Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

Prevalence of potentially inappropriate medication among older patients in a primary care unit of a tertiary care hospital in Thailand: a retrospective cross-sectional study

OBJECTIVE

Older adults are prone to developing multiple chronic diseases and have increased medication usage. This has led to the prescription of potentially inappropriate medications (PIMs). This study aimed to assess PIM prevalence among patients visiting the primary care unit (PCU) of a tertiary care hospital and evaluate the associated factors.

DESIGN

A retrospective cross-sectional study by reviewing medical records in the hospital information system.

SETTING

The PCU of a tertiary care hospital.

PARTICIPANTS

Patients aged ≥65 years who visited the PCU between 1 June and 30 November 2023 and received at least one oral medication.

PRIMARY AND SECONDARY OUTCOME MEASURES

PIMs were diagnosed using the updated American Geriatrics Society Beers criteria 2023, and logistic regression was used to identify factors associated with PIM prescriptions.

RESULTS

The study included 1600 participants, of whom 62.9% were female, with a median age of 72.0 years (IQR=68.0-77.0). The prevalence of PIMs was 39.4%. The three most common PIMs prescribed were diuretics, benzodiazepines and sulfonylureas. An increasing number of underlying diseases, presenting with acute illness (compared with follow-up only) and being treated by staff physicians (compared with trainee physicians) were significantly associated with increased odds of PIM prescriptions (adjusted OR (95% CI) = 1.59 (1.42 to 1.79), 1.58 (1.28 to 1.94) and 1.84 (1.33 to 2.54), respectively).

CONCLUSION

PIM prescriptions among older patients in the PCU were high, particularly in those with multiple comorbidities and acute illness presentations. Therefore, physicians should prescribe medications with caution, and various explicit criteria can be used as screening tools to prevent PIM prescriptions.

Prevalence of potentially inappropriate prescribing in community-dwelling older adults: an application of STOPP/START version 3 to The Irish Longitudinal Study on Ageing (TILDA)

PURPOSE

Potentially inappropriate prescribing includes prescribing potentially inappropriate medicines (PIMs), where risk of medication-related harm may outweigh the clinical benefit(s), and potential prescribing omissions (PPOs), whereby clinically indicated medications are unprescribed without good reason. This study aimed to assess prevalence of PIMs and PPOs (subset of STOPP/START version 3) in older community-dwelling adults and any association with healthcare utilisation and functional decline over time.

METHODS

Retrospective cohort study of a nationally representative longitudinal study of ageing in Ireland (n = 3619) (2016-2018). Logistic regressions examined association of patient characteristics with PIMs/PPOs and between prevalent PIMs/PPOs and functional decline. Negative binomial regressions examined association between PIM/PPO with healthcare utilisation over time.

RESULTS

Participants' mean age was 74.2 years (SD 6.99), 53.9% were female and were prescribed a mean of 4.02 (SD 3.16) medications. A total of 1123 (31.0%) participants experienced STOPP PIMs and 1309 (36.2%) START PPOs. STOPP PIMs were associated with increased hospital admissions (adjusted incident rate ratio (aIRR) 1.38, 95% confidence interval (CI) 1.08, 1.75), and functional decline (adjusted odds ratio (aOR) 1.46, 95% CI 1.11, 1.91) at follow-up. Age ≥ 75 years (aOR 1.32, 95% CI 1.10, 1.57) and three or more chronic conditions (aOR 5.19, 95% CI 3.69, 7.31) were significantly associated with START PPOs.

CONCLUSION

Approximately one-third of study participants experienced STOPP PIMs, associated with an increased risk of hospital admissions and functional decline. START PPOs also occurred in over one-third, associated with increasing age and degree of multimorbidity. Balancing the risk: benefit of medications for older people with multimorbidity remains challenging.

Drug prescription patterns and compliance with WHO and beers criteria in older patients

BACKGROUND

As the population ages, the prevalence of chronic diseases increases, leading to greater reliance on multiple medications that are conducted to increase the risk of adverse drug reactions (ADR) that may cause higher morbidity and mortality rates. This study aims to evaluate medication prescribing patterns in the older adults and assess compliance with the World Health Organization (WHO) guidelines and Beers Criteria.

METHODS

A cross-sectional study was conducted over six months in 2022, collecting prescriptions for patients aged 65 and above from a 24-hour community pharmacy in Iran. The prescriptions were analyzed according to the WHO prescribing guidelines, including the mean number of prescribed drugs, the number of injectable drugs and antibiotics per prescription, and also the prescription of drugs with generic names and from the list of Essential Drug List (EDL). In addition, the prescriptions were assessed according to the Beers Criteria for the frequency of prescription of potentially inappropriate medications (PIMs). Also, polypharmacy, which is defined as the prescription of more than five drugs per prescription, has been investigated based on the number of drugs prescribed per prescription.

RESULTS

1,053 older patient prescriptions were assessed, whose average age was 72.3 ± 6.7 years, with 36.2% of prescriptions involving polypharmacy (five or more drugs). The most frequent medical discipline of prescribers was general practice (30.3%). The average number of drugs per prescription was 4.1 ± 2.1, which exceeded the WHO recommendation. Additionally, 47.3% of prescriptions contained at least one PIM according to the Beers Criteria, with non-steroidal anti-inflammatory drugs (NSAIDs) being the most common (17.9%). The relative frequency of injectable drugs and antibiotics used per prescription was 20.8 and 18.9%, respectively, while 7.6% of prescriptions did not use generic names.

CONCLUSIONS

The study highlights concern about levels of polypharmacy and PIM use in older patients. While the low rate of antibiotic prescribing and relatively high use of generic drugs indicate some positive adherence to WHO guidelines, the frequent prescription of PIMs and the high average number of drugs per prescription point to substantial room for improvement.

Inappropriate medication prescribing, polypharmacy, potential drug-drug interactions and medication regimen complexity in older adults attending three referral hospitals in Asmara, Eritrea: a cross-sectional study

BACKGROUND

Older adults often face several chronic illnesses that require them to take multiple medications. The increased number of prescribed medications has led to more complex medication regimens, putting older adults at a higher risk of potential drug-drug interactions, inappropriate medication prescribing, and adverse events. This study aimed to assess inappropriate prescribing practices, polypharmacy, medication regimen complexity, and their determinants in older adults.

METHODS

A cross-sectional study was conducted among older adults (aged 65 years and above) who visited three referral hospitals in Asmara, Eritrea, between June and August, 2023. A stratified random sampling technique was used, and data were collected from patient prescriptions, medical cards, and through interviews with a questionnaire. Inappropriate medication prescribing was evaluated using STOPP (Screening Tool of Older Person's Prescriptions)/ START (Screening Tool to Alert to Right Treatment) criteria version 3. Potential drug-drug interactions (pDDIs) and medication regimen complexity (MRC) were assessed using Lexi-comp drug interaction checker and MRC index, respectively. Descriptive statistics, logistic regression, Pearson's correlation coefficient, independent samples t-test, one-way Analysis of Variance, and paired t-test were employed using IBM SPSS (version-26.0).

