Screening Tool Of Older People's Prescriptions Research Articles

Medication Appropriateness among Older Persons Admitted to a General Hospital in Malaysia

Introduction: Many tools have been developed to determine medication appropriateness in older persons including the 2015 American Geriatric Society (AGS) Beers criteria and the Screening Tool of Older People’s Prescriptions (STOPP) criteria. We aimed to determine and compare the prevalence of potentially inappropriate medications (PIMs) based on the Beers criteria 2015 and the STOPP criteria v2 among older persons admitted to a general hospital in Malaysia. Methods: A cross-sectional study comprising of 160 patients aged 65 years old and above admitted to the general medical wards of a tertiary teaching hospital were recruited. Beers criteria 2015 and the STOPP criteria v2 were used to evaluate participants’ medication list on admission, during hospitalisation and on discharge for PIMs. Prevalence of PIMs which was calculated as the total number of patients with one or more PIMs over the total number of patients. Results: The prevalence of PIMs identified by Beers criteria 2015 on admission, during hospitalisation and on discharge were 54.85%, 64.40% and 48.80% respectively. The prevalence of PIM based on STOPP criteria v2 were 33.08%, 47.50% and 42.50% respectively. The most prevalent PIMs according to Beers criteria 2015 and STOPP criteria v2 were diuretics, tramadol, ticlopidine, proton pump inhibitor, benzodiazepines and antipsychotics. Conclusion: The prevalence of PIMs use is high among hospitalised older persons in Malaysia. While it is not possible to avoid all PIMs listed in the Beers and STOPP criteria, clinicians should exercise caution in prescribing drugs such as benzodiazepines, antipsychotics and proton pump inhibitors for older persons weighing the risk versus benefit of the drugs.

Analysis of Potentially Inappropriate Drug Prescribing in Hospitalized Elderly Patients

Abstract The study was conducted at the Clinical Centre Kragujevac, during the period March-May 2016. The study population consisted of patients older than 65 that were treated at different departments of the Clinic for Internal Medicine. Data were collected from hospital medical records of patients and anonymous semi-structured questionnaires. STOPP (screening tool of older people's prescriptions)/ START (screening tool to alert to right treatment) criteria from 2014 were used to monitor the outcome of interest. Based on the outcome PIM (potentially inappropriate drugs)/PPO (potential prescribing omissions), respondents were divided into groups of cases - patients to whom at least one potentially inappropriate drug determined by STOPP criteria was prescribed and those with at least one potential prescribing omission determined by START criteria. Control groups were patients without these outcomes. Most commonly, PIM was detected in the treatment of cardiovascular system diseases (27.12%), followed by the use of drugs that predispose falls in elderly (20.34%). The most important risk factors for the occurrence of PIM were female gender (OR=3.27; 95% CI 1.01-10.64), polypharmacy (5-8 drugs used simultaneously) (OR=3.10; 95% CI 1.11-12.04) and with whom the patient lives (OR=11.26; 95% CI 1.46-86.68). The use of STOPP/START criteria is proved to be efficient in the detection of PIM/PPO at the secondary level of health care. Full attention should always be paid to patients who are at the highest risk for inappropriate drug prescription. Doctors should make their decisions conscientiously and in line with clinical evidence, not blindly believing the pharmaceutical representatives.

Nutritional Status and Potentially Inappropriate Medications in Elderly.

