Screening Tool To Alert To Right Treatment Research Articles

Medication Optimization Protocol Efficacy for Geriatric Inpatients

There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients. To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy. This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024. The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients' primary care physicians and community pharmacists. The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events. Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group). In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy. UMIN Clinical Trials Registry: UMIN000035265.

Medication Appropriateness for Older Nursing Home Patients With a Limited Life Expectancy: From STOPP/START Version 2 to the ReNeWAL Criteria

ObjectivesTo adapt the 2015 Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria to older nursing home patients with a limited life expectancy of 1.5 to 2 years. DesignA modified Delphi consensus study. Setting and ParticipantsThe study was established in The Netherlands and conducted online. The international panel consisted of 23 experts with experience in medicine for older people. MethodsThe expert panel was presented with the 2015 STOPP/START criteria using an online survey program (Survey Monkey). The panelists were asked for their opinion on the appropriateness of the STOPP and START criteria, and adaptations to these criteria for older nursing home patients with a limited life expectancy on 4-point Likert scales. Consensus was defined as ≥70% of the panelists answering (very) inappropriate or (very) appropriate, and (completely) disagree or (completely) agree. ResultsTwenty-one panelists completed all 3 Delphi rounds. The final list of “Represcribing for Nursing home residents With A Limited life expectancy (ReNeWAL)” criteria comprises 132 criteria: 98 criteria to stop (70 original STOPP criteria and 28 adapted) and 34 criteria to start (16 original START criteria and 18 adapted) for older nursing home patients with a limited life expectancy. Considerations that panelists mentioned for adapting criteria were mainly prevention and treatment of discomfort. Conclusion and ImplicationsIt is clear that represcribing for older nursing home patients is highly complex and requires the consideration of various elements. The ReNeWAL criteria may be useful in enhancing represcribing for older nursing home patients with a limited life expectancy.

Evaluation of potentially inappropriate medications for the elderly according to beers, STOPP, START, and Chinese criteria.

Objective: Polypharmacy prevalence is increasing worldwide, and it is becoming more popular among the elderly. This study aimed to compare the prevalence of potentially inappropriate medications (PIMs) using the Beers criteria (2019 edition), criteria for potentially inappropriate medications for older adults in China (Chinese criteria), Screening Tool of Older Persons' Prescriptions (STOPP), and Screening Tool to Alert to Right Treatment (START) criteria and to identify risk factors associated with PIM use. Methods: This was a cross-sectional study with a sample of 276 inpatients aged ≥65 years old from January 2020 to June 2020. A cross-sectional study was conducted to analyze PIMs based on the Beers (2019 edition), Chinese, STOPP, and START criteria. PIMs use was analysed based on four different criteria and logistic regression analysis was used to investigate independent factors associated with PIM use. Results: The mean number of medications used by the elderly population was nine (range, 0-28). A total of 252 patients (accounting for 91.30%) took five or more medications and 120 patients (accounting for 43.48%) took 10 or more medications. The prevalence rates of PIMs were 66.30% (183/276), 55.07% (152/276), 26.45% (73/276), and 64.13% (177/276) determined by the Beers, Chinese, STOPP, and START criteria, respectively. The top PIMs screened using the Beers, Chinese, and STOPP criteria were proton pump inhibitors, clopidogrel, and benzodiazepines, respectively. Missed use of ACEI in patients with systolic heart failure and/or coronary artery disease was found to be the most common potential prescription omission (PPOs) analyzed using the START criteria. Logistic regression analysis showed that the strongest predictor of PIMs, as determined by all four criteria, was an increased number of medications (p < 0.001). Age was another risk factor for PIMs based on the STOPP criteria in our study (p < 0.05). Conclusion: Polypharmacy and PIMs were common in our study, and the risk of PIMs correlated with polypharmacy. Application of the Beers, Chinese, STOPP, and START criteria is a useful tool for detecting PIM use.

The Prevalence of Potential Prescribing Omissions for Antiplatelets and Statins in Older Adults With Atherosclerotic Cardiovascular Disease.