RESULTS

A total of 430 respondents, with a similar male to female ratio, were included. The prevalence of polypharmacy was 5.3% (95%CI: 3.2, 7.5). Moreover, the prevalence of clinically significant pDDI was 51% (95%CI: 46, 56). The most common medicines involved in clinically significant pDDIs were enalapril (n = 179) and acetylsalicylic acid (n = 124). The presence of chronic illness (AOR = 7.58, 95%CI: 3.73, 15.39) and the number of drugs prescribed (AOR = 2.80, 95%CI: 1.91, 4.10) were predictors of clinically significant pDDIs. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were 27.4% (95% CI: 23.4, 31.8) and 13.3% (95% CI: 10.3, 16.7), respectively. The most common PIMs were long-acting sulfonylureas (n = 63) and aldosterone antagonists (n = 19). Besides, proton pump inhibitors (PPIs) (n = 41) and cardio-selective beta-blockers (n = 14) were the most common PPOs identified. Age (AOR: 0.95, 95% CI: 0.92, 0.98), presence of chronic illness (AOR: 1.51, 95% CI: 0.81, 2.80), and number of drugs prescribed (AOR: 2.01, 95% CI: 1.51, 2.69) were significant factors associated with PIM. MRCI score was a significant determinant of PPO (AOR: 1.25, 95% CI: 1.14, 1.38). The mean (SD) of the overall MRCI score was 9.1 (3.7), with dose frequency being the major contributor. The number of drugs prescribed was a determinant of MRCI score (r = 0.625, p < 0.001).

CONCLUSION

Inappropriate medication prescribing and clinically significant drug-drug interactions were common among older adults, highlighting the need for immediate attention from policymakers, program managers, and healthcare professionals.

The effects of high quality team medicine on outcomes of chronic limb-threatening ischemia patients with infrapopliteal bypass

OBJECTIVES

A team approach for treatment of patients with CLTI is used worldwide. However, the quality of team medicine is a concern. The Global Vascular Guidelines provide recommendations for high quality team medicine, but there is limited knowledge of the significance of team quality in CLTI treatment. The objective of this study is to evaluate the effects of team quality on clinical outcomes after infrapopliteal bypass.

METHODS

A retrospective analysis was performed in 337 patients who underwent 414 infrapopliteal bypasses under a team medicine approach at a single center between 2009 and 2021. In 2017, team medicine was reorganized for improvement of quality. Comparisons were made between before (Group 1; 160 patients, 195 limbs) and after (Group 2; 177 patients, 219 limbs) reorganization. The primary endpoints were limb salvage and wound healing after infrapopliteal bypass.

RESULTS

The patients included 227 males (67%) and had a median age of 76 [68-83] years. Diabetes mellitus was present in 67% and end-stage renal disease with hemodialysis in 37%. The follow-up rate was 96% in a mean follow-up period of 31±30 months. The 3-year limb salvage rate was significantly lower in Group 1 (before reorganization) than in Group 2 (after reorganization) (84% vs 95%, p = .001). The wound healing rates in the whole cohort were 72% at 6 months and 85% at 12 months, with no significant differences between the groups. In multivariate analysis, the risk factors for major amputation were treatment before reorganization (HR 2.68; p = .017), hemodialysis (HR 2.27; p = .017), and non-ambulatory status (HR 2.63; p = .005).

CONCLUSIONS

A reorganized team approach with the goal of higher quality was independently associated with reduced major amputation for patients with CLTI treated with infrapopliteal bypass. This result indicates the importance of a high quality team approach for success of this treatment.

Prevalence of Potentially Inappropriate Prescribing in Older Adults in Gulf Cooperation Council Countries: A Systematic Review and Meta-Analysis

INTRODUCTION

Potentially Inappropriate Prescribing (PIP) poses a significant risk to patient safety and associated with poor healthcare outcomes in Gulf Cooperation Council (GCC) countries. This study aimed to assess PIP prevalence and patterns in older adults across all care settings in GCC.

METHODS

A comprehensive search was conducted on six medical databases to identify studies assessing the PIP prevalence in older adults using validated criteria in GCC. Pooled prevalence estimates and odds ratios were calculated using STATA Software (version 16). Statistical heterogeneity was evaluated with the I² statistic, and publication bias was assessed using funnel plot symmetry and Egger's regression test. The risk of bias was assessed using the JBI Prevalence Critical Appraisal Tool.

RESULTS

Fourteen eligible studies conducted over ten years included 18,647 patients. The median prevalence of PIP was 54.4% (IQR: 37.6-62.1%), higher in hospital settings (59.5%; IQR: 53.7-65.3%) compared to primary care (44.2%; IQR: 18.5-54.4%). Cardiovascular medications were the most common PIP (15,353 occurrences). Polypharmacy was significantly associated with PIP exposure (OR: 5.26; 95% CI: 2.33-11.84). The odds of PIP exposure were significantly increased among older individuals with chronic kidney disease (OR: 1.87; 95% CI: 1.19-2.54) and diabetes (OR: 1.74; 95% CI: 1.18-2.30).

CONCLUSION

This study highlights high PIP prevalence among older adults in GCC countries, particularly in hospital settings. Polypharmacy and certain chronic conditions were significantly associated with PIP exposure. These findings emphasize the need for targeted interventions to improve prescribing practices and medication safety.

Use of the Patient Portal to Discuss Medications Among People with Dementia and Their Care Partners

BACKGROUND

People with dementia (PWD) often use potentially inappropriate medications (PIM), exposing them to harm. Patient portals are a promising platform for delivering deprescribing educational interventions to reduce PIM use, yet little is known about how PWD and their care partners use patient portals to communicate with clinicians about medications.

OBJECTIVE

To characterize the content of patient portal messages relating to medications among PWD, care partners, and clinicians, to inform development of a portal-based intervention to reduce use of PIM among PWD.

DESIGN

Descriptive analysis of data from the electronic health record and qualitative analysis of patient portal messages.

PARTICIPANTS

Adults 65 and older, categorized as having dementia based on EHR algorithm, who received care in an academic health system from 2017 to 2022.

APPROACH

Electronic health record data were analyzed using descriptive statistics. Qualitative coding identified topics raised in portal messages.

KEY RESULTS

A total of 399 message threads from 159 unique patients were analyzed. Patients were on average 78.4 years old (SD 8.0). Most (65%) were female, White (76%), and non-Hispanic/Latinx (96%); 15% had a registered proxy portal user. The most common topics raised in portal messages were logistics (42%), concerns about adverse effects/treatment burden (25%), asking for new medications (23%), and openness to stopping medications (21%). Qualitative analysis revealed three main themes related to deprescribing: (1) Opportunities to deprescribe, (2) challenges to deprescribing, and (3) medication-related counseling in the portal.

CONCLUSIONS

PWD and their care partners frequently raise medication concerns in the portal, suggesting it is a promising platform for delivering deprescribing interventions for this population. Future research should identify characteristics of portal-based interventions that would best support deprescribing for PWD and develop pragmatic workflows.

Evaluating the effectiveness of the Smart About Meds (SAM) mobile application among patients discharged from hospital: protocol of a randomised controlled trial

INTRODUCTION

Almost half of patients discharged from hospital are readmitted or return to the emergency department (ED) within 90 days. Non-adherence to medication changes made during hospitalisation and the use of potentially inappropriate medications (PIMs) both contribute to postdischarge adverse events. We developed Smart About Meds (SAM), a patient-centred mobile application that targets medication non-adherence and PIMs use. This protocol describes a randomised controlled trial (RCT) to evaluate SAM.

METHODS AND ANALYSIS

A pragmatic, stratified RCT will evaluate SAM among 3250 adult patients discharged from hospital. At discharge, consenting participants will be randomised 1:1 to usual care or SAM. SAM integrates novel patient-centred features with pharmacist monitoring to manage non-adherence to new medication regimens. SAM also notifies patients of PIMs in their regimen, with advice to discuss with their physician.Following discharge, patients will be followed for 90 days to measure the primary composite outcome of ED visits, hospital readmissions and death. Secondary outcomes will include primary adherence to medication changes, secondary adherence to disease-modifying medications, patient empowerment and health-related quality of life.The primary outcome will be analysed according to intention-to-treat. Multivariable logistic regression will estimate differences between treatment groups in the proportion of patients experiencing the primary outcome and will assess modification of intervention effects by hospital, unit, age, sex and comorbidity burden. With a sample size of 3250, the study will have 80% power to detect a 5% absolute reduction in the primary outcome. Binary and continuous secondary outcomes will be assessed using multivariable logistic and linear regression, respectively.

