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

[Translated article] Pharmaceutical recommendations for therapeutic appropriateness in patients with multiple sclerosis

OBJECTIVE

To determine the prevalence of PIMDINAC criteria and to implement pharmacological interventions in a population with multiple sclerosis over 55 years of age.

METHODS

Retrospective, observational, open-label study, including patients with multiple sclerosis aged 55 years and older during December 2022 and February 2023. The main variable determined was the percentage of compliance with the PIMDINAC criteria.

RESULTS

Ninety-five patients were included, with the presence of PIMDINAC criteria detected in 67.4%. The most frequently detected criterion was non-adherence to concomitant treatment (84.4%), followed by drug-drug interactions (56.2%) and potentially inappropriate medication (25%). A total of 20 pharmaceutical interventions were performed in 17 patients (17.9%). Potentially inappropriate medication was responsible for 11 interventions, non-adherence for 7, and drug-drug interactions for 2. The 81.8% of interventions were accepted, resulting in the discontinuation of 15 inappropriately prescribed drugs. The prevalence of PIMDINAC criteria in this group of patients is high. The study revealed that PIMDINAC criteria were prevalent in 67.4% of the study population, with polypharmacy playing an important role, suggesting the potential for a multidisciplinary approach, through pharmaceutical interventions to address unnecessary or duplicate treatments.

Feasibility and reliability of a quality indicator system for an ambulatory dispensing service

Background

For a medication dispensing service to function with quality, continuous evaluation is required, which is why it is necessary to have reliable measurement tools that make it possible. Quality indicators can serve as tools for managing quality, as they are variables that directly or indirectly measure changes in a situation and help evaluate the progress made in addressing it. This article aims to determine the feasibility and reliability of a quality indicator system for a drug dispensing service for paediatric outpatients in two Mexican hospitals.

Methods

A study of the development type of health systems and services at a microlevel was conducted from October 2020 to October 2021 in the pharmaceutical service of two Mexican hospitals. To determine the feasibility of the quality indicators, a retrospective evaluation was performed, which considered the indicators that could be calculated with the available information to be feasible. To determine reliability, an inter-observer agreement study (Kappa (κ)) was performed.

Results

The feasibility analysis revealed that all five reference indicators related to the structure were feasible in both hospitals. In the Infantil of the Californias hospital, all six process indicators evaluated were feasible, whilst only one was found feasible in H+ Querétaro. As for outcome indicators, only one was feasible in the Infantil of the Californias hospital. The causes of non-feasibility in both hospitals were the non-documentation of the primary data related to the stages of the process and the lack of instruments to measure patient satisfaction. The reliability of the indicators showed little variability.

Conclusion

Although not all indicators were feasible, solutions were proposed so that the 15 reference indicators could be used if an organization decided to do so. The reliability of the indicators was demonstrated, evidencing the importance of the data sheet as a tool to generate valid reliable measures.This article is part of the Hospital pharmacy, rational use of medicines and patient safety in Latin America Special Issue: https://www.drugsincontext.com/special_issues/hospital-pharmacy-rational-use-of-medicines-and-patient-safety-in-latin-america/.

[New tools for medication review: DRP in patients treatment with proton pump inhibitors]

OBJECTIVE

To analyze, using the medication review program, Revisem®, the prevalence of drug-related problems (DRP) in patients in the province of Valencia who were on active treatment with proton pump inhibitors (PPI) in 2022.

DESIGN

Descriptive and retrospective observational study.

MATERIAL AND METHODS

The pharmacotherapeutic history of 295 patients was analyzed following the criteria proposed by the Pharmaceutical Care Network Europe, using the Revisem® digital platform of the Muy Ilustre Colegio Oficial de Farmacéuticos (MICOF).

RESULTS

The mean age of the patients was 81.8 ± 11.1 years and 66.4% were women. At least one DRP was detected in 97.3% of patients. 46.9% of the DRP analyzed were interactions, of which 29.7% involved a PPI, with omeprazole being the most frequent. DRPs with PPI are significantly related to certain patient conditions and pharmacological groups, such as female sex, age over 54 years and polypharmacy.

CONCLUSIONS

The application of the Revisem® digital platform allows the detection of a high prevalence of DRP at the provincial level. The application of new technological tools to detect the prevalence of DRP is essential to optimize patient treatments.

Chronic benzodiazepine usage among older people: prevalence, indications, and treatment modifications in patients admitted to an acute geriatric unit

AIM

To investigate the prevalence and indications of benzodiazepines (BZD) usage among patients admitted to an acute geriatric unit and assess changes in prescriptions.

METHODS

BZD indications were documented reviewing clinical records, with appropriateness assessed based on the STOPP-START criteria. Changes in BZD prescriptions were recorded at discharge and 3 months later.

RESULTS

Among the 366 patients included (mean age: 92.8 years, 68% females), 91 (24.9%) were on BZD upon admission, being inappropriate in 93.4%. At discharge, BZD discontinuation was observed in 40.7% and dose reduction initiated in 57.4%. Among patients discharged without prescriptions, 10.8% resumed their use at 3 months. Of those discharged with BZD tapering, 74.1% were still on them 3 months later.

CONCLUSIONS

The majority of patients employing BZD lacked a medical indication. Admission to a geriatric ward resulted in successful discontinuation or dose reduction for most patients but was not maintained in the outpatient setting.

A description of risk associated with use of antipsychotics among community dwelling older adults: A descriptive cross-sectional study

The objective of this research was to analyze the risk of adverse effects in patients older than 65 years with dementia and in concomitant treatment with antidementia and antipsychotic drugs and who are cared for by community nurses. A retrospective cross-sectional descriptive study was carried out. A total of 332 patients who were cared for by primary care teams participated. Most of the patients were women, totally dependent for the basic activities of daily living and residing in the family home. They were polymedicated and there was poor therapeutic adherence. The risk of adverse effects was higher in polymedicated patients who had been taking antipsychotics for longer periods and in those who had a main caregiver. However, those patients who had been assessed by the community nurse were protected from suffering adverse effects. This study demonstrates how integrated and continuous nursing care can reduce adverse effects in this type of patient.

Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review

AIMS

The aim of this umbrella review was to identify tools and guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs), evaluate development and validation methods, and describe evidence levels for medication inclusion.

METHODS

Searches were conducted on MEDLINE (Ovid), Embase.com, Cochrane CDSR, CINAHL (EBSCO), Web of Science Core Collection and guideline databases from the date of inception to 7 July 2022. Following the initial search, an additional search was conducted to identify an updated versions of tools on 17 July 2023. We analysed the contents of tools and guidelines.

RESULTS

From 23 systematic reviews and guidelines, we identified 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines. Most tools (83.2%) were developed to use for older persons, including 14 for those with limited life expectancy. Seven tools were for children <18 years (7.37%). Most explicit/mixed tools (78.57%) and all guidelines were validated. We found 484 PIMs and 202 medications with different appropriateness independent of disease for older persons with normal and limited life expectancy, respectively. Only two tools and eight guidelines reported the evidence level, and a quarter of medications had high-quality evidence.

CONCLUSIONS

Tools are available for a diversity of populations. There were discrepancies, with the same medication being classified as inappropriate in some tools and appropriate in others, possibly due to low-quality evidence. In particular, tools for patients with limited life expectancy were developed based on very limited evidence, and research to generate this evidence is urgently needed. Our medication lists, along with the level of evidence, could facilitate efforts to strengthen the evidence.

