Polypharmacy Among Older Adults in Subacute and Long-Term Care Setting Essay

I will complete the title, acknowledgement and dedication section,

Abstract

Background: Polypharmacy is a complex issue among the elderly population due to multiple morbidities that necessitate the regular use of five or more medications, thereby leading to adverse drug effects (ADEs) in long-term care and subacute settings.

Objective: The aims of the integrative review is to assess the effectiveness of STOPP/START criteria in reducing polypharmacy and the impact of ADEs in the elderly.

Methods: Database (EMBASE and PubMed) were searched for literature published from 2017 through August 2022 to identify studies examining the STOPP/START criteria in the elderly populations. Studies eligible included older adults ages 65 years and older, using interventions to reduce polypharmacy and input ADEs and the STOPP/START criteria.

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Results: Fifteen out of six-nine studies were identified, met inclusion criteria. The number of participants in the studies reviewed ranged from130 to 16,687 participants. Researchers assessed inappropriate medication utilization in five studies by comparing Beers criteria, MAI, GheOp3, and other interventions with the STOPP/START criteria. The STOPP/START criteria were used in eight studies. One study used the STOPP criteria to create a computer alert system-based (CAS-based) as their intervention, and another study used the STOPPfrail to assess inappropriate medication utilization.

Conclusions: The findings of the review suggest that the intervention STOPP/START criteria targeted at the elderly either in the nursing homes, community residential settings, or the hospital setting can decrease inappropriate medication use despite the varied quality of studies and prevalence of inappropriate medication use among studies with similar characteristics. The review also emphasizes the importance of future studies addressing preventable ADEs in older adults.

Dedication

For my Mother, Husband, and Children

To my husband, Dr. J thank you for the strong foundation and support you gave me since the start of my nursing career. To my mother, Mrs, thank you for always believing in the best of me, teaching me to reach out for my dreams, and giving me the rich heritage of faith. To my children who supported me with the upkeep of our residence, especially Michael who always gave me moral support.

Acknowledgements

I would like to thank Dr. Joe and the other faculty members for their support throughout the Doctor of Nursing Practice (DNP) program for ensuring the successful completion of this alternative integrative review assignment. I would also like to thank my husband, for his never-ending support and encouragement.

Contents

Significance of the Practice Problem.. 6

Theoretical Framework. 7

Methodology. 8

Review Protocol 8

Inclusion/Exclusion Criteria. 8

Data Analysis. 8

Results and Discussion. 8

Characterization of the Body of Literature. 8

Findings Synthesis: 9

Conclusions and Further Recommendations. 9

Implications for Nursing Practice. 9

Conclusions and Contributions to the Professions of Nursing. 9

Recommendations. 10

References. 11

Appendices, Tables, and Figures. 13

Appendix A.. 13

Appendix B.. 14

Polypharmacy Among Older Adults in Subacute and Long-Term Care Setting

Patients aged 65 years and older residing in subacute and long-term care (LTC) settings regularly take five or more medications (WHO, 2019). As a result, the risk for adverse drug effects (ADEs) increase considerably among them, leading to hospitalizations, falls, dizziness, delirium, decreased appetite, confusion, incontinence, bleeding, serious kidney injuries, electrolyte imbalance (hypokalemia, hyperkalemia), symptomatic orthostatic hypotension, constipation, diarrhea, and dyspepsia (Curtin et al., 2020; Hosseini et al., 2018). This paper is an integrative review exploring the global, national and local impact of polypharmacy and its ADEs on the elderly and the financial burden on the health care systems. It also assesses the effectiveness of the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert doctors to Right Treatment (STOPP/START) tool (Gallagher et al., 2008; O’Mahony et al., 2015) in reducing polypharmacy and lowering ADEs in the subacute and long-term settings.

Problem Statement

Polypharmacy is a crucial patient safety issue in the elderly population in the healthcare setting due to its strong correlation with increased risk of ADEs and drug-drug interactions (Curtin et al., 2020). The adverse effects of polypharmacy include increased risk of falls, delirium, appetite changes, and electrolyte imbalances among others. Patient safety issues are significantly high in the elderly populations residing in nursing homes and sub-acute settings (Curtin et al., 2020). Therefore, understanding polypharmacy is important in helping providers develop effective strategies of gaining insights into patients’ medications, prescriptions, and prevention of ADEs of polypharmacy (Crowley et al., 2020). The proposed PICOT question that served as a foundation for the integrative review paper is; for patients aged 65 years and older residing in a subacute/long-term care center, does the implementation of the STOPP/START criteria affect adverse drug reactions compared to current practice?

Significance of the Practice Problem

Polypharmacy refers to the routine consumption of five or more medications, including those prescribed and over-the-counter (WHO, 2019). Polypharmacy among patients aged 65 and older is a considerable concern in healthcare settings globally due to its high prevalence. For example, American adults taking five or more medications for the past 30 days were older, with 10.8% aged 18–14, 41.7% aged 45–64, and 47.5% were aged 65 and older between 2007 and 2010. Adults taking five or more drugs considered themselves as having fair or poor health (39.6%) compared to those taking one to four medications (14.3%) (CDC/NCHS, 2014). The prevalence of polypharmacy among nursing home residents in the US is also estimated to be 40% (Gohar et al., 2016). As per the prescription drug data analysis conducted by Khezrian et al. (2020), polypharmacy among older adults in the United States increased from 6.3% to 10.7% between 1999–2000 and 2007–2008.

Polypharmacy among the elderly will continue to be a global public health concern due to the population’s increase (Butool et al., 2018). The global population of elderly individuals will double from 8% in 2010 to 16% in 2050. Global states incur significant costs due to polypharmacy. Accordingly, it accounts for 4% ($18 billion) of the world’s avoidable costs (WHO, 2019). Polypharmacy among older adults in the healthcare systems costs about $2 billion each year with Medicare beneficiaries being two times more likely to experience medication-related problems (MRPs) due to polypharmacy than those who took fewer drugs (Almodóvar & Nahata, 2019; Frankenthal et al., 2017). In addition, the diagnosis of chronic diseases such as depression, congestive heart failure, and respiratory conditions are strongly associated with MRPs (Almodóvar & Nahata, 2019). However, significant evidence shows that the total global health care cost can be reduced to 0.3% through proper management of polypharmacy (WHO, 2019).

Besides the concomitant impact on health outcomes and health care costs, polypharmacy predisposes elderly patients to an increased risk of ADEs due to drug-drug interactions and decreased medication metabolism rate (Curtin et al., 2020; WHO, 2019). A systematic review of randomized trials conducted by Thillainadesan et al., (2018) revealed that polypharmacy among older adults hospitalized in Australia caused ADEs, as evidenced by health problems that included falls, confusions, functional decline, increased health care cost, and death.
Consequently, Gallagher et al., (2008) raised the need for evidence-based interventions such as the STOPP/START criteria to help reduce polypharmacy and associated ADEs among patients aged 65 years or more residing in subacute and LTC settings.

Polypharmacy among the elderly in subacute settings is largely attributed to comorbidities-targeted treatment, which leads to ADEs and inefficient disease management (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016; Rafie et al., 2019). Prescribers in these settings are usually provided important information on a medication’s benefits, risks, and guidelines for prescribing them but are not trained on how and when to start deprescribing (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016). The multiple comorbidities facing the elderly patients also force providers to use clinical practice guidelines (CPGs) without considering medication effects on their patients. There is also the challenge of discontinuing drugs prescribed by other providers (specialists) if the patient seems to be tolerating the mediation well; predisposing providers to prescribe more than one medication for the patients (Hill-Taylor et al., 2016).

To effectively address polypharmacy among elderly patients in subacute settings, there must be a systematic approach for detecting and eliminating inappropriate medications. This can be achieved by using screening tools such as the STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015), which have shown good inter-rater reliability between physicians and pharmacists. The screening tools improve the quality of prescribing and reduction in polypharmacy, falls, episodes of delirium, length of hospital stay, and medical expenses (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016).

The STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015) inform prescribers when and how to stop the medication for elderly patients. The findings of Curtin et al. (2020), Foley et al. (2020), Hill-Taylor et al. (2016), and O’Connor et al. (2016) reveal that following the STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015) reduces the number of regular medications taken by elderly patients living in Nursing Home settings. These criteria can also help reduce falls, delirium episodes, length of hospital stay, care visits, and medication costs. Overall, the STOPP/START criteria can improve outcomes regarding the discontinuation of medications (Gallagher et al., 2008; O’Mahony et al., 2015).

Translation Science Framework

Translation science framework must always serve as a foundation for practice. All the concepts and Promoting Action on Research Implementation Health Services (PARIHS) model were analyzed, explored, and related to practice change in implementation and dissemination. The evidence obtained from the literature reviewed guided developments of the integrative review to bridge research to practice. The Promoting Action on Research Implementation Health Services (PARIHS) model served as the conceptual framework for the implementation of the EBP project. The PARIHS model developed by Kitson and colleagues helps examine the implementation of evidence-based practice (EBP) interventions in a healthcare setting (Kitson et al., 1998, Rycroft-Malone et al., 2002; 2004; 2008). The PARIHS model aims to assist in developing a program to implement as a way of making EBP-related changes (Kitson et al., 1998; Rycroft-Malone et al., 2002; 2004; 2008). The framework can be used to implement the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) (Gallagher et al., 2008; O’Mahony et al., 2015; Sallevelt et al., 2020). The PARIHS framework consists of three elements, namely, evidence, context, and facilitation, related to the successful implementation.

The successful implementation of an EBP relies on the type of evidence being used, the quality of the context, and the kind of facilitation required to enable the change process. Therefore, the PARIHS framework consists of successful implementation (SI), which represent the function (F) of the three interplay core elements; the nature and type of evidence (E), the qualities of the context (C), and the introduction and the process of facilitation (F); SI = F (E, C, F) (Kitson et al., 1998; 2008; Rycroft-Malone et al., 2004; Stetler et al., 2011).

Methodology

Review Protocol

The purpose of this literature search was to find research related to the utilization of STOPP/START criteria intervention and its impact on reducing adverse drug effects (ADEs) among the older adults residing in a subacute and long-term care setting. A systematic literature search was conducted on electronic databases of EMBASE and PubMed and using the keywords “Nursing home residents, Older adults STOPP/START Criteria,” “Older adults STOPP/START Criteria, Randomized Controlled Trials”; “Potentially Prescribing Omissions, Clinical Decision Support Systems”; “Patient Safety, Adverse Drug Effects, STOPP/START criteria.” The limitations used to obtain relevant articles related to the intervention were the articles published from 2017 through August 2022, articles published in the English language, the age of patients being 65 years and above, and screening of article titles. The initial search led to 69 articles. The articles were reduced to 10 after applying the inclusion and exclusion criteria. Five additional relevant articles were manually searched upon reviewing the articles retrieved from the database search. The articles included in this literature synthesis are as follows; four systematic review studies, five randomized controlled trials, one qualitative study, one longitudinal study, one comparison of RCTs study, three retrospective studies. The Johns Hopkins Evidence-Base Practice Research Appraisal Tool and Evidence Level of Quality Guided were utilized to review the appraisal and rate the quality of the studies. The common theme identified in the selected studies is that STOPP/START criteria are a practical approach for addressing polypharmacy in adults and preventing adverse drug events.

