Drugs & Aging

, Volume 29, Issue 10, pp 829–837 | Cite as

Inappropriate Prescribing and Related Hospital Admissions in Frail Older Persons According to the STOPP and START Criteria

  • Olivia DalleurEmail author
  • Anne Spinewine
  • Séverine Henrard
  • Claire Losseau
  • Niko Speybroeck
  • Benoit Boland
Original Research Article



Over the last few years, the Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria have been increasingly used to evaluate the prevalence of inappropriate prescribing. However, very few studies have evaluated the link between these criteria and clinical outcomes.


The objectives of this study were to evaluate the prevalence of inappropriate prescribing according to STOPP and START in a population of frail elderly persons admitted acutely to hospital; to evaluate whether these inappropriate prescribing events contributed to hospital admissions; and to identify determinants of hospital admissions potentially related to inappropriate prescribing.


This was a cross-sectional study including all frail older patients admitted to a 975-bed teaching hospital over a 12-month period. A pharmacist and a geriatrician independently detected events of prescribing of potentially inappropriate medication (PIM) and potential prescribing omission (PPO), using the STOPP and START criteria, respectively, in all patients included in the study. They determined whether the inappropriate prescribing event was the main cause or a contributory cause of hospital admission. Demographic, clinical and geriatric clinical syndromes (i.e. cognitive impairment, falls) were evaluated as potential determinants of hospital admissions related to inappropriate prescribing, using multivariate methods (i.e. logistic regression and a classification tree).


302 frail older persons (median age 84 years) were included in the study. PIMs (prevalence 48 %) mainly involved overuse and/or misuse of benzodiazepines, aspirin and opiates. PPOs (prevalence 63 %) were mainly related to underuse of calcium and vitamin D supplementation, aspirin and statins. Overall, inappropriate prescribing according to STOPP (54 PIMs) and/or START (38 PPOs) led or contributed to hospital admission in 82 persons (27 %). The multivariate analyses indicated a relation between PIM-related admissions and a history of previous falls (p < 0.001), while the PPO-related admissions were associated with a history of osteoporotic fracture (p < 0.001) and atrial fibrillation (p = 0.004).


Using the STOPP and START criteria, it was found that inappropriate prescribing events (both PIMs and PPOs) were frequent and were associated with a substantial number of acute hospital admissions in frail older persons. Fall-induced osteoporotic fracture was the most important cause of hospital admission related to inappropriate prescribing and should be a priority for pharmacological optimization approaches.


Atrial Fibrillation Hospital Admission Osteoporotic Fracture Comprehensive Geriatric Assessment Inappropriate Prescribe 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



O. Dalleur was funded by the Federal Public Service Health of the Belgian government as part of a national project on implementation of clinical pharmacy in hospitals. The authors have no conflicts of interest that are directly relevant to the content of this article. The investigators thank Coralie Deliens and Christelle Vercheval for their valuable contribution to the data collection; Dominique Wouters, chief pharmacist, for her support and for facilitating the conduct of this study; and Ana Bastos for her advice.

Supplementary material

40266_2012_16_MOESM1_ESM.pdf (212 kb)
Supplementary material 1 (PDF 211 kb)