Frailty assessment to individualize treatment in older patients with lymphoma

PURPOSE

A study analyzing the application of a protocol of comprehensive geriatric assessment (CGA) in older patients with lymphoma was carried out to allow frailty-based patient classification and individualized treatment.

METHODS

Lymphoma patients older than 70 years referred to the Geriatric Clinic at a tertiary hospital between May 2016 and March 2021 were included. The assessment protocol included comorbidity, polypharmacy, nutritional, functional, and mental status, geriatric syndromes, and life expectancy. CGA enabled patient classification into four groups (Type I to Type IV) based on frailty assessment instrument scoring and clinical, functional, and mental status. Variables were compared using parametric and non-parametric statistical tests and Kaplan-Meier survival curves.

RESULTS

Ninety-three patients (55.9% women) were included. Median age was 81.1 years (± 5.7). 23 patients (24.7%) were classified as robust (type I), 30 (32.3%) as pre-frail (type II) with potentially reversable deficits, 38 (40.9%) as frail (type III), and 2 (2.2%) as requiring palliative care (type IV). Patients received oncospecific treatment with modifications carried out in 64.5% of cases based on CGA results. Differences in overall survival (p = 0.002), response to treatment (p < 0.001) and likelihood of increased frailty (p = 0.024) were observed, with type III-IV patients showing significantly worse outcomes.

CONCLUSION

Performance of standardized, systematic CGA by geriatricians permits older lymphoma patients to be classified according to frailty, with significant differences in terms of clinical outcomes across groups. We propose incorporating CGA performed by geriatricians as part of the multidisciplinary care team to optimize therapeutic strategy for these patients.

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: uptake and clinical impact

INTRODUCTION

STOPP/START criteria for potentially inappropriate medications (PIMs, STOPP) and potential prescribing omissions (PPOs, START) have gained considerable interest and traction since they were first published in 2008. This review focuses on their uptake and impact in various clinical settings.

AREAS COVERED

STOPP/START criteria, now in their third iteration, are explicit criteria designed to facilitate detection of common and clinically important PIMs and PPOs during routine medication review in any clinical setting. We examine the influence of the criteria, particularly in clinical trials that focused on their impact on clinically relevant endpoints.

EXPERT OPINION

STOPP/START criteria are widely used in several countries within Europe and beyond for medication review and audit. As a discreet intervention, the criteria have been tested in several single-center and two large-scale multi-center clinical trials. The single-center trials indicate that STOPP/START criteria reduce polypharmacy, inappropriate prescribing, ADRs (adverse drug reactions), medication cost and falls. In contrast, the SENATOR and OPERAM multicentre trials did not demonstrate significant reduction in ADRs, all-cause mortality, drug-related hospital readmissions, nor any improvement in quality-of-life. Further clinical trials are required to examine whether STOPP/START criteria as an intervention can deliver significant clinical benefit in a reproducible manner in various clinical settings.

[Longitudinality in Primary Care and Polypharmacy. A Systematic Review]

The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.

Prevalence of Potentially Inappropriate Prescriptions According to the New STOPP/START Criteria in Nursing Homes: A Systematic Review

The demand for long-term care is expected to increase due to the rising life expectancy and the increased prevalence of long-term illnesses. Nursing home residents are at an increased risk of suffering adverse drug events due to inadequate prescriptions. The main objective of this systematic review is to collect and analyze the prevalence of potentially inadequate prescriptions based on the new version of STOPP/START criteria in this specific population. Databases (PubMed, Web of Science and Cochrane) were searched for inappropriate prescription use in nursing homes according to the second version of STOPP/START criteria. The risk of bias was assessed with the STROBE checklist. A total of 35 articles were assessed for eligibility. One hundred and forty nursing homes and more than 6900 residents were evaluated through the analysis of 13 studies of the last eight years. The reviewed literature returned prevalence ranges between 67.8% and 87.7% according to the STOPP criteria, according to START criteria prevalence ranged from 39.5% to 99.7%. The main factors associated with the presence of inappropriate prescriptions were age, comorbidities, and polypharmacy. These data highlight that, although the STOPP/START criteria were initially developed for community-dwelling older adults, its use in nursing homes may be a starting point to help detect more efficiently inappropriate prescriptions in institutionalized patients. We hope that this review will help to draw attention to the need for medication monitoring systems in this vulnerable population.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

Background

Multimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.

Materials and methods

We randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.

Results

Among the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p &lt; 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.

Conclusion

Multimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.

Liaison psychiatry before and after the COVID-19 pandemic

INTRODUCTION

the COVID-19 pandemic had an impact on hospital admissions. The clinical profiles of patients referred to liaison psychiatry teams (LPT) remained stable over the last few decades. We postulate changes in patient profiles due to the COVID-19 pandemic.

MATERIALS AND METHODS

a total of 384 patients admitted to a tertiary care University Hospital in Madrid (Spain) and referred to LPTs were recruited. Patients referred 5 months before and after the first admission for COVID-19 were included. Clinical and sociodemographic characteristics were collected, and non-parametric hypothesis contrast tests were used to study possible differences between both periods.

RESULTS

patients referred during the pandemic were significantly older (U = 2.006; p = .045), most of them were admitted to medical hospitalization units (χ2 (2) = 5.962; p = 015), and with a different reason for admission. There was an increase in the rate of adjustment disorders (χ2 (1) =7.893; p = 005) and delirium (χ2 (1) =9.413; p = 002), as well as psychiatric comorbidity (χ2 (2) = 9.930; p = .007), and a reduction in the proportion of patients treated for substance misuse (χ2 (5) = 19.152; p = .002). The number of deaths increased significantly (χ2 (1) = 6.611; p = .010). In persons over 65 years inappropriate prescription was significantly lower (χ2 (1) = 8.200; p = .004).

CONCLUSIONS

the pandemic had an impact on the activity of the LPTs due to the change in the clinical profile and evolution of referred patients, maintaining standards of care that are reflected through prescription.

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.

Decision-support systems for managing polypharmacy in the elderly: A scoping review

Polypharmacy, the consuming of more than five drugs, is a public health problem. It can lead to many interactions and adverse drug reactions and is very expensive. Therapeutic guidelines for managing polypharmacy in the elderly have been issued, but are highly complex, limiting their use. Decision-support systems have therefore been developed to automate the execution of these guidelines, or to provide information about drugs adapted to the context of polypharmacy. These systems differ widely in terms of their technical design, knowledge sources and evaluation methods. We present here a scoping review of electronic systems for supporting the management, by healthcare providers, of polypharmacy in elderly patients. Most existing reviews have focused mainly on evaluation results, whereas the present review also describes the technical design of these systems and the methodologies for developing and evaluating them. A systematic bibliographic search identified 19 systems differing considerably in terms of their technical design (rule-based systems, documentary approach, mixed); outputs (textual report, alerts and/or visual approaches); and evaluations (impact on clinical practices, impact on patient outcomes, efficiency and/or user satisfaction). The evaluations performed are minimal (among all the systems identified, only one system has been evaluated according to all the criteria mentioned above) and no machine learning systems and/or conflict management systems were retrieved. This review highlights the need to develop new methodologies, combining various approaches for decision support system in polypharmacy.

