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Potentially inappropriate prescribing in a falls clinic using the STOPP and START criteria


Background Potentially inappropriate prescribing is increasingly common in older patients with falls. However, published indicators to assess inappropriate prescribing remains unestablished in many countries. Objective This study determined the burden and profile of potentially inappropriate prescribing among patients attending a falls clinic using the STOPP/START criteria and evaluated the factors for falls potentially associated to inappropriate prescribing. Setting University of Malaya Medical Centre Falls Clinic. Method Data of individuals aged ≥ 65 years referred to the falls and syncope clinic were extracted from the falls registry. Potentially inappropriate prescribing was determined with the STOPP/START version 2 criteria. The relationship between potentially inappropriate prescribing with polypharmacy (≥ 5 medications), comorbidities and clinical variables were determined using Pearson’s chi-square and potential confounders adjusted for with multivariate regression. Main outcome measure Potentially inappropriate medicines and/or omitted medicines using STOPP/START criteria. Results Data from 421 individuals, aged 77.8 ± 6.7 years and 53.4% women, were included. Potentially inappropriate prescribing was present in 311 (73.9%). Potentially inappropriate medicines use accounted for 84.6% of the 325 prescriptions. 361/659 instances (54.8%) were falls-risk-increasing drugs, with vasodilators (49.3%) being the main potentially inappropriate medicine identified. Of the 177/421 with polypharmacy, 169/177 (95.5%) were exposed to ≥ one potentially inappropriate medicine. 129 instances of potentially omitted medicines were observed in 109 prescriptions (25.9%). Conclusion STOPP/START criteria are useful to identify potentially inappropriate prescribing at the falls and syncope clinic. This finding has important implications for medication review strategies at falls clinic. Future research should determine whether identifying potentially inappropriate prescribing may reduce adverse falls outcomes among patients in this setting.

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  1. Cheng X, Yang Y, Schwebel DC, Liu Z, Li L, Cheng P, et al. Population ageing and mortality during 1990–2017: A global decomposition analysis. PLoS Med. 2020; 1;17(6).

  2. Gao LU, Maidment I, Matthews FE, Robinson L, Brayne C. Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II. Age Ageing. 2018;47:220–5.

    Article  Google Scholar 

  3. Assiri GA, Shebl NA, Mahmoud MA, Aloudah N, Grant E, Aljadhey H, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open. 2018;8(5):e019101.

    Article  Google Scholar 

  4. Wallace E, McDowell R, Bennett K, Fahey T, Smith SM. Impact of potentially inappropriate prescribing on adverse drug events, health related quality of life and emergency hospital attendance in older people attending general practice: a prospective cohort study. J Gerontol A Biol Sci Med Sci. 2017;72(2):271–7.

    Article  Google Scholar 

  5. Alex D, Khor HM, Chin AV, Hairi NN, Othman S, Khoo SPK, et al. Cross-sectional analysis of ethnic differences in fall prevalence in urban dwellers aged 55 years and over in the Malaysian Elders Longitudinal Research study. BMJ Open. 2018;8(7):1–6.

    Article  Google Scholar 

  6. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R. Medication-related falls in the elderly: causative factors and preventive strategies. Drugs Aging. 2012;29(5):359–76.

    CAS  Article  Google Scholar 

  7. Masumoto S, Sato M, Maeno T, Ichinohe Y, Maeno T. Potentially inappropriate medications with polypharmacy increase the risk of falls in older Japanese patients: 1-year prospective cohort study. Geriatr Gerontol Int. 2018;18(7):1064–70.

    Article  Google Scholar 

  8. Hartikainen S, Lönnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007;62(10):1172–81.

    Article  Google Scholar 

  9. Berdot S, Bertrand M, Dartigues JF, Fourrier A, Tavernier B, Ritchie K, et al. Inappropriate medication use and risk of falls—a prospective study in a large community-dwelling elderly cohort. BMC Geriatr. 2009;9(1):1–10.

    Article  Google Scholar 

  10. Van Der Velde N, Stricker BHC, Pols HAP, Van Der Cammen TJM. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol. 2007;63(2):232–7.

    Article  Google Scholar 

  11. Mcmahon CG, Cahir CA, Kenny RA, Bennett K. Inappropriate prescribing in older fallers presenting to an Irish emergency department. Age Ageing. 2014;43:44–50.

    Article  Google Scholar 

  12. O’Mahony D, O’sullivan D, Byrne S, O’connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8.

    Article  Google Scholar 

  13. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: asystematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38(5):360–72.

    CAS  Article  Google Scholar 

  14. Galvin R, Moriarty F, Cousins G, Cahir C, Motterlini N, Bradley M, et al. Prevalence of potentially inappropriate prescribing and prescribing omissions in older Irish adults: findings from The Irish LongituDinal Study on Ageing study (TILDA). Eur J Clin Pharmacol. 2014;70(5):599–606.