(1) Background: The association between polypharmacy and malnutrition has been investigated in several studies; however, few of these specifically deepened the relationship between potentially inappropriate medication and malnutrition. With a descriptive approach, the primary aim of our study was to evaluate the impact of the nutritional status, assessed with the Mini Nutritional Assessment (MNA), on potentially inappropriate medications (PIM), estimated 10-year survival, and the risk of adverse drug reactions in elderly patients; the secondary aim was to evaluate how the Screening Tool of Older People’s Prescriptions (STOPP), Screening Tool to Alert to Right Treatment (START), and BEERS 2019 criteria identify PIM compared to nutritional status. (2) Methods: In this study, 3091 subjects were enrolled, of whom 2748 (71.7%) were women; the median age was 80 years, with an interquartile range between 75 and 85 years of age. The subjects were assessed at the outpatient service for frail older people of the University Hospital of Cagliari. The study population was evaluated for their: MNA, Charlson Comorbidity Index, 10-year survival estimation, BEERS 2019, STOPP and START criteria, and ADR Risk scores. (3) Results: We divided the study population into three groups: MNA1 (MNA score ≥ 24), MNA2 (23.5–17), and MNA3 (<17): the severity of comorbidities, STOPP and START alerts, and BEERS 2019 criteria were significantly worse in both MNA2 and MNA3 compared to MNA1—with the exception of BEERS “non-anti-infective medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults”. Moreover, the estimated 10-year survival was significantly higher in MNA1 than in MNA2 and MNA3, and also in MNA2 compared to MNA3. Finally, the ADR risk scores were significantly lower in MNA1 than in MNA2 and MNA3. (4) Conclusions: Our study demonstrated the association between nutritional status and PIM checked with the BEERS 2019 criteria, and, for the first time, with the STOPP and START criteria.

Selected Domains within a Comprehensive Geriatric Assessment in Older Patients with Non-Hodgkin Lymphoma are Highly Associated with Frailty

BackgroundThe incidence of Non-Hodgkin Lymphoma (NHL) is increasing, particularly among older patients who tend to have worse outcomes and can be predisposed to increased toxicities and less treatment tolerance. Therefore, a thorough pre-treatment assessment is essential. A comprehensive geriatric assessment (CGA) can be used to evaluate the older patient considering chemotherapy and is the preferred evaluation tool. However, a formal CGA is laborious, complex and time-consuming.ObjectivesTo characterize older adults with NHL and determine the CGA variables with the greatest association to frailty in order to propose a more simplified assessment.MethodsWe performed a cross-sectional study using data collected from CGAs in NHL patients > 65 years admitted to our oncology service, from September 2015 to August 2017. Our evaluation parameters included: polypharmacy, a screening tool of older people's prescriptions (STOPP), the Lawton scale, Barthel index, Katz index, gait speed, a Timed Up and Go (TUG) test, a Mini-Mental state examination (MMSE), the Yesavage and Gijon scales, a Mini-nutritional assessment (MNA), a Geriatric Syndromes assessment, and a Cumulative Illness Rating Scale-Geriatric (CIRS-G). The formal CGA was comprised of nine domains; frailty was defined as an impairment in > 2 domains. Each parameter was individually compared with frailty, and the results were used to build different multivariate models using logistic regression analyses to obtain the variables with the highest frailty association.ResultsA total of 253 patients were included. Their median age was 75.4 years (range 65–92), and 62.1% had > 1 impaired domain, with 39.9% considered frail. Bivariate analysis showed strong associations with age > 85 and all the geriatric parameters except for STOPP. Our final multivariate analysis resulted in 5 domains (the use of > 5 medications, a Lawton < 7, TUG > 20, Yesavage > 5, and the presence of at least one geriatric syndrome) being significantly associated with frailty and performing similarly to a CGA.ConclusionIn our population of older NHL patients, an abbreviated evaluation based of only five domains, polypharmacy, TUG, Lawton scale, Yesavage scale and the presence of at least one geriatric syndrome, had similar performance to a formal CGA in determining frailty.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

BackgroundDrug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.ObjectivesTo identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.DesignA realist synthesis.SettingPrimary care, hospital care and nursing homes.PatientsPatients aged ≥ 65 years.InterventionsAny intervention based on the use of the STOPP/START tools.Review methodsDatabase and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.ResultsWe developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.LimitationsNone of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.ConclusionsNo particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.Study registrationThis study is registered as PROSPERO CRD42018110795.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.