Inclusion/Exclusion Criteria

The DNP student screened abstracts and full texts of literature that correspond with the inclusion criteria. Research articles included primary research written in English from 2017 up to 2022. Interventions must have targeted the older adult population with an age mean of 65 years and older were implemented in the nursing home setting, community-dwelling for the elderly, and hospital settings.

Intervention that was implemented in studies that aimed at reduction of PIPs, PPO, PIMs including electronic deprescribing intervention, clinical decision support systems, use of STOPP/START criteria, comparison of STOPP/START criteria, and other intervention such as Beers criteria, MAI, and GheOp3, pharmacist and physician-led interventions and the comparison of intervention and usual care. Studies that had primary outcomes measures of reducing PIPs, PPOs, PIMs, and secondary outcome measures that evaluated falls, cognitive functions, ADEs, quality of life, mortality, and hospitalization were included. Studies that did not meet the inclusion criteria were excluded.

Data Analysis

The DNP student extracted the data using the PICOT question. Research with incomplete data was excluded from the analysis to prevent the risk of bias. Studies with multiple sites, only data with residential long-term care facilities for older adults were included. Studies comparing intervention groups to control groups and comparing instruments were also analyzed.

Additionally, data examined were country, descriptive data, publication year, type of study, setting, population characteristics, type of intervention and control group, the impact of the intervention on PIPs, PPOs, and PIMs. Meta-analysis could not be done due to the heterogeneity in data resulting from different designs and lengths of studies. A Johns Hopkins Evidence-Base Table for SR and other studies was completed. A qualitative method was used to organize the data.

Results and Discussion

Characterization of the Body of Literature

Fifteen out of six-nine studies met inclusion criteria. Most of the included studies were conducted in Europe. Researchers assessed inappropriate medication utilization in five studies by comparing Beers criteria, MAI, GheOp3, and other interventions with the STOPP/START criteria. The STOPP/START criteria were used in eight studies. One study used the STOPP criteria to create a computer alert system-based (CAS-based) as their intervention, and another study used the STOPPfrail to assess inappropriate medication utilization. The studies reviewed also used protocols, CDS tools, educational intervention, and medication reviews conducted either by pharmacists, providers, or a combination of both.

The number of participants in the studies reviewed ranged from 130 to 16,687 participants. Eligibility criteria for participants were mainly dependent on meeting the age requirement of being 65 years and older. Additionally, the exclusion criteria of the reviewed studies reviewed included participants under palliative care who died, transferred, or had incomplete data. However, one study conducted by Curtin et al., (2020) looked at polypharmacy at end-of-life. Furthermore, all studies reviewed collected data on inappropriate medication use through medical records, medication administration charts, and databases.

The reviewed studies reveal that the use of STOPP/START criteria can reduce inappropriate medication use and reduce ADEs. However, the studies had strengths and limitations. The studies’ strengths include the specific search of studies using STOPP/START criteria, the general search of studies and systematic reviews of inappropriate prescribing, inappropriate medication use, and the inclusion of different type study designs. It also includes the consistency of age limitation of 65 years and older across the studies and the ability of the studies to compute the weighted average of PIPs, PIMs, and PPOs rate for community and hospitalized patients. The consistency of the definition of polypharmacy and appropriate use of medication across studies also forms the strength of the selected studies. Other studies’ strengths were the comparisons of RCTs and physicians and pharmacist-led studies using interventions.

The study’s limitations consisted of the inclusion of different types of study design that generated heterogeneous data; therefore, a meta-analysis could not be performed, study periods, the variation of inappropriate medication use expressed in the studies, and some studies searching in only two databases. The other limitation included the geographical origin of the instruments based in Europe and the USA. Some studies lacked information on missing data, such as the loss of participants and the variation of the setting of the studies.

The evaluation and outcome of the integrative review contribute to the effectiveness of intervention of STOPP/START criteria to address preventable ADEs in the elderly. The review of included studies was often found to significantly reduce polypharmacy and impact ADEs. The review of medication involving both physicians and pharmacists also effectively decrease medication utilization in two studies. The STOPP/START criteria were used to identify PIPs, PPOs, and PIMs. There was a significant decrease in PIP, PPOs, and PIMs when STOPP/START criteria were used regardless of how and who applied the intervention.

Findings Synthesis

Polypharmacy among the elderly is one of the problems arising from comorbidity-targeted treatment. Authors of the selected studies found that polypharmacy leads to adverse drug events (ADEs) and the prescription of inappropriate medications (PIM); making the elderly less likely to obtain their required treatments (Blum et al., 2021; Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020).

Boersma et al.’s (2019) and Cossette et al.’s (2017) completed randomized control trials that combined clinical decision systems, the Systematic Tool to Reduce Inappropriate Prescribing (STRIP) assistance, and the Computerized Alert System (CAS) based on the STOPP/START criteria. Curtin et al., (2020) completed an unblinded, randomized, pragmatic clinical trial; and Parker et al., (2019) conducted a randomized control study utilizing only the STOPP/START criteria for their interventions. The findings of the studies showed that screening tools such as the STOPP/START criteria had good inter-rater reliability among both physicians and pharmacists, and their impact on the reduction of polypharmacy and ADEs were also revealed (Blum et al., 2021; Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019). The findings also showed that using STOPP/START criteria alone or inclusion of the STOPP/START criteria in the clinical decision support system could assist prescribers and facilitate appropriate prescription, which would, in turn, reduce the medication patients are taking to mitigate ADEs (Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019).

Polypharmacy, PIPs, PPOs, and PIMs, continue to be prevalent in the elderly. The four systematic reviewed conducted by Earl et al., (2020); Thomas et al., (2019); Storms et al., (2017); and Thillainadesa et al., (2018) assessed the use of STOPP/START criteria to identify the prevalence of inappropriate medication use and to reduce PIMs, PIPs, PPOs in older adult age 65 years older and also residing in the long-term care facilities. These studies’ findings showed the impact of STOPP/START intervention in identifying and reducing PPOs, PIPs, and PIMs, which intend to decrease the effect of ADEs.

The most crucial issues with seniors are the exposures to PIPs, PPOs, PIMs, which exposures them to risk for moderate, severe, or fatal ADEs (Thomas et al., 2020). These issues prompted Thomas et al., (2020), Dalton et al., (2020), and Stojanović et al., (2019) to conduct retrospective studies to compare the STOPP/START criteria with other interventions for its effectiveness. The studies showed that all the interventions could identify PIPs and PPOs. However, some tools, such as the Ghent Older People’s Prescriptions Community Pharmacy Screening Tool (GheOp3), detected significantly more PIPs than the STOPP/START criteria. In contrast, the START criteria performed better in screening for PPOs. Although some of the tools performed better than the STOPP/START tool, the most important outcome of the studies is the identification of PIPs, PPOs, and the reduction of PIPs, PPOs and effects of this outcome to reduction of ADEs.

The studies by Dalton et al., (2019) a comparison RCT, Damoiseaux-Volman et al., (2020) a longitudinal study, and Foley et al., (2020) a qualitative study revealed the importance of using interventions such as the STOPP/START tool to reduce PPOs, PIPs, PIMs, and ADEs. Dalton et al., (2019), Damoiseaux-Volman et al., (2020), and Foley et al., (2020) reveal that method of communication among prescribers, pharmacists, and nursing staff in conjunction use of STOPP/START tool affect’s the implementation of tools and also use of the tools improve significantly overtime by prescribers when implemented.

Conclusions and Further Recommendations

Implications for Nursing Practice

The DNP Essentials guided the development of this integrative paper. The essentials act as the foundational outcome competencies deemed essential for all graduates of a DNP program regardless of specialty or functional focus” (AACN, 2006, p. 8). The eight DNP essentials served as a guide throughout the integrative review paper. The evidence obtained from the reviewed literature guided development of the integrative review to bridge research to practice. The findings of this integrative paper have considerable implications for nursing practice. The findings reveal the importance of implementing STOPP/START criteria in the nursing home and subacute settings. The successful implementation of STOPP/START criteria requires healthcare providers in these settings to collaborate to achieve optimum outcomes. The implementation of the intervention will prevent polypharmacy and its ADEs through medication reconciliation. It will also provide the clinical team with EBP tools and guidelines for medication reconciliation while promoting timely, effective, efficient, quality, and safe patient-centered care. It will also improve providers’ and nurses’ confidence in identifying potentially inappropriate medications and reducing polypharmacy which will impact ADEs, rehospitalization, and minimize costs.

Conclusions and Contributions to the Professions of Nursing

Polypharmacy is a significant issue among long-term care and subacute settings, impacting providers’ quality of patient care. Polypharmacy is associated with adverse outcomes such as ADEs, confusion, falls, death, and hospitalization (Thillainadesan et al., 2018). The findings of this review suggest that the STOPP/START criteria targeted at the elderly either in the nursing homes, community residential settings, or the hospital setting can decrease PIMs, PPOs, and PIPs (Earl et al., 2020; Storms et al., 2017; Thillainadesan et al., 2018, Thomas et al., 2019). As a result, nurses and other healthcare providers should consider its adoption to promote safety, quality, and efficiency in elderly care.

Although the reviewed studies showed a reduction of inappropriate medication use, the findings of the studies cannot be generalized due to heterogeneity of data, varied samples sizes, and prevalence of inappropriate medication use among studies with similar characteristics. However, the studies show the importance of medication review and the use of interventions such as STOPP/START criteria in identifying inappropriate medication use in older adults. The review also raises the need for future studies that focus on addressing preventable ADEs in old adults.

Recommendations

It is essential to have accurate medication reviews in older adults with polypharmacy to prevent ADEs in this patient population. The STOPP/START criteria and education of its use should be considered in long-term care and subacute settings. Nurse practitioners, nursing staff, and center leadership input should be obtained for future quality improvement projects. Future policies should promote a systematical inclusion of the STOPP/START criteria the standard practice in the long-term care and subacute facilities. The criteria should also be incorporated in the electronic health record (EHR) in the setting, if possible, to improve adherence and its consistency in use for elderly care.