Background The Screening Tool to Alert to Right Treatment (START) criteria for older adults was developed to recognize potential prescribing omissions (PPOs) of clinically indicated medications. According to these criteria, statins and antiplatelets should be prescribed for older adults with a documented history of coronary artery, cerebral, or peripheral vascular disease unless contraindicated. Aim This study aimed to investigate physicians' adherence to START criteria and identify the prevalence of PPO, considering the prescription of statins and antiplatelets in older patients with a history of coronary artery, cerebral, or peripheral vascular disease. Methods In this single-center, cohort, retrospective study, patients aged >65 years with a history of coronary artery, cerebral, or peripheral vascular disease were included. The prevalence of PPO for statins and antiplatelet therapy was identified. This study was guided by the screening Tool of Older Persons'Prescriptions (STOPP)/START criteria published in 2016. Results A total of 244 patients with a history of coronary, cerebral, or peripheral vascular disease were included in this study. Statin use was appropriately observed in 131/220 (59.5%)while antiplatelets were appropriately observed in 219/237 (92.4%). Therefore, the PPO for statins and antiplatelets was 40.5% and 7.6%, respectively. Conclusion The results of this study identified that the prevalence of PPO for statins and antiplatelets for older adults was high. We encourage prescribers to utilize tools such as Beer's criteria or STOPP/START, which may assist their decision in addition to their clinical judgment in weighing the benefit to the risk of starting or stopping antiplatelets or statins in older adult patients.

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 economicallyeffective 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.

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.

STOPP/START Anti-aggregation and Anticoagulation Alerts in Atrial Fibrillation.

Atrial Fibrillation (AF) is common in the elderly. A key component of AF management is Oral Anticoagulant Therapy (OAT), consisting of Vitamin K Antagonists (VKAs) or Direct Oral Anticoagulants (DOACs). The aim of the present study is to check, using STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) Criteria, if such drugs are potentially inappropriately prescribed/omitted in an elderly population with AF, and to determine their impact on mortality. This study included patients (n = 427) with nonvalvular AF consecutively evaluated between 2013 and 2019 at the Geriatric Outpatient Service, University Hospital of Monserrato, Cagliari, Italy, and followed up for 36 months. The OAT group included 330 patients; the other 97 patients constituted the non-OAT group. The sample was assessed for STOPP/START criteria. We found no difference (p > 0.1) in comorbidity burden, frailty, and cardio-cerebro-vascular disease prevalence in the two groups, which also did not present a difference in 36-month mortality (p = 0.97). OAT was overall appropriately taken, and 62.4% of OAT-group presented the START criterion to take antiplatelets but also the STOPP criterion not to take them, because of the simultaneous anticoagulant intake. In the non-OAT group, 69.1% presented the START criterion to take anticoagulants, and 21.6% the START criterion to take antiplatelets. Patients with AF are often prone to under or over-prescription, particularly of antithrombotic drugs. The STOPP/START criteria are a valid tool to assess and correct wrong therapeutic choices. In frail and comorbid subjects, survival is not correlated with the assumption of OAT.

Prevalence and Associated Predictors of Inappropriate and Omitted Medications Prescribing in Older Patients with Advanced Cancer: A Cross-Sectional Study.

This study aimed to identify the prevalence and significant predictors of both potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) events among geriatric patients with advanced cancer using the STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria. This retrospective cross-sectional study included patients aged ≥65 years who were diagnosed and treated for advanced stage of cancer. Patients' medical charts were evaluated to identify polypharmacy (≥5 medications) prevalence as well as potential PIMs and POMs incidents and their associated predictors. SPSS software was used to perform the analysis. Multivariate logistic regression models were used to identify factors associated with dependent variables including PIMs use and POMs. Electronic medication charts of 510 patients were evaluated. The average age of the patients was 73.25 years, and 264 (51.8%) patients were males. The average number of medications prescribed per patient was 10.3 (range-2-26). Polypharmacy was present in 85.9% of patients, while excessive polypharmacy prevalence was 52.2%. At least one PIM was encountered in 253 patients (49.6%), while at least one POM was encountered in all patients owing to the omission of pneumococcal vaccines. The most common PIMs were opioid analgesics, followed by benzodiazepines, and hypnotics. Additionally, the most omitted medications, excluding vaccinations, were cardiovascular agents and laxatives in patients on regular opioid analgesics. Polypharmacy and diagnosis with solid cancer compared to hematological cancer were associated with increased odds for PIMs occurrence (ORs = 1.293 (p < 0.001) and 3.022 (p = 0.03), respectively), while coexistence of hypertension diagnosis in cancer patients was associated with increased the odds for POMs events (OR = 2.286 (p = 0.007)). Polypharmacy, PIMs, and POMs were highly prevalent among older cancer patients based on the polypharmacy definition and STOPP/START Criteria.