Risk Assessment Of Adverse Drug Reactions In Elderly Patients With Chronic Diseases

Introduction: The adverse drug reaction (ADR) is 4-7 times more common in elderly patients.  That was also related to changes in pharmacokinetics and pharmacodynamics that triggered the emergence of Drug-Related Problems. Objective: The purpose of this study was to assess ADR in elderly patients with chronic diseases using the GerontoNET Score and the Screening Tool of Older People's Prescriptions (STOPP) criteria.  Methods: The research design used a cross-sectional study which was analyzed descriptively. The sample consisted of 72 patients, aged more than 60 years, accompanied by chronic diseases, and hospitalized at Waluyo Jati Kraksaan Hospital. The exclusion criteria were patients referred to the Intensive Care Unit.  Assessment to see the risk of ADR in elderly patients with chronic diseases using the GerontoNet Score while the wrong type of drug is given to elderly patients using the STOPP criteria. The variables contained in the GerontoNET Score are comorbid conditions ³4 (score= 1), heart failure (score= 1), liver disease (score = 1), the number of drugs such as: £5 (score= 0); 6-7 (score=1); ³8 (score=4), history of ADR (score=2), kidney failure (score=1).  Results: The variable with the most ADR risk factors was the number of drugs ³8 drugs as many as 47 patients (65.3%) with GerontoNET score ³4 as much as 70.8%.  The types of drugs included in the STOPP criteria are clopidogrel, Arixtra (fondaparinux), beta-blockers, NSAIDs, and furosemide.  Conclusion: The risk factor for ADR was the number of drugs ³8 drugs.

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

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

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

The prolonged current survival of human immunodeficiency virus (HIV) patients exposes them to new problems arising from the comorbidities they face. To describe the situation of comorbidities, polypharmacy, therapeutic complexity and adherence in people living with HIV over 65years of age and to assess the presence of potentially inappropriate prescriptions (PIP) by applying deprescription criteria. Observational study including HIV people (> 65years) from a university tertiary level hospital. Demographic, clinical and pharmacotherapeutic characteristics of the patients and their treatments were studied. The prevalence of polypharmacy (> 5 medications) and the pharmacotherapy complexity, quantified by the Medication Regimen Complexity Index (MRCI), were calculated. Therapeutic adherence was assessed by the Simplified Medication Adherence Questionnaire (SMAQ) and the medication possession ratio, according to prescription dispensing records. The Screening Tool of Older People's Prescriptions (STOPP) and List of Evidence-baSed depreScribing for CHRONic patients (LESS-CHRON) criteria were applied to identify PIP. PIP in elderly people living with HIV. Thirty patients were included, 73% of whom were men, with a median age of 71years (IQR 67 - 76) and a median duration of infection of 17years (IQR, 9 - 21). Seventy percent of the patients suffered from dyslipemia, 66.7% from hypertension, 43.3% from diabetes and 26.7% from mental health disorders. Seventy percent of the patients took more than 5 medications and 30% more than 10. The MRCI of concomitant medications was higher (18.3 points) than the MRCI of antiretroviral therapy (5.1 points), 66.7% of the studied population was classified as adherent. Finally, 70% of the patients present some PIP according to the STOPP or LESS-CHRON criteria. The polypharmacy was significantly associated (p = 0.008) with meeting deprescription criteria. The elderly people living with HIV present numerous comorbidities and met the criteria for polypharmacy. Their pharmacotherapy complexity is mainly determined by the concomitant treatments. There is a high prevalence of meeting deprescription criteria in people living with HIV over the age of 65 and a clear relationship between polypharmacy and deprescription. The optimization of pharmacotherapy is necessary in this population.

Title Assessing Potentially Inappropriate Medications in Seniors: Differences between American Geriatrics Society and STOPP Criteria, and Preventing Adverse Drug Reactions.