Prevalence of inappropriate prescribing in complex chronic patients: Time trends in a health department of Valencia, Spain (2015-2019)

BACKGROUND AND OBJECTIVE

Inappropriate prescribing (IP) is an important cause of health problems among elderly and complex chronic patients (CCPs).

OBJECTIVE

Surveillance of IP prevalence among elderly and CCPs in a health department. IP time trends across the period 2015-2019.

METHOD

Descriptive population-based study.

SETTING

'València-Clínic-Malvarrosa' Health Department, Valencia, Spain.

PERIOD

2015-2019.

SUBJECTS

Complete set of CCPs in the department, defined by clinical risk groups. Number of CCPs (annual average in the period): 9102 (75% ≥65 years of age). IP was measured using an indicator consisting of 13 specific types of prescriptions defined as inappropriate.

ANALYSES

frequencies and time trends, both overall and by specific type.

RESULTS

Overall prevalence of IP ranged from 0.276 (2015) to 0.289 (2018) per patient, without time trend. The most frequent inappropriate prescription was type 1: "≥75 years of age with inappropriate medication", which showed a stable rate across the period. Some types of inappropriate prescriptions displayed favourable decreasing time trends, while others showed no change or an unfavourable trend (i.e., joint prescription of absorbents and urinary antispasmodics).

CONCLUSIONS

IP prevalence is a serious and persistent problem among the elderly and CCPs, especially in the oldest. It is therefore necessary its continuous surveillance (overall and by specific types of prescription). As well as interventions to optimise prescribing, thus improving the quality and efficiency of care for the elderly and CCPs.

Person-centred care provided by a multidisciplinary primary care team to improve therapeutic adequacy in polymedicated elderly patients (PCMR): randomised controlled trial protocol

INTRODUCTION

The increase in elderly population has led to an associated increase in multiple pathologies, frailty, polypharmacy, healthcare costs, decreased quality of life and mortality. We designed an intervention based on person-centred care model. This article outlines a study protocol, which aims to explore the effects of the intervention to improve therapeutic adequacy in polymedicated elderly patients.

METHODS AND ANALYSIS

An open, randomised, multicentre, controlled clinical trial. The study population includes polymedicated (≥8 prescription medications) patients ≥75 years old. In the intervention group, the multidisciplinary team (primary care pharmacist, family doctor and nurse) will meet to carry out multidimensional reviews (frailty, clinical complexity, morbidity and therapeutic adequacy) of the study subjects. If changes are proposed to the treatment plan, a clinical interview will be conducted with the patient to agree on changes in accordance with their preferences. Follow-up visits will be scheduled at 6 and 12 months. In the control group, where the usual clinical practice will be followed, the necessary data will be collected to compare the results.The key variables are the variation in the mean number of incidents (potentially inappropriate prescription) per patient, the number of medications, the number of changes implemented to the treatment plan and the variation in the number of hospital admissions.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the IDIAPJGol and by the University of Barcelona's Bioethics Commission. The results are expected to be published in peer reviewed open-access journals, and as part of a doctoral thesis.

TRIAL REGISTRATION NUMBER

NCT04188470. Pre-results.

Potentially inappropriate prescribing in older adults in Mexico

OBJECTIVE

To identify and quantify potentially inappropriate prescribing (prescripción potencialmente inapropiada, PPI) and other drug prescribing problems in public health care services in a population-based study at the three existing levels of complexity in Mexico.

METHODS

Descriptive analysis of the Study on Satisfaction of Users of the Social Protection System in Health 2014–2016, prescription and drug supply section, to obtain the prevalence of PPI in older adults (≥ 65 years), based on Beers, STOPP, Prescrire and BSP listings using AM (older adults) prescription indicators, one for each listing.

RESULTS

Most older adults (67%) were prescribed at least one medication, with a mean of 2.7 medications per prescription. The PPI prevalence was 74% according to the BSP criteria, 67% according to the STOPP listing, 59% with the Beer criteria, and 20% with Prescrire. The most frequent PPI prescriptions were NSAIDs, vasodilators and sulfonylureas.

CONCLUSIONS

The use of PPIs in AM is high in Mexico. The higher prevalence found in this study may reflect the use of a source with population representativeness. The partial use and adaptations of the criteria make difficult comparing the studies; however, the STOPP criteria are the ones with the highest prevalence, as they cover a greater number of drugs and their use is more common in the first level of care.

Impact of a Pharmaceutical Care Program at Discharge on Patients at High Risk of Readmission According to the Hospital Score

Background: A significant percentage of hospital readmissions within 30 days of discharge are a result of avoidable drug-related problems. Stratifying patients according to readmission risk is key to pharmaceutical intervention (PI) design strategies to improve treatment outcomes. Objective: To assess whether a pharmaceutical care (PC) program at discharge in polymedicated patients at high potentially avoidable readmission (PAR) risk, according to the HOSPITAL score, improves 30-day readmission rate (30-dRR). Methods: This prospective controlled, quasi-experimental, 11-month study included 163 chronic polymedicated patients (>5 medications) at high PAR risk according to the HOSPITAL score. We calculated the 30-dRR and number of medication variations and Medication Regimen Complexity Index-E (MRCI-E) after PI. Results were compared with a retrospective cohort of chronic patients at high PAR risk. Results: The 30-dRR was 18.4% in the intervention group and 25.6% in the control group (odds ratio [OR] = 0.66; 95% CI = 0.38 to 1.14). Total medication reduction (-1.28; 95% CI = -1.88 to -0.68), number of high-risk medications in chronic patients (-0.58; 95% CI = -0.9 to -0.26), and MRCI-E (-6.42; 95% CI = -8.07 to -4.76) were statistically significant (P < .001). The number of medications at discharge was associated with an increased readmission risk (OR = 1.07; 95% CI = 1.01 to 1.14). Conclusions: The degree of polypharmacy and patients' treatment complexity after hospital discharge significantly reduced as a result of the PC program compared with the control group. This highlights the need for patient selection and prioritization strategies for implementing PIs focused on reducing polypharmacy and preventing drug-related problems that may cause PAR.

Potentially Inappropriate Medications and Potential Prescribing Omissions in Elderly Patients Receiving Post-Acute and Long-Term Care: Application of Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment Criteria

Background: Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria have been used to detect potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). These criteria were applied to geriatric Portuguese patients receiving post-acute and long-term care to assess the prevalence and predictors of PIMs and PPOs. Methods: An observational, retrospective, cross-sectional and multicenter study was performed in 161 patients (aged ≥65 years) from eight Units for Integrated Continuous Care. Results: In these studied patients (mean age: 81.6, 64% female, median number of medications: 9) PIMs were detected in 85.1% and PPOs in 81.4% of patients. While PIMs mainly involved the central nervous system and psychotropic drugs (66.5%), PPOs were mostly related to musculoskeletal system (55.3%) and cardiovascular (39.8%) system. A subsequent analysis with logistic regression found the female gender, the hospital provenience, and the number of medications as predictors of PIMs. Predictors of PPOs were the Charlson Comorbidity Index and history of recent fractures. Conclusion: PIMs and PPOs were highly prevalent in the studied patients receiving post-acute and long-term care in Units for Integrated Continuous Care. Therefore, STOPP/START criteria might be an effective tool for improving prescribing quality and clinical outcomes in these frail elderly patients.

