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Clinicians making real‐time decisions on medication management have available to them a variety of tools that can be used to guide prescribing. These tools have been developed to help identify medications that should be avoided, drug–drug/drug–disease interactions, and optimal medication doses. They also provide opportunities for educating patients, families, and clinical trainees. While each tool has both benefits and drawbacks in daily use, it is important for prescribers to become familiar with these tools and proficient in the clinical application of at least one. Table 10.3 lists the various available tools, which are described further here.

The 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 tables^20,21:

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 validation^23,24. 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 medications printed on a pocket‐sized card	The routine use of the Pill Pruner tool:Reduced the number of medications on hospital discharge (30)Limited the number of medications taken by older patients on admission to the hospitalLed to sustained changes 90 days post discharge	Studied only in hospitalized patients aged ≥75. Application to ‘frail elderly only’ (30). Based on one observational study without a control arm. Does not provide guidance for tapering medications.
Tool	Timeline	Description	Positive aspects	Limitations
Drug Burden Index (DBI)	Introduced in 2007, USA (31)	Measures cumulative exposure to anticholinergic and sedative medications and its impact on physical and cognitive functions (32,33) Demonstrates that exposure to anticholinergic and sedative drugs is associated with poorer function in community dwellers (31)	Best predicts adverse health outcomes among other tools in the assessment of anticholinergic burden (34). Takes into account medication dose (32).	Applicable to high‐functioning, community‐dwelling older adults. Dose of studied medications estimated, not accounting for different pharmacokinetic and pharmacodynamics profiles. Does not take into account drug–drug interactions (31).
Tool	Timeline	Description	Positive aspects	Limitations
Tool to Reduce Inappropriate Medications (TRIM)	Introduced in 2016, US Veterans Affairs (VA) medical centre (36)	Web‐based design for electronic medical records data extraction using algorithms to identify potentially problematic medications and regimens	Assesses medication overprescribing. Algorithms identify medication regimen discrepancies, poor treatment adherence, potential overtreatment of diabetes and hypertension, inappropriate drug renal dosing, and a list of patient reported medication‐related adverse reactions.	Validated only in outpatient clinical setting and for use with the VA medical centre electronic health records. Time‐ and resource‐intensive. Computer‐based only; non‐automated process for medication reconciliation. Does not address medication underprescribing.
Tool	Timeline	Description	Positive aspects	Limitations
Fit for the Aged (FORTA)	Introduced in 2008, Germany (37)	Medications classified as: A: Absolutely B: Beneficial C: Careful D: Don’t Compilation list with more than 270 drugs in almost 30 major medical indications (38)	Validated by expert consensus. Useful in everyday clinical routine.	Relies on expert professional judgement. Does not address drug–drug or drug–disease interactions (21).

One of the tools most widely used by pharmacists is the Medication Appropriateness Index (MAI). This tool was introduced in 1992 and modified in 2010.^26‐29 It regards each medication individually, assessing 10 important aspects of medication use using a Likert scale to rate appropriateness and providing a single score to help identify inappropriate medications that can be targeted for deprescribing. The 10 items addressed are as follows:

1 Recognize if there is a clear indication for such medication.

2 Gauge the effectiveness of such medication for the condition.

3 Address if the dosage is correct.

4 Confirm that the directions are correct.

5 Assess if such directions are practical and doable to put into practice.

6 Evaluate for clinically significant drug–drug interactions.

7 Evaluate for clinically significant drug–disease or condition interactions.

8 Assess if there is unnecessary duplication with another treatment.

9 Evaluate if the duration of the therapy is acceptable.

10 Assess if such medication is the least expensive alternative compared to others of equal utility.

The answers lead to three rating choices (three‐point Likert scale):

 A = appropriate

 B = marginally appropriate

 C = inappropriate

A maximum score of 18 is related to a level of ‘maximum inappropriateness’. While this tool is very comprehensive and well‐validated and has been shown to identify more problematic medications than the Beers Criteria, it is time‐consuming, requires more clinical expertise than other tools, and does not help the clinician prioritize drugs for deprescribing. For this reason, it is most often used in research settings or for teaching clinical trainees learning how to conduct reviews of complex drug regimens in a stepwise manner.^27,28