Key problems for seniors are their exposure to “potentially inappropriate medications” and “potential medication omissions”, which place them at risk for moderate, severe, or fatal adverse drug reactions. This study of 82,935 first admissions to acute care hospitals in Calgary during 2013–2018 identified 294,160 Screening Tool of Older People’s Prescriptions (STOPP) potentially inappropriate medications (PIMs) (3.55/patient), 226,970 American Geriatric Society (AGS) Beers PIMs (2.74/patient), 59,396 START potential prescribing omissions (PPOs) (0.72/patient), and 85,288 STOPP PPOs (1.03/patient) for which a new prescription corrected the omission. This represents an overwhelming workload to prevent inappropriate prescriptions continuing during the hospitalisation and then deprescribe them judiciously. Limiting scrutiny to the most frequent PIMs and PPOs will identify many moderate, severe, or fatal risks of causing adverse drug reactions (ADRs) but to identify all PIMs or PPO involving moderate or severe risks of ADRs also involves searching lower in the frequency list of patients. Deciding whether to use the STOPP or AGS Beers PIM lists is an important issue in searching for ADRs, because the Pearson correlation coefficient for agreement between the STOPP and AGS Beers PIM totals in this study was 0.7051 (95% CI 0.7016 to 0.7085; p < 0.001). The combined lists include 289 individual PIM medications but STOPP and AGS have only 159 (55%) in common. The AGS Beers lists include medications used in the US and STOPP/START those used in Europe. The AGS authors recommend using both criteria. The ideal solution to the problem is to implement carefully constructed Clinical Decision Support Systems (CDSS) as in the SENATOR trial, then for an experienced pharmacist to focus on the key PIMs and PPOs likely to lead to moderate, severe, or fatal ADRs. The pharmacist and key decision makers on the services need to establish a collegial relationship to discuss frequently changing the medications that place the patients at risk. Then, the remaining PIMs and PPOs that relate to chronic disease management can be discussed by phone with the family physician using the discharge summary, which lists the medications for potential deprescribing.

Improving the Care of Older Patients by Decreasing Potentially Inappropriate Medications, Potential Medication Omissions, and Serious Drug Events Using Pharmacogenomic Data about Variability in Metabolizing Many Medications by Seniors.

Polypharmacy, potentially inappropriate medications (PIMs) identified by the American Geriatrics Society and Screening Tool of Older People’s Prescriptions (STOPP), potential prescribing omissions (PPOs) identified by Screening Tool to Alert to Right Treatment (START) and serious drug events (SDEs), are major problems for seniors. They correlate with increased risks of rehospitalization and death within six months of hospital discharge. About 75% of commonly prescribed medications are metabolized by P450 cytochrome enzymes. Electronic medical records (EMRs) providing integrated comprehensive pharmacogenomic advice are available only in very large health organizations. The study design of this article is a cross-sectional analysis of the American Geriatrics Society (AGS) and STOPP PIM and START PPO databases integrated with three P450 cytochrome enzyme databases (Flockhart Tables, DrugBank, and Rx Files) and the data are reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. To enable optimally prudent prescribing this article presents for primary care physicians and physicians in remote or rural areas without access to such services a comprehensive integration of the data on PIM and PPO medications with the data on the P450 cytochrome isoforms that metabolize these medications. Additionally presented are the medications metabolized by multiple isoforms and medications that inhibit or induce individual or multiple isoforms. The most extensive metabolic activities involve the central nervous system, anxiolytic, antidepressive, antipsychotic, musculoskeletal, and cardiovascular drugs. The P450 cytochrome isoforms that metabolize the most medications are 3A457, 2C9, 2D6, and 2C19 and nearly all central nervous systems medications compete to be metabolized by 3A457. Medications with the largest inducer or inhibitor activity are highlighted and also a list of commonly prescribed medications that are neither PIMs nor PPOs but compete for metabolism by the same isoforms.

Polypharmacy among older advanced lung cancer patients taking EGFR tyrosine kinase inhibitors