Assessment of the Risk of Antipsychotics in Patients with Dementia in Actual Clinical Practice in Primary Health Care

Behavioral and psychological symptoms are almost universal in elderly patients with dementia. Antipsychotic drugs can be used but only in specific contexts as they can generate severe adverse effects. The main aim of this research was to evaluate the use of antipsychotic drugs in patients with accompanying treatment for dementia in actual clinical practice in primary health care. We further sought to analyze risk variables and factors associated and to acknowledge how sociodemographic and clinical factors weighed on adverse effects' occurrence. A multicentric cross-sectional descriptive study was performed in three provinces of Spain. Stratified random sampling was performed to select 332 patients. Clinical data from their digital medical records were collected by their family doctors. The Global risk defined if the patients were subjected to risk. Univariate, bivariate, and multivariate analyses were performed. The most used antipsychotics were quetiapine (65.5%), haloperidol (21.75%), and risperidone (15.8%); 93.8% of patients showed risk, and 81.1% of doses and 75.5% of treatment durations were inappropriate. These two last factors increased the global risk 23 and 20 times, respectively. Conclusions: In actual clinical practice conditions, a high use of antipsychotic drugs was found in patients with dementia. Most patients had inappropriate doses and treatment duration, factors that increased the risk of adverse effects considerably.

The impact of PIPs on mortality and readmissions in older adults: a retrospective cohort study

PURPOSE

Our aim was to determine the impact of potentially inappropriate prescriptions (PIP), according to "Screening Tool of Older Persons' Prescriptions" criteria version 2 (STOPP-2), on mortality and hospital admissions.

METHODS

Monocentric retrospective cohort study. Patients over 65 years of age and who were consecutively discharged from internal medicine at a Spanish university hospital in 2016 were included. The mortality and hospital admissions of the cohort of patients were analysed using their electronic health records within two years from the time of discharge. Analysis was done based on the type and number of STOPP-2 criteria as well as taking into account the total number of medications. The subdistribution hazard ratios (SHR) were estimated through a competing proportional hazards model.

RESULTS

A total of 270 patients with a median age of 82 years (interquartile range/IQR 76-86 years), and 152 (56.3%) women were studied. It was found out that 28.3% of patients with PIP died compared to 17.2% of patients without it. Digoxin (B1 STOPP-2 criterion) with a subdistribution hazard ratio (SHR) 2.40 (95% CI 0.63-9.18), selective serotonin re-uptake inhibitors/SSRIs (D4) with a SHR 1.76 (95% CI 0.52-5.96) and neuroleptic drugs (K2) with a SHR 2.01 (95% CI 0.82-4.95) non-significantly increased the risk of death. Dementia (SHR 5.45; 95% CI 2.76-10.78) was then the only statistically significant risk factor for death. Sixty percent of patients with a PIP had shown at least one hospital admission compared to 51% of patients without it. The number of drugs at discharge (SHR 1.03; 95% CI 1.01-1.05) and having 1-2 STOPP-2 criteria (SHR 1.17; 95% CI 1.02-1.35) significantly increased the risk of hospital admission.

CONCLUSION

The number of drugs at discharge and having any STOPP criteria significantly increased the risk of hospital admission in this cohort. PIP, only according to some specific STOPP-2 criteria involving digoxin, neuroleptics and SSRIs, might associate with a statistically non-significantly higher risk on mortality.

[Prescription appropriateness in elderly patients with polypharmacy in primary care: Cluster-randomized controlled trial PHARM-PC]

Objetivos

Evaluar la efectividad de la revisión sistemática de medicación realizada por farmacéutico sobre medicaciones potencialmente inapropiadas (MPI), resultados en salud y costes.

Diseño

Ensayo clínico prospectivo, abierto, controlado y aleatorizado por clústeres.

Emplazamiento

Seis centros de atención primaria de las Islas Baleares.

Participantes

Se incluyeron 42 clústeres (21 por grupo), y 549 pacientes de ≥ 65 años y ≥ 5 medicamentos crónicos, de los cuales 277 se asignaron al Grupo Intervención (GI) y 272 al Grupo Control (GC). Se excluyeron pacientes: institucionalizados, desplazados, atendidos habitualmente por la sanidad privada, o en atención domiciliaria.

Intervención

Detección de MPI por parte del farmacéutico mediante combinación de métodos explícitos e implícitos y comunicación de las alternativas terapéuticas más apropiadas al médico prescriptor.

Mediciones

Se evaluaron la proporción de pacientes con MPI y número medio de MPI/paciente (variables principales); así como morbilidad, mortalidad, y costes (variables secundarias).

Análisis estadístico

Siguiendo el principio de intención de tratar, se compararon las variables cuantitativas y cualitativas mediante las pruebas t Student y X², respectivamente. Los resultados se expresaron como diferencia de proporciones para variables cualitativas y diferencia de medias para cuantitativas, con los correspondientes intervalos de confianza 95% (IC 95%).

Resultados

Después de la intervención, la proporción de pacientes con MPI disminuyó un 13,7% (IC 95%: 9,3; 18,2) más en GI que GC. El número medio de MPI/paciente y coste medio de MPI/paciente disminuyeron en 0,43 (IC 95%: 0,32; 0,54) y 72,11€ (IC 95%: 26,15; 118,06) más en GI que GC, respectivamente. Sin embargo, no se observaron diferencias estadísticamente significativas en morbilidad, mortalidad ni en costes de episodios asistenciales.

Conclusiones

La detección de MPI y emisión de recomendaciones por el farmacéutico pudo contribuir a reducir significativamente MPI y gasto en medicamentos, pero sin alcanzar diferencias estadísticamente significativas en morbimortalidad ni costes de episodios asistenciales.

[Analysis of potentially inappropriate prescriptions according to the START criteria in nursing homes]

BACKGROUND AND OBJECTIVE

The potentially inappropriate prescription by omission of a drug is defined as the failure to prescribe drugs that are clinically indicated. The objective of this article is to describe and analyse the evolution of inappropriate prescriptions by omission in nursing homes of a health department.

MATERIAL AND METHODS

Retrospective observational descriptive study carried out in nursing homes of the Valencia-Clínico-Malvarrosa health department during the period 2016-2018. All institutionalized patients during this period were included. The prevalence of potentially inappropriate prescriptions by omission was assessed based on version 2 of the START criteria. The variables came from the electronic medical records of ambulatory care of the Conselleria de Sanitat (Abucasis).

RESULTS

2251 different patients were selected, mean age of 79,53years, 69% women, and an average of 4,60 chronic drugs/resident. A total of 2647 inappropriate prescriptions by omission were identified during the study period, and the results were similar during these 3years. The most prevalent START criteria were those related to the musculoskeletal system and the cardiovascular system, and those related to analgesic consumption. The mean value of inappropriate prescriptions by omission prevalence for the period studied were 39.54%.

CONCLUSION

The results of our study confirm a high prevalence of potentially inappropriate prescriptions by omission in residents of nursing homes, and the maintenance of this prevalence during the 3years of the study.