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Parker, K., Bull-Engelstad, I., Benth, J. A., Aasebø, W., von der Lippe, N., Reier-Nilsen, M., Os, I., &Stavem, K. (2019). Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65 years with chronic kidney disease: a randomized clinical trial. European Journal of Clinical Pharmacology, 75(11), 1503–1511. https://doi.org/10.1007/s00228-019-02727-9

Rafie, C. L., Zimmerman, E. B., Moser, D. E., Cook, S., &Zarghami, F. (2019). A lung cancer research agenda that reflects the diverse perspectives of community stakeholders: Process and outcomes of the SEED method. Research Involvement and Engagement, 5(3). https://doi.org/10.1186/s40900-018-0134-y

Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., &Estabrooks, C. (2002).Ingredients for change: revisiting a conceptual framework. Quality & safety in health care, 11(2), 174–180. https://doi.org/10.1136/qhc.11.2.174

Rycroft-Malone, J., Harvey, G., Seers, K., Kitson, A., McCormack, B., &Titchen, A. (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13(8), 913–924. 10.1111/j.1365-2702.2004.01007x

Sallevelt, B. T. G. M., Huibers, C. J. A., Knol, W., Puijenbroek, E. van, Egberts, T., & Wilting, I. (2020). Evaluation of clarity of the STOPP/START criteria for clinical applicability in prescribing for older people: A quality appraisal study. Biomedical Journal Open, 10(2), e033721.https://doi.org/10.1136/bmjopen-2019-033721

Stetler, C. B., Damschroder, L. J., Helfrich, C. D., & Hagedorn, H. J. (2011). A guide for applying a revised version of the PARIHS framework for implementation. Implementation Science, 6, 99.https://doi.org/10.1186/1748-5908-6-99

Stojanović, M., Vuković, M., Jovanović, M., Dimitrijević, S., &Radenković, M. (2019). GheOP 3 S tool and START/STOPP criteria version 2 for screening of potentially inappropriate medications and omissions in nursing home residents. Journal of Evaluation in Clinical Practice, 26(1), 158–164. https://doi.org/10.1111/jep.13107

Storms, H., Marquet, K., Aertgeerts, B., &Claes, N. (2017).Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review. European Journal of General Practice, 23(1), 69–77. https://doi.org/10.1080/13814788.2017.1288211

Thillainadesan, J, Gnjidic, D, Green, S, Hilmer, S. N.(2018) Impact of deprescribing interventions in older hospitalized patients on prescribing and clinical outcomes: A systematic review of randomised trials. Drugs Aging, 35(4), 303–319.doi: 10.1007/s40266-018-0536-4

Thomas, R. E., & Nguyen, L. T. (2020).Title assessing potentially inappropriate medications in seniors: Differences between American Geriatrics Society and STOPP Criteria and preventing adverse drug reactions. Geriatrics (Basel, Switzerland), 5(4), 68.https://doi.org/10.3390/geriatrics5040068

Thomas, R. E., & Thomas, B. C. (2019). A systematic review of studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years. Current Aging Science,12(2), 121–154. doi: 10.2174/1874609812666190516093742. PMID: 31096900.

World Health Organization. (‎2019)‎. Medication safety in polypharmacy: Technical report.https://apps.who.int/iris/handle/10665/325454

Appendices, Tables, and Figures

BUY A CUSTOM- PAPER HERE

Appendix A

Johns Hopkins Nursing Evidence-Based Practice

Appendix G Individual Evidence Summary Tool

Article Number

Author and Date

Evidence Type

Sample, Sample Size, Setting

Findings That Help Answer the EBP Question

Observable Measures

Limitations

Evidence Level, Quality

Multicenter Partially Blinded Cluster Randomized Control Trial

(RCTs).

Sample:

Randomized

Sample Size:

Intervention cluster group: 54 (963 participants).

Control cluster group: 56 (1045 participants).

Setting:

110 cluster inpatient wards within university base hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland.

Eligibility Criteria:

2008 Old adults (> 70 years)with multimorbidity (> 3 chronic conditions) and polypharmacy (> 5 drugs used long term).

❑ N/A

The study findings showed that inappropriate prescribing was common in older adults with multimorbidity and polypharmacy. The STOPP/START tool was effective in reducing the inappropriate medication and polypharmacy.

The aim of study was to assess the effects of optimizing pharmacotherapy, with the support of software based clinical decision support tool on drug related hospital admission and other clinical outcomes in older adults with multimorbidity and pharmacy, compared to usual care.

Intervention cluster group:

Usual care with support of clinical decision software system deploying STOPP/START Criteria to identify potentially inappropriate prescribing.

Control cluster group:

Usual care

Main Outcome Measure:

Primary outcome:

-Frist drug related to hospital admission within 12 months.

Secondary outcome:

-Falls, death, pain, activities of daily leaving, adherence to medication and quality of life at 12 months.

Study design, partially blinded RCTs.

Cluster randomization was only for doctors and not the hospital level which can lead to potential contamination in the control cluster which cannot be ruled out.

STRIP was not used in the controlled group

Dependent on retrospective chart review is a gold standard, however, depend the quality of documentation of the medical records.

No guarantee that replication of the OPERAM will likely yield the same effect due to lower limit confidence interval.

Low powered trial for the targeted effect due to higher primary outcome in the control group which was more than expected in the original sample size calculation.

I/A

Boersma, M. N., Huibers, C. J. A., Drenth-van Maanen, A. C., Emmelot-VonkM. H., WiltingI.,&Knol, W. (2019). The effect of providing prescribing recommendations on appropriate prescribing: A cluster-randomized controlled trial in older adults in a preoperative setting.Br J ClinPharmacol, 85(9), 1974–1983. doi: 10.1111/bcp.13987. Epub 2019 Jul 3. PMID: 31108564; PMCID: PMC6710520.

A Cluster-Randomized Controlled Trial (RCT).

Sample:

Randomized

Sample Size:

N = 124

Intervention Group: n = 65

Control Group: n = 59

Setting:

Preoperative geriatric outpatient clinic

of the University Medical Centre, Utrecht.

Eligibility Criteria:

Patient aged 70 years and above, who are five or medications scheduled for elective surgery between October 2014 and July 2016.

Exclusion Criteria:

Patient no-show and surgery cancellation.

Recommendation given to the wrong patient.

❑ N/A

The study finding showed the inclusion of the STOPP/START tool in Systematic Tool to Reduce Inappropriate Prescribing (STRIP) assisted prescribers and improved appropriate prescribing practice among them in a preoperative geriatric outpatient clinic.

The study also revealed the appropriateness of prescribing improvement to the intervention group based on the decreased potentially inappropriate medications (PIMs) identified with STOPP/START version 2.

The aim of the study is to integrate the STOPP/START tool with the STRIP assistant clinical decision support system and evaluate the effectiveness of appropriate prescribing and mortality in a preoperative setting.

Primary Care:

Number of medication changes made because of potential prescribing omissions (PPOs), PIMs, and suboptimal dosages according to the prescribing recommendations.

Secondary Outcome:

3-month postoperative mortality.

Intervention Group:

Prescribing recommendations were generated by a physician using the STRIP assistance and given to residents.

Controlled Group:

Residents performed a medication review according to usual care.

The controlled group had more experienced residents specializing in geriatrics and fewer residents specialized in nursing home medicine. This situation could lead to bias since less-experienced residents’ willingness to implement recommendations will be low.

Limitation in variable and small cluster size.

Contamination of the controlled group due to joint care by residents from the intervention group.

The use of STRIP with recommended STOPP/START criteria version 1, which is not the most recent version

I/A

Cossette, B., Éthier, J. F., Joly-Mischlich, T., Bergeron, J., Ricard, G., Brazeau, S., Caron, M., Germain, O., Payette, H., Kaczorowski, J., & Levine, M. (2017). Reduction in targeted potentially inappropriate medication use in elderly inpatients: A pragmatic randomized controlled trial. Eur J ClinPharmacol, 73(10), 1237–1245. doi: 10.1007/s00228-017-2293-4. Epub 2017 Jul 17. PMID: 28717929.

Pragmatic single-site RCT

RCT with block randomization

Sample:

Random

Sample Size:

n = 231

Patients were randomly assigned to control and intervention groups in a 1:1 ratio using block sizes of 2, 4, and 6, and stratification by hospital site. Sample: 139 interventions (126 analyzed); 133 control group patients (128 analyzed).

Population: Adults, aged 65 years and above, with at least one geriatric-explicit criterion for PIMs.

Setting:

University hospital in Canada

Eligibility Criteria:

Adults, aged 65 years and above, with at least one geriatric-explicit criterion for PIMs.

Exclusion Criteria:

Patients from the emergency department, psychiatric unit, intensive care unit, and palliative care unit were excluded.

❑ N/A

The outcome of the study revealed that a CAS-based pharmacist-physician intervention resulted in significantly higher drug cessation and dosage reduction in targeted PIMs, as compared to usual clinical care.

Use of a computer alert system-based pharmacist-physician intervention model to compare the change in the use of PIMs with usual clinical care. A panel of experts used STOPP criteria to develop the model.

Primary outcome: Drug cessation or dosage decrease implemented in targeted PIMs.

Secondary outcome: Length of stay, in-hospital death, ED visits, and readmissions within 30 days of discharge.

Clinical relevance of the computer alert system notifications:

1. 50% in the control group and 30% in the intervention group.

2. Significant drug cessation and dosage decrease in the intervention group as compared to the control group, 48 hours after alert (30%) and hospital discharge (20.8%). Average/mean time to analyze a patient file and complete the interventions was approximately 44.25 minutes in the intervention group.

3. No significant decrease in readmissions or inpatient death rates for intervention group as compared to the control group.

Lack of evaluation of clinical outcomes of the interventions, such as adverse drug reactions.

Limited diagnosis coding related to institution.

Training effect occurrence due to physicians attending to both the intervention and control groups.

Loss of 15% randomization due to request of permission to use patient’s clinical information after discharge.

I/A

Article Number

Author and Date

Evidence Type

Sample, Sample Size, Setting

Findings That Help Answer the EBP Question

Observable Measures

Limitations

Evidence Level, Quality

Curtin, D., Jennings, E., Daunt, R., Curtin, S., Randles, M., Gallagher, P., &O’Mahony, D. (2020). Deprescribing in older people approaching end of life: A randomized controlled trial using STOPPFrail criteria.J Am Geriatric Soc.,68(4),762–769. doi: 10.1111/jgs.16278. PMID: 31868920.

RCT:

A parallel-group, unblinded, randomized, pragmatic clinical trial

Sample:

Random

Sample Size:

n = 130;

Intervention Group: n = 65;

Control Group: n = 65

Setting:

Two acute-care hospitals in Cork City, Ireland.

Eligibility Criteria:

Adults, aged 75 years or above, with advanced frailty and polypharmacy (five or more drugs) who have been transferred to long-term care from the hospital.

❑ N/A

The study showed that, with the implementation of the STOPPFrail guide, there was a significant reduction in polypharmacy and medication costs in frail, older participants.

No significant findings could be found by comparing the two groups with respect to falls, mortality, the quality of life, and rehospitalization.

The aims of the study are:

1. To evaluate the effectiveness of the STOPPFrail tool developed for deprescribing in older patients with advanced frailty.

2. To present the STOPPFrail guide for deprescribing to physicians who otherwise use their clinical judgement.

The primary outcome is a decrease in the number of regular medications within three months.

The secondary outcome is the impact on rehospitalization, falls, the quality of life, monthly medication costs, and mortality.

Intervention Group:

Usual pharmaceutical care supplemented by individualized deprescribing using the STOPPFrail guide.

Control Group:

Received usual pharmaceutical care from the pharmacist and hospital physicians.

The generalizability of the findings is limited due to the inclusion of only two acute hospitals in Ireland.