ETHICS AND DISSEMINATION

The Research Ethics Board of the McGill University Health Centre in Montréal, Canada has approved this study. Results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences. If effective, SAM will be made available in app stores.

TRIAL REGISTRATION NUMBER

NCT05371548.

Adopting STOPP/START Criteria Version 3 in Clinical Practice: A Q&A Guide for Healthcare Professionals

The growing complexity of geriatric pharmacotherapy necessitates effective tools for mitigating the risks associated with polypharmacy. The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria have been instrumental in optimizing medication management among older adults. Despite their large adoption for improving the reduction of potentially inappropriate medications (PIM) and patient outcomes, the implementation of STOPP/START criteria faces notable challenges. The extensive number of criteria in the latest version and time constraints in primary care pose practical difficulties, particularly in settings with a high number of older patients. This paper critically evaluates the challenges and evolving implications of applying the third version of the STOPP/START criteria across various clinical settings, focusing on the European healthcare context. Utilizing a "Questions & Answers" format, it examines the criteria's implementation and discusses relevant suitability and potential adaptations to address the diverse needs of different clinical environments. By emphasizing these aspects, this paper aims to contribute to the ongoing discourse on enhancing medication safety and efficacy in the geriatric population, and to promote more person-centred care in an aging society.

Prevalence of potentially inappropriate medications and prescription dynamics in elderly hospitalized patients in Spain

PURPOSE

In recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75.

PATIENTS AND METHODS

This was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria.

RESULTS

A total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed.

CONCLUSION

In this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge. These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.

Development of explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A multidisciplinary qualitative study

PURPOSE

The management of type 2 diabetes mellitus patients has changed over the past decade, and a large number of antidiabetic drug treatment options are now available. This complexity poses challenges for healthcare professionals and may result in potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus which can be limited using screening tools. The effectiveness of explicit tools such as lists of potentially inappropriate prescriptions has been widely demonstrated. The aim was to set up nominal groups of healthcare professionals from several disciplines and develop a list of explicit definition of potentially inappropriate prescriptions of antidiabetic drugs.

METHODS

In a qualitative, nominal-groups approach, 30 diabetologists, general practitioners, and pharmacists in France developed explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus. A nominal group technique is a structured method that encourages all the participants to contribute and makes it easier to reach an agreement quickly. Each meeting lasted for two hours.

RESULTS

The three nominal groups comprised 14 pharmacists, 10 diabetologists, and 6 general practitioners and generated 89 explicit definitions. These definitions were subsequently merged and validated by the steering committee and nominal group participants, resulting in 38 validated explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs. The definitions encompassed four contexts: (i) the temporary discontinuation of a medication during acute illness (n = 9; 24%), (ii) dose level adjustments (n = 23; 60%), (iii) inappropriate treatment initiation (n = 3; 8%), and (iv) the need for further monitoring in the management of type 2 diabetes mellitus (n = 3; 8%).

CONCLUSION

The results of our qualitative study show that it is possible to develop a specific list of explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus by gathering the opinions of healthcare professionals caring for these patients. This list of 38 explicit definitions necessitates additional confirmation by expert consensus before use in clinical practice.

Potentially inappropriate prescribing in polymedicated older adults with atrial fibrillation and multimorbidity: a Swedish national register-based cohort study

Introduction

Current research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults.

Methods

Swedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls.

Results

PIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88-2.07]) and overall mortality (HR = 2.09 [2.03-2.16]), CV (HR = 1.34 [1.30-1.37]) and overall hospitalisation (HR = 1.48 [1.46-1.51]), stroke (HR = 1.93 [1.78-2.10]), bleeding (HR = 1.10 [1.01-1.21]), and falls (HR = 1.63 [1.56-1.71]).

Conclusion

The present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population.

Applicability of STOPP/START prescribing criteria in integrated Swedish administrative health registries and a Swedish population-based cohort

PURPOSE

The STOPP/START criteria are frequently applied in observational studies to assess potentially inappropriate prescribing in older adults. This study aimed to assess the applicability of the three available STOPP/START versions in two distinct data sources.

METHODS

To evaluate the applicability of the three versions of STOPP/START criteria, we used two observational data sources: (i) Integrated Swedish administrative health registries (ISHR) encompassing routinely collected health data and (ii) the population-based Swedish National study on Aging and Care in Kungsholmen (SNAC-K), based on health professional-led clinical assessments. The Anatomical Therapeutic Classification code (ATC) was used to categorise medications. Diseases were categorised using the international classification of diseases version 10 (ICD10).

RESULTS

The first STOPP/START version demonstrated an applicability rate of 80% in ISHR and 84% in SNAC-K. The second version demonstrated an applicability of 64% in ISHR and 74% in SNAC-K. The third version showed an applicability of 66% in ISHR and 77% in SNAC-K. Challenges in applicability included broad definitions, vague terminology, and the lack of information on disease severity, symptomatic traits, and stability of certain conditions.

CONCLUSION

The applicability of the STOPP/START criteria in observational studies seems to have decreased in more recent versions of the tool. Population-based studies with comprehensive clinical assessments may offer higher applicability compared to studies based on administrative data. Future versions of the STOPP/START criteria should prioritise clear and unambiguous definitions to improve their applicability in research and promote result generalisability and comparability.

Considering Adverse Effects of Common Antihypertensive Medications in the ED

PURPOSE OF REVIEW

To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department.

RECENT FINDINGS

All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.

Variability in the prevalence of inappropriate medication use among older adults: A review highlighting the importance of screening methods and database types

AIMS

The global older population is growing rapidly, and the rise in polypharmacy has increased potentially inappropriate medication (PIM) encounters. PIMs pose health risks, but detecting them automatically in large medical databases is complex. This review aimed to uncover PIM prevalence in individuals aged 65 years or older using health databases and emphasized the risk of underestimating PIM prevalence due to underutilization of detection tools.

METHODS

This study conducted a broad search on the Medline database to identify articles about the prevalence of PIMs in older adults using various databases. Articles published between January 2010 and June 2023 were included, and specific criteria were applied for study selection. Two literature reviews conducted before our study period were integrated to obtain a perspective from the 1990s to the present day. The selected papers were analysed for variables including database type, screening method, adaptations and PIM prevalence. The study categorized databases and original screening tools for clarity, examined adaptations and assessed concordance among different screening methods.

RESULTS

This study encompassed 48 manuscripts, covering 58 sample evaluations. The mean prevalence of PIMs within the general population aged over 65 years was 27.8%. Relevant heterogeneity emerged in both the utilized databases and the detection methods. Adaptation of original screening tools was observed in 86.2% (50/58) of cases. Half of the original screening tools used for assessing PIMs belonged to the simple category. About a third of the studies employed less than half of the original criteria after adaptation. Only three studies used over 75% of the original criteria and more than 50 criteria.

CONCLUSIONS

This extensive review highlights PIM prevalence among the older adults, emphasizing method intricacies and the potential for underestimation due to data limitations and algorithm adjustments. The findings call for enhanced methodologies, transparent algorithms and a deeper understanding of intricate rules' impact on public health implications.

Management of potentially inappropriate medication use among older adult's patients in primary care settings: description of an interventional prospective non-randomized study

BACKGROUND

The management of inappropriate medication use in older patients suffering from multimorbidity and polymedication is a major healthcare challenge. In a primary care setting, a medication review is an effective tool through which a pharmacist can collaborate with a practitioner to detect inappropriate drug use.

