Abstract

Background: STOPP/START was formulated to identify potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) in older people. The purpose of this study was to determine the prevalence of PIP and PPO in older Irish patients in residential care using STOPP/START.

Methods: data were collected prospectively from seven publicly funded nursing homes within the Munster Region of Ireland over 3 weeks. Data recorded included: current medication, current medical conditions, previous medical conditions, biochemistry, sex and age. STOPP/START was applied to each patient record.

Results: of the 313 patients recruited, 74.4% (233) were female, mean age (±SD) 84.4 (±7.5) years. The total number of medicines prescribed was 2,555 [range: 1–16; median: 8 (IQR 6–10 )]. STOPP identified 329 instances of PIP in 187 (59.8%) patients and START identified 199 PPOs in 132 (42.2%) patients. The number of medicines prescribed was positively associated with PIP identified by STOPP (rs = 0.303, < 0.01). Age, sex and the number of medicines prescribed were not associated with prescribing omissions using START.

Conclusions: a high proportion of patients recruited were prescribed at least one potentially inappropriate medicine, or had an omission of a clinically indicated medicine. Incorporating these tools into every-day practice could play a pivotal role in improving prescribing in this cohort.

Introduction

The occurrence of potentially inappropriate prescribing (PIP) is a well-documented problem in older adults [1–3]. Beers' criteria [4], an American-based screening tool, has been used in observational studies to quantify the rate of PIP in a variety of settings globally. In European nursing home settings, PIP rates of up to 48% have been reported [5, 6]. Authors of these studies have expressed caution over the use of Beers' criteria, owing to the lack of inclusion of some commonly encountered instances of PIP, the listing of several drugs that are not contraindicated in older people in the European setting (e.g. doxazosin), differences in the availability of drugs between the European and American markets and the fact that these criteria do not address the under-use of medicines, i.e. potential prescribing omissions (PPOs) [5, 6].

A new European physiological system-based screening tool, STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment), has been recently developed [7]. STOPP addresses instances of PIP, whereas START focuses on instances of PPO. Both STOPP and START have displayed good inter-rater reliability when applied by pharmacists and physicians to the same patient profiles [8, 9].

There is currently a lack of studies regarding the prevalence of PIP and PPOs in older Irish nursing home residents, despite recent efforts by the Health Information and Quality Authority (HIQA) to introduce medication review standards for patients in this setting [10]. Thus, this study aimed to provide a baseline indication of the prevalence of PIP and PPOs in older Irish nursing home patients using STOPP and START.

Methods

All publicly funded nursing homes in a large county in the Munster region of Ireland (Munster is one of four provinces, holding nearly 30% of the Irish population) were approached sequentially. All seven who agreed to participate were included. Patients were prospectively recruited from patient lists, held by the matron within each nursing home facility. Data collection took place over a 3-week period in 2008, during which all patients ≥65 years within each nursing home facility were recruited. Patients were excluded if they were terminally ill, i.e. those who were actively dying with a palliative care management plan in place.

Data collected included: current medication and medical conditions, relevant previous medical conditions, biochemistry results, allergy status, sex and age. Medicines prescribed were categorised according to their anatomical therapeutic chemical (ATC) code.

The rate of PIP was defined as the number of patients with at least one potentially inappropriate medicine prescribed, according to STOPP. The PPO rate was defined as the number of patients with at least one PPO according to START.

One-tailed bi-variate correlations (Spearmans' rho correlation coefficient) for non-parametric data were calculated to determine the relationship between the number of medicines prescribed, sex, age and the occurrence of PIP and PPO. A probability value of <0.05 was considered significant. Statistical analysis was performed using Statistics Package for Social Sciences version 15.0 (Chicago, IL, USA).

Ethical approval was granted by the local ethics committee.

Results

A total of 313 patients were recruited, out of a possible 365, with a mean age (±SD) of 84.4 (±7.5) years, and 74.4% (233) were female. More than half of the population (= 171; 54.6%) were aged 80 years or older.

The total number of medicines prescribed was 2,555; range 1–16; median 8 (IQR: 6–10). The six most commonly prescribed classes of medicines within the ATC system were: central nervous system (CNS) (= 930; 36.4%), alimentary tract and metabolism (= 553; 21.6%), cardiovascular system (= 388; 15.1%), blood and blood-forming organs (= 236; 9.2%), respiratory system (= 115; 4.5%) and musculoskeletal system (= 72; 2.8%).