The STOPPFrail guide was created by a university affiliated with the hospital, which might have influenced physicians’ willingness to participate in the study.

Participants were not blinded.

No quality control measures were created to assess the accuracy of the STOPPFrail guide.

A small sample size was used in the study.

The design was not clustered, which will decrease the possibility of contamination bias.

I/A

A pharmacist-physician pair retrospectively review the case records of all SENATOR RCT trial intervention patients.

Sample:

N = 204 intervention patients for the SENATOR RCT trial conducted at Cork University Hospital (CUH), an 810-bed tertiary referral center in southern Ireland.

The SENATOR RCT was conducted in six large acute-care teaching hospitals in six European countries.

Eligible Criteria:

· Adults older than 65 years who consented for enrolment in the trial within 60 hours of hospital admission; were prescribed medication for more than 3 active chronic medical disorders; and who expected the duration of hospital stay to be greater than 48 hours.

· All patients who were randomized to the intervention arm at the CUH site were included in the study.

Exclusion Criteria:

One hundred and fourteen STOPP/START criteria (version 2) recommendations based on the following three criteria were excluded: STOPP A1, START II, and START 12.

The findings of the study revealed that in 204 intervention patients, the SENATOR software produced 925 STOPP/START recommendations. Nearly three quarters of the recommendations were judged clinically relevant (73.6%); however, nearly half of these were deemed of “possibly low relevance” (320/681; 47%). Recommendations deemed to be of higher clinical relevance were significantly more likely to be implemented than those of lower clinical relevance (P< 0.05).

All patients were randomized to the intervention arm.

The aim of the study is to systematically evaluate the clinical relevance of these recommendations and establish if such relevance significantly affects the implementation rate of computer-generated STOPP/START criteria.

Inter-rate reliability (IRR) was determined in a sample of three pharmacists and three physicians (one consultant geriatrician and two specialist registrars i.e., senior residents in geriatric medicine) by applying the study independently and assigning a degree of clinical relevance to the STOPP/START criteria from 20 randomly selected intervention cases.

Limitations of the study include the following:

1) The retrospective design.

2) The subjectivity of raters must be considered as bias.

a) Previous studies have shown that the rating scale with poor IRR are likely due to result in low estimates of IRR in subsequent studies.

b) A scale with fewer or more specific categories would allow less room for discrepancy between raters and produce a higher IRR kappa value.

3) Agreement may have been affected by raters on account of simply interpreting the scale differently.

II/A

A Cluster Randomized Control Trial for Comparison of a Pharmacist Approach and a Physician Approach

Sample Size/Setting:

Cork University Hospital an 810-bed tertiary referral center in Southern Ireland.

RCT 1: conducted from May 2011 to May 2012.

RCT 2: conducted from June 2011 to July 2012.

Eligibility Criteria:

-Older adults >65 years

-Participant enrollment was within 48hrs of presentation to hospital with an acute illness.

-In both RCTs Pharmacist and physicians who routinely work in the hospital provided the care.

Both RCT 1 & 2: included individual admitted under the care of specialist in cardiology, respiratory medicine, endocrinology, renal medicine, and orthopedics.

RCT 1: included patient admitted to radiation oncology services.

RCT 2: included patient admitted to rheumatology, general, vascular surgery and general internal medicine.

The findings of the study revealed that physicians are more significantly likely to implement the STOPP/START criteria than pharmacist.

The adherence of the use of STOPP/START criteria by physicians improve the prevention of ADRs in older adults. However, non-implementation pf intervention by some pharmacist may have contributed in the prevention of ADRs in old adults.

The purpose of the study was to compare the prescriber implementation rate of STOPP/START recommendation between the physician and pharmacist approach in a two RCTs and provide a narrative summary of the comparable clinical outcome.

Intervention /Control Group:

One group of attending consultant prescribers was assigned to the intervention arm of the study and the other was assigned to the control group.

Primary Outcome:

Comparison of the implementation of STOPP/START criteria by physician and pharmacist.

Secondary Outcome:

To identify components of within the intervention that may have affected the prescriber’s implementation and to compare the implementation of of STOPP/START criteria by pharmacist and recommendation of other pharmacist-delivered recommendation.

Pharmacist provided other recommendation not just STOPP/START criteria.

Mode communication also differed between pharmacist and physician.

Physician who were elected for the studies already worked in the hospitals whereas the pharmacist did not.

Single-centre comparisons of one pharmacist and one physician

These differences may affect the implementations, outcome and generazability of the study.

II/B

A longitudinal Study

Sample Size:

Total of data included was 16,687 admissions.

Sample/Setting

A large hospital admission data collected of older patients of >70 years based on an electronic health records cohort including data from 2015 to 2019.

The setting was a 1002-bed university medical center located in Amsterdam, the Netherlands.

Inclusion Criteria:

Hospital admission >

24 hrs to one of 26 clinical departments, with admission dates > November 1^st 2015 and discharge dates < November 1^st 2019 (4 full years).

The findings of the study found majority of older adult patients admitted to the hospital had potentially inappropriate prescribing. The use of STOPP/START criteria improved prescribing relatively overtime when considering complexity of admission.

The aim of the study to evaluate the prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in old adult population in the hospital setting.

Inclusion of diagnosis not relevant to the study was included which could lead to underestimation of prevalence of PIMs and PPOs.

Routine data was collected which affected the establishment of whether clinicians followed the STOPP/START criteria for clinical reason such as side effects.

Generalizable of the study will not possible. The study was only conducted in one hospital.

III/B

Earl, T., Katapodis, N., Schneiderman, S., Shoemaker-Hunt, S., & PhD, PharmD. (2020). Using deprescribing practices and the screening tool of older persons’ potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults. Journal of Patient Safety, 16, S23–S35. https://doi.org/10.1097/PTS.0000000000000747.

Systematic Review

Sample:

n=27 articles consisting of 26 studies and 1 systematic review, which met the inclusion criteria.

Evaluation of intervention related to deprescribing (n=14 studies) and use of STOPP criteria to reduce PIMs (n=12 studies, 1 systematic review) in older adults.

RCTs n=4

Feasibility studies n=4

Intervention studies n=2

Cost study n = 1

Pilot study n = 1

Hybrid implementation-effectiveness design n = 1

Database Search:

The systematic review of literature was conducted between 2008 and 2018. The search was conducted in two databases—CINAHL and MEDLINE.

Study Settings for Deprescribing Intervention:

· Long-term care facilities

· Community pharmacies

· Inpatient hospital geriatric unit

· Hospital outpatient departments

· Hospital during discharge

Inclusion Criteria: Those studies were included which

· were published in English,

· explicitly focused on deprescribing, polypharmacy, use of STOPP and related interventions, and targeted to older adults, and

· examined the effectiveness of these interventions on PIMs and preventable ADEs.

Exclusion Criteria: Those studies were excluded which

· were out of scope of studies,

· focused on pediatric and children care,

· were not intervention studies (e.g., epidemiology studies and commentaries), and

· did not have the outcome reported.

The finding of the study revealed that deprescribing interventions and interventions using the STOPP criteria seem effective in reducing polypharmacy and PIMs in older adults, respectively.

The purpose of the study was to review the evidence of patient safety practices aimed at reducing preventable ADEs in older adults, specifically:

· Deprescribing intervention to reduce polypharmacy,

Use of the STOPP to reduce PIMs.

Most of the studies had a small sample size, ranging from 40 to 490 participants.

The focus of the study reviewed was on older adults. However, there were only 3 interventions involving geriatricians.

The studies varied widely in terms of the outcomes examined, with the majority evaluating the effect of the intervention on process outcomes.

II/A

Foley, R. A., Hurard, L. L., Cateau, D., Koutaissoff, D., Bugnon, O., &Niquille, A. (2020).Physicians’, nurses’ and pharmacists’ perceptions of determinants to deprescribing in nursing homes considering three levels of action: A qualitative study. Pharmacy (Basel, Switzerland), 8(1), 17. https://doi.org/10.3390/pharmacy8010017

Qualitative

Study

Sample:

Purposive sampling

Sample Size: n = 21;

The participants were divided into two focus groups:

Pharmacists (n = 11) and Nurses (n = 10).

Setting:

Nursing homes in Switzerland, specifically those in two regions of the French-speaking part— Vaud and Fribourg.

The study showed that physicians were personally concerned with deprescribing with regard to patient safety; nurses were concerned with building trust with patients and the timing of deprescribing; and pharmacists followed the deprescribing guidelines. Relatives and residents feared that the care would be interrupted by deprescribing. At the institutional level, the lack of time for discussing patient health and treatment duration was found to be a significant factor. The complexity of collaboration among professionals for deprescribing was also a contributing factor.

The findings suggested that deprescribing can be completed when there is interprofessional collaboration and cooperation during the implementation process.

The purpose of the study is to understand and compare the perceptions and practices of nurses, pharmacists, and physicians of Swiss nursing homesin deprescribing, with reference to the implementation of a three-level approach—individual, institutional, and healthcare systems.

Six semi-structured interviews that focused on the participants’ individual experiences and practices were conducted.

The study was conducted in two cantons of the French-speaking part of Switzerland that already had a strong interprofessional collaboration.

The data collection method was different for nurses and pharmacists.

Pharmacists were the only healthcare professionals represented by the authors of the paper.

III/(A/B)

Article Number

Author and Date

Evidence Type

Sample, Sample Size, Setting

Findings That Help Answer the EBP Question

Observable Measures

Limitations

Evidence Level, Quality

Parker, K., Bull-Engelstad, I., Benth, J. A., Aasebø, W., von der Lippe, N., Reier-Nilsen, M., Os, I., &Stavem, K. (2019). Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65 years with chronic kidney disease: a randomized clinical trial. European Journal of Clinical Pharmacology,75(11), 1503–1511. https://doi.org/10.1007/s00228-019-02727-9

Single-blind, multicenter, parallel-group Randomized Control Trial

Sample Size:

n=180 patients

Intervention group: (n=92)

Control group: (n=88)

Setting:

Three Nephrology centers: (Akershus University Hospital; Olso University Hospital, Ulleval; and VestreViken Hospital Trust, Drammen) from July 2015 to January 2017.

Inclusion Criteria:

Patient age 65 years and older with advance chronic kidney disease stage 5 (CKD).

Patient on Peritoneal Dialysis (PD) and Hemodialysis (HD)

Exclusion Criteria:

Moderate to severe reduction in cognition impairment.

Severe hearing and visual impairment and inadequate knowledge of Norwegian language.

The findings of the study revealed the intervention of STOPP/START criteria identified PIPs, PPOs and reduced numbers of PPOs. But did not affect medication adherence and health-related quality of life (HRQoL)

The purpose of the study is to identify PIPs and PPOs using the STOPP/START criteria in elderly patients with advanced CKD and to reduce PIPs, PPOs and determine the effects on medication review, adherence and HRQoL.

Primary Outcome:

Reduction in PIPs, PPOs, improvement of adherence of medication during the 6 months observation period.

Secondary Outcome:

Change mediations and PCS and MCS scores.

Intervention Group:

STOPP/STARTcriteria

Control Group:

Usual Care.