AIM

This project described the implementation of a systematic process for the management of potentially inappropriate medication use among Lebanese older adults. Its aim was to involve pharmacists in geriatric care and to suggest treatment optimization through the analysis of prescriptions using explicit and implicit criteria.

METHOD

This study evaluated the medications of patients over 65 years taking a minimum of five chronic medications a day in different regions of Lebanon. Descriptive statistics for all the included variables using mean and standard deviation (Mean (SD)) for continuous variables and frequency and percentage (n, (%)) for multinomial variables were then performed.

RESULTS

A total of 850 patients (50.7% women, 28.6% frail, 75.7 (8.01) mean age (SD)) were included in this study. The mean number of drugs per prescription was 7.10 (2.45). Roughly 88% of patients (n = 748) had at least one potentially inappropriate drug prescription: 66.4% and 64.4% of the patients had at least 1 drug with an unfavorable benefit-to-risk ratio according to Beers and EU(7)-PIM respectively. Nearly 50.4% of patients took at least one medication with no indication. The pharmacists recommended discontinuing medication for 76.5% of the cases of drug related problems. 26.6% of the overall proposed interventions were implemented.

DISCUSSION

The rate of potentially inappropriate drug prescribing (PIDP) (88%) was higher than the rates previously reported in Europe, US, and Canada. It was also higher than studies conducted in Lebanon where it varied from 22.4 to 80% depending on the explicit criteria used, the settings, and the medical conditions of the patients. We used both implicit and explicit criteria with five different lists to improve the detection of all types of inappropriate medication use since Lebanon obtains drugs from many different sources. Another potential source for variation is the lack of a standardized process for the assessment of outpatient medication use in the elderly.

CONCLUSION

The prevalence PIDP detected in the sample was higher than the percentages reported in previous literature. Systematic review of prescriptions has the capacity to identify and resolve pharmaceutical care issues thus improving geriatric care.

Enhancing healthcare access for an older population: The age-friendly emergency department

Healthcare systems face significant challenges in meeting the unique needs of older adults, particularly in the acute setting. Age-friendly healthcare is a comprehensive approach using the 4Ms framework-what matters, medications, mentation, and mobility-to ensure that healthcare settings are responsive to the needs of older patients. The Age-Friendly Emergency Department (AFED) is a crucial component of a holistic age-friendly health system. Our objective is to provide an overview of the AFED model, its core principles, and the benefits to older adults and healthcare clinicians. The AFED optimizes the delivery of emergency care by integrating age-specific considerations into various aspects of (1) ED physical infrastructure, (2) clinical care policies, and (3) care transitions. Physical infrastructure incorporates environmental modifications to enhance patient safety, including adequate lighting, nonslip flooring, and devices for sensory and ambulatory impairment. Clinical care policies address the physiological, cognitive, and psychosocial needs of older adults while preserving focus on emergency issues. Care transitions include communication and involving community partners and case management services. The AFED prioritizes collaboration between interdisciplinary team members (ED clinicians, geriatric specialists, nurses, physical/occupational therapists, and social workers). By adopting an age-friendly approach, EDs have the potential to improve patient-centered outcomes, reduce adverse events and hospitalizations, and enhance functional recovery. Moreover, healthcare clinicians benefit from the AFED model through increased satisfaction, multidisciplinary support, and enhanced training in geriatric care. Policymakers, healthcare administrators, and clinicians must collaborate to standardize guidelines, address barriers to AFEDs, and promote the adoption of age-friendly practices in the ED.

Deprescribing in Older Poly-Treated Patients Affected with Dementia

Polypharmacy is an important issue in older patients affected by dementia because they are very vulnerable to the side effects of drugs'. Between October 2021 and September 2022, we randomly assessed 205 old-aged outpatients. The study was carried out in a Center for Dementia in collaboration with a university center. The primary outcomes were: (1) deprescribing inappropriate drugs through the Beers and STOPP&START criteria; (2) assessing duplicate drugs and the risk of iatrogenic damage due to drug-drug and drug-disease interactions. Overall, 69 men and 136 women (mean age 82.7 ± 7.4 years) were assessed. Of these, 91 patients were home care patients and 114 were outpatient. The average number of the drugs used in the sample was 9.4 drugs per patient; after the first visit and the consequent deprescribing process, the average dropped to 8.7 drugs per patient (p = 0.04). Overall, 74 potentially inappropriate drugs were used (36.1%). Of these, long half-life benzodiazepines (8.8%), non-steroidal anti-inflammatory drugs (3.4%), tricyclic antidepressants (3.4%), first-generation antihistamines (1.4%), anticholinergics (11.7%), antiplatelet drugs (i.e., ticlopidine) (1.4%), prokinetics in chronic use (1.4%), digoxin (>0.125 mg/day) (1.4%), antiarrhythmics (i.e., amiodarone) (0.97%), and α-blockers (1.9%) were included. The so-called "duplicate" drugs were overall 26 (12.7%). In total, ten potentially dangerous prescriptions were found for possible interactions (4.8%). We underline the importance of checking all the drugs taken periodically and discontinuing drugs with the lowest benefit-to-harm ratio and the lowest probability of adverse reactions due to withdrawal. Computer tools and adequately trained teams (doctors, nurses, and pharmacists) could identify, treat, and prevent possible drug interactions.

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study

BACKGROUND AND OBJECTIVES

Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality.

METHODS

This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method.

RESULTS

This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index.

CONCLUSIONS

Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

OBJECTIVES

This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada.

DESIGN

Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0).

SETTING AND PARTICIPANTS

LTC residents in Ontario between January 1, 2016, and December 31, 2019.

METHODS

We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models.

RESULTS

The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria.

CONCLUSIONS AND IMPLICATIONS

This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

Time-dependent association between STOPP and START criteria and gastrointestinal bleeding in older patients using routinely collected primary care data

PURPOSE

Only few studies have assessed the preventive effect of the STOPP/START criteria on adverse events. We aim to quantify 1) the association between nonadherence to STOPP/START criteria and gastrointestinal bleedings, and 2) the association between exposure to the potentially harmful START-medications and gastrointestinal bleedings.

DESIGN

A retrospective cohort study using routinely collected data of patients aged ≥ 65 years from the electronic health records (EHR) of 49 general practitioners (GPs) in 6 GP practices, from 2007 to 2014. The database is maintained in the academic research network database (AHA) of Amsterdam UMC, the Netherlands.

METHODS

Gastrointestinal bleedings were identified using ICPC codes and free text inspections. Three STOPP and six START criteria pertaining to gastrointestinal bleedings were selected. Cox proportional hazards regression with time-dependent covariate analysis was performed to assess the independent association between nonadherence to the STOPP/START criteria and gastrointestinal bleedings. The analysis was performed with all criteria as a composite outcome, as well as separately for the individual criteria.

RESULTS

Out of 26,576 participants, we identified 19,070 Potential Inappropriate Medications (PIM)/Potential Prescribing Omission (PPO) instances for 3,193 participants and 146 gastrointestinal bleedings in 143 participants. The hazard ratio for gastrointestinal bleedings of STOPP/STARTs, taken as composite outcome, was 5.45 (95% CI 3.62-8.21). When analysed separately, two out of nine STOPP/STARTs showed significant associations.

CONCLUSION

This study demonstrates a significant positive association between nonadherence to the STOPP/START criteria and gastrointestinal bleeding. We emphasize the importance of adherence to the relevant criteria for gastrointestinal bleeding, which may be endorsed by decision support systems.

Potentially inappropriate medications and potential prescribing omissions in hospitalised older adults in New Zealand: A retrospective study

OBJECTIVE

Medication errors can have detrimental effects on patient outcomes, yet there are limited data on the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among older adult inpatients in New Zealand (NZ). This study investigated exposure to PIMs and PPOs in older adults in a New Zealand hospital.