Medication-Related Problems in Older People with Multimorbidity in Catalonia: A Real-World Data Study with 5 Years' Follow-Up

Aging, multimorbidity, and polypharmacy are associated with medication-related problems (MRPs). This study aimed to assess the association that multimorbidity and mortality have with MRPs in older people over time. We followed multimorbid, older (65–99 years) people in Catalonia from 2012 to 2016, using longitudinal data and Cox models to estimate adjusted hazard ratios (HR). We reviewed electronic health records to collect explanatory variables and MRPs (duplicate therapy, drug–drug interactions, potentially inappropriate medications (PIM), and contraindicated drugs in chronic kidney disease (CKD) or liver disease). There were 723,016 people (median age: 74 years; 58.9% women) who completed follow-up. We observed a significant (p < 0.001) increase in the proportion with at least one MRP (2012: 66.9% to 2016: 75.5%); contraindicated drugs in CKD (11.1 to 18.5%) and liver disease (3.9 to 5.3%); and PIMs (62.5 to 71.1%), especially drugs increasing fall risk (67.5%). People with ≥10 diseases had more MRPs (in 2016: PIMs, 89.6%; contraindicated drugs in CKD, 34.4%; and in liver disease, 9.3%). All MRPs were independently associated with mortality, from duplicate therapy (HR 1.06; 95% confidence interval (CI) 1.04–1.08) to interactions (HR 1.60; 95% CI 1.54–1.66). Ensuring safe pharmacological treatment in elderly, multimorbid patient remains a challenge for healthcare systems.

Focus on Depression in Parkinson's Disease: A Delphi Consensus of Experts in Psychiatry, Neurology, and Geriatrics

Major and minor forms of depression are significant contributors to Parkinson's disease morbidity and caregiver burden, affecting up to 50% of these patients. Nonetheless, symptoms of depression are still underrecognized and undertreated in this context due to scarcity of evidence and, consequently, consistent clinical guideline recommendations. Here, we carried out a prospective, multicentre, 2-round modified Delphi survey with 49 questions about the aetiopathological mechanisms of depression in Parkinson's disease (10), clinical features and connections with motor and nonmotor symptoms (10), diagnostic criteria (5), and therapeutic options (24). Items were assessed by a panel of 37 experts (neurologists, psychiatrists, and a geriatrist), and consensus was achieved in 81.6% of them. Depressive symptoms, enhanced by multiple patient circumstances, were considered Parkinson's disease risk factors but not clinical indicators of motor symptom and disease progression. These patients should be systematically screened for depression while ruling out both anhedonia and apathy symptoms as they are not necessarily linked to it. Clinical scales (mainly the Geriatric Depression Scale GDS-15) can help establishing the diagnosis of depression, the symptoms of which will require treatment regardless of severity. Efficacious and well-tolerated pharmacological options for Parkinson's comorbid depression were selective serotonin reuptake inhibitors (especially sertraline), dual-action serotonin and norepinephrine reuptake inhibitors (venlafaxine, desvenlafaxine, and duloxetine), multimodal (vortioxetine, bupropion, mirtazapine, and tianeptine), and anti-Parkinsonian dopamine agonists (pramipexole, ropinirole, and rotigotine). Tricyclic antidepressants and combining type B monoamine oxidase inhibitors with serotonergic drugs have serious side effects in these patients and therefore should not be prescribed. Electroconvulsive therapy was indicated for severe and drug-refractory cases. Cognitive behavioural therapy was recommended in cases of mild depression. Results presented here are useful diagnostic and patient management guidance for other physicians and important considerations to improve future drug trial design.

Potentially inappropriate prescriptions and therapeutic complexity in older HIV patients with comorbidities

BACKGROUND

The prolonged current survival of human immunodeficiency virus (HIV) patients exposes them to new problems arising from the comorbidities they face.

OBJECTIVES

To describe the situation of comorbidities, polypharmacy, therapeutic complexity and adherence in people living with HIV over 65 years of age and to assess the presence of potentially inappropriate prescriptions (PIP) by applying deprescription criteria.

METHODS

Observational study including HIV people (> 65 years) from a university tertiary level hospital. Demographic, clinical and pharmacotherapeutic characteristics of the patients and their treatments were studied. The prevalence of polypharmacy (> 5 medications) and the pharmacotherapy complexity, quantified by the Medication Regimen Complexity Index (MRCI), were calculated. Therapeutic adherence was assessed by the Simplified Medication Adherence Questionnaire (SMAQ) and the medication possession ratio, according to prescription dispensing records. The Screening Tool of Older People's Prescriptions (STOPP) and List of Evidence-baSed depreScribing for CHRONic patients (LESS-CHRON) criteria were applied to identify PIP.

MAIN OUTCOME MEASURE

PIP in elderly people living with HIV.

RESULTS

Thirty patients were included, 73% of whom were men, with a median age of 71 years (IQR 67 - 76) and a median duration of infection of 17 years (IQR, 9 - 21). Seventy percent of the patients suffered from dyslipemia, 66.7% from hypertension, 43.3% from diabetes and 26.7% from mental health disorders. Seventy percent of the patients took more than 5 medications and 30% more than 10. The MRCI of concomitant medications was higher (18.3 points) than the MRCI of antiretroviral therapy (5.1 points), 66.7% of the studied population was classified as adherent. Finally, 70% of the patients present some PIP according to the STOPP or LESS-CHRON criteria. The polypharmacy was significantly associated (p = 0.008) with meeting deprescription criteria.

CONCLUSION

The elderly people living with HIV present numerous comorbidities and met the criteria for polypharmacy. Their pharmacotherapy complexity is mainly determined by the concomitant treatments. There is a high prevalence of meeting deprescription criteria in people living with HIV over the age of 65 and a clear relationship between polypharmacy and deprescription. The optimization of pharmacotherapy is necessary in this population.

Medication-related problems in older people in Catalonia: A real-world data study

PURPOSE

The aim of this study was to determine medication-related problems (MRPs) in primary care patients over 65 years of age.

METHODS

Cross-sectional study based on the electronic health records of patients (65-99 years of age) visited in 284 primary health care centers during 2012 in Catalonia.

VARIABLES

age, sex, sociodemographic variables, number of drugs, kidney and liver function and MRPs (duplicate therapy, drug-drug interactions, potentially inappropriate medications [PIMs] and drugs contraindicated in chronic kidney disease and in liver diseases). Unconditional logistic regression models were used to identify the factors associated with MRPs in patients with multimorbidity.

RESULTS

916 619 older people were included and 853 085 of them met the criteria for multimorbidity. Median age was 75 years and 57.7% of them were women. High percentages of MRPs were observed: PIMs (62.8%), contraindicated drugs in chronic kidney disease (12.1%), duplicate therapy (11.1%), contraindicated drugs in liver diseases (4.2%), and drug-drug interactions (1.0%). These numbers were higher in the subgroup of patients with ≥10 diseases. The most common PIMs were connected to drugs that increase the risk of fall (66.8%), antiulcer agents without criteria for gastroprotection (40.6%), and the combination of drugs with anticholinergic effects (39.7%). In the multivariate analysis, the variables associated with all MRPs among the patients with multimorbidity were the number of drugs and the number of visits.

CONCLUSIONS

The coexistence of multimorbidity and polypharmacy is associated with an elevated risk of MRPs in older people. Medication safety for older patients constitutes a pressing concern for health services.