ObjectivePolypharmacy (PP) is a common problem among the older adults and has a potential effect on health-related problems. However, the significance of PP in older advanced non–small cell lung cancer (NSCLC) patients and those on oral molecular-targeted anticancer agents is unclear. Materials and methodsThis retrospective, nonrandomized study reviewed the records of 334 advanced NSCLC patients who underwent epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment. PP was defined as ≥ 5 concomitant medications. Potentially inappropriate medication (PIM) use was measured using the updated screening tool of older people's prescriptions (STOPP) ver. 2 criteria. We also estimated survival distributions using the Kaplan–Meier method, compared between–group differences using the log-rank test, explored potential predictors of survival using Cox regression, and performed cluster analysis to identify factors affecting multiple-medication use. ResultsThe PP and PIM use prevalence was 38.4% and 31.9%, respectively. The median overall survival (OS) for PP(+) and PP(−) patients was 19.4 and 27.3 months, respectively. Multivariate analysis revealed a significant correlation between PP and OS. The frequency of unexpected hospitalization during EGFR-TKI treatment was higher in PP(+) patients compared to PP(−) patients (49.4% vs. 29.4%; odds ratio = 2.34). ConclusionPP is an independent prognostic factor in older advanced NSCLC patients taking EGFR-TKIs. PP can be used as a simple indicator of such patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalization during treatment.

Evidence-based application of explicit criteria to assess the appropriateness of geriatric prescriptions at admission and hospital stay.

BackgroundInappropriate prescribing in the elderly is a critical issue in primary care, causing a higher risk of Adverse Drug Reactions (ADRs) and resulting in major patient safety concerns. At international level, many tools have been developed to identify Potentially Inappropriate Medications (PIMs).ObjectiveThe aim of this study was the application of Beers, Screening Tool of Older People's Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) and Improving Prescribing in the Elderly Tool (IPET) criteria as key tool to improve the quality of prescribing.MethodsA retrospective study was conducted using the aforementioned criteria. Two different cohorts of elderly patients were enrolled between January 2015 and December 2016, 1800 at admission and 1466 at hospital stay. The index of each criterion divided by politherapy were correlated with comorbidities (Pearson correlation). A comparison was made between admission and hospital stay through a Student's t test of the average of the index.ResultsThe Proton Pump Inhibitors (PPIs) were the most prescribed PIMs according Beers criteria in both patient cohorts (56%). The most detected drug-drug and drug-disease interactions at admission and at hospital stay were 3 or more drugs active on the Central Nervous System (CNS) as they can predispose to fall-risk. The most detected PIMs with STOPP criteria at admission were PPIs administered for more than 8 weeks. Inhaled β2-agonists or antimuscarinics were the most prescribed Potential Prescription Omissions (PPOs) according to START criteria. Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in patients with high blood pressure were the most detected PIMs according to IPET criteria during hospital stay. A significant correlation between the comorbidities and the all index at hospital stay, while at admission there was no significant correlation for Beers and IPET index.ConclusionThe prescriptive criteria were a useful tool for assessing the quality of prescriptions in the geriatric population and identifying their critical issues.

Adaptation and Validation of the Screening Tool of Older People's Prescriptions Instrument for the Indonesian Population.

Objective:In this study, we aimed to prepare and validate an Indonesian version for the Screening Tool of Older People's Prescriptions (STOPP), which is an instrument to identify inappropriate medications for elderly patients.Methods:The Indonesian version of STOPP (STOPP_INA) was developed using modified transcultural adaptation guidelines from the American Academy of Orthopedic Surgeons. Our method consisted of translating original STOPP into Indonesian (forwardly translation), synthesis of forward translation, translation into English and synthesis of back translation, a review by the copyright holder of STOPP, a review by the expert team, pretest, revision of STOPP_INA, field test, and psychometric analysis of the final version of the questionnaire. The study design for this part was quasi-experimental with purposive sampling for members of the translator's team, expert's team, and respondents in the pretest, but they were different from field testing that used purposive and postsurvey sampling for respondents. Content validity and face validity were used to construct the validity of STOPP_INA by assessing item-level content validity and correlation between items and total values. Internal consistency was measured with Cronbach's alpha coefficient.Findings:The expert panel agreed on a list of 81 criteria. Five (62.50%) of expert team members agreed and could be continued to the field test without revision of STOPP_INA and 3 (37.50%) agreed with a revision. The research subjects in the psychometric test had 230 respondents, 5 (2.17%) resigned, with an average of item-level content validity index of 0.99. The construct validity analysis showed that 5-item criteria are “not valid,” namely in A1, A3, B7, B10, and C3. Reliability analysis showed the Cronbach's Alpha and Cronbach's Alpha Based on Standardized Items were 0.978 and 0.979.Conclusion:The expert team was be agreed on 81 criteria (100%) of adaptation of STOPP version 2 criteria. There were 5 criteria that not valid statistically, they could not be removed from the instrument because they can influence content and construct of the instrument. The STOPP_INA has been developed for the Indonesian population, currently being tested in clinical practice against elderly patients undergoing hospitalization.

