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Revisão da Medicação em Idosos Institucionalizados: Aplicação dos Critérios STOPP e START

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Introduction: Elderly population is frequently polymedicated, including with potentially inappropriate medications (PIM), sometimes instead of preventive medication, designated as potentially prescribing omissions (POM). Objectives: This study aims to characterize and to quantify the occurrence of PIM and POM in a sample of institutionalized elderly patients through a medication review using STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria. Methods: A descriptive cross-sectional study was used, where 4 elderly facilities were invited to participate. Patients aged ≥65 and using ≥5 medicines were included in the study and their medication was analyzed using STOPP and START criteria. Data were analyzed using univariate and bivariate descriptive statistics (Mann-Whitney U and Kruskal-Wallis tests), considering a significance level of 95%. Results: The final sample included 126 individuals, with a mean age of 84.81 years (SD=6.126), 69.0% being female. A total of 1315 medicines were analyzed, and 214 PIM (16.27%) and 90 POM (6.84%) were identified through the application of the STOPP and START criteria, respectively. Data indicates that 75.4% of the sample had one or more PIM (M=1.71 /patient; SD=1,470) and 42.9% had one or more POM (M=0.72/patient; SD=1,048). Conclusion: The application of the STOPP and START criteria enabled the identification of a considerable amount of PIM and POM, indicating them as tools that contribute to review and change, if necessary, the instituted therapy in elderly. The development of pharmaceutical competencies in the care of geriatric patients, even though not evaluated in the current study, may constitute the basis for future opportunities for pharmaceutical intervention and valuing of the pharmacist’s role.
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... A Portuguese study reported that the STOPP/START criteria are useful tools to perform medication review in nursing home patients and changes of drug therapy because besides detecting PIM, they also allowed the detection of DRPs related to the non-drug treatment despite existing indication (Silva et al., 2014). The application of STOPP criteria allowed concluding that, according to these criteria, the number of PIMs prescribed to older inpatients follows that observed in studies from Canada (Thomas et al., 2020) and Spain (Martin et al., 2017) but is very high when compared with the number of PIMs observed in Malaysia (Loganathan et al., 2019) and Swiss (Urfer et al., 2016). ...
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Background: Age-related comorbidities prone older adults to polypharmacy and to an increased risk of potentially inappropriate medication (PIM) use. This work aims to analyze the concordance and overlap among the EU(7)-PIM list, 2019 Beers criteria, and Screening Tool of Older Person’s Prescriptions (STOPP) version 2 criteria and also to analyze the prevalence of PIM. Methods: A retrospective cohort study was conducted on older inpatients of an internal medicine ward. Demographic, clinical, and pharmacological data were collected, during March 2020. After PIM identification by the EU(7)-PIM list, Beers criteria, and STOPP v2 criteria, the concordance and overlap between criteria were analyzed. A descriptive analysis was performed, and all the results with a p -value lower than 0.05 were considered statistically significant. Results: A total of 616 older patients were included in the study whose median age was 85 (Q1–Q3) (78–89) years. Most of the older patients were male (51.6%), and the median (Q1–Q3) number of days of hospitalization was 17 (13–22) days. According to the EU(7)-PIM list, Beers criteria, and STOPP criteria, 79.7, 92.0, and 76.5% of older adults, respectively, used at least one PIM. A poor concordance (<63.4%) among criteria was observed. An association between PIM and the number of prescribed medicines was found in all applied criteria. Moreover, an association between the number of PIMs and diagnoses of endocrine, nutritional, and metabolic diseases, mental, behavioral, and neurodevelopmental disorders, and circulatory system diseases and days of hospitalization was observed according to Beers criteria, and that with diseases of the circulatory system and musculoskeletal system and connective tissue was observed according to STOPP criteria. Conclusion: Despite the poor concordance between the EU(7)-PIM list, 2019 Beers, and STOPP v2 criteria, this work highlights the need for more studies in inpatients to develop strategies to facilitate the identification of PIM to decrease the high prevalence of PIM in hospitalized patients. The poor concordance among criteria also highlights the need to develop new tools adapting the existing criteria to medical ward inpatients.