Depression in Alzheimer's Disease: A Delphi Consensus on Etiology, Risk Factors, and Clinical Management

Background: Alzheimer's disease (AD) and other forms of dementia are among the most common causes of disability in the elderly. Dementia is often accompanied by depression, but specific diagnostic criteria and treatment approaches are still lacking. This study aimed to gather expert opinions on dementia and depressed patient management to reduce heterogeneity in everyday practice. Methods: Prospective, multicenter, 2-round Modified Delphi survey with 53 questions regarding risk factors (11), signs and symptoms (7), diagnosis (8), and treatment (27) of depression in dementia, with a particular focus on AD. The questionnaire was completed by a panel of 37 expert physicians in neurodegenerative diseases (19 neurologists, 17 psychiatrists, and 1 geriatrician). Results: Consensus was achieved in 40 (75.5%) of the items: agreement in 33 (62.3%) and disagreement in 7 (13.2%) of them. Among the most relevant findings, depression in the elderly was considered an early sign (prodromal) and/or a dementia risk factor, so routine cognitive check-ups in depressed patients should be adopted, aided by clinical scales and information from relatives. Careful interpretation of neuropsychological assessment must be carried out in patients with depression as it can undermine cognitive outcomes. As agreed, depression in early AD is characterized by somatic symptoms and can be differentiated from apathy by the presence of sadness, depressive thoughts and early-morning awakening. In later-phases, symptoms of depression would include sleep-wake cycle reversal, aggressive behavior, and agitation. Regardless of the stage of dementia, depression would accelerate its course, whereas antidepressants would have the opposite effect. Those that improve cognitive function and/or have a dual or multimodal mode of action were preferred: Duloxetine, venlafaxine/desvenlafaxine, vortioxetine, tianeptine, and mirtazapine. Although antidepressants may be less effective than in cognitively healthy patients, neither dosage nor treatment duration should differ. Anti-dementia cholinesterase inhibitors may have a synergistic effect with antidepressants. Exercise and psychological interventions should not be applied alone before any pharmacological treatment, yet they do play a part in improving depressive symptoms in demented patients. Conclusions: This study sheds light on several unresolved clinical challenges regarding depression in dementia patients. Further studies and specific recommendations for this comorbid patient population are still needed.

Drug interactions for elderly people with mental and behavioral disorders: a systematic scoping review

OBJECTIVES

To identify drug interactions of potentially inappropriate medications and mental and behavioral disorders, according to explicit potentially inappropriate medications criteria-based tools.

METHODOLOGY

A systematic scoping review was conducted in February 2020. Study characteristics, potentially inappropriate medications, drug interactions, rationale, and therapeutic management proposed were extracted. The commercialization and potentially inappropriate medications standard as essential in Brazil and in the world were identified. Therapeutic management was proposed for the most cited potentially inappropriate medications.

RESULTS

36 tools including 151 drug interactions, in addition to 132 potentially inappropriate medications with concerns related to six mental and behavioral disorders were identified. Cognitive impairment and dementia were the most frequently disorders reported and antipsychotics, anticholinergics, and benzodiazepines were the pharmacological classes more involved in the drug interactions. Despite the tools recommended risperidone and quetiapine when the use of antipsychotics were inevitable; levodopa + carbidopa for Parkinson's disease; and short and intermediate half-life benzodiazepines; the quality of the evidence needs to be assessed. In this review, sleep hygiene; deprescription; medication review; and clinical monitoring of adverse drug reactions are strongly recommended. In addition, to consider agomelatine, bupropion, moclobemide and melatonin as potential safer options for benzodiazepines.

CONCLUSION

Knowing the clinical conditions or risk morbidities associated with the use of potentially inappropriate medications and management of these medications for safer therapeutic equivalents or non-pharmacotherapeutic alternatives are relevant for patient safety.

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.

Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START

Aim

To meet the current need in different European countries for improving prescribing in older adults, we aimed to create an update screening tool getting origin from the two user friendly criterion sets: the STOPP/STARTv2 criteria and CRIME criteria.

Findings

Based on thorough literature review, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified. As a result, 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced.

Message

TIME criterion set is an update screening tool reported from Eastern Europe that included experts from geriatrics and other specialties frequently giving care to older adults and some additional practical explanations for clinical use.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.

Purpose

To improve prescribing in older adults, criterion sets have been introduced from different countries. While current criterion sets are useful to some extent, they do not meet the need in some European countries. Turkish inappropriate medication use in the elderly (TIME) criteria was planned to meet this need.

Methods

In phase 1, the user friendly sets: STOPP/START version2 and CRIME criteria were combined. National experts composed of geriatricians and non-geriatricians were invited to review and comment. In phase 2, thorough literature review was performed and reference-based revisions, omissions, and additions were made. Explanatory additions were added to some criteria to improve application in practice. In phase 3, all working group members reviewed the criteria/explanations and agreed on the final content.

Results

Phase 1 was performed by 49 expert academicians between May and October 2016. Phase 2 was performed by 23 working group academicians between October 2016 and November 2018 and included face-to-face interviews between at least two geriatrician members and one criterion-related specialist. Phase 3 was completed between November 2018–March 2019 with review and approval of all criteria by working group academicians. As a result, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified from the first draft. A total of 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced.

Conclusion

TIME criteria is an update screening tool that differs from the current useful tools by the interactive study of experts from geriatrics and non-geriatrics, inclusion of practical explanations for some criteria and by its eastern European origin. TIME study respectfully acknowledges its roots from STOPP/START and CRIME criteria. Studies are needed whether it would lead improvements in older adults’ health.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.

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<.04), 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.

[Adequacy of the pharmacological prescription during the admission in a geriatric hospital. Clinical experiencie with STOPP/START criteria]

BACKGROUND AND OBJECTIVES

The elderly patient is particularly vulnerable to potentially inappropriate prescription (PIP) due to physiological reasons, comorbidity, polypharmacy or the different pharmacokinetics/pharmacodynamics of drugs. The aim of this study was to determine the prevalence of PIP according to the STOPP-START criteria in patients over 65 years admitted into a geriatric hospital, as well as to appraise its acceptance by geriatricians.

MATERIAL AND METHODS

Retrospective observational study. Patients older than 65 years consecutively admitted to medium/long-stay units were included. The study information was obtained by reviewing the clinical record of the patients. The PIP according to the STOPP-START criteria were assessed by the geriatrician, who decided whether or not to modify the medication and recorded the reasons.

RESULTS

247 patients were included, mean age was 82.6 years (SD 7.3), 72.1% of patients were female and a median of 7 drugs (25-75 percentile: 4-9). 78.9% (95%CI: 73.3-83.9) of patients had at least one PIP STOPP-START at admission, 44.9% (95%CI: 38.6-51.4) PIP-STOPP and 59.5% (95%CI: 53.1-65.7) PIP-START. At hospital discharge, the prevalence of PIP-STOPP-START was 46.2% (95%CI: 39.8-52.6), 19.0% (95%CI: 14.3-24.5) of PIP-STOPP and 34.4% (95%CI: 28.5-40.7) PIP-START.

