Identification of Potentially Inappropriate Prescribing in Outpatient

Geriatric using STOPP/START Criteria at X Hospital Jakarta

Numlil Khaira Rusdi

, Dini Indah Komariah

,Nora Wulandari

, and Arya Govinda Roosheroe

Faculty of Pharmacy and Science, University Muhammadiyah Prof. DR. Hamka, Delima Street II/IV, Jakarta, Indonesia

Divisi of Geriatric, Department of Internal Medicines, Cipto Mangunkusumo Hospital, Pangeran Diponegoro Street 71,

Jakarta, Indonesia

Keywords: Geriatrics, STOPP/START Criteria, Potentially Inappropriate Medicine (PIM), Adverse Drug Reactions.

Abstract: Chronic diseases and decreased physiological function in geriatric patients play a role in the increased

Potentially Inappropriate Prescribing (PIP) and Adverse Drug Reactions (ADR). STOPP/START Criteria

(Screening Tool of Older Person's Prescriptions/Screening Tool to Alert to Right Treatment) is one of the

screening tools to identify Potentially Inappropriate Prescribing. The purpose of this study was to find out

how much Potentially Inappropriate Medicines (PIM) potential and Potency Prescribing Omissions (PPO) at

X hospital using STOPP START toolkit. This was a non-experimental descriptive study. Samples were

collected retrospective in January-March 2017. STOPP/START criteria were used as a screening tool to

identify Potentially Inappropriate Medication (PIM) and Potential Prescribing Omissions (PPO). In 91

samples of outpatient geriatric at X hospital, the potential for PIM according to the STOPP Criteria was

1.9% of a total of 560 drugs with criteria were for the administration of benzodiazepines in patients with a

history of falls, anticholinergics and antipsychotics in dementia patients, glimepiride administration in

geriatric patients with DM type 2. For the potential of negligence in drug administration according to the

START Criteria, there was 3.8% with the most occurrence being the administration of acetylcholinesterase

inhibitors in dementia patients. Of the 560 medications administered to outpatient geriatric patients, 1.9%

were included in the STOPP criteria and 3.8% included in the START criteria.

1 INTRODUCTION

The phenomenon of population ageing is a

phenomenon that has occurred worldwide. Between

2015 and 2050, the population of 60 years or older is

expected to increase from 12% to 22%. By 2050 it is

estimated that the number of elderly people in the

world reaches 2 billion inhabitants (Iona et al.

2015). In Indonesia, the elderly population in 2017

numbered approximately 23.66 million people

(9.03%) and is estimated to increase to 48.19 million

in 2035 (Kementrian Kesehatan RI 2017).

A large number of elderly population in

Indonesia will have an impact on the health sector in

the form of health decline which resulting in

increased service costs (Kementrian Kesehatan RI

2017). Increasing age in the elderly can alter the

body's physiological system, but it may also alter the

pharmacokinetic and pharmacodynamic profile of

the drug. The elderly group has multiple

comorbidities and is more often hospitalized, which

increases the risk of polypharmacy and the potential

for inappropriate prescribing (Corsonello et al.

2009).

Some lists of drugs have been made by experts

for use by medical circles in the treatment of

geriatric patients i.e. Beers Criteria (

The American

Geriatrics Society 2012)

or Canadian Criteria

(McLeod et al. 1997). The STOPP/START Criteria

(Screening Tool for Older Person's Prescriptions /

Screening Tool to Alert to Right Treatment) were

made to identify potentially inappropriate

medication (PIM) (Gallagher et al. 2011).

STOPP/START criteria were made according to the

body's physiological system consisting of 80 STOPP

Criteria and 34 START Criteria (O’Mahony et al.

2014). The STOPP/START criteria were created in

2003 with the aim of addressing the possible

shortcomings of the Beers criteria. The criteria

consist of Potentially Inappropriate Medication

(PIM) described by STOPP, and Potential

Prescribing Omissions (PPO) prescriptions,

112

Rusdi, N., Komariah, D., Wulandari, N. and Roosheroe, A.

Identiﬁcation of Potentially Inappropriate Prescribing in Outpatient Geriatric using STOPP/START Criteria at X Hospital Jakarta.

DOI: 10.5220/0008240301120116

In Proceedings of the 1st Muhammadiyah International Conference on Health and Pharmaceutical Development (MICH-PhD 2018), pages 112-116

ISBN: 978-989-758-349-0

described by the START. This START method is

intended to improve treatment success in geriatric

patients (O'Mahony et al. 2014).