... 8,20,21Around half the patients (49.8%) were aged between 75-84 years, which reflects a national and global tendency of increasing life expectancy. The sample of a study byPeriquito (2014)included ages from 67 to 97 years, with a mean age of 84.81 years. Such findings were higher than those of the present study, perhaps because the study was carried out in Portugal, a country with a greater life expectancy. ...
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Identified the inappropriate prescription of drugs in elderly assisted geriatric outpatient clinic in the region of Vale do Rio Pardo in Rio Grande do Sul according to the criteria of STOPP and START. Cross-sectional study of 221 elderly, based on retrospective analysis of medical records using comprehensive geriatric assessment data held in the first visit. Descriptive variables were age, sex, number of pathologies and number of medications in use. And the study variables were potentially inappropriate medications (MPI) and potentially omitted medications (MPO), according to the STOPP and START criteria. Descriptive statistics were performed with frequencies, means and standard deviations where appropriate. It was observed 157 (71%) female patients. The average age was 75 (±8.26) years, 49.8% in the range of 75-84 years. The average number of drugs was 3 (±2.27), with 22.63% using 5 or more medications. The average pathologies was 3.45 (±2.02). They identified 194 prescriptions of MPI and observed 93 MPO. The most identified were the MPI for the cardiovascular system, especially β noncardioselective blockers and acetylsalicylic acid. Also MPO were found most of the cardiovascular system, with emphasis on acetylsalicylic acid and inhibitors of angiotensin converting enzyme. This is sample of elderly with significant prevalence of inappropriate prescribing of drugs. Studies using the STOPP criteria and START in different health care settings can qualify the care provided to the elderly.
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Se avaliar procedimentos é importante em todas as áreas, na saúde a sua relevância tem um papel acrescido. Essa preocupação na criação de sistemas que permitam avaliar o circuito e gestão da medicação em espaços onde residem idosos, assume uma importância que tem de ser devidamente enquadrada. É notório que muitos Problemas Relacionados com os Medicamentos (PRMs) podem ser facilmente identificados quando existem sistemas integrados de controlo eficientes, diminuindo o risco de exposição a erros de medicação. Todos estes procedimentos devem ser devidamente coordenados pelo farmacêutico.
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Se avaliar procedimentos é importante em todas as áreas, na saúde a sua relevância tem um papel acrescido. Essa preocupação na criação de sistemas que permitam avaliar o circuito e gestão dos medicamentos em espaços onde residem idosos, assume uma importância que tem de ser devidamente enquadrada. É notório que muitos Problemas Relacionados com os Medicamentos (PRM) podem ser facilmente identificados quando existem sistemas integrados de controlo eficientes, diminuindo o risco de exposição a erros de medicamentos. Ao longo desta nota técnica, procuramos analisar alguns trabalhos publicados nos últimos anos, nesta área. Diferentes estudos com diferentes protocolos, avaliaram múltiplas variáveis no circuito e gestão do medicamento em Instituições de Longa Permanência para Idosos (ILPI). Assim, da análise desses estudos, levantamos alguns pontos que podem e devem ser mais aprofundados no futuro, tendo o farmacêutico um papel ativo neste assunto.
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Background: Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators. Methods: A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison. Results: Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70-74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics. Conclusions: PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.
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Background Between 25% and 40% of hospital admissions in elderly patients may be linked to drug-related problems. Therefore prevention and recognition of inappropriate prescribing of medicines in elderly patients is one of the principle health care quality and safety issues. Aim To identify and compare the rate of inappropriate prescribing in elderly patients using two validated screening tools: STOPP/START criteria and Beers criteria. Materials and methods A cross-sectional observational study on prescriptions of 600 patients aged ≥65 years was conducted. STOPP/START criteria and Beers criteria were applied to detect inappropriate prescriptions. Feedback was obtained from clinicians about measures to reduce potentially inappropriate prescriptions (PIPs) and related adverse drug events. Results There were 19.8% and 7.3% PIPs found using STOPP/START criteria and Beers criteria, respectively. The most commonly found PIP with both criteria was the prescribing of calcium channel blockers among hypertensive patients with chronic constipation. Of the 19.8% PIPs found with STOPP/START criteria, 7% were potential prescribing omissions, the most common of which was statins not prescribed for diabetic patients with multiple cardiovascular risk factors. STOPP/START criteria detected more of PIPs in inpatients than outpatients. Polypharmacy and increasing age were important risk factors for PIPs. Most of the clinicians agreed that monitoring of adverse drug reactions would be helpful. Conclusion The STOPP/START criteria detected more PIPs compared with the commonly used Beers criteria. Application of such screening tools to prescribing decisions may reduce unnecessary medication, related adverse events, hospital admissions, and cost.