METHODS

Electronic medical records of 846 older adults (≥ 65 years) discharged from the Auckland District Health Board between June 2020 and May 2021 were retrospectively reviewed to extract data on sociodemographic, medication and diagnostic information. STOPP/START version 2 was used to evaluate PIMs and PPOs on admission and discharge.

RESULTS

The mean age was 77.47 ± 8.12 years, and 51% were female. On admission, 48% had ≥1 PIMs and 40% had ≥1 PPOs. On discharge, 45% had ≥1 PIMs and 40% had ≥1 PPOs. Increasing age (adjusted odds ratio [AOR] = 1.02, 95% CI [confidence interval] 1.01, 1.04), number of medicines (AOR = 1.23, CI 1.17, 1.29) and 28-day admission history (AOR = 1.58, CI 1.15, 2.18) were associated with higher odds of PIMs use on admission. At discharge, the number of medicines (AOR = 1.19, CI 1.13, 1.25) and history of readmission (AOR = 1.47, CI 1.08, 2.02) were associated with higher odds of PIMs. Female patients had higher odds of PPOs both on admission (AOR = 1.35, CI 1.02, 1.78) and discharge (AOR = 1.34, CI 1.01, 1.78). Māori, Asian and Pacific patients were more likely to have prescribing omissions compared to NZ Europeans.

CONCLUSIONS

Prescribing omissions and inappropriate medications were common in older inpatients. There were differences observed between different ethnic groups, with NZ Europeans having fewer omissions than other ethnic groups. These findings highlight key opportunities for health-care providers to improve medication use in older adults in NZ.

Potentially inappropriate medication and frailty in older adults: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess existing studies to demonstrate the association between potentially inappropriate medication (PIM) and frailty.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched major electronic databases (PubMed, Web of Science, the Cochrane Library, Embase, CINHAL, PsycInfo, China National Knowledge Infrastructure, China Biology Medicine disk, Weipu, and Wanfang) from their inception until February 25, 2023 (data updated on May 4, 2023), for observational studies investigating PIM and frailty. I2 was used to measure the heterogeneity between studies quantitatively. A random effect model calculated pooled effect size owing to high heterogeneity. Subgroup analysis was conducted to explore sources of heterogeneity. Additionally, the studies' quality was evaluated using the Newcastle Ottawa Scale (a modified Newcastle Ottawa Scale was used to evaluate cross-sectional studies).

RESULTS

Twenty-four studies were included for systematic review, 14 of which were included in the meta-analysis. After pooling the effect size, the odds ratio with PIM as the dependent variable was 1.12 (95%CI: 1.01-1.25), and that with frailty as the dependent variable was 1.75 (95%CI: 1.25-2.43), indicating a bidirectional association between PIM and frailty.

CONCLUSIONS

PIM and frailty interact with each other and have a bidirectional association, thus providing additional information for early clinical identification and prevention of frailty, and medication safety management.

How to Deprescribe Potentially Inappropriate Medications During the Hospital-to-Home Transition: Stakeholder Perspectives on Essential Tasks

PURPOSE

Nearly all older patients receiving postacute home health care (HHC) use potentially inappropriate medications (PIMs) that carry a risk of harm. Deprescribing can reduce and optimize the use of PIMs, yet it is often not conducted among HHC patients. The objective of this study was to gather perspectives from patient, practitioner, and HHC clinician stakeholders on tasks that are essential to postacute deprescribing in HHC.

METHODS

A total of 44 stakeholders, including 14 HHC patients, 15 practitioners (including 9 primary care physicians, 4 pharmacists, 1 hospitalist, and 1 nurse practitioner), and 15 HHC nurses, participated. The stakeholders were from 12 US states, including New York (n = 29), Colorado (n = 2), Connecticut (n = 1), Illinois (n = 2), Kansas (n = 2), Massachusetts (n = 1), Minnesota (n = 1), Mississippi (n = 1), Nebraska (n = 1), Ohio (n = 1), Tennessee (n = 1), and Texas (n = 2). First, individual interviews were conducted by experienced research staff via video conference or telephone. Second, the study team reviewed all interview transcripts and selected interview statements regarding stakeholders' suggestions for important tasks needed for postacute deprescribing in HHC. Third, concept mapping was conducted in which stakeholders sorted and rated selected interview statements regarding importance and feasibility. A content analysis was conducted of data collected in the individual interviews, and a mixed-method analysis was conducted of data collected in the concept mapping.

FINDINGS

Four essential tasks were identified for postacute deprescribing in HHC: (1) ongoing review and assessment of medication use, (2) patent-centered and individualized plan of deprescribing, (3) timely and efficient communication among members of the care team, and (4) continuous and tailored medication education to meet patient needs. Among these tasks, developing patient-centered deprescribing considerations was considered the most important and feasible, followed by medication education, review and assessment of medication use, and communication.

IMPLICATIONS

Deprescribing during the transition of care from hospital to home requires the following: continuous medication education for patients, families, and caregivers; ongoing review and assessment of medication use; patient-centered deprescribing considerations; and effective communication and collaboration among the primary care physician, HHC nurse, and pharmacist.

Medication-Related Problems and Their Intervention in the Geriatric Population: A Review of the Literature

In order to implement the principles of providing clinically and economically effective care, the current state of healthcare must be evaluated, and challenges must be addressed. As part of a physician's role in such a context, one tool consists of identifying medication-related problems (MRPs) and accordingly implementing best practices and innovative strategies to improve patient healthcare outcomes. The geriatric population is expected to have passed through the natural ageing process and experienced several physiological and biological changes that impact their bodies and lives. In the presence of geriatric syndromes and the increased number of medications consumed, the risk of MRPs such as polypharmacy, potentially inappropriate medication (PIM), adverse events, drug-drug interactions, and risk of non-adherence increases. Different interventions that focus on practical and perceptual barriers have been studied, and different tools to define clinically important prescribing problems relating to PIM have been established. The Beers Criteria and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria are the most widely used sets of explicit PIM criteria; however, they are still limited in Saudi Arabia. These tools should be considered in clinical settings to improve healthcare outcomes in the geriatric population, and the clinical relevance of enhancing medication should also be explored from the point of view of both the patient and healthcare practitioners.

Policies Shaping Nursing Home Medication Practices: Involving Nurses to Advance Individualized Deprescribing

Deprescribing is a common practice in the care of older adults, including those living in nursing homes (NHs). Deprescribing represents an individualized approach to optimizing medication use; it considers the risks, benefits, and goals of an individual, and can mitigate the effects of polypharmacy and potentially inappropriate medications. In NH settings, prescribing practices are shaped directly and indirectly by historical and contemporaneous policies at federal, state, and local levels, which have primarily targeted chemical restraints and unnecessary medications. Understanding these policies, their impact, and potentially unintended consequences is essential for gerontological nursing to transition toward individualized practices and approaches to deprescribing. [Journal of Gerontological Nursing, 49(9), 15-20.].

The effects of pharmaceutical interventions on potentially inappropriate medications in older patients: a systematic review and meta-analysis

Introduction

Potentially inappropriate medications (PIMs) is a particular concern in older patients and is associated with negative health outcomes. As various interventions have been developed to manage it, we performed a systematic review and meta-analysis to evaluate the effect of pharmaceutical interventions on outcomes of PIMs in older patients.

Methods

Meta-analysis of eligible randomized controlled trials (RCTs) was conducted to report the outcomes of pharmaceutical interventions in older patients searching from the databases of Cochrane Library, PubMed, Embase, Web of Science, Clinicaltrials.gov, SinoMed and Chinese Clinical Trial Registry (ChiCTR). The PRISMA guidelines were followed and the protocol was registered in PROSPERO (CRD42019134754). Cochrane bias risk assessment tool and the modified Jadad scale were used to assess the risk bias. RevMan software was used for data processing, analysis and graphical plotting.