The Pill Pruner checklist was introduced in 2009 and designed to be ‘a simple medication guide based on STOPP criteria’.³⁰ It consists of a list of 13 commonly prescribed medications printed on a pocket‐sized card for use in assessing medication appropriateness in frail, hospitalized older adults:

1 Loop diuretics (‘only for patients with heart failure, not venous insufficiency’)

2 Thiazides (‘not in patients with hyponatremia, gout, or venous insufficiency’)

3 Calcium antagonists (‘not in patients with heart failure/constipation/postural hypotension’)

4 Alpha blockers / labetalol (‘not in patients with postural hypotension/falls/turns’)

5 Anti‐platelet drugs (‘not in patients with GI bleeding or funny turns without focal neurology’)

6 Tricyclic antidepressants (‘not in patient with confusion, constipation, postural hypotension, urinary retention’)

7 Benzodiazepines (‘not in patients with confusion, falls’)

8 Anticholinergics (‘not in patients with confusion, falls, constipation’)

9 Antihistamines (‘not in patients with confusion, falls’)

10 SSRIs (‘not in patients with confusion, hyponatremia, falls’)

11 Antipsychotics (‘not in patients with parkinsonism, epilepsy, falls’)

12 NSAIDS (‘not! Avoid if at all possible’)

13 Proton pump inhibitors (‘not unless clear history of reflux, ulcers’)

Research showed that the routine use of the Pill Pruner tool safely limits the number of medications taken by older patients on admission to the hospital, reduces the number of medications on hospital discharge, and reminds about the need to communicate medication changes to the patient’s primary practitioner by ensuring that the hospital discharge summary accurately reflects the medications changes made in the hospital.³⁰ In the original study, patients were followed up at 90 days post‐hospital discharge, and the changes made while in the hospital were maintained as an outpatient.

The Drug Burden Index (DBI) was introduced in 2007³¹ and is designed to measure cumulative exposure to anticholinergic and sedative medications, including its impact on physical and cognitive function.^32,33 Despite its limitations (see Table 10.3), the DBI is useful for predicting the risk of ADRs, as a high DBI has been correlated with an increased risk for functional decline in community‐dwelling older adults and an increased risk of falls in residents of long‐term care facilities.^33‐35

The Tool to Reduce Inappropriate Medications (TRIM) was developed in 2016 at the US Veterans Affairs (VA) Medical Center.³⁶ TRIM uses a computer algorithm based on Beers and STOPP criteria to identify PIMs and provide recommendations for medication discontinuation. The computer programme extracts information from the electronic health record related to age, medications, and chronic medical conditions, identifying high‐risk patients and providing feedback reports to clinicians for evaluating the medication regimen. These algorithms identify medication regimen discrepancies, poor treatment adherence, potential overtreatment of diabetes and hypertension, inappropriate drug renal dosing, and a list of patient‐reported medication‐related adverse reactions.³⁶ While TRIM has only been validated in the US VA system, the potential for this tool to have widespread applicability and positively impact the care of older adults on a population health level in the era of electronic health record use is significant.

The Fit fOR The Aged (FORTA) tool was introduced in 2008 as a classification system to help prescribers screen for PIMS and PPOs in older adults.^37,38 It is the first to combine both positive and negative labelling into one tool and has been validated in various settings and countries. The FORTA system classifies each medication into one of the following four categories:

 Class A (A‐bsolutely) = indispensable drug; clear‐cut benefit in terms of efficacy/safety ratio proven in elderly patients for a given indication

 Class B (B‐eneficial) = drugs with proven or obvious efficacy in the elderly but limited extent of effect or safety concerns

 Class C (C‐areful) = drugs with questionable efficacy/safety profiles in the elderly, to be avoided or omitted in the presence of too many drugs, lack of benefits, or emerging side effects; review/find alternatives

 Class D (D‐on’t) = avoid in the elderly; omit first; review/find alternatives

Initial studies have shown improvement in medication management and fall reduction with the use of FORTA.³⁹