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Appropriateness of prescribing can be assessed by various measures and screening instruments. The aims of this study were to investigate the effects of pharmacists' interventions on appropriateness of prescribing in elderly patients, and to explore the relationship between these results and hospital care utilization during a 12-month follow-up period. The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalization was investigated, was used. The criteria from the instruments MAI, STOPP and START were applied retrospectively to the 368 study patients (intervention group (I) n = 182, control group (C) n = 186). The assessments were done on admission and at discharge to detect differences over time and between the groups. Hospital care consumption was recorded and the association between scores for appropriateness, and hospitalization was analysed. The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for I but not for C (1.42 to 0.93 vs. 1.46 to 1.66 respectively, p<0.01). The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for I but not for C (0.36 to 0.09 vs. 0.42 to 0.45 respectively, p<0.001). The summated score for MAI was reduced for I but not for C (8.5 to 5.0 and 8.7 to 10.0 respectively, p<0.001). There was a positive association between scores for MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively). No association was detected between the scores of the tools and total re-visits to hospital. The interventions significantly improved the appropriateness of prescribing for patients in the intervention group as evaluated by the instruments MAI, STOPP and START. High scores in MAI and STOPP were associated with a higher number of drug-related readmissions.
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Purpose This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria. Methods An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75 years and older were randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed. Results 672 patients [median age (Q1–Q3) 82 (79–86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1–Q3 7–13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p < 0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p < 0.001) was observed. Polypharmacy (≥ 10 medicines) was the strongest predictor of IP [OR = 11.34 95% confidence interval (CI) 4.96–25.94], PIMs [OR = 14.16, 95% CI 6.44–31.12], Beers-listed PIMs [OR = 8.19, 95% CI 3.01–22.28] and STOPP-listed PIMs [OR = 8.21, 95% CI 3.47–19.44]. PIMs was the strongest predictor of PPOs [OR = 2.79, 95% CI 1.81–4.28]. Conclusions A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different.
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Article
Purpose To analyse the potentiality of STOPP/START criteria for changing inappropriate prescribing (IP) in elderly polypharmacy patients, and their usefulness as perceived by general practitioners (GPs). Subjects and methods This was a cross-sectional study with 100 patients aged ≥ 65 years on four medications or more, from 20 GP lists across three health centres. The study variables included: age, sex, comorbidity, medications, IP (STOPP/START criteria), and GP adherence to recommendations, reasons for not adhering and perception of the toolkit's usefulness. Data were collected from electronic medical records and interviews with GPs. Results Patients (mean age 77 ± 5.7 years, 64% women) were prescribed a mean of 12.3 drugs/person, 8.7 for chronic conditions. We identified 92 instances of IP in 58 patients (95%CI 48–68%): 55 STOPP criteria in 42 patients (most involving acetylsalicylic acid 20%, NSAIDs 18% or benzodiazepines 16%) and 37 START in 31 patients. For all GPs, ≥ 1 instance of IP was detected, only two accepting all the recommendations. GPs adhered to 43/92 recommendations (46.7%, 95%CI 36.3–57.1%): 22/55 STOPP (40%, 95%CI 27–53%) and 21/37 START (56.8%, 95%CI 39.5-74.1%). Key reasons for not adhering were not being the prescribing physician (42%) and not seeing benefits (44%). While 95% trusted the recommendations, only 65% thought them feasible. Conclusions Detecting IP using STOPP/START criteria is no guarantee of improving prescribing to the same extent, since GPs accept < 50% of recommendations. While GPs generally appreciate the relevance of the tool and claim to trust it, many believe applying it is not feasible in practice, time being the main barrier cited.