Shortage period of follow-up due to expected high mortality rate of participants.

The use of medication adherence to calculate the simple size. However, there were no comparable studies with figure of effect size to be expected.

High proportion of missing data for outcome which will affect the generalizability of findings.

Physicians who were responsible implementing the medication changes were seeing both the intervention and control group.

The STOPP/START criteria were created for generalized older adults with chronic diseases not a single disease.

I/A

Stojanović, M., Vuković, M., Jovanović, M., Dimitrijević, S., &Radenković, M. (2019).GheOP 3 S tool and START/STOPP criteria version 2 for screening of potentially inappropriate medications and omissions in nursing home residents. Journal of Evaluation in Clinical Practice, 26(1), 158–164. https://doi.org/10.1111/jep.13107

Retrospective observational study

Sample Size:

n=422 and 400 participants met the criteria.

Settings:

Gerontology Center in Belgrade and Serbia.

The study was conducted from January to June 2018.

Inclusion Criteria:

Age 65 years and older and must be on at least one medication.

Participants who visited for a primary care physician at the Gerontology Center in Belgrade and Serbia.

The study was conducted from January to June 2018

The study findings showed that both tools STOPP/START criteria and Ghent Older People’s Prescriptions Community Pharmacy Screening Tool (GheOp3) detected PIPs and PPO’s. However, the GheOp3 detected significantly PIPs than STOPP. But the START criteria detected PPOs much better than GheOp3.

The findings also showed that the STOPP/START criteria correlated positively with mentioned variable than GheOp3.

The aim of the study was to compare the ability of STOPP/START criteria and GHeOp3 to detect PIPs and PPOs among elderly patients visiting their primary care physician.

Objective measured:

The effectiveness of detection of PIPs and PPOs using STOPP/START criteria and GheOp3.

Limited vaccination, cardiovascular system PIPs were observed.

Missing antiplatelet therapy was highly ranked in START criteria, however, 60% of patients were older than 80 years which influenced this finding as some guideline for antiplatelet in this age group is not recommended.

II/B

Systematic Review

Sample Size:

n=22 studies met the inclusion criteria.

Electronic databases (MEDLINE, EMBASE) were searched for literature from 2004 to 2016 to identify studies examining inappropriate medication use in residential long-term care facilities for the elderly. Addition research studies of interest were also searched in the reference list of included articles.

Key Words: ‘medication errors’ and ‘adverse drug event’ in the setting ‘nursing home’ were also included in the search strategy

Inclusion Criteria:

Research articles and conference papers written in English, Dutch, French, and German; relying on a minimum of one of seven instruments frequently used to assess inappropriate medication use (Beers criteria, STOPP, START, PRISCUS list, ACOVE, BEDNURS and MAI were included.

Exclusion Criteria:

· Irrelevant study topic

· Sample size <100

· Different instrument used.

· Different setting

· Full text not available.

❑ N/A

The study finding revealed that inappropriate medication use in residential long-term care facilities was determined using the Beers criteria of 2003 and STOPP criteria. The study also showed that the prevalence of inappropriate medication use varied among the studies, although the research study designs and assessments with identical instruments were similar.

The purpose of this study was to systematically review literature to evaluate the prevalence of inappropriate medication use in residential long-term care facilities for the elderly.

Some studies researchers could not be blinded, this can be subject to sampling bias.

Only two data bases were searched and only two geographical origin were researched (USA, Europe)

Some studies had non-transparent data, lack of information on loss of participants, medication review was set out as point prevalence, heterogeneity data hampered meta-analysis, limiting statements on prevalence of inappropriate medications use and prevalence of inappropriate medication use were strongly varied among studies with similar characteristics.

I/B

Thillainadesan, J., Gnjidic, D., Green, S., Hilmer, S.N. (2018).Impact of deprescribing interventions in older hospitalized patients on prescribing and clinical outcomes: A systematic review of randomised trials. Drugs Aging,35(4), 303–319.doi: 10.1007/s40266-018-0536-4. PMID: 29541966.

Systematic review of RCTs

Sample:

Randomized

Sample Size:

Nine RCTs (n = 2522 subjects)

Deprescribing Interventions:

· Pharmacist-led (n = 4)

· Physician-led (n = 4)

· Multidisciplinary (n = 1)

Database Search:

Ovid MEDLINE, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL

The search for RCTs was conducted from 1 January 1996 to April 2017.

Eligibility Criteria:

· RCTs reporting on deprescribing interventions to reduce PIMs in older hospitalized adults.

· Outcome of reduction of PIMs through measurements such as STOPP criteria, Drug Burden Index (DBI), Medication Appropriateness Index (MAI), and updated Beers list.

· Only RCTs published in English between 1 January 1996 and April 2017.

· Participants aged 65 years and above

· Implementation of interventions in the hospital settings.

Exclusion Criteria:

· Non-English studies

· Uncontrolled studies

· Non-RCT studies

· Studies not having a hospital setting.

❑ N/A

The study outcome suggested that deprescribing interventions in the hospital is feasible, safe, and generally effective in reducing PIMs. However, the current evidence is limited, of low quality, and the impact on clinical outcomes is unclear. Future studies are recommended.

The aim of the study was to investigate the efficacy of deprescribing interventions in older inpatients to reduce PIMs and the impact on clinical outcomes.

Primary Outcome:

Reduction in PIMs.

Secondary Outcomes:

Measurement of clinical relevance including mortality, falls, cognitive function, adverse drug withdrawal events, quality of life, and hospitalizations

Significant heterogeneity in outcome measures prevented meta-analysis of the study.

Missing could not be retrieved for some studies.

Conclusion on efficacy based on the intervention type could not be made due to the limited number of studies with similar interventions and outcome measures.

Most of the studies had short-term follow-ups and thus, the long-term impact of the interventions remains unclear.

The study only included RCTs.

Only five of the nine studies were eligible for the primary outcome.

Quality of the trials included varied and randomization was adequate in two of the nine studies.

None of the studies were eligible to examine the secondary outcome.

I/A

Retrospective Study

Sample:

N = 82,935 first-time admissions to an acute-care hospital in Calgary during 2013–2018

Literature Review:

RCTs to reduce PIMs and ADRs

A comparison of many cross-sectional studies had five RCTs assessing hospitalized patients aged 65 years or above using STOPP criteria to reduce the number of PIMs and/or ADRs.

· In a study of 359 patients (average age 82) in Israel, the pharmacist provided 245 STOPP and START 82 recommendations.

· In a study of 400 patients in Ireland (median age 76), the participants were randomized to usual pharmacist care or usual pharmacist care + assessment by the STOPP/START criteria.

· In a study of 732 patients in Ireland, participants were randomized to usual pharmacist care (medication reconciliation and surveillance of prescriptions order sheets with written specific advice to prescribers) or usual pharmacist care along with assessment by STOPP/START criteria and answering questions.

· The SENATOR RCT, which was the largest study with 1537 patients in six European countries, was intended to provide software support so that attending physicians could avoid PIMs, PPOs, and ADRs.

❑ N/A

The study findings revealed that over the five-year period under study, there were 294,160 STOPP PIMs (3.55/patient) and 226,970 AGS Beers PIMs (2.74/patient), 59,396 START PPOs (0.72/patent) and 85,288 STOPP PPOs (1.03/patients) for which a new prescription corrected the omission. The study presented the most comprehensive comparison between STOPP and AGS Beers PIMs in literature to date. The study also demonstrated that inappropriate prescribing presented four interrelated problems requiring resolutions:

· The increased workload of pharmacists and physicians.

· The study showed that pharmacists will encounter at least 150 types of PIMs and 24 types of PPOs.

· Within the five-year period, the STOPP criteria had higher PIMs.

The Pearson correlation was 0.7051 for both STOPP and the AGS Beers. Therefore, the research recommended combining both criteria.

The researchers also concluded that, to resolve the problems of PIMs and PPOs, and for careful construction and implementation of CDSS as the SENATOR, trials for experienced pharmacists to focus on PIMs and PPOs are likely to lead to moderate, severe, or fatal ADRs and discussing identification of these medications with physicians. The remaining PIMs and PPOs related to chronic disease management can be discussed with family physicians on phone using the discharge summary which lists the medications for potential deprescribing.

The aim of the study was to identify in the large cohort of 82,935 patients admitted to the four Calgary hospitals between 2013–2018 for the first time in that period, if there was a correlation of STOPP and AGS Bears PIMs and START PPOs with subsequent rehospitalization and death. It also aimed to provide data to motivate physicians to focus on and deprescribe the PIMs and PPOs with the highest correlations with these adverse outcomes.

A comparison of the many cross-sectional studies had five RCTs assessing hospitalized patients aged 65 years and above using STOPP criteria to reduce the number of PIMs and/or ADRs.

Most CDSS recommendations had low clinical significance. The staff was busy and according to the hospital, it was short of staff. The staff was also unwilling to change the medication. Since it had been prescribed by the family physician and not them, it was not their prerogative

The studies were all conducted outside of the United States.

Retrospective study.

II/B

Thomas, R. E., & Thomas, B. C. (2019).A systematic review of studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years. Curr Aging Sci.,12(2), 121–154. doi: 10.2174/1874609812666190516093742. PMID: 31096900.

A systematic review

Sample:

Sixty-two studies of the updated 2015 criteria assessing the prescribing by physicians in 31 countries. Nearly all are community patients. n = 1,854,698 included two RCTs and 60 non-randomized, cross-sectional studies.

Thirty-two studies were carried out on community patients while thirty included hospitalized patients.

Patients were 65-years-old and above.

Database Search:

The search conducted from

2 January 2019 in Medline, Embase, and PubMed identified 562 studies of which 62 were retained for review. The data were abstracted independently.

Exclusion Criteria:

Previous versions of STOPP/START or Beers criteria

❑ N/A

The result of the studies showed higher rate of PIP/PIM/PPO in community and hospitalized patients. The recommendation from the research was to have RCTs for intervention to reduce existing PIP/PIM/PPO prescription and prescriptions causing adverse effects and enable regulatory authorities to monitor and reduce inappropriate prescriptions in real time.

Also, the need to determine whether the substantial difference in both criteria is due to the difference in medication availability between countries or data availability to assess the criteria.

The purpose of the study is to identify all studies using the updated 2015 STOPP/START or American Geriatric Society 2015 Beers criteria and evaluate whether the studies with lower rates of inappropriate prescribing had lower rates of emergency and hospital visits, adverse medication effects, and mortality.

A far greater number of community patients were assessed (1,843,637 = 99.4%) than hospitalized patients (11,061 = 0.6%).

There were only two studies in African countries, one in China, and none in Russia and the large majority of other countries.

The authors of Beers criteria recommended using both STOPP/START and the Beers criteria. However, only 13 studies had both criteria in the studies.

Of the five community studies, only one reported that using both criteria resulted in exactly the same percentages for three PIPs and identified numerous different PIPs. The dissimilarity was due to the medication list of both criteria and medication availability and usage across countries.

