Potentially inappropriate prescribing in institutionalised older patients in Spain: the STOPP-START criteria compared with the Beers criteria
Objective: The aims of this study were to identify potentially inappropriate prescribing using the Beers and STOPP criteria. The START criteria were applied to detect prescription omission in the geriatric population. We compared the utility of these criteria in institutionalised older people.
Methods: Descriptive study reviewing the medication and clinical records of 81 residents (aged 65 years and more) by pharmacists in a nursing home in the Lleida region (Spain).
Results: The mean patients’ age was 84 (SD=8) years, with an average of 5 drugs per resident (total prescriptions: 416 medicines). The Beers criteria identified potentially inappropriate medication use in 25% of patients and 48% of patients used at least 1 inappropriate medication according to STOPP criteria. The most frequent potentially inappropriate medications for both criteria were long-acting benzodiazepines and NSAIDs. START detected 58 potential prescribing omissions in 44% of patients. Calcium-vitamin D supplementation in osteoporosis was the most frequent rule (15%), but omissions corresponding to the cardiovascular system implied 23% of patients.
Conclusion: The STOPP-START criteria reveal that potentially inappropriate prescribing (PIP) is a highly prevalent problem among Spanish nursing home residents, and a statistically significant positive correlation was found between the number of medicines prescribed and the number of PIP detected in this study. The STOPP criteria detect a larger number of PI medications in this geriatric population than the Beers criteria. The prescribing omissions detected by the START criteria are relevant and require intervention. Pharmacists’ review of medications may help identify potentially inappropriate prescribing and, through an interdisciplinary approach, working with physicians may improve prescribing practices among geriatric residents of nursing homes
2. Instituto Nacional de Estadística. Avance padrón municipal 2011. Available at: http://www.ine.es/prensa/np648.pdf (Accessed 20 April 2011).
3. Consejo General de Colegios Oficiales de Farmacéuticos. Estadísticas Sanitarias 2008 España. pag 34. Available at: http://www.portalfarma.com/pfarma/taxonomia/general/ gp000016.nsf/voDocumentos/120C1F228EDEF914C125764E00352390/$File/estadisticas_sanitarias.pdf (Accessed 20 April 2011).
4. O'Neill C, Hughes CM, Jamison J, Schweizer A. Cost of pharmacological care of the elderly: Implications for healthcare resources. Drugs Aging. 2003;20(4):253-261.
5. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345-351.
6. Gallagher P, O'Mahony D. STOPP (screening tool of older persons' potentially inappropriate prescriptions): Application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing. 2008;37(6):673-679.
7. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: How well can it be measured and optimised? Lancet. 2007;370(9582):173-184.
8. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus. Arch Intern Med. 2003;163(22):2716-2724.
9. O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. Eur Geriatr Med 2010;1(1):45-51.
10. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (screening tool of older person's prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72-83.
11. Delgado Silveira E, Muñoz García M, Montero Errasquin B, Sánchez Castellano C, Gallagher PF, Cruz-Jentoft AJ. Prescripción inapropiada de medicamentos en los pacientes mayores: Los criterios STOPP/START. Rev Esp Geriatr Gerontol. 2009;44(5):273-279.
12. Lang PO, Hasso Y, Belmin J, Payot I, Baeyens JP, Vogt-Ferrier N, Gallagher P, O'Mahony D, Michel JP. STOPP-START: Adaptation of a French language screening tool for detecting inappropriate prescriptions in older people. Can J Public Health. 2009;100(6):426-431.
13. Lang PO, Hasso Y, Drame M, Vogt-Ferrier N, Prudent M, Gold G, Pierre Michel J. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing. 2010;39(3):373-381.
14. Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, Tulkens PM. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: A randomized, controlled trial. J Am Geriatr Soc. 2007;55(5):658-665.
15. Loganathan M, Singh S, Franklin BD, Bottle A, Majeed A. Interventions to optimise prescribing in care homes: Systematic review. Age Ageing. 2011;40(2):150-162.
16. Cabanero-Martinez MJ, Cabrero-Garcia J, Richart-Martinez M, Munoz-Mendoza CL. The spanish versions of the Barthel index (BI) and the Katz index (KI) of activities of daily living (ADL): A structured review. Arch Gerontol Geriatr. 2009;49(1):e77-e84.
17. Lobo A, Saz P, Marcos G, Dia JL, de la Camara C, Ventura T, Morales Asin F, Fernando Pascual L, Montanes JA, Aznar S. Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population. Med Clin (Barc). 1999;112(20):767-774.
18. Hosia-Randell HM, Muurinen SM, Pitkala KH. Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland: A cross-sectional study. Drugs Aging. 2008;25(8):683-692.
19. Ruggiero C, Lattanzio F, Dell'Aquila G, Gasperini B, Cherubini A. Inappropriate drug prescriptions among older nursing home residents: The Italian perspective. Drugs Aging. 2009;26(Suppl 1):15-30.
20. Byrne S, Ryan C, O'Mahony D, Weedle P, Kennedy J, Ahern E. Inappropriate prescribing in the elderly: a review of primary care and nursing home prescriptions. Int J Pharm Pract. 2008;16(Suppl 1): A36-A37.
21. Perri M 3rd, Menon AM, Deshpande AD, Shinde SB, Jiang R, Cooper JW, Cook CL, Griffin SC, Lorys RA. Adverse outcomes associated with inappropriate drug use in nursing homes. Ann Pharmacother. 2005;39(3):405-411.
22. Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: An update of the evidence. J Am Pharm Assoc. 2002;42(6):847-857.
23. Conejos Miquel MD, Sanchez Cuervo M, Delgado Silveira E, Sevilla Machuca I, Gonzalez-Blazquez S, Montero Errasquin B, Cruz-Jentoft AJ. Potentially inappropriate drug prescription in older subjects across health care settings. Eur Geriatr Med. 2010;1(1):9-14.
24. Fidalgo García ML, Molina García T, Millán Pacheco F, Orozco Díaz P, Benavente Moreda I, Casado López M, López Bilbao C. Prescripción farmacéutica en residencias de ancianos. Comparación con ancianos ambulatorios. Medifam. 2001;11(2):55-70.
25. Sotoca JM, Anglada H, Molas G, Fontanals S, Rovira M, Sebastian L. Aplicación de los nuevos criterios de prescripción inadecuada STOPP-START a pacientes geriátricos institucionalizados. Farm Aten Primaria. 2011;9(1):2-7.
26. Gongora L, Puche E, Garcia J, Luna JD. Inappropriate prescriptions in elderly residents of nursing homes. Rev Esp Geriatr Gerontol. 2004;39(1):19-24.
27. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013-1019.
28. Bejarano Romero F, Pinol Moreso JL, Mora Gilabert N, Claver Luque P, Brull Lopez N, Basora Gallisa J. Increased benzodiazepine use in elderly women attending urban primary health care centers. Aten Primaria. 2008;40(12):617-621.
29. Barbera T, Avellana JA, Moreno Royo L. Are benzodiazepines correctly used in the elderly? Rev Clin Esp. 2007;207(3):138-140.
30. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous benzodiazepine regimens in the elderly: Effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry. 2001;158(6):892-898.
31. Tinetti ME. Clinical practice. preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-49.
32. Sicras-Mainar A, Pelaez-de-Lono J, Castella-Rosales A, Rodriguez-Darriba M. Consumption of inappropriate psychotropic drugs in residential homes for the elderly: Comparative study between 2001 and 2006. Farm Hosp. 2008;32(2):96-101.
33. Ryan C, O'Mahony D, Kennedy J, Weedle P, Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68(6):936-947.
34. Pattanaworasate W, Emmerton L, Pulver L, Winckel K. Comparison of prescribing criteria in hospitalised Australian elderly. Pharm Pract (Internet). 2010;8(2):132-138.
35. Snowdon J, Day S, Baker W. Current use of psychotropic medication in nursing homes. Int Psychogeriatr. 2006;18(2):241-250.
36. Laroche ML, Charmes JP, Nouaille Y, Picard N, Merle L. Is inappropriate medication use a major cause of adverse drug reactions in the elderly? Br J Clin Pharmacol. 2007;63(2):177-186.
37. Chang LF, Lutfiyya MN, El-Khabiry E. Results of chart reviews conducted to evaluate primary care patients seen by second and third year family medicine residents for potential adverse polypharmacy. Pharm Pract (Internet). 2007;5(2):85-88.
38. Fialova D, Topinkova E, Gambassi G, Finne-Soveri H, Jonsson PV, Carpenter I, Schroll M, Onder G, Sorbye LW, Wagner C, Reissigova J, Bernabei R, AdHOC Project Research Group. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293(11):1348-1358.
39. Kamel HK. Underutilization of calcium and vitamin D supplements in an academic long-term care facility. J Am Med Dir Assoc . 2004;5(2):98-100.
40. Barry PJ, Gallagher P, Ryan C, O'Mahony D. START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36(6):632-638.
41. Kvan E, Pettersen KI, Landmark K, Reikvam A, INPHARM study investigators. Treatment with statins after acute myocardial infarction in patients >or=80 years: Underuse despite general acceptance of drug therapy for secondary prevention. Pharmacoepidemiol Drug Saf. 2006;15(4):261-267.
42. Spinler SA. Safety and tolerability of antiplatelet therapies for the secondary prevention of atherothrombotic disease. Pharmacotherapy. 2009;29(7):812-821.
43. Masoudi FA, Rathore SS, Wang Y, Havranek EP, Curtis JP, Foody JM, Krumholz HM. National patterns of use and effectiveness of angiotensin-converting enzyme inhibitors in older patients with heart failure and left ventricular systolic dysfunction. Circulation. 2004;110(6):724-731.
44. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 1997;277(2):115-121.
45. Kuijpers MA, van Marum RJ, Egberts AC, Jansen PA, OLDY (OLd people Drugs & dYsregulations) Study Group. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol. 2008;65(1):130-133.
46. Martin-Baranera M, Sanchez Ferrin P, Armario P, Geriatric HTA Study Group. Prevalence of hypertension in elderly long-term care residents in Spain. the geriatric HTA study. Med Clin (Barc). 2006;127(18):681-687.
47. Marcum ZA, Handler SM, Wright R, Hanlon JT. Interventions to improve suboptimal prescribing in nursing homes: A narrative review. Am J Geriatr Pharmacother. 2010;8(3):183-200.
48. Gallagher PF, O'Connor MN, O'Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: A randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845-854.
The authors hereby transfer, assign, or otherwise convey to Pharmacy Practice: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print pr epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Author Self-Archiving Policy
Pharmacy Practice permits and encourages authors to post and archive the final pdf of the articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.