Article
Objective. - Potentially inappropriate prescription of drugs is frequent in older subjects, but may vary in different health care settings and with the use of different criteria. We compared the performance of two different tools (Beers and STOPP-START) in the detection of potentially inappropriate drugs and prescribing omissions of appropriate drugs in older patients cared in three different settings. Method. - STOPP-START and Beers criteria were used in 50 consecutive outpatients seen in a hospital geriatric clinic (HC), 50 random patients of a public primary care (PC) clinic, and 50 random patients living in an assisted nursing home (NH). Results. - Mean age increased with the complexity of the setting (from 78.8 years in PC to 84.5 years in NH patients), as did the number of females (from 46% in PC to 76% in NH). STOPP criteria detected more cases of potentially inappropriate prescription than Beers criteria (47% vs 23%, p < 0.001). Beers criteria detected potentially inappropriate drugs in 24% (PC), 26% (HC) and 20% (NH) of the subjects (p = 0.92 for the difference between settings). STOPP criteria detected potentially inappropriate drugs in 36% (PC), 54% (HC) and 50% (NH) of the subjects (p = 0.22 for the difference). The number of subjects with two or more inappropriate prescriptions was higher with STOPP (16%) than with Beers criteria (5%. P = 0.003). START criteria found that 28% (PC), 54% (HC) and 46% (NH) of the subjects were not receiving drugs indicated for some diseases (p = 0.022 for the difference between settings). Conclusions. - STOPP criteria detected a higher number of subjects with potentially inappropriate drug prescription than Beers criteria in all health care settings, although there were some differences across settings. START criteria also showed different performance in each setting.
Article
Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.
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Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. For this reason, great efforts have been made in the search for interventions to improve efficacy, safety and appropriateness of prescriptions in this vulnerable population. Among these interventions, the avoidance of medications that are considered to be inappropriate, i.e. potentially inappropriate medications (PIMs), has been considered a valuable treatment option. The aim of the present review was to summarize evidence about the use of explicit criteria for PIMs to reduce the risk of adverse drug reactions (ADRs) in older people. A PIM is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is evidence in favour of a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs, and among these, the Beers criteria have been the most frequently applied until recently. However, evidence suggests that such criteria can not easily be applied in European countries: several drugs listed in the 2003 Beers criteria were rarely prescribed or were not available in Europe and 2003 Beers-listed PIMs were not associated with ADRs in some studies. In the past few years, START/STOPP criteria have been developed and applied in several different studies and populations showing a greater ability to predict ADRs with respect to Beers criteria and to prevent potentially inappropriate prescribing. In 2012, Beers criteria have been updated using an evidence-based approach and future studies will investigate the impact of these and other criteria coming from ongoing studies on clinical outcomes relevant to geriatric populations.
Article
Underuse of medication considered beneficial is particularly common in elderly patients. A new Screening Tool to Alert Doctors to the Right Treatment (START) has been published to identify potential prescribing omissions. To quantify and characterize potential prescribing omissions of cardiovascular risk management therapy using START criteria. This study was conducted in the Stroke Unit of the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, located in the Eastern Central Region of Portugal. During 6 months, the medical files of all elderly patients (age ≥ 65 years) admitted with acute cardiovascular disease were reviewed and the START criteria applied to the information of medication, at admission and at the time of discharge from the hospital Stroke Unit. Potential prescribing omissions of cardiovascular and endocrine pharmacological therapy were identified and the difference in the potential prescribing omissions between admission and discharge from hospital Stroke Unit was also evaluated. At the time of admission to the Stroke Unit, 101 potential prescribing omissions were found in 68.1 % (n = 91) of elderly (average 1.11 omissions per patient), of which 84.2 % (n = 85) were corrected at the time of discharge. In 14 patients, 16 omissions found at admission were not corrected during hospitalization, and in 5 patients 5 new omissions were detected. Prescribing omissions of beneficial drugs are highly prevalent in acutely ill admitted to a Stroke Unit. START criteria represent a simple, evidence-based and easy-to-use tool to screen underuse of cardiovascular risk management therapy in elderly patients.