CONCLUSIONS

The comprehensive geriatric assessment and the use of the STOPP-START criteria can significantly reduce the prevalence of PIP among patients admitted to a geriatric hospital. Nevertheless, issues such as frailty, multimorbidity and functional goals would be taken into account in the appropriateness of the prescription.

Tackling frailty at primary care: evaluation of the effectiveness of a multicomponent intervention through a randomised controlled trial: study protocol

INTRODUCTION

This project focuses on how frailty is addressed in primary healthcare (PHC) and will evaluate the effectiveness of a multifactorial intervention (considering the appropriateness of the pharmaceutical prescription, the nutritional care provided and the exercise intervention) for persons with frailty, in terms of improving their functional capacity and reducing the incidence of adverse events related to frailty. The final evaluation will be made at 12 months' follow-up.

METHODS AND ANALYSIS

Pragmatic multicentre cluster randomised controlled clinical trial, single blind with two arms: multifactorial intervention in PHC versus usual follow-up. The randomisation unit is the patient list and the analysis unit is the patient. In addition, a cost-effectiveness study and a qualitative study will be carried out, the latter based on semistructured interviews and focus groups. Two hundred persons (100 per study branch) all aged ≥70 years, presenting frailty, but functionally independent and resident in the community, will be recruited. A baseline evaluation will be carried out prior to the intervention, with follow-up at 6 and 12 months. The main study variables considered will be functional capacity and incidence of adverse events; the secondary variables considered will be the patients' sociodemographic characteristics, nutritional status, level of physical activity and drug consumption, together with data on comorbidity, cognitive and affective status and health-related quality of life. Data will be analysed according to the intention-to-treat principle using a 5% significance level.

ETHICS AND DISSEMINATION

The study will at all times be conducted in strict accordance with the provisions of the Declaration of Helsinki and with the national legislation regulating patients' autonomy. All patients recruited will be asked to provide written informed consent before taking part in the clinical trial. On completion of the study, the principal investigator expects to publish the results of this research in a peer-reviewed open access scientific journal.

TRIAL REGISTRATION NUMBER

ISRCTN17143761.

Multimorbidity patterns in chronic older patients, potentially inappropriate prescribing and adverse drug reactions: protocol of the multicentre prospective cohort study MoPIM

INTRODUCTION

Multimorbidity is a major challenge for current healthcare systems and professionals. From the different approaches that have been proposed to analyse this issue, the hypothesis of the existence of association patterns of different chronic conditions is gaining visibility. In addition, multimorbidity can be associated to polypharmacy, which can lead to a higher risk of potentially inappropriate prescribing (PIP) and consequently to adverse drug reactions (ADRs). The general objective of this novel study is to identify the association between PIP, multimorbidity patterns, polypharmacy and the presence of ADRs in older patients admitted for exacerbation of chronic diseases.

METHODS AND ANALYSIS

The MoPIM (morbidity, potentially inappropriate medication) study is a multicentre prospective cohort study of an estimated sample of 800 older (≥65 years) patients admitted to five general hospitals in Spain due to an exacerbation of a chronic disease. Patients referred to home hospitalisation, admitted due to an acute process or with a fatal outcome expected at the time of admission are excluded. Sociodemographic data, chronic morbidities and geriatric syndromes, number of chronic prescribed medications, PIP at admission to hospital and on discharge, according to the newest screening tool of older screening tool of older person's potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria, and ADRs during hospitalisation are being collected. Multimorbidity patterns will be identified using cluster analyses techniques, and the frequency of polypharmacy, PIP and ADRs will be calculated. Finally, the possible relationship between those indicators will be identified through bivariate and multivariate analyses.

ETHICS AND DISSEMINATION

The project has been approved by the clinical research ethics committees of each centre: Comité Ético de investigación Clínica del Parc Taulí, Comitè Ètic d'Investigació Clínica Osona per a la Recerca i Educació Sanitàries (FORES), Comité de Ètica de la Investigación con Medicamentos (CEIm)-Parc de Salut MAR, Comité Ético de Investigación Clínica de Euskadi, Comité de Ética de Investigación del Hospital Universitario de Canarias. The results will be actively and mainly disseminated through publication in peer-reviewed journals and communications in scientific conferences.

TRIAL REGISTRATION NUMBER

NCT02830425.

[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.

[Inappropriate drug use in palliative care: SPANISH version of the STOPP-Frail criteria (STOPP-Pal)]

Multiple medication and inappropriate drug prescription are prevalent and challenging problems in older patients in end-of-life situations, and increases both preventable adverse events and health care costs. Recent literature recommends de-prescribing some drugs in patients with short life expectancy, when the aim of drug treatments is not prevention or cure, but symptom control. Recently, a list of explicit criteria (STOPP-Frail) intended to guide prescribing physicians in decision making on the use of drugs in older patients with terminal conditions. This article presents a Spanish version of such criteria, which have been named STOPP-Pal to avoid confusion with the current concept of frailty.

[Updated report on STOPP-START criteria in Primary Care]

INTRODUCTION

The aim of this study is to determine the rate of potentially inappropriate prescriptions (PIP) in people older than 64 years of age in Avilés, Asturias, Spain.

MATERIALS AND METHODS

A descriptive cross-sectional study was conducted in six Health Care Centres. A sample of 400 people was selected, obtained by a random sampling proportional to the population registered in each Health Centre. A review was made of the computerised clinical records, and the STOPP-START (version 2014 with 114 items) criteria were applied to evaluate the PIP.

RESULTS

The study contained 378 (95.5%) patients with a mean age of 75.4 (SD: 7.4) and of which 57.7% were women. Almost all (94.2%: 95% CI; 91.7-96.7) met some PIP criteria. Taking only the STOPP criteria into consideration, 52.4% (95%CI: 47.2-57.6) met at least one breach, and in the START criteria a 90.5% (95%CI; 87.4-93.6), which was reduced to 40.5% (95%CI; 36.4-45.6) if criteria on vaccination were removed. In the STOPP criteria, the most frequent PIP was taking benzodiazepines followed by the use of medication without indications based on the evidence; in the START, the criteria was the anti-pneumococcus vaccination, and the lack of taking vitamin D supplements and calcium in osteoporosis.

CONCLUSIONS

There were high levels of PIP, very superior to the previous version, especially for the START criteria. There is a high level of PIP related to the use of benzodiazepines and the use of medication without any clinic evidence. The STOPP-START criteria are useful in Primary Care to assess the PIP.

Application of the STOPP criteria in hospitalised elderly patients to detect and optimise inappropriate psychopharmaceutical prescriptions

BACKGROUND

Psychotropic drugs are frequently used in the elderly population, but their inappropriate prescription can cause numerous adverse effects and interactions.

OBJECTIVE

To evaluate the impact of a multidisciplinary intervention to detect and optimise inappropriate prescriptions of psychotropic drugs in patients aged over 75 years in a hospital setting.

DESIGN, SETTING, SUBJECTS AND METHODS

A prospective study which included every patient aged over 75 years admitted to the Consorcio Hospital General in Valencia, Spain, and who had been prescribed psychotropic drugs inappropriately, carried out over 1 year. The intervention was to detect inappropriate prescriptions of psychotropic drugs using the STOPP criteria, treatment optimisation by a team of psychiatrists, readjustment of the electronic prescription register, and communication to the primary care physician. The impact of the intervention was assessed by measuring the persistence of the changes made 3 months after discharge and by quarterly assessment of inappropriate prescriptions.