STOPP

STOPP identified 329 instances of PIP in 187 (59.8%) patients (Table 1). Ninety eight (31.3%) patients were prescribed one, 47 (15.0%) were prescribed two, 32 (10.2%) were prescribed three and 10 (3.2%) were prescribed four or more potentially inappropriate medicines. Of the 65 criteria in STOPP, 48 (73.9%) were used to identify these.

Table 1.

Potentially inappropriate medicines identified by STOPP

Criteria Total 
Cardiovascular system (%) 
 Digoxin >125 µg/day 3 (0.9) 
 Loop diuretic and ankle oedema 6 (1.8) 
 Loop diuretic first line for hypertension 8 (2.4) 
 Cardio-selective β-blocker and COPD 2 (0.6) 
 Calcium channel blocker and constipation 6 (1.8) 
 Thiazide diuretic and gout 3 (0.9) 
 Aspirin and warfarin without H2 antagonist/ proton pump inhibitor 2 (0.6) 
 Aspirin: not indicated 9 (2.7) 
 Diltiazem or verapamil and class III or IV heart failure 3 (0.9) 
 Aspirin to treat dizziness not clearly attributable to cerebrovascular disease 3 (0.9) 
Total cardiovascular system 45 (13.7) 
Central nervous system (%) 
 Tricyclic antidepressant and dementia 20 (6.1) 
 Tricyclic antidepressant and glaucoma 3 (0.9) 
 Tricyclic antidepressant and constipation 3 (0.9) 
 Tricyclic antidepressant and opiate or calcium channel blocker 2 (0.6) 
 Tricyclic antidepressant and urinary retention 3 (0.9) 
 Long-term long half-life benzodiazepine 48 (14.6) 
 Neuroleptic as long-term hypnotics, i.e. >1 month 19 (5.8) 
 >1 month use neuroleptic in Parkinson's disease 7 (2.1) 
 Phenothiazine and epilepsy 5 (1.5) 
 >1 week first generation antihistamine 1 (0.3) 
Total central nervous system 111 (33.7) 
Respiratory system (%) 
 Nebulised ipratropium with glaucoma 2 (0.6) 
Total respiratory system 2 (0.6) 
Gastro intestinal system (%) 
 Diphenoxylate/codeine phosphate for chronic diarrhoea 1 (0.3) 
 Diphenoxylate/loperamide/codeine phosphate for acute infective gastroenteritis 1 (0.3) 
 Metoclopramide/ prochlorperazine and Parkinsonism 1 (0.3) 
 Proton pump inhibitor for peptic ulcer disease at full therapeutic dosage for >8 weeks 56 (17.0) 
 Anticholinergic antispasmodic and chronic constipation 18 (5.5) 
Total gastro intestinal system 77 (23.4) 
Musculoskeletal system (%) 
 NSAID and history of peptic ulcer disease 1 (0.3) 
 NSAID and hypertension 3 (0.9) 
 Long-term continuous NSAID for osteoarthritis 2 (0.6) 
 NSAID and heart failure 2 (0.6) 
 Aspirin and warfarin and NSAID 2 (0.6) 
 Long-term corticosteroid (>3 months) as monotherapy for rheumatoid arthritis or osteoarthritis 3 (0.9) 
 Long-term NSAID/colchicine for gout without contra indication to allopurinol 1 (0.3) 
Total musculoskeletal system 14 (4.3) 
Genitourinary system (%) 
 Bladder antimuscarinic drug and dementia 1 (0.3) 
 Antimuscarinic drug and chronic glaucoma 2 (0.6) 
 Antimuscarinic drug and chronic constipation 1 (0.3) 
 Antimuscarinic drug and chronic prostatism 1 (0.3) 
 α-Blocker in males and frequent incontinence 2 (0.6) 
 α-Blocker and long-term urinary catheter in situ 1 (0.3) 
Total genitourinary system 8 (2.4) 
Falls (%) 
 Benzodiazepine 18 (5.5) 
 Neuroleptic drug 9 (2.7) 
 First generation antihistamine 6 (1.8) 
 Long-term opiate 5 (1.5) 
Total Falls 38 (11.6) 
Analgesics (%) 
 Use of powerful opiate as first line therapy for mild-moderate pain 10 (3.0) 