Reducing Potentially Inappropriate Prescriptions for Older Patients Using Computerized Decision Support Tools: Systematic Review.

BackgroundOlder adults are more vulnerable to polypharmacy and prescriptions of potentially inappropriate medications. There are several ways to address polypharmacy to prevent its occurrence. We focused on computerized decision support tools.ObjectiveThe available literature was reviewed to understand whether computerized decision support tools reduce potentially inappropriate prescriptions or potentially inappropriate medications in older adult patients and affect health outcomes.MethodsOur systematic review was conducted by searching the literature in the MEDLINE, CENTRAL, EMBASE, and Web of Science databases for interventional studies published through February 2018 to assess the impact of computerized decision support tools on potentially inappropriate medications and potentially inappropriate prescriptions in people aged 65 years and older.ResultsA total of 3756 articles were identified, and 16 were included. More than half (n=10) of the studies were randomized controlled trials, one was a crossover study, and five were pre-post intervention studies. A total of 266,562 participants were included; of those, 233,144 participants were included and assessed in randomized controlled trials. Intervention designs had several different features. Computerized decision support tools consistently reduced the number of potentially inappropriate prescriptions started and mean number of potentially inappropriate prescriptions per patient. Computerized decision support tools also increased potentially inappropriate prescriptions discontinuation and drug appropriateness. However, in several studies, statistical significance was not achieved. A meta-analysis was not possible due to the significant heterogeneity among the systems used and the definitions of outcomes.ConclusionsComputerized decision support tools may reduce potentially inappropriate prescriptions and potentially inappropriate medications. More randomized controlled trials assessing the impact of computerized decision support tools that could be used both in primary and secondary health care are needed to evaluate the use of medication targets defined by the Beers or STOPP (Screening Tool of Older People’s Prescriptions) criteria, adverse drug reactions, quality of life measurements, patient satisfaction, and professional satisfaction with a reasonable follow-up, which could clarify the clinical usefulness of these tools.Trial RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO) CRD42017067021; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017067021

Study protocol for a single-centre, prospective, non-blinded, randomised, 12-month, parallel-group superiority study to compare the efficacy of pharmacist intervention versus usual care for elderly patients hospitalised in orthopaedic wards

IntroductionGiven that polypharmacy and potentially inappropriate prescribing are common in elderly orthopaedic patients, pharmacist interventions to improve medication practices among this population are important. However, past studies have reported mixed...

Antidepressant use in older inpatients: current situation and application of the revised STOPP criteria.

Antidepressant use increases as age rises. Moreover, older patients are more sensitive to side effects and drug interactions. This descriptive study aims to map antidepressant use among patients at the geriatrics department of a university hospital and to evaluate whether prescribing happens in an evidence-based manner. Patients aged 75 years and over, admitted to the geriatrics department of the Middelheim Hospital in Antwerp between February and July 2017 were included. We checked whether they took antidepressants, which types and doses were prescribed, who prescribed the antidepressants, and whether prescribing was in concordance with the revised STOPP (Screening Tool of Older People's Prescriptions) criteria. Out of the 239 included patients, 61 were found to use antidepressants, with depression being the most important indication. General practitioners appeared to be the most frequent prescribers. Trazodone was the most prescribed antidepressant and was often used for sleeping disorders. Antidepressants were taken longer than recommended in almost one out of five cases. Patients with diabetes and renal insufficiency were prescribed antidepressants less frequently. Only 2.8% of the study participants were prescribed antidepressants for anxiety disorders. We can conclude that prescription of antidepressants in older patients at the geriatrics department is often not evidence based. Clear guidelines may offer a solution; therefore more studies are needed on antidepressant use in older patients.