Results

Sixty-five thousand, nine hundred seventy-one patients in 14 RCTs were included. Of the primary outcomes, pharmaceutical interventions could significantly reduce the incidence of PIMs in older patients (OR = 0.51, 95% CI: 0.42, 0.62; p < 0.001), and the number of PIMs per person (MD = -0.41, 95%CI: -0.51, -0.31; p < 0.001), accompanying by a low heterogeneity. Subgroup analysis showed that the application of computer-based clinical decision support for pharmacological interventions could remarkably decrease the incidence of PIMs and two assessment tools were more effective. Of the secondary outcomes, the meta-analysis showed that pharmacological interventions could reduce the number of drugs used per person (MD = -0.94, 95%CI: -1.51, -0.36; p = 0.001) and 30-day readmission rate (OR = 0.58, 95%CI: 0.36, 0.92; p = 0.02), accompanying by a low heterogeneity. However, the pharmaceutical interventions demonstrated no significant improvement on all-cause mortality and the number of falls.

Conclusion

Our findings supported the efficacy of pharmaceutical interventions to optimize the use and management of drugs in older patients.

Systematic review registration

https://clinicaltrials.gov/, CRD42019134754.

The Impact of Xerostomia on Food Choices-A Review with Clinical Recommendations

Xerostomia and hyposalivation are highly prevalent conditions in old age, particularly among multimorbid elders, and are often attributed to the use of multiple medications. These conditions negatively affect oral functions, such as chewing, swallowing, speech, and taste. Additionally, the lack of lubrication of the oral mucosa frequently leads to super-infections with candida. Denture retention and comfort may also be compromised. The risk of dental caries and erosion of natural teeth increases since saliva, which is essential for repairing initial lesions in tooth structures, is insufficient. The dry sensation in the mouth also impacts the emotional and social well-being of elderly individuals. Patients experiencing xerostomia often avoid certain foods that are uncomfortable or difficult to consume. However, some foods may alleviate the symptoms or even stimulate salivation. This review discusses the limited available evidence on nutritional advice for patients with xerostomia and aims to provide insight into the patient's perspective while offering clinical recommendations. Future studies should focus on investigating the nutritional intake of individuals suffering from xerostomia or hyposalivation in order to ensure oral health comfort, prevent malnutrition, and minimize the impact on their quality of life.

Global Mapping of Potentially Inappropriate Prescribing for Older Adults in Community Settings: An Umbrella Review

Potentially inappropriate prescribing (PIP) is a major public health concern with several undesirable health consequences for older adults. In this overview, we aimed to map and gather information from existing literature to provide a better insight into the prevalence of PIP among community dwellers. Electronic databases were searched from their inception to April 2022. The quality of the included systematic reviews (SRs) was assessed using the assessment of multiple systematic reviews checklist. The degree of overlap within the SRs was also evaluated (2% overlap). All SRs on the prevalence of PIP in older individuals in community settings were included, and a narrative approach was used to synthesize data. Nineteen SRs comprising 548 primary studies met the inclusion criteria, and the average quality of the included SRs was moderate. More than half (50.5%) of the primary studies were conducted in Europe, followed by the United States (22.8%), and Asia (18.9%). Thirty different criteria were used in the primary studies to estimate the prevalence of PIP. The most widely used criteria were those presented in Beers (41.8%) and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) (21.8%) criteria. Benzodiazepines, nonsteroidal anti-inflammatory drugs, and antidepressants were the most frequently reported PIPs. A considerable variation in the prevalence of PIP ranging from 0% to 98% was reported by SRs. However, there is a high degree of uncertainty regarding the extent of PIP in community settings. To identify knowledge-to-action gaps, SR authors should consider the differences in prevalence of PIP according to settings, applied tools, data sources, geographical areas, and specific pathologies. There is also a need for primary and SR studies from low- and middle-income countries regarding the prevalence of PIP.

It's time to take a sustainable approach to health care in the face of the challenges of the 21st century

Health challenges in the 21st century have become increasingly complex and global. The recent COVID-19 pandemic has only exacerbated the many problems faced by health care systems around the world and sadly, exposed various flaws. With ageing populations, particularly in Canada, as well as unavoidable factors such as globalization and accelerating climate change, it is becoming imperative to implement a new health care approach based on intersectorality and interdisciplinarity. Furthermore, links must be forged between all the stakeholders, i.e. the researchers, the health system and its specialists, the communities and the individuals themselves. It is in this perspective, where everyone concerned must be equally involved in attaining a better quality of life, that the concepts of One Health and sustainable health must be deployed.

Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial

OBJECTIVE

To study the effects of a primary care medication review intervention centred around an electronic clinical decision support system (eCDSS) on appropriateness of medication and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared with a discussion about medication in line with usual care.

DESIGN

Cluster randomised clinical trial.

SETTING

Swiss primary care, between December 2018 and February 2021.

PARTICIPANTS

Eligible patients were ≥65 years of age with three or more chronic conditions and five or more long term medications.

INTERVENTION

The intervention to optimise pharmacotherapy centred around an eCDSS was conducted by general practitioners, followed by shared decision making between general practitioners and patients, and was compared with a discussion about medication in line with usual care between patients and general practitioners.

MAIN OUTCOME MEASURES

Primary outcomes were improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilisation (AOU) at 12 months. Secondary outcomes included number of medications, falls, fractures, and quality of life.

RESULTS

In 43 general practitioner clusters, 323 patients were recruited (median age 77 (interquartile range 73-83) years; 45% (n=146) women). Twenty one general practitioners with 160 patients were assigned to the intervention group and 22 general practitioners with 163 patients to the control group. On average, one recommendation to stop or start a medication was reported to be implemented per patient. At 12 months, the results of the intention-to-treat analysis of the improvement in appropriateness of medication (odds ratio 1.05, 95% confidence interval 0.59 to 1.87) and the number of prescribing omissions (0.90, 0.41 to 1.96) were inconclusive. The same was the case for the per protocol analysis. No clear evidence was found for a difference in safety outcomes at the 12 month follow-up, but fewer safety events were reported in the intervention group than in the control group at six and 12 months.

CONCLUSIONS

In this randomised trial of general practitioners and older adults, the results were inconclusive as to whether the medication review intervention centred around the use of an eCDSS led to an improvement in appropriateness of medication or a reduction in prescribing omissions at 12 months compared with a discussion about medication in line with usual care. Nevertheless, the intervention could be safely delivered without causing any harm to patients.

TRIAL REGISTRATION

NCT03724539Clinicaltrials.gov NCT03724539.

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.

Clinical, economic and humanistic outcomes of medication therapy management services: A systematic review and meta-analysis

Background: Medication therapy management (MTM) services is a method that can effectively improve patients’ conditions, but the efficacy of economic and humanistic outcomes remain unclear. This systematic review and meta-analysis aim to use economic, clinical and humanistic outcomes to evaluate the multi-benefits of MTM services.

Method: A systematic review and meta-analysis was conducted by retrieving PubMed, EMBASE, the Cochrane Library and ClinicalTrial.gov from the inception to April 2022. There were two reviewers screening the records, extracting the data, and assessing the quality of studies independently.