166 INAPPROPRIATE PRESCRIBING IN COMMUNITY-DWELLING OLDER ADULTS: A CROSS SECTIONAL REVIEW USING THE STOPP/START CRITERIA

Abstract Background Older adults are a heterogenous cohort of patients, often with multiple comorbidities and prescribed numerous drugs. Polypharmacy, defined as use of five or more medications, and inappropriate prescribing are risk factors for adverse outcomes. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria that facilitate medication review in older people to aid better prescribing and health outcomes. This review aims to identify inappropriate prescribing in the community-dwelling older adult attending Integrated Care Programme for Older Persons (ICPOP). Methods We performed a cross-sectional review of patients attending the ICPOP Hub between January 2022 and May 2022. Patients’ prescriptions were obtained from pharmacies and/or General Practitioners (GP) and cross checked against the medications brought to their appointment. Patients’ past medical history was obtained from the patient, GP and hospital letters. Their prescriptions were analysed using the STOPP/START criteria. Results This study included 68 patients. The mean age was 83.5 years. Polypharmacy was present in 94%, with an average of 9.5 drugs prescribed. Common medications identified via STOPP criteria were hypnotic z-drugs in patients with falls (13.2%); loop diuretics for pedal oedema without heart failure (11.8%) and benzodiazepines for &amp;gt;4 weeks in patients with falls (10.3%). Common medications identified to commence via START criteria were vitamin D supplement in those with falls (32.4%); bone anti-resorptive therapy in those with osteoporosis (13.2%); laxatives in patients taking opiates (11.8%) and acetylcholinesterase inhibitors in those with memory impairment (8.8%). 48 participants had medications commenced with 46 having medications stopped. Only 9 patients required no change to their medication prescription. Following STOPP/START, there was an overall reduction in prescribed medications by 0.12 (p=0.494). Conclusion Applying STOPP/START criteria lead to a reduction in inappropriate medications prescribed in our multi-morbid older people cohort while identifying appropriate treatments to improve health outcomes.

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes. To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients. This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022. The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study. Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit. A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list. In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

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

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

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.

Under-prescription of medications in older adults according to START criteria: A cross-sectional study in Lebanon.

Background and AimsUnder‐prescription is defined as the exclusion of medications indicated for the treatment of certain conditions without any rationale for not prescribing them. The under‐prescription of medications is highly prevalent among older adults (≥65 years) receiving polypharmacy. This study aimed to assess the prevalence of the under‐prescription of medications using the Screening Tool to Alert to Right Treatment (START) criteria version 2 and to identify the predictors of having potential prescribing omissions (PPOs).MethodsThis cross‐sectional, face‐to‐face interview study was carried out between September 2021 and February 2022. The study comprised community‐dwelling older adults taking at least one medication on a regular basis. The study questionnaire included the patients' demographics, clinical data, and comorbidities. PPOs were identified using the START criteria. The χ 2 test was used to assess the association between under‐prescription of medication and the demographic/clinical variables. Multivariable logistic regression was performed to explore factors associated with under‐prescription of medications as the dependent variable and taking all variables that showed a p < 0.05 in the bivariate analysis as independent.ResultsA total of 444 older adults agreed to participate in this study. The mean age of participants was 71 ± 8.6; the majority of them, 305 (68.7%), were men. Polypharmacy was present in 261 patients (58.8%) and underprescribing of medications in 260 patients (58.6%). The highest percentage of under‐prescribing of medications was reported with statins in 115 patients (44.2%) followed by aspirin in 93 (35.7%), and angiotensin‐converting enzyme inhibitors in 61 (23.4%). The results of the multivariable analysis showed that patients with underprescribed medications had higher odds of polypharmacy (odds ratio [OR]: 2.015, confidence interval [CI] 95% 1.362–2.980, p < 0.001) and higher Charlson Comorbidity Index (OR 2.807, CI 95% 1.463–5.85, p = 0.02).ConclusionThe present findings highlight that PPOs are highly prevalent among community‐dwelling older adults in Lebanon. Multimorbidity and polypharmacy were the identified predictors for under‐prescription of medications in this population.