 Long-term opiates and chronic constipation 1 (0.3) 
 Long-term opiates in those with dementia 4 (1.2) 
Total analgesics 15 (4.6) 
Duplicate class (%) 19 (5.8) 
Total duplicate class 19 (5.8) 
Total PIMs 329 
Criteria Total 
Cardiovascular system (%) 
 Digoxin >125 µg/day 3 (0.9) 
 Loop diuretic and ankle oedema 6 (1.8) 
 Loop diuretic first line for hypertension 8 (2.4) 
 Cardio-selective β-blocker and COPD 2 (0.6) 
 Calcium channel blocker and constipation 6 (1.8) 
 Thiazide diuretic and gout 3 (0.9) 
 Aspirin and warfarin without H2 antagonist/ proton pump inhibitor 2 (0.6) 
 Aspirin: not indicated 9 (2.7) 
 Diltiazem or verapamil and class III or IV heart failure 3 (0.9) 
 Aspirin to treat dizziness not clearly attributable to cerebrovascular disease 3 (0.9) 
Total cardiovascular system 45 (13.7) 
Central nervous system (%) 
 Tricyclic antidepressant and dementia 20 (6.1) 
 Tricyclic antidepressant and glaucoma 3 (0.9) 
 Tricyclic antidepressant and constipation 3 (0.9) 
 Tricyclic antidepressant and opiate or calcium channel blocker 2 (0.6) 
 Tricyclic antidepressant and urinary retention 3 (0.9) 
 Long-term long half-life benzodiazepine 48 (14.6) 
 Neuroleptic as long-term hypnotics, i.e. >1 month 19 (5.8) 
 >1 month use neuroleptic in Parkinson's disease 7 (2.1) 
 Phenothiazine and epilepsy 5 (1.5) 
 >1 week first generation antihistamine 1 (0.3) 
Total central nervous system 111 (33.7) 
Respiratory system (%) 
 Nebulised ipratropium with glaucoma 2 (0.6) 
Total respiratory system 2 (0.6) 
Gastro intestinal system (%) 
 Diphenoxylate/codeine phosphate for chronic diarrhoea 1 (0.3) 
 Diphenoxylate/loperamide/codeine phosphate for acute infective gastroenteritis 1 (0.3) 
 Metoclopramide/ prochlorperazine and Parkinsonism 1 (0.3) 
 Proton pump inhibitor for peptic ulcer disease at full therapeutic dosage for >8 weeks 56 (17.0) 
 Anticholinergic antispasmodic and chronic constipation 18 (5.5) 
Total gastro intestinal system 77 (23.4) 
Musculoskeletal system (%) 
 NSAID and history of peptic ulcer disease 1 (0.3) 
 NSAID and hypertension 3 (0.9) 
 Long-term continuous NSAID for osteoarthritis 2 (0.6) 
 NSAID and heart failure 2 (0.6) 
 Aspirin and warfarin and NSAID 2 (0.6) 
 Long-term corticosteroid (>3 months) as monotherapy for rheumatoid arthritis or osteoarthritis 3 (0.9) 
 Long-term NSAID/colchicine for gout without contra indication to allopurinol 1 (0.3) 
Total musculoskeletal system 14 (4.3) 
Genitourinary system (%) 
 Bladder antimuscarinic drug and dementia 1 (0.3) 
 Antimuscarinic drug and chronic glaucoma 2 (0.6) 
 Antimuscarinic drug and chronic constipation 1 (0.3) 
 Antimuscarinic drug and chronic prostatism 1 (0.3) 
 α-Blocker in males and frequent incontinence 2 (0.6) 
 α-Blocker and long-term urinary catheter in situ 1 (0.3) 
Total genitourinary system 8 (2.4) 
Falls (%) 
 Benzodiazepine 18 (5.5) 
 Neuroleptic drug 9 (2.7) 
 First generation antihistamine 6 (1.8) 
 Long-term opiate 5 (1.5) 
Total Falls 38 (11.6) 
Analgesics (%) 
 Use of powerful opiate as first line therapy for mild-moderate pain 10 (3.0) 
 Long-term opiates and chronic constipation 1 (0.3) 
 Long-term opiates in those with dementia 4 (1.2) 
Total analgesics 15 (4.6) 
Duplicate class (%) 19 (5.8) 
Total duplicate class 19 (5.8) 
Total PIMs 329 

