Recommended tools for medication review and prescription optimization in geriatric patients

Overview

In the last two decades the number of drugs prescribed to the older patients is increasing steadily. Polypharmacy – despite being beneficial in the treatment of multimorbid patients –also confers a risk of medication-related adverse reactions such as drug-drug interactions, adverse drug events, inappropriate drug prescription, higher level of frailty and increased mortality in some studies. Evaluating of prescribed and used medication by a geriatrician is an integral part of geriatric clinical approach. For medication review, identification of potentially inappropriate and risky medications use, but also detection of potentially beneficial but not (yet) prescribed medications, evaluation of their effectiveness and safety in the context of chronic co-morbidities, geriatric syndromes and frailty.

To evaluate quality of drug prescribing in older age standardized instruments could be used. Among many existing tools STOPP/START explicit criteria of potentially inappropriate and potentially beneficial medications in patients 65 years and older are currently recommended. For specific situations e.g. for patients with frailty syndrome, disability and limited life expectancy STOPP-Frail criteria seems to be the most suitable tool, for patients with the high risk of falls or falls in the recent history STOPP-Fall criteria enables to identify fall-risk medications, and for those with cognitive impairment drugs with stronger anticholinergic properties should be avoided. 

Medication review with the use of the above-mentioned explicit tools enables systematic deprescribing of drugs without valid indication, of drugs inappropriate in old age in general and in an individual patient in particular, to avoid using duplicate medications, as well as drugs which are not in line with patient goals and preferences. The geriatric medication review address also problems of „underprescribing“, when beneficial drug is not prescribed. Medication review is a procedure which results in rational and optimal prescription, improves its safety, prevents adverse drug events, and their related costs. This article reviews current standardized and validated tools and supports their use by clinicians during (regular) comprehensive assessment of medication in ambulatory and hospital clinical care. 

Keywords:

Falls – polypharmacy – medication review – tools for geriatric prescribing optimization – explicit crtieria- geriatric frailty – anticholinergic medications