I/A

Appendix B

Summary of Systematic Reviews (SR)

Citation	Question	Search Strategy	Inclusion/ Exclusion Criteria	Data Extraction and Analysis	Key Findings	Recommendation/Implications	Level of Evidence
Earl, T., Katapodis, N., Schneiderman, S., Shoemaker-Hunt, S., & PhD, PharmD. (2020). Using deprescribing practices and the screening tool of older persons’ potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults. Journal of Patient Safety, 16, S23–S35. https://doi.org/10.1097/PTS.0000000000000747.	What is the effect of interventions for deprescribing and using the STOPP criteria on preventable ADEs for older adults?	The literature strategy was conducted in two databases (CINAHL and MEDLINE) for peer-reviewed literature published from 2008 to 2018 utilizing the terms related to deprescribing and STOPP interventions, targeted at older adults and aimed at outcomes of interest (e.g., reduction of preventable ADEs, polypharmacy, or PIMs, and other relevant outcomes). Key Words: patient safety, adverse drug events, deprescribing, STOPP criteria, older adults, patient harm.	Inclusion Criteria: Those studies were included which · were published in English, · explicitly focused on deprescribing, polypharmacy, use of STOPP and related interventions, and targeted to older adults, and · examine the effectiveness of these interventions on PIMs and preventable ADEs. Exclusion Criteria: Those studies were excluded which · were out of scope of studies, · focused on pediatric and children care, · were not intervention studies (e.g., epidemiology studies and commentaries), and · did not have the outcome reported.	Data extraction was conducted through CINAHL and Medline. Data analysis was completed using a PRISMA flow diagram of selected literature, and an evidence table was also constructed for systematic reviews and single studies.	The finding of the study revealed that deprescribing interventions and interventions using the STOPP criteria seem effective in reducing polypharmacy and PIMs in older adults, respectively.	A recommendation was made for future research of systematic review and meta-analysis on the effectiveness of approaches of clinical outcome and comparisons of the efficacy of different multicomponent interventions of STOPP and how to implement them to improve the use effectively, and evidence-based care is needed.	II/A
Storms, H., Marquet, K., Aertgeerts, B., &Claes, N. (2017).Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review. European Journal of General Practice, 23(1), 69–77. https://doi.org/10.1080/13814788.2017.1288211	No PICOT question was provided in this study.	Electronic databases (MEDLINE, EMBASE) were searched for literature from 2004 to 2016 to identify studies examining inappropriate medication use in residential long-term care facilities for the elderly. Addition research studies of interest were also searched in the reference list of included articles. Key Words: ‘medication errors’ and ‘adverse drug event’ in the setting ‘nursing home’ were also included in the search strategy	Inclusion Criteria: Research articles and conference papers written in English, Dutch, French, and German; relying on a minimum of one of seven instruments frequently used to assess inappropriate medication use (Beers criteria, STOPP, START, PRISCUS list, ACOVE, BEDNURS and MAI were included. Exclusion Criteria: · Irrelevant study topic · Sample size <100 · Different instrument used. · Different setting · Full text not available.	Two researchers (HS, KM) independently extracted data using a pre-defined extraction form (Microsoft Excel). Data analysis was completed using a PRISMA flow diagram of the study selection process, and a descriptive data table was also constructed to show the characteristics of studies included.	The study finding revealed that inappropriate medication use in residential long-term care facilities was determined using the Beers criteria of 2003 and STOPP criteria. The study also showed that the prevalence of inappropriate medication use varied among the studies, although the research study designs and assessments with identical instruments were similar.	Recommendation: The study finding recommended that it is essential to monitor inappropriate mediation use despite varying quality; numerous studies assessed inappropriate mediation use. Implication: Futures policies to promote medication review protocols and make them as a standard of care in the long-term care facilities.	I/B
Thillainadesan, J., Gnjidic, D., Green, S., Hilmer, S.N. (2018).Impact of deprescribing interventions in older hospitalized patients on prescribing and clinical outcomes: A systematic review of randomised trials. Drugs Aging,35(4), 303–319.doi: 10.1007/s40266-018-0536-4. PMID: 29541966.	No PICOT question was provided in this study.	Database Search: Ovid MEDLINE, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL The search for RCTs was conducted from 1 January 1996 to April 2017. Key Words: OldOR elder OR geriatric* OR gerontology HospitalOR inpatient OR admitted OR admission* OR separation* Inappropriate Prescribing/OR Deprescriptions/ OR Polypharmacy/ OR deprescri* PR “STOPP” .mp. OR Potentially Inappropriate Mediation List OR “Beers Criteria”.	Eligibility Criteria: · RCTs reporting on deprescribing interventions to reduce PIMs in older hospitalized adults. · Outcome of reduction of PIMs through measurements such as STOPP criteria, Drug Burden Index (DBI), Medication Appropriateness Index (MAI), and updated Beers list. · Only RCTs published in English between 1 January 1996 and April 2017. · Participants aged 65 years and above · Implementation of interventions in the hospital settings. Exclusion Criteria: · Non-English studies · Uncontrolled studies · Non-RCT studies · Studies not having a hospital setting.	Two researchers (JT, SG) independently screened potential studies for inclusion. The primary investigator (JT) used the pre-agreed data extraction form to extract the data. The original authors were contacted if the data needed were missing or were unclear. The data was then summarized into a PRISMA flow diagram and descriptive data table.	The study outcome suggested that deprescribing interventions in the hospital is feasible, safe, and generally effective in reducing PIMs. However, the current evidence is limited, of low quality, and the impact on clinical outcomes is unclear. Future studies are recommended.	The studies imply that deprescribing is achievable and effective in reducing PIMs. Future studies should be conducted and powered to assess clinically relevant outcomes, including functional status, falls, rehospitalization and mortality. Implementation studies should also explore translating of research findings into standard routine care.	I/A
Thomas, R. E., & Thomas, B. C. (2019).A systematic review of studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years. Curr Aging Sci.,12(2), 121–154. doi: 10.2174/1874609812666190516093742. PMID: 31096900.	No PICOT question was provided in this study.	Database Search: The search conducted from 2 January 2019 in Medline, Embase, and PubMed identified 562 studies of which 62 were retained for review. The data were abstracted independently. Kew Words: Potentially inappropriate prescriptions, potential prescribing omission, inappropriate prescribing, polypharmacy medication errors, STOPP/START criteria, American Geriatrics Society Beers 2015 criteria, systematic review.	Exclusion Criteria: Previous versions of STOPP/START or Beers criteria	The titles and abstracts were read independently, and two reviewers then abstracted the data. The data was then summarized into a PRISMA flow diagram and descriptive data table.	The result of the studies showed higher rate of PIP/PIM/PPO in community and hospitalized patients. The recommendation from the research was to have RCTs for intervention to reduce existing PIP/PIM/PPO prescription and prescriptions causing adverse effects and enable regulatory authorities to monitor and reduce inappropriate prescriptions in real time. Also, the need to determine whether the substantial difference in both criteria is due to the difference in medication availability between countries or data availability to assess the criteria	The research identified high PIMs, PIP, and PPO rates in the community and hospitalized patients. Future RCTs for intervention are recommended to reduce new/existing PIPs/PIMs/PPO prescriptions and reduce adverse drug effects.	I/A

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Abstract
Background: Polypharmacy is a complex issue among the elderly population due to multiple morbidities that necessitate the regular use of five or more medications, thereby leading to adverse drug effects (ADEs) in long-term care and subacute settings.
Objective: The aims of the integrative review is to assess the effectiveness of STOPP/START criteria in reducing polypharmacy and the impact of ADEs in the elderly.
Methods: Database (EMBASE and PubMed) were searched for literature published from 2017 through August 2022 to identify studies examining the STOPP/START criteria in the elderly populations. Studies eligible included older adults ages 65 years and older, using interventions to reduce polypharmacy and input ADEs and the STOPP/START criteria.
Results: Fifteen out of six-nine studies were identified, met inclusion criteria. The number of participants in the studies reviewed ranged from130 to 16,687 participants. Researchers assessed inappropriate medication utilization in five studies by comparing Beers criteria, MAI, GheOp3, and other interventions with the STOPP/START criteria. The STOPP/START criteria were used in eight studies. One study used the STOPP criteria to create a computer alert system-based (CAS-based) as their intervention, and another study used the STOPPfrail to assess inappropriate medication utilization. The studies reviewed also used protocols, CDS tools, educational intervention, and medication reviews conducted either by pharmacists, providers, or a combination of both.
Conclusions: The findings of the review suggest that the intervention STOPP/START criteria targeted at the elderly either in the nursing homes, community residential settings, or the hospital setting can decrease inappropriate medication use despite the varied quality of studies and prevalence of inappropriate medication use among studies with similar characteristics. The review also emphasizes the importance of future studies addressing preventable ADEs in old adults.

Dedication

I WILL COMPLETE MY SELF

Acknowledgments

I WILL COMPLETE MY SELF

Contents
[Insert Title here] 1
Abstract 2
Dedication 3
Acknowledgements 4
Introduction 6
Problem Statement 6
Significance of the Practice Problem 6
Theoretical Framework 7
Methodology 8
Review Protocol 8
Inclusion/Exclusion Criteria 8
Data Analysis 8
Results and Discussion 8
Characterization of the Body of Literature 8
Findings Synthesis: 9
Conclusions and Further Recommendations 9
Implications for Nursing Practice 9
Conclusions and Contributions to the Professions of Nursing 9
Recommendations 10
References 11
Appendices, Tables, and Figures 13
Appendix A 13
Appendix B 14