    Article  Google Scholar 

  15. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–51.

    Article  Google Scholar 

  16. Valderas JM, Starfi B, Sibbald B. Defining comorbidity: implications for understanding health and health services. Ann Fam Med. 2009;7:357–63.

    Article  Google Scholar 

  17. Gan SY, Saedon NI, Subramaniam S, Husna Alias NF, Mohd Nasir SS, Abu Hashim NFI, et al. Syncope, dizziness and falls overlap among patients referred to a falls and syncope service at the University of Malaya Medical Centre. Int J Cardiol. 2017;249:S22.

    Article  Google Scholar 

  18. de Ruiter SC, Biesheuvel SS, van Haelst IMM, van Marum RJ, Jansen RWMM. To STOPP or to START? Potentially inappropriate prescribing in older patients with falls and syncope. Maturitas. 2020;131:65–71.

    Article  Google Scholar 

  19. Montroya JJ, Bowlesb RP, Skibbec LE, McClellandd MM. Use of fall risk-increasing drugs around a fall-related injury in older adults: a systematic review Laura. Physiol Behav. 2017;176(1):139–48.

    Google Scholar 

  20. Chen LL, Tangiisuran B, Shafie AA, Hassali MAA. Evaluation of potentially inappropriate medications among older residents of Malaysian nursing homes. Int J Clin Pharm. 2012;34(4):596–603.

    CAS  Article  Google Scholar 

  21. Hasan SS, Kow CS, Thiruchelvam K, Chong DWK, Ahmed SI. An evaluation of the central nervous system medication use and frailty among residents of aged care homes in Malaysia. Neuroepidemiology. 2017;49(1–2):82–90.

    Article  Google Scholar 

  22. Mucalo I, Hadžiabdić MO, Brajković A, Lukić S, Marić P, Marinović I, et al. Potentially inappropriate medicines in elderly hospitalised patients according to the EU(7)-PIM list, STOPP version 2 criteria and comprehensive protocol. Eur J Clin Pharmacol. 2017;73(8):991–9.

    Article  Google Scholar 

  23. Dalleur O, Spinewine A, Henrard S, Losseau C, Speybroeck N, Boland B. Inappropriate prescribing and related hospital admissions in frail older persons according to the stopp and start criteria. Drugs Aging. 2012;29(10):829–37.

    Article  Google Scholar 

  24. Zia A, Kamaruzzaman SB, Myint PK, Tan MP. The association of antihypertensives with postural blood pressure and falls among seniors residing in the community: a case-control study. Eur J Clin Invest. 2015;45(10):1069–76.

    CAS  Article  Google Scholar 

  25. Weiss J, Freeman M, Low A, Fu R, Kerfoot A, Paynter R, et al. Benefits and harms of intensive blood pressure treatment in adults aged 60 years or older. Ann Intern Med. 2017;166(6):419.

    Article  Google Scholar 

  26. de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: I. Cardiovascular drugs. J Am Med Dir Assoc. 2018;19(4):371.e1-371.e9.

    Article  Google Scholar 

  27. Seppala LJ, Wermelink AMAT, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics J Am Med Dir Assoc. 2018;19(4):371.e11-371.e17.

    Article  Google Scholar 

  28. Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others J Am Med Dir Assoc. 2018;19(4):372.e1-372.e8.

    Article  Google Scholar 

  29. Ryan C, O’Mahony D, Kennedy J, Weedle P, Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68(6):936–47.

    Article  Google Scholar 

  30. Sloane PD, Gruber-Baldini AL, Zimmerman S, Roth M, Watson L, Boustani M, et al. Medication undertreatment in assisted living settings. Arch Intern Med. 2004;164(18):2031–7.

    Article  Google Scholar 

  31. Sallevelt BTGM, Huibers CJA, Knol W, Van PE, Egberts T, Wilting I. Evaluation of clarity of the STOPP/START criteria for clinical applicability in prescribing for older people: a quality appraisal study. BMJ Open. 2020;10(2):1–8.

    Article  Google Scholar 

  32. Glintborg B, Andersen SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Heal Care. 2007;16(1):34–9.

    Article  Google Scholar 

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All the authors listed have had a significant role in the execution of the project and drafting of the manuscript. We would like to acknowledge the Falls and Syncope Service, University of Malaya Medical Centre for providing the falls data.


This work was supported by an Impactful Interdisciplinary Research Grant (lIRG024A-2019) awarded by the Health and Wellbeing Research Cluster, University of Malaya.

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Chiam, R., Saedon, N., Khor, H.M. et al. Potentially inappropriate prescribing in a falls clinic using the STOPP and START criteria. Int J Clin Pharm 44, 163–171 (2022).

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  • Accidental falls
  • Adverse drug events
  • Aged
  • Inappropriate prescribing
  • STOPP START criteria