Drug-related problems identified during medication review before and after the introduction of a clinical decision support system.

To facilitate the identification of drug-related problems (DRPs) during medication review, several tools have been developed. Explicit criteria, like Beers criteria or STOPP (Screening Tool of Older Peoples' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria, can easily be integrated into a clinical decision support system (CDSS). The aim of this study was to investigate the effect of adding a CDSS to medication review software on identifying and solving DRPs in daily pharmacy practice. Pre- to post-analysis of clinical medication reviews (CMRs) performed by 121 pharmacies in 2012 and 2013, before and after the introduction of CDSS into medication review software. Mean number of DRPs per patient, type of DRPs and their resolution rates were compared in the pharmacies pre- and post-CDSS using paired t tests. In total, 9151 DRPs were identified in 3100 patients pre-CDSS and 15268 DRPs were identified in 4303 patients post-CDSS. The mean number of identified DRPs per patient (aggregated per pharmacy) was higher after the introduction of CDSS (3.2 vs 3.6 P<.01). The resolution rate was lower post-CDSS (50% vs 44%; P<.01), which overall resulted in 1.6 resolved DRPs per patient in both groups (P=.93). After the introduction of CDSS, 41% of DRPs were detected by the CDSS. The resolution rate of DRPs generated by CDSS was lower than of DRPs identified without the help of CDSS (29% vs 55%; P<.01). The two most prevalent DRP types were "Overtreatment" and "Suboptimal therapy" in both groups. The prevalence of "Overtreatment" was equal in both groups (mean DRPs per patient: 0.84 vs 0.77; P=.22), and "Suboptimal therapy" was more frequently identified post-CDSS (mean DRPs per patient: 0.54 vs 1.1; P<.01). The introduction of CDSS to medication review software generated additional DRPs with a lower resolution rate. Structural assessment including a patient interview elicited the most relevant DRPs. Further development of CDSS with more specific alerts is needed to be clinical relevant.

Charlson Comorbidity Index, inappropriate medication use and cognitive impairment : Bermuda Triangle.

The aim is to evaluate the association between the Charlson Comorbidity Index (CCI), polypharmacy, inappropriate medication use and cognitive impairment in long-term care facility patients. Across-sectional study including 105 long-term care facility residents was performed. The Charlson Comorbidity Index (CCI) was used. Inappropriate drug use (IDU) was defined according to the STOPP (Screening Tool of Older People's Prescriptions) criteria. Univariate analysis to identify variables associated with patient outcome related with cognitive impairment was investigated with χ2, Pearson correlation, Fisher exact, and Mann-Whitney Utest where appropriate. For the multivariate analysis, the possible factors identified with univariate analysis were further entered into logistic regression analysis. Asignificant difference was found between gender, CCI and cognitive impairment (p= 0.038, p= 0.01). While every one point increment in the CCI increases the risk of cognitive impairment 3.1fold (95% CI= 1.8-5.4, p< 0.001), hypertension increases the risk 12fold (95% CI= 2.5-67.8, p= 0.002). While the correlation between Mini-Mental Status Examination (MMSE) score and polypharmacy is significant (p= 0.015), the correlation between MMSE and IDU was insignificant (p= 0.739). The association of urogenital system drugs and dementia was significant (p= 0.044). Comorbidities, especially hypertension and old age, are risk factors for cognitive impairment. Polypharmacy correlates with MMSE and is considered arisk factor for cognitive impairment. Inappropriate medication use is high among long-term care facility residents. More studies on large cohorts are needed regarding optimal drug prescription and detection of specific drugs that may have an impact on cognitive performance.

Applying STOPP Guidelines in Primary Care Through Electronic Medical Record Decision Support: Randomized Control Trial Highlighting the Importance of Data Quality.