RESULTS

Of 4571 admissions, 378 inappropriate prescriptions were detected in 346 patients. The drugs most frequently used were long half-life benzodiazepines (70%), which were substituted in 62% of the cases, withdrawn in 32%, and maintained in 6%. At 3 months follow-up, the changes had been maintained by the patients' primary care physician in 67%. Evaluation of the prescriptions during the subsequent quarters of the year showed a significant decrease in the inappropriate prescriptions, especially benzodiazepines.

CONCLUSIONS

Coordinated intervention by pharmacologists and psychiatrists in hospital settings, and communication between these professionals and primary care teams, can reduce psychotropic drugs inappropriately prescribed to the elderly.

[The most common STOPP/START criteria in Spain. A review of the literature]

OBJECTIVE

To analyse STOPP/START criteria found most frequently in the studies carried out in Spain, in order to identify the main areas of potentially inappropriate prescribing.

METHODS

A literature review was carried out on the original studies performed in Spain that applied the original version of the STOPP/START criteria and that described the most common STOPP and/or START criteria found. In each study, a weighted analysis was performed on the criteria found, by assigning 5 points to the criterion in first position, 4 points to the criterion in second position, and so on to fifth criterion. The total points of each analysed criterion were then obtained.

RESULTS

A total of 19 original studies analysing STOPP criteria were selected, 14 of them also studying all START criteria. From the total of studies, 11 were developed in out-of-hospital care, and 8 in hospital care. The STOPP criterion with the highest weighted assessment was B7 (long-term, long-acting benzodiazepines), followed by J (any duplicate drug class prescription). The START criterion with the highest weighted assessment was F4 (statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present), followed by E3 (calcium and vitamin D supplement in patients with known osteoporosis: previous fragility fracture, acquired dorsal kyphosis).

CONCLUSIONS

The most common areas of potentially inappropriate prescribing are well defined, and suggest a particular intervention in some specific therapeutic points.

[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article]

Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.

Pharmacist comprehensive review of treatment compared with STOPP-START criteria to detect potentially inappropriate prescription in older complex patients

Objectives

To compare potentially inappropriate prescribing (PIP) according to the clinical judgement of the pharmacist with PIP according to explicit STOPP-START criteria in institutionalised and hospitalised patients with multiple pathologies. To describe and compare the main pharmacological groups involved and determine the factors associated with the detection of PIP in these patients.

Method

A prospective multicentre observational study of institutionalised and hospitalised multipathology patients aged >65 years. A specialised pharmacist used his best clinical judgement to detect PIP based on a comprehensive review of the complete chronic treatment of patients, which is an essential activity in interdisciplinary care. STOPP-START criteria were used as an aid tool to detect PIP. The main variable was the number of PIP incidents detected.

Results

Detected PIP incidents were analysed in 338 patients. Clinical judgement detected more PIP incidents (35%) than did STOPP-START criteria. More PIP incidents unrelated to these criteria were detected in institutionalised patients than in hospitalised patients. Clinical judgement mainly detected PIP incidents related to incorrect doses and drug interactions (p<0.001); however, STOPP-START criteria mainly detected PIP incidents related to drug duplication and insufficiently treated diagnosis or symptoms (p=0.001 and p<0.001). In total, 93.8% of the PIP incidents were detected in polypharmacy patients (≥5 drugs). Institutionalised and high-level polypharmacy (≥10 drugs) patients were at the highest risk of PIP.

Conclusions

A large number of PIP incidents were detected in institutionalised and hospitalised patients with multiple pathologies. The inclusion of a pharmacist in the multidisciplinary team facilitated the detection of PIP incidents, particularly in the institutionalised population and patients treated with high-level polypharmacy which were not detected by explicit STOPP-START criteria.

Potentially inappropriate prescribing according to STOPP-2 criteria among patients discharged from Internal Medicine: prevalence, involved drugs and economic cost

AIM

This study aims to determine the prevalence of potentially inappropriate prescribing (PIP) among patients discharged from Internal Medicine, the drugs and factors associated and economic cost of PIP.

METHODS

This retrospective cross-sectional, single-center study included participants aged ≥65 years consecutively discharged from the Internal Medicine Unit in a tertiary hospital of Southern Spain. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP-2) criteria version 2 (2015 update). The association of PIP with chronic conditions was analyzed using multilevel logistic regression model. Data on economic cost associated to PIP were determined according to the computerized prescribing database of Andalusia ("Receta XXI").

RESULTS

Out of the 275 patients studied, a total of 249 PIPs were detected in 114 (41.5%) patients of whom 79 (28.7%) had one or two STOPP-2 criteria and 35 (12.7%) 3 or more criteria. The most involved drugs were benzodiazepines (45.5%); antithrombotics (14.5%), including anticoagulants or antiplatelets, and opioids (11.4%). The multivariate logistic regression analysis identified polypharmacy (OR=11.00; 95% CI 1.41-85.52) and extreme polypharmacy (OR=26.25; 95% CI 3.34-206.07) as independent risk factors for PIP. The mean cost of PIP was €18.75±4.24 per patient and month. Opioids accounted for the highest percentage expenditure of PIP (39.02%), followed by inhaled bronchodilator drugs (30.30%), antithrombotics (12.20%) and benzodiazepines (7.92%).

CONCLUSIONS

PIP is frequent among patients discharged from Internal Medicine. The number of prescribed drugs was independently associated to PIP and benzodiazepines were the most involved drugs. PIP was associated to a significant economic cost.

[Impact of medium-term outcomes of inappropriate prescribing in older patients discharged from a short stay unit]

Objetivo

Estudiar la asociación entre prescripciones potencialmente inapropiadas (PPI) y eventos adversos a los 30 y 180 días tras el alta de una unidad de corta estancia (UCE).

Material y método

Estudio analítico observacional de cohortes retrospectivo que incluyó pacientes ≥ 75 años al alta de una UCE. Se utilizó la versión 2 de los criterios STOPP-START. La variable resultado fue la presencia de algún evento adverso a 30 y 180 días.

Resultados

Se incluyeron 179 pacientes con una media de 84 (DE: 5) años. La presencia de ≥ 1PPI al alta no se asoció con la aparición de algún evento adverso a los 30 ni a los 180 días de manera global. La presencia de ≥ 1PPI al alta de fármacos del proceso cardiovascular tuvo mayor riesgo de presentar algún evento adverso a los 30 días del alta (OR ajustada 2,1; IC 95%: 1,0-3,2; p = 0,045), los fármacos del proceso «neuropsiquiátrico y riesgo de caídas» se relacionaron con deterioro funcional a los 30 días del alta (OR ajustada 6,3; IC 95%: 1,7-22,5; p = 0,005), y la omisión de fármacos del sistema cardiovascular se asoció con el reingreso a los 180 días (OR ajustada 3,6; IC 95%: 1,5-8,3, p = 0,003).

Conclusiones

La presencia de eventos adversos de pacientes ancianos dados de alta de una UCE podría relacionarse con PPI detectadas por algunos criterios STOPP-START, y concretamente con los fármacos de los procesos cardiovasculares, neuropsiquiátrico y relacionado con las caídas.