Tools to Reduce Polypharmacy

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Interventions to Improve Prescribing

A systematic review by Loganathan and coworkers7 summarized the effect of interventions to improve prescribing and concluded that staff education in the form of academic detailing has strong evidence for improvement in prescribing in nursing homes and care homes. The successful studies in the review included interactive techniques: (1) academic detailing with face-to-face interaction between a group of experts and prescribing physicians, (2) nursing workshops, and (3) family education. In this

The Beers Criteria

This explicit list of medications (Table 1, Table 2) was created by expert consensus in 1991 and originally intended to identify inappropriate medication use in nursing home residents.10 In 1997, the criteria were revised to apply more generally to persons 65 and older.11 The criteria were again updated in 2003 with a list of 48 inappropriate medications or drug classes and a list of 20 combinations of medications inappropriate in the setting of specific diagnoses and conditions.12 The Beers

Improved Prescribing in the Elderly Tool, Also Known as the Canadian Criteria

The Improved Prescribing in the Elderly Tool (IPET)16 was developed by applying criteria for inappropriate medications from McLeod and colleagues17 to 362 inpatients, resulting in 45 different medications in 14 classes of drugs considered inappropriate. Although the IPET is similar to the Beers criteria, the Beers list identifies more medications that are potentially inappropriate.18 There is insufficient convincing evidence regarding the use of IPET to reduce the incidence of adverse drug

Screening Tool to Alert Doctors to Right Treatments and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions

These tools20, 21 were developed by an interdisciplinary team of geriatricians, primary care physicians, pharmacists, geriatric psychiatrists, and pharmacologists in Ireland. The Screening Tool to Alert Doctors to Right Treatments (START) tool consists of 22 evidence-based indicators of drugs commonly omitted by physicians. START is validated, with a high interrater reliability between physicians and pharmacists.22 The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions

Medication Appropriateness Index

The MAI uses implicit criteria to measure elements of appropriate prescribing (Table 3). It consists of 10 elements considered necessary for appropriate prescribing, including indication, effectiveness, appropriate dose, practical and correct directions, absence of interactions, lack of therapeutic duplication, appropriate duration, and low cost.25 The MAI involves the use of clinical judgment to assess each criterion, but has operational definitions and explicit instructions to standardize the

Fit for the Aged Criteria

In this scheme, medications are graded based on Fit for the Aged Criteria (FORTA) class29: A, indispensible, with obvious benefit; B, proven efficacy but limited effects or possible safety concerns; C, questionable efficacy or safety; and D, avoid. In a small pilot study in Germany,30 patients admitted to a geriatric medical ward had medications assessed on admission and at discharge using the criteria, and changes were made according to the criteria and also to reduce drug interactions. There

The Assess, Review, Minimize, Optimize, Reassess

The Assess, Review, Minimize, Optimize, Reassess31 tool (Table 4) is a functional and interactive evidence-based practice tool that is designed for use in nursing home residents. The tool takes into account patients' clinical profiles and functional status, including physiologic reserves. It can be used in patients (1) receiving 9 or more medications, (2) seen for initial assessment, (3) with falls or behavioral disturbance, and/or (4) admitted for rehabilitation. The primary goal of using this

Good Palliative-Geriatric Practice Algorithm

The Good Palliative-Geriatric Practice algorithm32 (Fig. 1) was a consensus-based flow chart developed in 2004 for nursing homes to reduce polypharmacy. The algorithm was used in 6 nursing homes in Israel, with 119 patients in the intervention group and 71 patients in the control group. There was a significant reduction in mortality, hospitalization, and cost. At the end of 1 year, an average of 2.8 drugs per patient was discontinued, and there were no significant adverse effects caused by

Patient-Focused Drug Surveillance

Patient-Focused Drug Surveillance34 was an intervention study for elderly persons in nursing homes in Sweden. The intervention involved a physician-led, patient-focused approach, taking into account the patient's health condition to appropriately optimize medication therapy and reduce polypharmacy. Outcomes studied included mortality, health care utilization, number of medications, health status, and periodic evaluations of quality of drug treatment. The study found improvement in optimum

Geriatric Risk Assessment Medguide

Geriatric Risk Assessment Medguide35 is a clinical informatics tool that generates prospective monitoring plans based on potential risk for falls or for delirium within 24 hours of nursing home admission. Its use was evaluated in 25 nursing homes, assessing not only falls and delirium, but also hospitalizations owing to adverse drug events and mortality. The use of the Geriatric Risk Assessment Medguide tool significantly reduced the rate of delirium. The rates of hospitalization and mortality

Prescribing Optimization Method

The Prescribing Optimization Method36 (Box 2) was developed to help general practitioners optimize medication use in older adults. POM is based on 6 questions that address the following: (1) undertreatment, (2) adherence, (3) drugs that can be discontinued or are inappropriate, (4) adverse drug events, (5) interactions, and (6) dosing frequency or formulation. Education of 45 primary care physicians about this approach resulted in improvement in optimum prescribing when applied to a patient

Anticholinergic Risk Scale

To create the Anticholinergic Risk Scale (ARS),37 (Table 5) the 500 most commonly prescribed drugs in the Veteran's Administration system were ranked according to anticholinergic potential and assigned a point value, and an individual's score was calculated by added the points for each drug. Increasing ARS score was significantly associated with anticholinergic adverse effects in a retrospective review of 132 geriatric patients and a prospective study of 117 primary care patients. Higher ARS

PRISCUS List

Developed in Germany, the PRISCUS list46 is a consensus list of potentially inappropriate medications developed among experts in a process that included a qualitative analysis of inappropriate medication lists from multiple countries, a literature search for medications that cause adverse drug events, development of a preliminary list of inappropriate medications for use in Germany, and generation of the final PRISCUS list using a modified Delphi process. The final outcome was a list of 83

Summary

The reduction in polypharmacy and avoidance of inappropriate medications is a common goal in the care of older persons, regardless of setting. While multidisciplinary teams and regular medication reconciliation and review can identify and reduce medication-related problems, tools to decrease the use of high-risk/low-benefit medications can help the individual clinician to improve prescribing. Numerous criteria, tools, algorithms, and scoring systems have been developed for use in a wide range

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  • Cited by (57)

    • Deprescribing in Older Adults With Cardiovascular Disease

      2019, Journal of the American College of Cardiology
      Citation Excerpt :

      Their complementary importance is in providing a framework for a holistic approach to patient care that necessitates the consideration of conditions and relevant contributing factors outside the index cardiovascular condition(s) being addressed (e.g., assessments of frailty, activities of daily living, fall risk, cognitive function [dementia, delirium, depression], and social environment) (see Table 6 for a real-world deprescribing example). Several tools, predominantly focused on care of older adults, are available to identify medications that may be appropriate for deprescribing (49). These tools have been divided into implicit and explicit tools.

    • Polypharmacy Reduction Strategies: Tips on Incorporating American Geriatrics Society Beers and Screening Tool of Older People's Prescriptions Criteria

      2017, Clinics in Geriatric Medicine
      Citation Excerpt :

      It is not surprising, therefore, that polypharmacy reduction strategies almost universally include a component to address the presence of high-risk or harmful prescribing in polypharmacy regimens. Several tools have been described for use in the elderly population that are designed to educate and guide clinicians in efforts to reduce polypharmacy.18,19 These various tools can be categorized as implicit-based and explicit-based approaches.

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    The authors have no relevant financial disclosures to report in relationship to this manuscript.

    Dr Holmes is supported by grant K23AG038476 from the National Institute on Aging.

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