laboratory results) of patients ≥ 65 years old, with at least one prescription in the last three months, from a PHC setting in the Vigo Health Authority (Spain). Original STOPP/START criteria were used, as well as a version adapted to Spanish PHC. Descriptive statistics and generalized linear models were applied.

RESULTS

The median number of medicines per patient was 5 (inter-quartile range: 3-7). The prevalence of PIM identified by the STOPP criteria was 37.5% and 50.7%, with the original criteria and the Spanish version, respectively. Using both versions of the START tool, the prevalence of under-prescription was 45.9% and 43.0%, respectively. A significant correlation was found between the number of STOPP PIM and number of prescriptions, and between the number of START PIM with Charlson comorbidity index and number of prescriptions. Of 87 criteria, 20 accounted for 80% of PIM.

CONCLUSION

According to STOPP/START criteria, there is a high level of PIM in PHC setting. To prevent PIM occurring, action must be taken.

Less travelled roads in clinical immunology and allergy: drug reactions and the environmental influence

Allergy and clinical immunology are examples of areas of knowledge in which working hypotheses are dominant over mechanistic understanding. As such, sometimes scientific efforts follow major streams and overlook some epidemiologically prevalent conditions that thus become underestimated by the research community. For this reason, we welcome the present issue of Clinical Reviews in Allergy and Immunology that is dedicated to uncommon themes in clinical immunology and allergy. First, comprehensive discussions are provided for allergy phenomena of large potential impact in clinical practice such as reactions to cephalosporins or aspirin-induced asthma and in everyday life such as allergies to food additives or legumes. Further, the issue addresses other uncommon themes such as urticaria and angioedema, cercarial dermatitis, or late-onset inflammation to soft tissue fillers. Last, there will be discussion on transversal issues such as olfactory defects in autoimmunity, interleukin 1 beta pathway, and the search for new serological markers in chronic inflammation. As a result, we are convinced that this issue will be of help to clinicians involved in internal medicine as well as to allergists and clinical immunologists. More importantly, we are convinced that these discussions will be of interest also to basic scientists for the numerous translational implications.

Consensus validation of the FORTA (Fit fOR The Aged) List: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly

BACKGROUND

Multimorbidity and polypharmacy represent a major problem for elderly patients; improvement of medication schemes is important and listing approaches (e.g. Beers list) are considered to be potentially useful.

OBJECTIVES

The aim of this study was to perform expert consensus validation of the FORTA (Fit fOR The Aged) List, a drug classification combining positive and negative labelling of drugs chronically prescribed to elderly patients.

METHODS

A two-round Delphi procedure was conducted involving 20 experts, 17 geriatric internists and 3 geriatric psychiatrists from Germany and Austria, evaluating the labels assigned to 190 substances or substance groups. These labels ranged from A (indispensable), B (beneficial), C (questionable) to D (avoid), depending on the state of evidence for safety, efficacy and overall age-appropriateness. The experts were also requested to suggest additional substances and indication areas for assessment and possible inclusion in the FORTA List. A weighted (corrected) consensus coefficient was generated for each substance to reflect (1) agreement with the original label, and (2) distribution among raters' labels.

RESULTS

The overall consensus for all items and raters was 92% (corrected). For 54/190 items (28.4%), a unanimous response was achieved as to the original author-based FORTA label choice. Twenty-four substances (12.6%) fell short of the consensus cutoff and were re-evaluated in a second round. This yielded confirmation of 171/190, or 90%, of the original author-based FORTA labels. A total of 35 new substances were also accepted for the FORTA List. Drugs used for dementia and dementia syndromes provoked particular response heterogeneity.

CONCLUSION

The FORTA List now reflects a wider consensus among experts, increasing its validity for clinical use. It represents a tool to improve the quality of drug prescription in older patients by identifying both inappropriate and omitted drugs, and thus overtreatment and undertreatment. The validation of FORTA's impact on clinical endpoints has yielded promising preliminary results, to be corroborated in ongoing larger trials.