Results: A total of 81 studies with 60,753 participants were included. MTM services were more effective in clinical outcomes with decreasing the rate of readmission (OR: 0.78; 95% CI: 0.73 to 0.83; I2 = 56%), emergency department visit (OR: 0.88; 95% CI: 0.81 to 0.96; I2 = 32%), adverse drug events (All-cause: OR: 0.68; 95% CI: 0.56 to 0.84; I2 = 61%; SAE: OR: 0.51; 95% CI: 0.33 to 0.79; I2 = 35%) and drug-related problems (MD: −1.37; 95% CI: −2.24 to −0.5; I2 = 95%), reducing the length of stay in hospital (MD: −0.74; 95% CI: −1.37 to −0.13; I2 = 70%), while the economic and humanistic outcomes were less effective.

Conclusion: Our systematic review and meta-analysis demonstrated that MTM services had great ability to improve patients’ clinical conditions while the efficacy of economic and humanistic outcomes, with some of the outcomes showing high degree of heterogeneity and possible publication bias, required more future studies to provide stronger evidence.

Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=349050], identifier [CRD42022349050].

Deprescribing, Polypharmacy and Prescribing Cascades in Older People with Type 2 Diabetes: A Focused Review

Deprescribing is the process by which medications are reduced without compromising safety to the patient (Jude et al. in 2022 Diabetes Ther 13: 619–634, 2022). The purpose of this narrative review is to discuss deprescribing as a topic, firstly discussing the benefits and pitfalls to such pharmacological interventions along with the current barriers and enablers to such a controversial topic, and then discussing deprescribing with respect to preventive medications, namely those that reduce the long term impacts of a condition or disease. Research that has previously focused on reducing polypharmacy has highlighted the benefits of such interventions, including reduction of adverse reactions or complications, improved patient satisfaction and quality of life, and improved cost effectiveness and drug compliance. Some potential harms that have been highlighted include an increased number of complications, increased symptoms of previously dampened conditions, and negligible changes in patient satisfaction that have stressed the importance of this intervention being patient centred and individualized to each patient. The implementation of deprescribing processes could drastically change the way people think about deprescribing and could be extremely beneficial to older patients living with type 2 diabetes worldwide. Developments in preventive medication deprescribing could pave the way for this intervention to become more common place improving the quality of life in patient’s final years.

Regional variations in excessive polypharmacy and potentially inappropriate drug use among older adults in Sweden: Trends from 2006 to 2020

Introduction: Potentially inappropriate drug use (PID) is common among older adults. Cross-sectional data suggest that there are marked regional variations in PID in Sweden. There is, however, a lack of knowledge about how the regional variations have changed over time. Objectives: This study aimed to investigate the regional differences in the prevalence of PID in Sweden, 2006-2020. Methods: In this repeated cross-sectional study, we included all older adults (≥75 years) registered in Sweden, yearly from 2006 to 2020. We used nationwide data from the Swedish Prescribed Drug Register linked at the individual level to the Swedish Total Population Register. We selected three indicators of PID according to the Swedish national "Quality indicators for good drug therapy in the elderly": 1) Excessive polypharmacy (use of ≥10 drugs); 2) Concurrent use of three or more psychotropic drugs; 3) Use of "drugs that should be avoided in older adults unless specific reasons exist." The prevalence of these indicators was calculated for each of Sweden's 21 regions, yearly from 2006 to 2020. The annual coefficient of variation (CV) was calculated for each indicator by dividing the standard deviation of the regions by the national average, to measure relative variability. Results: In the population of about 800,000 older adults per year, the national prevalence of "drugs that should be avoided in older adults," was reduced by 59% from 2006 to 2020. There was a slight decline in the use of three or more psychotropics, while the prevalence of excessive polypharmacy increased. The CV for excessive polypharmacy was 14% in 2006 and 9% in 2020 compared to 18% and 14% for "use of three or more psychotropics", and stable at around 10% for 'drugs that should be avoided in older adults.' Conclusions: The regional variation in potentially inappropriate drug use decreased or were stable from 2006 to 2020. The regional differences were largest for the use of three or more psychotropics. We found a general tendency that regions with a good performance at the start of the period performed well across the entire period. Future studies should investigate the reasons for regional variation and explore strategies to reduce unwarranted differences.

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.

Revisiting the inter-rater reliability of drug treatment assessments according to the STOPP/START criteria

AIMS

The aim of this study is to revisit the inter-rater reliability of drug treatment assessments according to the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria.

METHODS

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were independently identified by two physicians in two cohorts of older people (I: 200 hip fracture patients, median age 85 years, STOPP/START version 1; II: 302 primary care patients, median age 74 years, STOPP/START version 2). Kappa statistics were used to evaluate inter-rater agreement.

RESULTS

In cohort I, a total of 782 PIMs/PPOs, related to 68 (78%) out of 87 criteria, were identified by at least one assessor, 500 (64%) of which were discordantly identified by the assessors, that is, by one assessor but not the other. For four STOPP criteria, all PIMs (n = 9) were concordantly identified. In cohort II, 955 PIMs/PPOs, related to 80 (70%) out of 114 criteria, were identified, 614 (64%) of which were discordantly identified. For three STOPP criteria, all PIMs (n = 3) were concordantly identified. For no START criterion, with ≥1 PPO identified, were all assessments concordant. The kappa value for PIM/PPO identification was 0.52 in both cohorts. In cohort II, the kappa was 0.37 when criteria regarding influenza and pneumococcal vaccines were excluded. Further analysis of discordantly identified PIMs/PPOs revealed methodological aspects of importance, including the data source used and criteria wording.

CONCLUSIONS

When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.

Prevalence of potentially inappropriate prescribing in older adults in Central and Eastern Europe: a systematic review and synthesis without meta-analysis

We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach-summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9-63.2%, and the range was 6.5-95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.

Methods to elicit and evaluate the attainment of patient goals in older adults: A scoping review

OBJECTIVE

This scoping review aimed to identify patient goal elicitation and evaluation methods for older adults, and to investigate which methods can be used in medication optimization interventions for nursing home residents (NHRs).

METHODS

The Arksey and O'Malley framework guided the review. A search was launched in PubMed, Embase, CINAHL, and Web of Science. Reference selection and data extraction were performed by three independent reviewers, followed by team discussions to solve discrepancies. Inductive thematic analysis was applied to synthesize the data. Included papers were reconsidered to identify methods for medication optimization interventions for NHRs.

RESULTS

Ninety-six references, encompassing 38 elicitation and 12 evaluation methods, were included. Elicitation methods differed in structure, content, and patient involvement levels. Qualitative and quantitative methods were found to assess goal attainment. Five elicitation and three evaluation methods were developed for NHRs, but none of these contained a medication-related assessment.

CONCLUSION

A variety of goal elicitation and evaluation methods for older adults was found, but none for medication optimization interventions in NHRs.

PRACTICE IMPLICATIONS

A holistic approach seems important to integrate patient goals into medication optimization interventions, not limiting goal elicitation to a medication-related assessment. Also, the choice of assessor seems important to obtain patient goals.

A Study on the Perceptions of Korean Older Adult Patients and Caregivers about Polypharmacy and Deprescribing

Polypharmacy is continuously increasing among older adults. The resultant potentially inappropriate medications (PIMs) can be harmful to patient health. Deprescribing refers to stopping or reducing PIMs. In this study, the current status of polypharmacy and willingness of older adults to deprescribe were investigated among patients and caregivers who are not associated with one another. The survey used the Korean translated version of the revised Patients' Attitude Towards Deprescribing (rPATD) Scale. Data were collected through an online survey of 500 participants (250 patients and caregivers each) in this study. The following results were found for patients and caregivers, respectively: 74.8% and 63.6% felt their number of medications was high, 64.4% and 55.6% desired to reduce their medications, 70.4% and 60.8% were concerned about medication discontinuation, 63.2% and 61.2% had a good understanding of their medications, 77.6% and 76.4% were willing to be well informed, and 79.6% and 72% wanted to reduce the number of medications if medically feasible. Patients and caregivers commonly agreed to the burden of the number of medications they were taking, and were willing to reduce the number of medications if the doctor said it was possible. Doctors should consider this information during the deprescribing process, and promote deprescription while involving patients and caregivers in the decision-making process.