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.

Polypharmacy among Geriatric People: Community Pharmacy based study in Bhaktapur district, Nepal

Background and Objectives: Polypharmacy among geriatric group is a major problem. Risk of an adverse effect increases exponentially with number of drugs used, partly because multiple drug therapy reflects the presence of many disease. The aim of this study was to assess the polypharmacy among geriatric people visiting community pharmacy of Bhaktapur district. Material and Methods: A prospective cross sectional study was conducted among 114 geriatric people (&gt;60Years). The data collected from patients included: Socio-demographic details as age, gender, comorbid diseases, medication history. In this study, polypharmacy was considered as having &gt; 5 medications per prescription. Medication appropriateness for patient was analyzed by applying, screening tool to alert to right treatment (START) and screening tool of older person’s prescription (STOPP) criteria. Results: Out of 114 geriatric patients 57.9% were male and 42.1% were female. Number of drugs prescribed to the patients were 634 with an average of 5.56 drugs per person. Cardiovascular drugs accounted for most (33.4%) followed by gastrointestinal tract drugs (11.5%), anti-diabetic drugs (10.89%). Over the counter drugs (OTC) were more common among geriatric, mainly proton pump inhibitor and non-steroid anti-inflammatory drugs. Depending upon the number of drugs, five and more than five drugs were consumed by single patients (n=73). Poly pharmacy can be seen among 64.03% geriatric patients. Potentially inappropriate medications were prescribed to 54 patients, overprescribing to38.5% and omission to 8.7% depending upon screening tool to alert to right treatment (START) and screening tool of older person’s prescription (STOPP) START. Conclusions: In this study polypharmacy was more common among geriatric group. Geriatric group were receiving around 64.03% polypharmacy, 47.3% inappropriate prescription and 33.3% using over the counter 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.

Translation and adaptation of the STOPP-START screening tool to Portuguese for detecting inappropriate prescriptions in older people: a protocol

IntroductionRational prescribing for older adults is a challenge because they usually exhibit multimorbidity and multimedication. One available and reliable tool to tackle this issue consists of the Screening Tool of...

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.

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.

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress

ABSTRACTIntroduction: STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) are explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. This review examines the clinical trial evidence pertaining to STOPP/START criteria as an intervention.Areas covered: The literature was searched for registered clinical trials that used STOPP/START criteria as an intervention. In single-center trials, applying STOPP/START criteria improved medication appropriateness, reduced polypharmacy, reduced adverse drug reactions (ADRs), led to fewer falls, and lower medication costs. Two large-scale multi-center trials (SENATOR and OPERAM) examined the impact of computer-generated STOPP/START criteria on incident ADRs (SENATOR) and drug-related hospitalizations (OPERAM) in multi-morbid older people. Results of these trials will be publicized in 2020.Expert opinion: Applying STOPP/START criteria improves clinical outcomes in multi-morbid older people. Electronic deployment of STOPP/START criteria is a substantial technical challenge; however, recent clinical trials of software prototypes demonstrate feasibility. Even with well-functioning software for the application of STOPP/START criteria, the need remains for face-to-face interaction between attending clinicians and appropriately trained personnel (likely pharmacists) to explain and qualify specific STOPP/START recommendations in individual multi-morbid older patients. Such interaction is essential for the implementation of relevant STOPP/START recommendations.