Inappropriate Prescribing Among Elderly Home Care Patients in Japan

Background: Although several previous studies have examined the prevalence and risk factors associated with inappropriate prescribing (IP) among elderly patients, as identified by the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, no research has been conducted among elderly home care patients. Objective: This study aimed to explore the prevalence of IP and its risk factors as identified by the STOPP/START criteria among elderly home care patients in Japan. Study Design: Cross-sectional study. Setting: Home care settings in Japan. Participants: Eighty-nine patients aged 65 years or older who received regular home visiting services from Yamato Clinic between May 2013 and June 2013. Main Outcome Measure: The prevalence of IP and its risk factors as identified by the STOPP/START criteria. Results: Of the study population, 40.4% had at least one potentially inappropriate medication and 60.7% had at least one incidence of underprescribing. Risk factors for potentially inappropriate medications were hypertension, constipation, and polypharmacy, while those for underprescription were osteoporosis and polypharmacy. Conclusion: The prevalence of IP among elderly home care patients is high, with risk factors that include not only polypharmacy but also several specific underlying medical conditions.

Substance misuse in the older person: setting higher standards

The number of older substance misusers requiring treatment is likely to double over the next couple of decades. However, there are many misconceptions and myths about this often hidden population. Older people misuse alcohol, nicotine, prescription medication and illicit drugs. All indications are that this is increasing. This may be as a cause and/or the result of physical or mental illness, and the consequent morbidity and mortality are costly to the patient, their families and society. Patients present to a very wide variety of social and medical care settings, so screening and assessment for substance use are of paramount importance. This provides the opportunity to determine to what extent the substance problem is related to the presentation, which may be subtle and atypical in older people. Since evidence is accumulating of the benefit of treatment for substance problems in the older population, this group should not be marginalised and neglected by practitioners, researchers, educators and policy makers.

Safeguarding older adults from inappropriate over-the-counter medications: the role of community pharmacists

PURPOSE OF THE STUDY

To elicit the thought process or mental model that community pharmacists use when making recommendations on over-the-counter (OTC) medications to older adults and to elicit the current practices of community pharmacists in providing information, advice, and counseling to older adults about potentially inappropriate OTC medications.

DESIGN AND METHODS

Three separate focus groups with pharmacists were conducted with 5 to 8 pharmacists per group. A vignette about an elderly woman seeking an OTC sleep aid was used to elicit information that pharmacists seek to establish when making a recommendation. Focus groups were recorded, transcribed verbatim, and analyzed for themes using the initial and focused coding methods of grounded theory.

RESULTS

Community pharmacists' mental models were characterized by 2 similarities: a similarity in what community pharmacists seek to establish about patients and a similarity in when community pharmacists seek to establish it--the sequence in which they try to learn key details about patients. It was identified that pharmacists gather specific information about the patient's medication profile, health conditions, characteristics of the problem, and past treatments in order to make a recommendation. Community pharmacists recommended behavioral modifications and seeing their physician prior to recommending an OTC sleep aid, primarily due to medication safety concerns.

IMPLICATIONS

Pharmacists can play a key role in assisting older adults to select and use OTC medications.

Anticholinergic drug burden in older people's brain - how well is it measured?

Concurrent use of several drugs with potential anticholinergic properties is highly prevalent in the elderly. Methods to determine the overall anticholinergic drug burden have been developed to estimate the risk of central anticholinergic adverse effects. The objective of this MiniReview was to critically appraise the clinical utility of the methods used to assess the anticholinergic drug burden in older people's brain. We evaluated the in vitro method used to measure the anticholinergic activity in a patient's serum and the four anticholinergic drug scales: Anticholinergic Risk Scale, Anticholinergic Cognitive Burden, Drug Burden Index and Anticholinergic Drug Scale. Medline searches of the literature from January 1988 to January 2013 were performed. Studies that related anticholinergic drug burden to central adverse outcomes in elderly people were included, while case reports and studies of single substances were excluded. Despite the consistently reported association between a high anticholinergic drug burden and negative cognitive and psychomotor outcomes in older patients, there are discrepancies in the literature. Furthermore, no significant cognitive improvements after the anticholinergic drug burden was reduced have been shown in randomized controlled trials. It is reasonable to question whether the estimated anticholinergic drug burden can predict the overall brain effects of multiple anticholinergic agents in older people.