  1. 1.
    Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12.PubMedCrossRefGoogle Scholar
  2. 2.
    Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045–51.PubMedCrossRefGoogle Scholar
  3. 3.
    Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991;151(9):1825–32.PubMedCrossRefGoogle Scholar
  4. 4.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med. 1997;157(14):1531–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.PubMedCrossRefGoogle Scholar
  6. 6.
    Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.PubMedGoogle Scholar
  8. 8.
    Ryan C, O’Mahony D, Kennedy J, et al. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68(6):936–47.PubMedCrossRefGoogle Scholar
  9. 9.
    Cahir C, Fahey T, Teeling M, et al. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol. 2010;69(5):543–52.PubMedCrossRefGoogle Scholar
  10. 10.
    Pyszka LL, Seys Ranola TM, Milhans SM. Identification of inappropriate prescribing in geriatrics at a Veterans Affairs hospital using STOPP/START screening tools. Consult Pharm. 2010;25(6):365–73.PubMedCrossRefGoogle Scholar
  11. 11.
    Fernandez-Regueiro R, Fonseca-Aizpuru E, Lopez-Colina G, et al. Inappropriate drug prescription and adverse drug effects in elderly patients. Rev Clin Esp. 2011;211(8):400–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845–54.PubMedCrossRefGoogle Scholar
  13. 13.
    Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37(6):673–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Hamilton H, Gallagher P, Ryan C, et al. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Baeyens JP. Belgian care programme for older patients. J Nutr Health Aging. 2010;14(6):474–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Deschodt M, Flamaing J, Rock G, et al. Implementation of inpatient geriatric consultation teams and geriatric resource nurses in acute hospitals: a national survey study. Int J Nurs Stud. 2012;49(7):842–9.PubMedCrossRefGoogle Scholar
  17. 17.
    McCusker J, Bellavance F, Cardin S, et al. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999;47(10):1229–37.PubMedGoogle Scholar
  18. 18.
    Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–98.PubMedCrossRefGoogle Scholar
  20. 20.
    Speybroeck N, Berkvens D, Mfoukou-Ntsakala A, et al. Classification trees versus multinomial models in the analysis of urban farming systems in Central Africa. Agric Syst. 2004;80(2):133–49.CrossRefGoogle Scholar
  21. 21.
    Speybroeck N. Classification and regression trees. Int J Public Health. 2012;57(1):243–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Saegerman C, Speybroeck N, Roels S, et al. Decision support tools for clinical diagnosis of disease in cows with suspected bovine spongiform encephalopathy. J Clin Microbiol. 2004;42(1):172–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Gallagher P, Lang PO, Cherubini A, et al. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol. 2011;67(11):1175–88.PubMedCrossRefGoogle Scholar
  24. 24.
    Lang PO, Hasso Y, Drame M, et al. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age Ageing. 2010;39(3):373–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Barry PJ, Gallagher P, Ryan C, et al. START (Screening Tool to Alert doctors to the Right Treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36(6):632–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516–23.PubMedCrossRefGoogle Scholar
  27. 27.
    Cumming RG. Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging. 1998;12(1):43–53.PubMedCrossRefGoogle Scholar
  28. 28.
    Soriano TA, DeCherrie LV, Thomas DC. Falls in the community-dwelling older adult: a review for primary-care providers. Clin Interv Aging. 2007;2(4):545–54.PubMedGoogle Scholar
  29. 29.
    van der Velde N, Stricker BH, Pols HA, et al. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol. 2007;63(2):232–7.PubMedCrossRefGoogle Scholar
  30. 30.
    van der Velde N, Meerding WJ, Looman CW, et al. Cost effectiveness of withdrawal of fall-risk-increasing drugs in geriatric outpatients. Drugs Aging. 2008;25(6):521–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Iyer S, Naganathan V, McLachlan AJ, et al. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging. 2008;25(12):1021–31.PubMedCrossRefGoogle Scholar
  32. 32.
    Berger JS, Brown DL, Becker RC. Low-dose aspirin in patients with stable cardiovascular disease: a meta-analysis. Am J Med. 2008;121(1):43–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med. 1996;124(3):292–8.PubMedCrossRefGoogle Scholar
  34. 34.
    De Breucker S, Herzog G, Pepersack T. Could geriatric characteristics explain the under-prescription of anticoagulation therapy for older patients admitted with atrial fibrillation? A retrospective observational study. Drugs Aging. 2010;27(10):807–13.PubMedCrossRefGoogle Scholar
  35. 35.
    Brophy MT, Snyder KE, Gaehde S, et al. Anticoagulant use for atrial fibrillation in the elderly. J Am Geriatr Soc. 2004;52(7):1151–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Ogilvie IM, Newton N, Welner SA, et al. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med. 2010;123 (7):638–45.e4.Google Scholar
  37. 37.
    Mendelson G, Aronow WS. Underutilization of warfarin in older persons with chronic nonvalvular atrial fibrillation at high risk for developing stroke. J Am Geriatr Soc. 1998;46(11):1423–4.PubMedGoogle Scholar
  38. 38.
    Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “there’s got to be a happy medium”. JAMA. 2010;304(14):1592–601.PubMedCrossRefGoogle Scholar
  39. 39.
    Steinman MA. Polypharmacy and the balance of medication benefits and risks. Am J Geriatr Pharmacother. 2007;5(4):314–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49(2):200–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2012

Authors and Affiliations

  • Olivia Dalleur
    • 1
    • 2
    Email author
  • Anne Spinewine
    • 2
    • 3
  • Séverine Henrard
    • 4
  • Claire Losseau
    • 5
  • Niko Speybroeck
    • 4
  • Benoit Boland
    • 4
    • 5
  1. 1.Pharmacy DepartmentCliniques universitaires Saint-Luc, Université catholique de LouvainBrusselsBelgium
  2. 2.Louvain Drug Research InstituteUniversité catholique de LouvainBrusselsBelgium
  3. 3.Pharmacy DepartmentCHU Mont-Godinne, Université catholique de LouvainYvoirBelgium
  4. 4.Institute of Health and Society (IRSS)Université catholique de LouvainBrusselsBelgium
  5. 5.Geriatric Medicine, Cliniques universitaires Saint-LucUniversité catholique de LouvainBrusselsBelgium

Personalised recommendations