COPD, chronic obstructive pulmonary disease; NSAID, non-steroidal anti-inflammatory.

The CNS (= 111) accounted for the highest proportion of PIP identified, followed by the gastrointestinal system (= 77), the cardiovascular system (= 45) and patients who frequently fall (= 38) (Table 1).

Benzodiazepines accounted for the highest proportion of PIP identified [85 (25.8%)], and the second most common instance was the prescribing of proton pump inhibitors at extended full dose [56 (17.0%)].

Age (rs = 0.017, P = 0.736) and sex (rpb = 0.077, P = 0.172) were not associated with the identification of PIP using STOPP; however, the number of medicines prescribed was (rs = 0.303, P < 0.001).

START

START identified 199 PPOs in 132 (42.2%) patients (Table 2). A total of 86 (27.5%) patients had one PPO, 32 (10.2%) patients had two, seven (2.2%) patients had three and seven patients (2.2%) had four PPOs. Eighteen of the 22 START criteria (81.8%) were used to identify these PPOs.

Table 2.

PPOs identified by the START tool

Criteria Total 
Cardiovascular system (%) 
 Warfarin and atrial fibrillation 15 (7.5) 
 Aspirin 39 (19.6) 
 Antihypertensives 6 (3.0) 
 Statin 10 (5.0) 
 ACE Inhibitor and congestive heart failure 23 (11.6) 
 β–Blocker 17 (8.5) 
 ACE inhibitor and acute myocardial infarction 4 (2.0) 
Total cardiovascular system 114 (57.3) 
Respiratory system (%) 
 β2 agonist for COPD 12 (6.0) 
Total respiratory system 12 (6.0) 
Central nervous system (%) 
 Levodopa and Parkinson's disease 7 (3.5) 
 Antidepressants 1 (0.5) 
Total central nervous system 8 (4.0) 
Gastro-intestinal system (%) 
 Fibre supplement 1 (0.5) 
Total gastro-intestinal system 1 (0.5) 
Musculoskeletal system (%) 
 DMARD and rheumatoid arthritis 2 (1.0) 
 Bisphosphonate 3 (1.5) 
 Ca2+ and Vit D3 supplement 19 (9.5) 
Total musculoskeletal system 24 (12.0) 
Endocrine system (%) 
 Metformin 12 (6.0) 
 ACE inhibitor 2 (1.0) 
 Aspirin 12 (6.0) 
 Statin 14 (7.0) 
Total endocrine system 40 (20.1) 
Total PPOs 199 
Criteria Total 
Cardiovascular system (%) 
 Warfarin and atrial fibrillation 15 (7.5) 
 Aspirin 39 (19.6) 
 Antihypertensives 6 (3.0) 
 Statin 10 (5.0) 
 ACE Inhibitor and congestive heart failure 23 (11.6) 
 β–Blocker 17 (8.5) 
 ACE inhibitor and acute myocardial infarction 4 (2.0) 
Total cardiovascular system 114 (57.3) 
Respiratory system (%) 
 β2 agonist for COPD 12 (6.0) 
Total respiratory system 12 (6.0) 
Central nervous system (%) 
 Levodopa and Parkinson's disease 7 (3.5) 
 Antidepressants 1 (0.5) 
Total central nervous system 8 (4.0) 
Gastro-intestinal system (%) 
 Fibre supplement 1 (0.5) 
Total gastro-intestinal system 1 (0.5) 
Musculoskeletal system (%) 
 DMARD and rheumatoid arthritis 2 (1.0) 
 Bisphosphonate 3 (1.5) 
 Ca2+ and Vit D3 supplement 19 (9.5) 
Total musculoskeletal system 24 (12.0) 
Endocrine system (%) 
 Metformin 12 (6.0) 
 ACE inhibitor 2 (1.0) 
 Aspirin 12 (6.0) 
 Statin 14 (7.0) 
Total endocrine system 40 (20.1) 
Total PPOs 199 

COPD, chronic obstructive pulmonary disease; ACE, angiotensin-converting enzyme; DMARD, disease modifying antirheumatic drug; PPOs, potential prescribing omissions.

The cardiovascular system accounted for most of the PPOs identified (= 114; 57.3%), followed by the endocrine system (= 40; 20.1%), the musculoskeletal system (= 24; 12.1%) and the respiratory system (= 12; 6.0%).

The commonest PPO for the cardiovascular system was the omission of low-dose aspirin (= 39, 19.6%), followed by the omission of angiotensin-converting enzyme (ACE) inhibitors (= 23, 11.6%) and the omission of β-blockers in patients with angina (= 17, 8.5%). The omission of statins in patients with diabetes was the commonest omission for the endocrine system (= 14, 7.0%), followed by the omission of metformin (= 12, 6.0%) and aspirin (= 12, 6.0%). The omission of calcium and vitamin D supplements accounted for the majority of omissions noted for the musculoskeletal system (= 19; 79.2%).