Polypharmacy Among Older Adults in Subacute and Long-Term Care Setting
Patients aged 65 years and older residing in subacute and long-term care (LTC) settings are among those who regularly take five or more medications (WHO, 2019). The risk for adverse drug effects (ADEs) increase considerably in the older population, leading to hospitalizations, falls, dizziness, delirium, decreased appetite, confusion, incontinence, bleeding, serious kidney injuries, electrolyte imbalance (hypokalemia, hyperkalemia), symptomatic orthostatic hypotension, constipation, diarrhea, and dyspepsia (Curtin et al., 2020).
The paper outlines the global, national and local impact of polypharmacy and its ADEs on the elderly and the financial burden on the health care systems. The purpose of the integrative review was to assess effectiveness of the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert doctors to Right Treatment (STOPP/START) tool (Gallagher et al., 2008; O’Mahony et al., 2015) in reducing polypharmacy and its effectiveness in lowering ADEs in the subacute and long-term settings.
Problem Statement
Polypharmacy is a crucial patient safety issue in the elderly population in the healthcare setting due to its strong correlation with increased risk of ADEs and drug-drug interactions (Curtin., 2020). Patient safety issues are seen significantly in the elderly, and the majority of these elderly populations reside in nursing homes and subacute settings (Curtin., 2020). Understanding polypharmacy will help providers obtain effective strategies in gaining insight into patients’ medications, prescriptions, and prevention of ADEs of polypharmacy. The proposed PICOT question served as a foundation for the integrative review paper: For patients aged 65 years and older residing in a subacute/long-term care center, does the implementation of the STOPP/START program Criteria impact adverse drug reactions compared to current practice?
Significance of the Practice Problem
Polypharmacy is defined as the routine consumption of five or more medications, including those prescribed and over-the-counter (WHO, 2019). The significant patient safety problem that polypharmacy causes among patients aged 65 and older has caused considerable concern in healthcare settings globally (WHO, 2019). The global population of such elderly individuals will double from 8% in 2010 to 16% in 2050. Moreover, polypharmacy accounts for 4%, that is, $18 billion, of the world’s avoidable costs (WHO, 2019). Additionally, the total global health care cost can be reduced to 0.3% through proper management of polypharmacy (WHO, 2019).
As per the prescription drug data analysis conducted by Khezrian et al. (2020), polypharmacy among older adults in the United States has increased from 6.3% to 10.7% between 1999â€“2000 and 2007â€“2008. Between 2007 and 2010, American adults taking five or more medications past 30 days were older, with 10.8% aged 18â€“14, 41.7% were aged 45â€“64, and 47.5% were aged 65 and older. The adults were taking five or more drugs who considered themselves as having fair or poor health accounted for 39.6% compared to those taking one to four medications, who accounted for 14.3% (CDC/NCHS, 2014). The prevalence of polypharmacy among nursing home residents in the US was also estimated to be 40% (Gohar et al., 2016).
A study conducted among Medicare beneficiaries to evaluate the association between chronic diseases, polypharmacy, and medication-related problems (MRPs) by AlmodÃ³var and Nahata (2019) showed that polypharmacy among older adults in the healthcare systems costs about $2 billion each year and Medicare beneficiaries with polypharmacy were two times more likely to experience MRPs than those who took fewer drugs. The study also revealed that diagnosis of depression was strongly associated with MRPs and other chronic diseases, such as congestive heart failure, end-stage renal disease, and respiratory conditions. Hypertension also was associated with MRPs.
Besides the concomitant impact on health outcomes and health care costs, polypharmacy predisposes elderly patients to an increased risk of ADEs due to drug-drug interactions and decreased medication metabolism rate (Curtin et al., 2020; WHO, 2019). Therefore, developing a protocol using evidence-based practice (EBP) tools, such as the STOPP/START criteria (Gallagher et al., 2008), is essential to help reduce ADEs among patients aged 65 years or more and residing in subacute and LTC settings.
Polypharmacy is, therefore, a complex issue in the elderly population due to multiple morbidities, which necessitate the regular use of five or more medications. It is also seen as a global, national issue and an economic burden as people live longer, thereby increasing the number of people needing polypharmacy. A systematic review of randomized trials conducted by Thillainadesan et al., (2018) revealed that older adults hospitalized in Australia were associated with polypharmacy and potentially inappropriate medications (PIMs), and ADEs associated with the hospitalization were falls, confusions, functional decline, increased health care cost and death. The systematic review also showed that 54.8% were 65 years old and older among hospitalized patients, and they were on one or more PIMs at admission, and 26.8% were on multiple PIMs.
People age 65 and older are at risk of taking five or more medications, leading to ADEs such as falls, hospitalization, delirium, electrolyte imbalance, and hypotension (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016). According to CDC/NCHS (2014) people, aged 65 years and older taking five or more medications were 47.5% in 2007 â€“ 2010. The DNP project practicum site population is 65 years and older. The needs assessments revealed the unavailability of screening tools in the current practicum site and insufficient knowledge/confidence in prescribers for discontinuing the medication. Providing education on using the STOPP/START tool (Gallagher et al., 2008; O’Mahony et al., 2015) will resolve this issue.
Polypharmacy among the elderly is due to comorbidities-targeted treatment. This leads to ADEs, making them less likely to get the medicine they need (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016). Prescribers are usually provided important information on a medication’s benefits, risks, and guidelines for prescribing them. However, they are not trained on how and when to start deprescribing (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016).
In subacute and LTC settings, providers are challenged by the need to manage multiple chronic medical conditions, forcing them to use clinical practice guidelines (CPGs) without considering the effects of these medications on their patients. Discontinuation of drugs prescribed by other providers (specialists) is usually tricky if the patient seems to be tolerating the mediation well. Appropriate prescription of medication is essential for the population in this age group. A prescriber must know the effects of aging on physiology and pharmacokinetics and have sufficient knowledge of pharmacology to assess the risk and benefits of the prescribed medication. A prescriber should also be willing to spend time listening to the concerns of the patients, caregivers, and family members regarding the prescribed medications (Hill-Taylor et al., 2016).
To effectively disassociate ADEs from polypharmacy, there must be a systematic approach for detecting and eliminating inappropriate medications. This can be achieved by using screening tools such as the STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015), which have shown good inter-rater reliability between physicians and pharmacists. These screening tools have brought about demonstrable improvement in the quality of prescribing and reduction in polypharmacy, falls, episodes of delirium, length of hospital stay, and medical expenses (Curtin et al., 2020; Foley et al., 2020; Hill-Taylor et al., 2016; O’Connor et al., 2016).
There is an increased risk of medical conditions as people age, which results in multiple medications, leading to ADEs such as falls, hospitalization, delirium, electrolyte imbalance, hypotension, etc. The STOPP/START criteria can assist in achieving the goal of reducing polypharmacy and ADEs (Gallagher et al., 2008; O’Mahony et al., 2015).
The STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015) inform prescribers when and how to stop the medication for elderly patients. The findings of Curtin et al. (2020), Foley et al. (2020), Hill-Taylor et al. (2016), and O’Connor et al. (2016) reveal that following the STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015) reduces the number of regular medications taken by elderly patients living in Nursing Home setting. These criteria can also help reduce falls, delirium episodes, length of hospital stay, care visits, and medication costs. Overall, the study demonstrates that the STOPP/START criteria (Gallagher et al., 2008; O’Mahony et al., 2015) can improve outcomes regarding the discontinuation of medications.
Translation Science Framework
Translation science framework must always save as a foundation for practice. All these concepts and Promoting Action on Research Implementation Health Services (PARIHS) model were analyzed, explored, and was related to practice change in implementation and dissemination.
The Promoting Action on Research Implementation Health Services (PARIHS) model served as the conceptual framework for the Doctor of Nursing Practice (DNP) project. The PARIHS model helps examine the implementation of evidence-based practice (EBP) interventions in a healthcare setting. Kitson and colleagues developed this framework (Kitson et al., 1998, Rycroft-Malone et al., 2002; 2004; 2008). The PARIHS model aims to assist in developing a program to implement an intervention that can effectively make EBP-related changes (Kitson et al., 1998; Rycroft-Malone et al., 2002; 2004; 2008). The framework was used to implement the Screening Tool of Older Person’s Prescriptions and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) (Gallagher et al., 2008; O’Mahony et al., 2015). The PARIHS framework consists of three elements, namely, evidence, context, and facilitation, related to the successful implementation.
The successful implementation of an EBP relies on the type of evidence being used, the quality of the context, and the kind of facilitation required to enable the change process; therefore, the PARIHS framework consist of successful implementation (SI), which represent the function (F) of the three interplay core elements; the nature and type of evidence (E), the qualities of the context (C), and the introduction and the process of facilitation (F); SI = F (E, C, F) (Kitson et al., 1998; 2008, Rycroft-Malone et al., 2004).
Methodology
Review Protocol
The purpose of this literature search was to find research related to the utilization of STOPP/START criteria intervention and its impact on reducing adverse drug effects (ADEs) among the older adults residing in a subacute and long-term care setting.
A systematic literature search was conducted on electronic databases of EMBASE and PubMed and using the keywords “Nursing home residents, Older adults STOPP/START Criteria,” “Older adults STOPP/START Criteria, Randomized Controlled Trials”; “Potentially Prescribing Omissions, Clinical Decision Support Systems”; “Patient Safety, Adverse Drug Effects, STOPP/START criteria.” The limitations used to obtain relevant articles related to the intervention were the articles published from 2017 through August 2022, articles published in the English language, the age of patients being 65 years and above, and screening of article titles. The initial search led to 69 articles. The articles were reduced to 10 after applying the inclusion and exclusion criteria. Five additional relevant articles were manually searched upon reviewing the articles retrieved from the database search. The articles included in this literature synthesis are as follows; four systematic review studies, five randomized controlled trials, one qualitative study, one longitudinal study, one comparison of RCTs study, three retrospective studies
The common theme identified in the selected studies is that STOPP/START criteria are a practical approach for addressing polypharmacy in adults and preventing adverse drug events.
Inclusion/Exclusion Criteria
The DNP student screened abstracts and full texts of literature that correspond with the inclusion criteria. Research articles included primary research written in English from 2017 up to 2022. Interventions that targeted the older adult population with age mean of 65 years and older were implemented in the nursing home setting, community-dwelling for the elderly, and hospital settings.
Intervention that was implemented in studies that aimed at reduction of PIPs, PPO, PIMs including electronic deprescribing intervention, clinical decision support systems, use of STOPP/START criteria, comparison of STOPP/START criteria, and other intervention such as Beers criteria, MAI, and GheOp3, pharmacist and physician-led interventions and the comparison of intervention and usual care. Studies that had primary outcomes measures of reducing PIPs, PPOs, PIMs, and secondary outcome measures that evaluated falls, cognitive functions, ADEs, quality of life, mortality, and hospitalization were included. Studies that did not meet the inclusion criteria were excluded.
Data Analysis
The DNP student extracted the data using the PICOT question. Research with incomplete data was excluded from the analysis to prevent the risk of bias. Studies with multiple sites, only data with residential long-term care facilities for older adults were included. Studies comparing intervention groups to control groups and comparing instruments were also analyzed.
Additionally, data examined were country, descriptive data, publication year, type of study, setting, population characteristics, type of intervention and control group, the impact of the intervention on PIPs, PPOs, and PIMs. Meta-analysis could not be done due to the heterogeneity in data resulting from different designs and lengths of studies. A Johns Hopkins Evidence-Base Table for SR and other studies was completed. A qualitative method was used to organized the data.
Results and Discussion
Characterization of the Body of Literature
Fifteen out of six-nine studies were identified, met inclusion criteria. The inclusion and exclusion criteria section describes the main reasons for excluding studies. Most of the studies included were conducted in Europe. Researchers assessed inappropriate medication utilization in five studies by comparing Beers criteria, MAI, GheOp3, and other interventions with the STOPP/START criteria. The STOPP/START criteria were used in eight studies. One study used the STOPP criteria to create a computer alert system-based (CAS-based) as their intervention, and another study used the STOPPfrail to assess inappropriate medication utilization. The studies reviewed also used protocols, CDS tools, educational intervention, and medication reviews conducted either by pharmacists, providers, or a combination of both.
The number of participants in the studies reviewed ranged from130 to 16,687 participants. Eligibility criteria for participants were mainly dependent on meeting the age requirement of being 65 years and older. Additionally, the exclusion criteria of the studies reviewed excluded participants under palliative care who died, transferred, or had incomplete data. However, one study conducted by Curtin et al., (2020) looked at polypharmacy at end-of-life. Furthermore, all studies reviewed collected data on inappropriate medication use through medical records, medication administration charts, and databases.
The research reviewed were four systematic review studies, five randomized controlled trials, one qualitative study, one longitudinal study, one comparison of RCTs study, and three retrospective studies. The Johns Hopkins Evidence-Base Practice Research Appraisal Tool and Evidence Level of Quality Guided was utilized to review the appraisal and rate the quality of the studies.
The studies reviewed reveal that the use of STOPP/START criteria can reduce inappropriate medication use and impact the reduction of ADEs. However, the studies had strengths and limitations. The study’s limitations consisted of the inclusion of different types of study design generated heterogeneous data; therefore, a meta-analysis could not be performed, study periods, the variation of inappropriate medication use expressed in the studies, and some studies searching in only two databases. The other limitation included the geographical origin of the instruments based in Europe and the USA. Some studies lacked information on missing data, such as the loss of participants and the variation of the setting of the studies.
The studies’ strengths include the specific search of studies using STOPP/START criteria, the general search of studies and systematic reviews of inappropriate prescribing, inappropriate medication use, and the inclusion of different type study designs.
The consistency of age limitation of 65 years and older across the studies and the ability of the studies compute the weighted average of PIPs, PIMs, and PPOs rate for community and hospitalized patients. The consistency of the definition of polypharmacy and appropriate use of medication across studies. Other studies’ strengths were the comparisons of RCTs and physicians and pharmacist-led studies using interventions.
The evaluation and outcome of the integrative review contribute to the effectiveness of intervention of STOPP/START criteria to address preventable ADEs in the elderly. The review of included studies was often found to significantly reduce polypharmacy and impact ADEs. The review of medication involving both physicians and pharmacists also effectively decrease medication utilization in two studies. The STOPP/START criteria were used to identify PIPs, PPOs, and PIMs. There was a significant decrease in PIP, PPOs, and PIMs when STOPP/START criteria were used regardless of how and who applied the intervention.

