Suboptimal drugs therapy is a threat to older people, and listing tools providing guidance are developed to address this problem.
A systematic review was performed to identify and analyze such tools published until February 2018. A novel categorization was developed to separate patient-in-focus listing approaches (PILA) providing disease-related positive and negative guidance from drug-oriented, mostly negative listing approaches (DOLA, DOLA+: with disease specification).
In total, 76 tools were identified; only 9 were classified as PILA, 26 as DOLA, and 38 as DOLA+. Three DOLA(+) only address dementia. Most tools were developed in Europe or the USA and address community-dwellers. Thirty-two utilized a Delphi process, and only 10 provide a scoring system. Twenty tools utilize a questionnaire but no structured guidance or answers. Importantly, only 12 interventional clinical trials were identified reporting not only medication quality measures, but also clinical endpoints (e.g. falls, adverse drug reactions, hospitalization). For PILA, 4 trials showed positive, one negative clinical effects of a controlled intervention, for DOLA(+) 1 was positive, 7 negative (Fisher’s exact test p < 0.05).
An abundance of listing tools has been created. DOLAs that may be applied without intricate patient knowledge prevail over PILAs by sevenfold; unfortunately their clinical validation seems to be far less successful than that of patient-initiated approaches.
Drug therapy in older people has to be tailored to their individual, very divergent needs; tools requiring detailed medical knowledge about the patient as the starting point for medication optimization provide the best support.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
World Population Ageing (2017) United Nations, New York. Available at: http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf. Accessed July 18, 2018
Maher RL, Hanlon J, Hajjar ER (2014) Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 13:57–65
Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380:37–43
Mc Namara KP, Breken BD, Alzubaidi HAT, Bell JS, Dunbar JA, Walker C, Hernan A (2017) Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age Ageing 46:291–299
Molokhia M, Majeed A (2017) Current and future perspectives on the management of polypharmacy. BMC Fam Pract 18:70
Hamilton HJ, Gallagher PF, O'Mahony D (2009) Inappropriate prescribing and adverse drug events in older people. BMC Geriatr 9:5
Wauters M, Elseviers M, Vaes B, Degryse J, Dalleur O, Vander Stichele R, Christiaens T, Azermai M (2016) Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community-dwelling oldest old. Br J Clin Pharmacol 82:1382–1392
Cadogan CA, Ryan C, Hughes CM (2016) Appropriate polypharmacy and medicine safety: when many is not too many. Drug Saf 39:109–116
Morley JE (2014) Inappropriate drug prescribing and polypharmacy are major causes of poor outcomes in long-term care. J Am Med Dir Assoc 15:780–782
Leelakanok N, Holcombe AL, Lund BC, Gu X, Schweizer ML (2017) Association between polypharmacy and death: a systematic review and meta-analysis. J Am Pharm Assoc 57:729–738
Wehling M (2013) Drug therapy for the elderly. Springer, Vienna
Wehling M (2011) Guideline-driven polypharmacy in elderly, multimorbid patients is basically flawed: there are almost no guidelines for these patients. J Am Geriatr Soc 59:376–377
Irving G, Neves AL, Dambha-Miller H et al (2017) International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 7:e017902
American Geriatrics Society (2012) Beers Criteria Update Expert Panel (2012) American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 60:616–631
Gallagher P, Ryan C, Byrne S, Kennedy J, O Mahony D (2008) 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 46:72–83
Wehling M (2008) Drug therapy in the elderly: too much or too little, what to do? A new assessment system: fit for the aged FORTA. Dtsch Med Wochenschr 133:2289–2291
Wehling M (2009) Multimorbidity and polypharmacy: how to reduce the harmful drug load and yet add needed drugs in the elderly? Proposal of a new drug classification: fit for the aged. J Am Geriatr Soc 57:560–561
Kuhn-Thiel AM, Weiss C, Wehling M et al (2014) Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly. Drugs Aging 31:131–140
https://www.mh-hannover.de/29002.html. Accessed 01 Oct 2018. https://www.uniklinik-duesseldorf.de/fileadmin/Datenpool/einrichtungen/abteilung_fuer_allgemeinmedizin_id304/dateien/Projekte/RIME_2015_08_19.pdf. Accessed 01 Oct 2018
Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, Francis SD, Branch LG, Lindblad CI, Artz M, Weinberger M, Feussner JR, Cohen HJ (2004) Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 116:394–401
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12
Lipton HL, Bero LA, Bird JA, McPhee SJ (1992) The impact of clinical pharmacists’ consultations on physicians’ geriatric drug prescribing: a randomized controlled trial. Med Care 30:646–658
Shekelle PG (2001) ACOVE quality indicators. Ann Intern Med 135:653–667
Motter FR, Fritzen JS, Hilmer SN, Paniz ÉV, Paniz VMV (2018) Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol 74:679–700
Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE (2018) Tools for assessment of the appropriateness of prescribing and association with patient-related outcomes: a systematic review. Drugs Aging 35:43–60
Wehling M, Burkhardt H, Kuhn-Thiel A, Pazan F, Throm C, Weiss C, Frohnhofen H (2016) VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification. Age Ageing 45:262–267
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44:213–218
Matthews R (2000) Storks Deliver Babies (p < 0.008). Teach Stat 22:36–38
Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte LÃ©, Tulkens PM (2007) Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc 55:658–665
Conflict of interest
M.W. was employed by AstraZeneca R&D, Mölndal, as director of discovery medicine (=translational medicine) from 2003 to 2006, while on sabbatical leave from his professorship at the University of Heidelberg. Since returning to this position in January 2007, he has received lecturing and consulting fees from Sanofi-Aventis, Bayer, Berlin-Chemie, Boehringer-Ingelheim, Aspen, Novartis, Takeda, Roche, Pfizer, Bristol-Myers, Daichii-Sankyo, Lilly, Otsuka, Novo-Nordisk, Shire, and LEO Pharma. In addition, the FORTA classification was developed by M.W.
F.P. and J.K. declare no conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Pazan, F., Kather, J. & Wehling, M. A systematic review and novel classification of listing tools to improve medication in older people. Eur J Clin Pharmacol 75, 619–625 (2019). https://doi.org/10.1007/s00228-019-02634-z
- Listing approaches
- Patient-in-focus tools
- Drug-oriented tools
- Clinical endpoints