No significant relationship was found between the identification of PPOs nor any demographic variable tested [age (rs = 0.018, P = 0.753); sex (rpb = 0.033, P = 0.560) and number of prescribed medicines (rs = 0.069, P = 0.220)].

Discussion

This study shows that a significant proportion of older patients residing in long-term care facilities in the Munster region of Ireland have either a potentially inappropriate medicine prescribed (STOPP criteria: 59.8%) or are not prescribed a clinically indicated medicine (START: 42.2%). The PIP rates reported for this study are higher when compared with that reported in primary care (21.4%) [11] and in secondary care (35%) [12]. This may reflect the higher levels of chronic co-morbid illness, which results in higher levels of polypharmacy, a known, consistent predictor of PIP [13]. This was noted in the present study, i.e. an increase in the number of prescription medicines was associated with the occurrence of PIP using STOPP (rs = 0.303, P < 0.001).

A high proportion of the STOPP criteria identified PIP, an important finding following a recent study conducted by Hamilton et al., which found that the identification of PIP using STOPP was associated with the occurrence of adverse drug reactions, which were causal or contributory to hospitalisation [14].

This study shows that patients were often prescribed medicines acting on the CNS (36.4%). A third of the PIP identified by STOPP related to medicines prescribed for CNS disorders (33.7%, = 111), not counting the CNS medicines identified by virtue of the duplication of therapy. This finding emphasises and supports the HIQA specifications to target prescribing for the CNS in older patients in Irish nursing homes [10].

Medicines for the blood and blood-forming organs, which encompasses the prescribing of antiplatelet drugs and anticoagulants, accounted for almost 10% (= 236; 9.2%), of the medicines prescribed for this cohort. However, this is an underestimation of the true requirements for these medicines, as antiplatelet agents and anticoagulants accounted for a third (= 66; 33.2%) of the omissions identified by START criteria. This finding emphasises yet another of the stated HIQA priorities for review in older patients in Irish nursing homes. Similarly, other priority areas for review in older patients in Irish nursing homes as stated by HIQA were emphasised in this study and include NSAIDs, which accounted for total of 11 (3.3%) of the instances of PIP identified by STOPP.

The current study shows that there is a significant problem in relation to PIP in this frail older population. There is, therefore, a need to install PIP prevention measures for these patients, as a means of preventing adverse drug events (ADEs) and minimising avoidable excessive costs of medication. A recent systematic review found that the contribution of pharmacists in conducting regular medication review to decrease PIP in nursing home residents is less well established than for improving prescribing in hospital patients [15]; we believe that the STOPP and START screening tools could form the basis of a pharmaceutical care review for these patients. The feasibility of establishing such a service needs to be explored.

There were some limitations to the present study. We investigated prescribing in the frailest older population, with the awareness that many drugs that are technically indicated (e.g. statins) have little practical value, given that life expectancy in many patients is shorter than the average time to clinical benefit [16]. However, this was rarely stated in patients' notes. Secondly, many patients were poorly mobile. Therefore, drugs that could adversely affect balance and mobility may have been of less concern to the prescribers in such patients, even if technically inappropriate according to STOPP. This may therefore have lead to a higher rate of PIP in this study than is actually the case. Finally, data collection was mostly by extraction from case records and discussion with nursing staff, not by case-by-case ascertainment by discussion with the attending medical officers. Therefore, the precise reasons for PIP in this study could not always be clarified with precision.

Conclusion

This study shows that there are high rates of PIP and PPO in older patients in the Irish nursing homes studied. This study also shows that the STOPP and START criteria could be used to develop a pharmaceutical care intervention led by pharmacists. However, further research is warranted to determine the most effective and efficient delivery of such a service.

Key points

  • High proportions of older patients in Irish nursing homes are prescribed potentially inappropriate medicines or are not prescribed clinically indicated medicines.

  • Using screening tools, such as STOPP/START in routine clinical practice may help improve prescribing practices in this cohort.

  • STOPP/START could potentially be used by both prescribers and pharmacists in this setting.

Conflicts of interest

Drs O'Mahony, Byrne and Ryan in association with UCC have a licence agreement for the electronic development of the STOPP/START tool with CSIS Castletroy, Limerick.

Funding

Dr Ryan was funded by Enterprise Ireland under a proof of concept grant whilst conducting this study. No other funding was available for this study.

Acknowledgements

We would like to sincerely thank the Health Services Executive for supporting this project and those working in the participating nursing homes for all their assistance throughout the project.

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