Findings Synthesis
Polypharmacy among the elderly is one of the problems arising from comorbidity-targeted treatment. Several authors found that polypharmacy leads to adverse drug events (ADEs) and the prescription of inappropriate medications (PIM), making the elderly less likely to obtain the medicine they require (Blum et al., 2021, Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020). Blum et al., (2021). Boersma et al.’s (2019) and Cossette et al.’s (2017) completed randomized control trials that combined clinical decision systems, the Systematic Tool to Reduce Inappropriate Prescribing (STRIP) assistance, and the Computerized Alert System (CAS) based on the STOPP/START criteria. Curtin et al., (2020) completed an unblinded, randomized, pragmatic clinical trial (2020); Parker et al., (2019) conducted a randomized control study utilizing only the STOPP/START criteria for their interventions. The findings of the studies showed that screening tools such as the STOPP/START criteria had been proven to deliver good inter-rater reliability among both physicians and pharmacists, and their impact on the reduction of polypharmacy and ADEs were also revealed (Blum et al., 2021; Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019). The findings also showed that using STOPP/START criteria alone or inclusion of the STOPP/START criteria in the clinical decision support system could assist prescribers and facilitate appropriate prescription. The appropriate prescription would, in turn, reduce the medication patients are taking, thus mitigating the adverse drug effects (ADEs) (Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019).
Polypharmacy, PIPs, PPOs, and PIMs, continue to be prevalent in the elderly. The four systematic reviewed conducted by Earl et al., (2020); Thomas et al., (2019); Storms et al., (2017); and Thillainadesa et al., (2018) assessed the use of STOPP/START criteria to identify the prevalence of inappropriate medication use and to reduce PIMs, PIPs, PPOs in older adult age 65 years older and also residing in the long-term care facilities. These studies’ findings showed the impact of STOPP/START intervention in identifying and reducing PPOs, PIPs, and PIMs, which intend to decrease the effect of ADEs.
The most crucial issues with seniors are the exposures to PIPs, PPOs, PIMs, which exposures them to risk for moderate, severe, or fatal ADEs (Thomas et al., 2020); these issues prompt Thomas et al., (2020), Dalton et al., (2020), and Stojanovic et al., (2019) to conduct a retrospective to compare the STOPP/START criteria with other interventions to evaluate its effectiveness. These studies showed that all the interventions could identify PIPs and PPOs. However, some tools, such as the Ghent Older People’s Prescriptions Community Pharmacy Screening Tool (GheOp3), detected significantly more PIPs than the STOPP/START criteria. In contrast, the START criteria performed better in screening for PPOs. Although some of the tools performed better than the STOPP/START tool, the most important outcome of the studies is the identification of PIPs, PPOs, and the reduction of PIPs, PPOs and effects of this outcome to reduction of ADEs.
PIPs, PPOs, PIMs, continue to be a significant potential healthcare problem in the multimorbid older adults, and finding the medium of communication among providers, pharmacists, and nursing staff with conjunction use of the STOPP/START tool assist in improving the outcome of the reducing polypharmacy and impacting ADEs (Dalton et al., 2019). These three studies, a comparison study of RCTs by Dalton et al., (2019), a longitudinal study conducted by Damoiseaux-Volman et al., (2020), and a qualitative study by Foley et al., (2020), revealed the essential of using the intervention such as STOPP/START tool for the reduction of PPOs, PIPs, PIMs the impact of ADEs when PIPs, PPO, PIMs are identified. Dalton et al., (2019), Damoiseaux-Volman et al., (2020), and Foley et al., (2020) reveal that method of communication among prescribers, pharmacists, and nursing staff in conjunction use of STOPP/START tool affect’s the implementation of tools and also use of the tools improve significantly overtime by prescribers when implemented.
Conclusions and Further Recommendations
Implications for Nursing Practice
Polypharmacy among the elderly is one of the problems arising from comorbidity-targeted treatment. Several authors found that polypharmacy leads to adverse drug events (ADEs) and the prescription of inappropriate medications (PIM), making the elderly less likely to obtain the medicine they require (Blum et al., 2021, Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020). Blum et al., (2021). Boersma et al.’s (2019) and Cossette et al.’s (2017) completed randomized control trials that combined clinical decision systems, the Systematic Tool to Reduce Inappropriate Prescribing (STRIP) assistance, and the Computerized Alert System (CAS) based on the STOPP/START criteria. Curtin et al., (2020) completed an unblinded, randomized, pragmatic clinical trial (2020); Parker et al., (2019) conducted a randomized control study utilizing only the STOPP/START criteria for their interventions. The findings of the studies showed that screening tools such as the STOPP/START criteria had been proven to deliver good inter-rater reliability among both physicians and pharmacists, and their impact on the reduction of polypharmacy and ADEs were also revealed (Blum et al., 2021; Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019). The findings also showed that using STOPP/START criteria alone or inclusion of the STOPP/START criteria in the clinical decision support system could assist prescribers and facilitate appropriate prescription. The appropriate prescription would, in turn, reduce the medication patients are taking, thus mitigating the adverse drug effects (ADEs) (Boersma et al., 2019; Cossette et al., 2017; Curtin et al., 2020; Parker et al., 2019).
Polypharmacy, PIPs, PPOs, and PIMs, continue to be prevalent in the elderly. The four systematic reviewed conducted by Earl et al., (2020); Thomas et al., (2019); Storms et al., (2017); and Thillainadesa et al., (2018) assessed the use of STOPP/START criteria to identify the prevalence of inappropriate medication use and to reduce PIMs, PIPs, PPOs in older adult age 65 years older and also residing in the long-term care facilities. These studies’ findings showed the impact of STOPP/START intervention in identifying and reducing PPOs, PIPs, and PIMs, which intend to decrease the effect of ADEs.
The most crucial issues with seniors are the exposures to PIPs, PPOs, PIMs, which exposures them to risk for moderate, severe, or fatal ADEs (Thomas et al., 2020); these issues prompt Thomas et al., (2020), Dalton et al., (2020), and Stojanovic et al., (2019) to conduct a retrospective to compare the STOPP/START criteria with other interventions to evaluate its effectiveness. These studies showed that all the interventions could identify PIPs and PPOs. However, some tools, such as the Ghent Older People’s Prescriptions Community Pharmacy Screening Tool (GheOp3), detected significantly more PIPs than the STOPP/START criteria. In contrast, the START criteria performed better in screening for PPOs. Although some of the tools performed better than the STOPP/START tool, the most important outcome of the studies is the identification of PIPs, PPOs, and the reduction of PIPs, PPOs and effects of this outcome to reduction of ADEs.
PIPs, PPOs, PIMs, continue to be a significant potential healthcare problem in the multimorbid older adults, and finding the medium of communication among providers, pharmacists, and nursing staff with conjunction use of the STOPP/START tool assist in improving the outcome of the reducing polypharmacy and impacting ADEs (Dalton et al., 2019). These three studies, a comparison study of RCTs by Dalton et al., (2019), a longitudinal study conducted by Damoiseaux-Volman et al., (2020), and a qualitative study by Foley et al., (2020), revealed the essential of using the intervention such as STOPP/START tool for the reduction of PPOs, PIPs, PIMs the impact of ADEs when PIPs, PPO, PIMs are identified. Dalton et al., (2019), Damoiseaux-Volman et al., (2020), and Foley et al., (2020) reveal that method of communication among prescribers, pharmacists, and nursing staff in conjunction use of STOPP/START tool affect’s the implementation of tools and also use of the tools improve significantly overtime by prescribers when implemented.
Conclusions and Contributions to the Professions of Nursing

Polypharmacy is a significant issue among long-term care and subacute settings, impacting providers’ quality of care in these settings. Polypharmacy is also strongly associated with adverse outcomes such as ADEs, confusion, falls, death, and hospitalization (Thillainadesan et al., 2018)
The findings of this review suggest that the intervention STOPP/START criteria targeted at the elderly either in the nursing homes, community residential settings, or the hospital setting can decrease PIMs, PPOs, and PIPs (Earl et al., 2020; Storms et al., 2017; Thillainadesan et al., 2018, Thomas et al., 2019).
Although the studies reviewed showed a reduction of inappropriate medication use, the findings of the studies cannot be generalized due to heterogeneity of data, varied samples sizes, and varied prevalence of inappropriate medication use among studies with similar characteristics. Despite the different quality of studies, the studies thus show the importance of medication review and use of interventions such as STOPP/START criteria in identifying inappropriate medication use in older adults. The review also points out the importance of future studies addressing preventable ADEs in old adults.
Recommendations
It is essential to have accurate medication reviews in the old adults with polypharmacy, which will impact or prevent ADEs in the elderly. The STOPP/START criteria and education of the tool should be provided to all providers in the long-term care and subacute settings. NP, nursing staff, and center leadership input should be obtained for future quality improvement projects.
Future policies should promote a systematical inclusion or make the intervention standard practice in the long-term care and subacute facilities.
When guidelines are used frequently, the uses of the tools will become more accustomed to the tools and use these measurements as quality indicators and to benchmark. The criteria should also be incorporated in the electronic health record (EHR) in the setting, if possible, to improve adherence and convenience.

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Polypharmacy Among Older Adults in Subacute and Long-Term Care Setting Essay