most widely known tool is the Beers Criteria, introduced in 1991 by the American Geriatrics Society and updated most recently in 2019.20 It was created by geriatrician Dr Mark Beers and an expert panel using the Delphi method with the ‘intention to improve medication selection; educate clinicians and patients; reduce adverse drug events; and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults’. A list of potentially inappropriate medications (88 drugs) are divided into five categories, detailed in six tables20,21:
1 Drugs with potentially inappropriate use in older adults.
2 Drug‐disease (or syndrome) interactions that might exacerbate the disease (or drugs with potentially inappropriate use in older adults with some specific health conditions).
3 Drugs to be used ‘with caution’ in older adults.
4 Drug–drug interactions that should be avoided.
5 Medications to be avoided or adjusted given underlying renal function.
6 A list of drugs with ‘strong anticholinergic properties’. These medications were also referenced in the categories above.
The Beers Criteria are supported by evidence, and the tables provide a detailed rationale for recommendations, quality of evidence, and strength of recommendations, which is helpful for evidence‐based decision making. The tool is regularly updated, and once one is familiar with the various tables, it is easy to use for assessing inappropriate drug prescribing. Limitations include the fact that it does not address underprescribing,21 is not applicable in end‐of‐life settings,20 and has mixed results on predicting adverse outcomes.22 Additionally, since it was created in the United States, its applicability in other countries with different formularies may be limited.
To address the latter limitation, a European research group created the Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria in 2008, most recently updated in 2015.23,24 These tools were the first to categorize prescribing by organ system and include a list of potential prescribing omissions (PPOs). Version 2 criteria resulted in a 31% increase in the number of criteria through a European panel of experts’ consensus validation23,24. Although these criteria require more medical history to be obtained, they are clinically very practical and can significantly improve prescribing appropriateness, reducing potential adverse events. Evidence shows that when used within 72 hours in an older adult’s acute hospitalization, they can decrease the risk of ADRs by about 9% and the length of hospital stay by an average of three days.23 The STOPP criteria also have better performance than the Beers Criteria in identifying potentially inappropriate medication use contributing to acute hospitalization in older adults.25
Table 10.3 Tools to aid in the reduction of inappropriate medication use and polypharmacy.
| Tool | Timeline | Description | Positive aspects | Limitations |
|---|---|---|---|---|
| Beers Criteria (20) | Introduced in 1991, USA Endorsed by the American Geriatrics Society (AGS) Last updated in 2019 | Per AGS: ‘intention to improve medication selection; educate clinicians and patients; reduce adverse drug events; and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults’; and ‘not meant to be applied in a punitive manner’ | Widely used. Regular updates. Easy to assess inappropriate drug prescribing. Supported by evidence, and reviewed by a multidisciplinary expert panel of 13 clinicians (including physicians, nurses, and pharmacists) with experience in different practice settings. Tables provide detailed rationale, recommendations, quality of evidence, and strength of recommendation. Useful in ambulatory, acute, and institutionalized settings. | Applicable only to adults age 65 and older. Mostly applicable to clinical care in the USA. Not applicable in hospice and palliative care settings (20). Has mixed results on predicting adverse outcomes, hence be cautious about using as a quality of care monitoring tool (22). Does not address underprescribing (21). Many of the medications listed are over the counter (OTC), limiting potential detection of inappropriate prescribing. |
| Tool | Timeline | Description | Positive aspects | Limitations |
| Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) | Introduced in 2008, Europe (25). Updated in 2015 (23,24) | Distinguishes two aspects of inappropriate prescribing: 1. Potentially inappropriate medications (PIMs) => STOPP criteria 2. Potential prescribing omissions (PPOs) => START criteria Total of 114 criteria (80 STOPP criteria and 34 START criteria) | Highly clinically applicable. Evidence shows decrease in ADR and length of stay in acute inpatient setting (23). Better performance in identifying PIMs leading to acute hospitalization (25). | Safer treatment alternative suggestions not provided (21). STOPP and START are designed to be used together (24). STOPP requires more medical history information (24,25). |
| Tool | Timeline | Description | Positive aspects | Limitations |
| Medication Appropriateness Index (MAI) | Introduced in 1992, USA Modified in 2010 to provide a single score for each medication assessed (26–29) | Tool with 10 criteria applied to a particular medication to determine its appropriateness for a given patient (26–28) | Applies to any medication (including as needed, OT,C and alternative medicines). Includes practical aspects of care, such as medication administration, duration of therapy, and cost. Validated in hospital and clinical settings. Compared to the Beers Criteria, MAI identified more problematic medications. Valuable tool in the education of clinical learners (27,28). | Time‐consuming (on average, 10 minutes to review one medication). Relies on expert professional judgment, requiring a skilled clinician to evaluate the best answer to each question. Reliability issues when used by more than one evaluator. The individual drug MAI score does not help the clinician to prioritize a drug that should be changed. Does not take into account ADR, drug allergies, and medication adherence or underuse. Does not provide guidance on drug regimen modification to avoid adverse events related to drug withdrawal (27,28). |
| Tool | Timeline | Description | Positive aspects | Limitations |
| Pill Pruner | Introduced in 2009, New Zealand (30) |
‘A simple medication guide based on STOPP criteria’ consisting of a list of 13 commonly prescribed
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