The development and validation of a medicines optimisation tool to protect the physical health of people with severe mental illness (OPTIMISE)

BACKGROUND

The life expectancy of people with severe mental illness (SMI) is shorter than those without SMI, with multimorbidity and poorer physical health contributing to health inequality. Screening tools could potentially assist the optimisation of medicines to protect the physical health of people with SMI. The aim of our research was to design and validate a medicines optimisation tool (OPTIMISE) to help clinicians to optimise physical health in people with SMI.

METHODS

A review of existing published guidelines, PubMed and Medline was carried out. Literature was examined for medicines optimisation recommendations and also for reference to the management of physical illness in people with mental illness. Potential indicators were grouped according to physiological system. A multidisciplinary team with expertise in mental health and the development of screening tools agreed that 83 indicators should be included in the first draft of OPTIMISE. The Delphi consensus technique was used to develop and validate the contents. A 17-member multidisciplinary panel of experts from the UK and Ireland completed 2 rounds of Delphi consensus, rating their level of agreement to 83 prescribing indicators using a 5-point Likert scale. Indicators were accepted for inclusion in the OPTIMISE tool after achieving a median score of 1 or 2, where 1 indicated strongly agree and 2 indicated agree, and 75^th centile value of ≤ 2. Interrater reliability was assessed among 4 clinicians across 20 datasets and the chance corrected level of agreement (kappa) was calculated. The kappa statistic was interpreted as poor if 0.2 or less, fair if 0.21-0.4, moderate if 0.41-0.6, substantial if 0.61-0.8, and good if 0.81-1.0.

RESULTS

Consensus was achieved after 2 rounds of Delphi for 62 prescribing indicators where 53 indicators were accepted after round 1 and a further 9 indicators were accepted after round 2. Interrater reliability of OPTIMISE between physicians and pharmacists indicated a substantial level of agreement with a kappa statistic of 0.75.

CONCLUSIONS

OPTIMISE is a 62 indicator medicines optimisation tool designed to assist decision making in those treating adults with SMI. It was developed using a Delphi consensus methodology and interrater reliability is substantial. OPTIMISE has the potential to improve medicines optimisation by ensuring preventative medicines are considered when clinically indicated. Further research involving the implementation of OPTIMISE is required to demonstrate its true benefit.

TRIAL REGISTRATION

This article does not report the results of a health care intervention on human participants.

Implementation and Evaluation of Clinical Pharmacy Services on Improving Quality of Prescribing in Geriatric Inpatients in Vietnam: An Example in a Low-Resources Setting

Purpose

Geriatric inpatients generally have a high risk of drug-related problems (DRP) in prescribing following hospital admission, which are likely to cause negative clinical consequences. This is particularly evident in developing countries such as Vietnam. Therefore, clinical pharmacy service (CPS) aims to identify and resolve these DRPs to improve the quality use of medicines in the older population following hospital admission.

Patients and Methods

The study was conducted as a prospective, single-center study implemented at a general public hospital in Hanoi. Patients aged ≥60 years with at least three chronic diseases admitted to the Internal Medicine Department between August 2020 and December 2020 were eligible to be enrolled. A well-trained clinical pharmacist provided a structured CPS to identify any DRP in prescribing for each patient in the study. Clinical pharmacist interventions were then proposed to the attending physicians and documented in the DRP reporting system.

Results

A total of 255 DRP were identified in 185 patients during the study period. The most frequent types of DRP were underuse (21.2%), dose too high (12.2%), and contraindication (11.8%). There was a very high rate of approval and uptake by the physicians regarding the interventions proposed by the clinical pharmacist (82.4% fully accepted and 12.5% partially accepted). Of the interventions, 73.4% were clinically relevant (pADE score ≥0.1). In general, 9 out of 10 physicians agreed that CPS has significant benefits for both patients and physicians.

Conclusion

Improving clinical pharmacy services can potentially have a positive impact on the quality of prescribing in elderly inpatients. These services should officially be implemented to optimize the quality use of medicines in this population group in Vietnam.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Frailty and Potentially Inappropriate Prescribing in Older People with Polypharmacy: A Bi-Directional Relationship?

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people’s degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

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.

The effect of educational intervention on use of psychotropics in defined daily doses and related costs - a randomized controlled trial

OBJECTIVE

To investigate the effect of an educational intervention of nursing staff on change in psychotropic use and related costs among older long-term care residents.

DESIGN

A secondary analysis of a randomized controlled intervention study with 12 months of follow-up.

SETTING

Assisted living facilities in Helsinki, Finland.

SUBJECTS

Older (≥65 years) residents (N = 227) living in assisted living facility wards (N = 20) in Helsinki in 2011.

INTERVENTION

The wards were randomized into two groups. In one group, the nursing staff received training on appropriate medication therapy and guidance to recognize potentially harmful medications and adverse effects (intervention group); in the other group, the nursing staff did not receive any additional training (control group).

MAIN OUTCOME MEASURES

Change of psychotropic use counted as relative proportions of WHO ATC-defined daily doses (rDDDs) among older long-term care residents. In addition, the change in drug costs was considered. Comparable assessments were performed at 0, 6, and 12 months.

RESULTS

A significant decrease in both rDDDs and the cost of psychotropics was observed in the intervention group at 6 months follow-up. However, at 12 months, the difference between the intervention and control group had diminished.

CONCLUSIONS

Educational training can be effective in reducing the doses and costs of psychotropics. Further studies are warranted to investigate whether long-term effects can also be achieved by various educational interventions.

REGISTRATION NUMBER

ACTRN 12611001078943 KEY POINTSWe explored the effect of staff training on psychotropic use and associated costs among older long-term care residents.Educational training of nursing staff was beneficial as regards the actual drug doses of psychotropics, and cost savings in psychotropic medication were achieved.Educational training was efficient in the short-term, but further research is warranted to achieve long-term effects.

Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study

PURPOSE

To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment.

METHODS

PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate.

RESULTS

In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment.

CONCLUSION

One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.

Evaluation of a community-based memory clinic in collaboration with local hospitals to support patients with memory decline

Objective

This study evaluates the role of a specialised and multidisciplinary healthcare team, including a pharmacist, in providing medication management for patients with mild cognitive impairment (MCI) and dementia, in a memory clinic.

Methods

The study analysed the dataset of 102 patients of a geriatric and memory clinic in a rural area of Ontario, Canada. The case histories of the patients were reviewed a week before the clinic day and a pharmacist performed medication reconciliations. During the clinic day, cognitive tests were conducted and outcomes were discussed with the team, to create a care plan and schedule a follow-up within 3, 6 or 12 months.

Results

Most patients had an average of 5 prescriptions and 2 non-prescription medications deprescribed, and 57% of patients were started on memory-related medications. A total of 712 medications (p-value 0.001) were deprescribed, with 510 prescriptions and 202 non-prescription items. Out of the 712 deprescribed drugs, 374 were discontinued with no therapeutic substitutions, 202 were reduced in dosage and 136 were switched to a safer alternative. A total of 43 patients showed improved Activities of Daily Living (ADL) performance after 3 and 6 months and 68 patients showed improvement after 12 months.

Conclusion

This study highlights the importance of a multidisciplinary approach in addressing drug-therapy problems, medication optimisation, and deprescription in patients with dementia. The presence of a pharmacist in the multidisciplinary team enables impactful medication optimisation and leads to improved patient outcomes. This demonstrates the value of specialised expertise in medication management for patients with dementia.