BackgroundPotentially Inappropriate Prescriptions (PIPs) are a common cause of morbidity, particularly in the elderly.ObjectiveWe sought to understand how the Screening Tool of Older People’s Prescriptions (STOPP) prescribing criteria, implemented in a routinely used primary care Electronic Medical Record (EMR), could impact PIP rates in community (non-academic) primary care practices.MethodsWe conducted a mixed-method, pragmatic, cluster, randomized control trial in research naïve primary care practices. Phase 1: In the randomized controlled trial, 40 fully automated STOPP rules were implemented as EMR alerts during a 16-week intervention period. The control group did not receive the 40 STOPP rules (but received other alerts). Participants were recruited through the OSCAR EMR user group mailing list and in person at user group meetings. Results were assessed by querying EMR data PIPs. EMR data quality probes were included. Phase 2: physicians were invited to participate in 1-hour semi-structured interviews to discuss the results.ResultsIn the EMR, 40 STOPP rules were successfully implemented. Phase 1: A total of 28 physicians from 8 practices were recruited (16 in intervention and 12 in control groups). The calculated PIP rate was 2.6% (138/5308) (control) and 4.11% (768/18,668) (intervention) at baseline. No change in PIPs was observed through the intervention (P=.80). Data quality probes generally showed low use of problem list and medication list. Phase 2: A total of 5 physicians participated. All the participants felt that they were aware of the alerts but commented on workflow and presentation challenges.ConclusionsThe calculated PIP rate was markedly less than the expected rate found in literature (2.6% and 4.0% vs 20% in literature). Data quality probes highlighted issues related to completeness of data in areas of the EMR used for PIP reporting and by the decision support such as problem and medication lists. Users also highlighted areas for better integration of STOPP guidelines with prescribing workflows. Many of the STOPP criteria can be implemented in EMRs using simple logic. However, data quality in EMRs continues to be a challenge and was a limiting step in the effectiveness of the decision support in this study. This is important as decision makers continue to fund implementation and adoption of EMRs with the expectation of the use of advanced tools (such as decision support) without ongoing review of data quality and improvement.Trial RegistrationClinicaltrials.gov NCT02130895; https://clinicaltrials.gov/ct2/show/NCT02130895 (Archived by WebCite at http://www.webcitation.org/6qyFigSYT)

Medication review using a Systematic Tool to Reduce Inappropriate Prescribing (STRIP) in adults with an intellectual disability: A pilot study

A Systematic Tool to Reduce Inappropriate Prescribing (STRIP), which includes the Screening Tool to Alert doctors to Right Treatment (START) and the Screening Tool of Older Peoples’ Prescriptions (STOPP), has recently been developed in the Netherlands for older patients with polypharmacy in the general population. Active involvement of the patient is part of this systematic multidisciplinary medication review. Although annual review of pharmacotherapy is recommended for people with an intellectual disability (ID), a specific tool for this population is not yet available. Besides, active involvement can be compromised by ID. Therefore, the objective of this observational pilot study was to evaluate the process of medication review using STRIP in adults with an ID living in a centralized or dependent setting and the identification of drug-related problems using this tool. The study was performed in three residential care organizations for ID. In each organization nine clients with polypharmacy were selected by an investigator (a physician in training to become a specialized physician for individuals with an ID) for a review using STRIP. Clients as well as their legal representatives (usually a family member) and professional caregivers were invited to participate. Reviews were performed by an investigator together with a pharmacist. First, to evaluate the process time-investments of the investigator and the pharmacist were described. Besides, the proportion of reviews in which a client and/or his legal representative participated was calculated as well as the proportion of professional caregivers that participated. Second, to evaluate the identification of drug-related problems using STRIP, the proportion of clients with at least one drug-related problem was calculated. Mean time investment was 130minutes for the investigator and 90minutes for the pharmacist. The client and/or a legal representatives were present during 25 of 27 reviews (93%). All 27 professional caregivers (100%) were involved. For every client included at least one drug-related problem was identified. In total 127 drug-related problems were detected, mainly potentially inappropriate or unnecessary drugs. After six months, 15.7% of the interventions were actually implemented.Medication review using STRIP seems feasible in adults with an ID and identifies drug-related problems. However, in this pilot study the implementation rate of suggested interventions was low. To improve the implementation rate, the treating physician should be involved in the review process. Besides, specific adaptations to STRIP to address drug-related problems specific for this population are required.