The result of PIM identification with STOPP and

START screening tool has not been well

documented in Indonesia especially in DKI Jakarta

hospital. X Hospital (RSUPN DR. Cipto

Mangunkusumo) is a government hospital located in

Central Jakarta and is a referral of the National

Geriatric Center. From the results of the survey to

the hospital, the outpatient geriatric patients from

January to March 2017 at X hospital were numbered

1047 patients

2 METHOD

This experiment was a cross sectional study.

Samples were collected retrospectively in January -

March 2017. STOPP/START criteria were used as a

screening tool to identify Potentially Inappropriate

Medication (PIM) and Potential Prescribing

Omissions (PPO). The total population of 1047

patients and samples taken according to Taro

Yamane formula amounted to 91 using systematic

sampling (Moch Imron 2011). Inclusion criteria

were geriatrics aged 60 years or older, received the

medicine, diagnosis data, physical examination data

and laboratory data required. The exclusion criteria

were patients with forced home, and the patient died.

The data collected were secondary data in the

form of medical record number, patient initials, age,

sex, diagnosis, comorbidities, physical examination,

drugs used and laboratory information. Data

analyzed using STOPP/START Criteria to determine

the precision of prescribing that adjusted to the

medical record of the patients.

3 RESULTS

The results of the study showed that improper use of

medicines according to STOPP criteria included

giving benzodiazepines which could potentially

cause a risk of falls in the elderly. Besides that, there

were also the used of drug duplication,

anticholinergics, antipsychotics and Glimepiride

(Table 1).

The results study, the PPO according to the

START Criteria numbered to 3.8% or 21 incidents.

The highest incidence in this study was an omission

of acetylcholinesterase inhibitor therapy in 5

dementia patients, alpha-1 blocker therapy and 5a

reductase inhibitor in patients with BPH of 5 cases,

Table 2. The Frequency of PPO According to Criteria START

Criteria

Code

Descriptions N

C3 Acetylcholinesterase inhibitors in dementia patients 5

G1 Alpha 1 blocker in patients with BPH 5

G2 5a reductase inhibitor in BPH patients 5

E3 Vitamin D and calcium in patients with osteoporosis 3

A4 Antih

pertensive in patients with blood pressure> 140 / 90mmH

E6 Xanthine oxidase inhibitors in

out arthritis patients 1

C4 Topical prostaglandin or prostamide or topical beta blockers in glaucoma patients 1

Total 21

Table 1. PIM Frequency According to STOPP Criteria

Criteria

Code

Descriptions N

K1 Benzodiazepin that increase the risk of fallin

eriatric 4

A3 Concurrent use of one class drug or its derivatives 2

D8 Anticholiner

ics in

eriatric patients with delirium or dementia 1

D9 Antips

chotics in the elderl

with BPSD (dementia) 1

C3 Aspirin in the elderly with uncontrolled hypertension 1

J1 Glimepiride in the elderl

with t

pe 2 diabetes mellitus 1

Total 10

Identiﬁcation of Potentially Inappropriate Prescribing in Outpatient Geriatric using STOPP/START Criteria at X Hospital Jakarta

113

respectively. Furthermore, vitamin D and calcium

therapy were given in 3 patients with osteoporosis,

antihypertensive in 1 geriatric patient with blood

pressure> 140 / 90mmHg, xanthine oxidase inhibitor

therapy in 1 patient with gout arthritis and topical

prostaglandin or prostamide or beta-blocker therapy

in 1 patient with glaucoma (Table 2).

4 DISCUSSION

The most prevalent PIM criteria were the use of

benzodiazepine-class drugs in 4 geriatric patients

(40%). The use of benzodiazepines class of drugs

may lead to reduced sensory and impaired balance

(O’Mahony et al. 2014). In the elderly the

benzodiazepine profile may undergo changes related

to altered cytochrome P450 enzyme activity

(Sotaniemi et al. 1997) otherwise it may be caused

by other things such as diminished albumin which

leads to increased concentrations of benzodiazepines

in a free form (Hammerlein et al. 1998). In the

elderly there is also an increase in the sensitivity of

benzodiazepines to the central nervous system

(Hillmer et al. 2007; Sera et al. 2012; Naranjo et al.

1995). In a previous study, more than 40% of elderly

who received benzodiazepine-class drugs entered

emergency care after falling out (Cengotitabengoa et

al. 2018).

Concurrent use of one class of drugs or the

derivatives occurred to 2 patients (20%), i.e, the use

of dopamine agonist (pramipexole and levodova)

drugs. Drug duplication will increase as patients

develop chronic illness and the range can reach

40.38% to 43.50% with 1.45-1.62 duplications

(Cheng et al. 2014). Drug duplication were

associated with polypharmacy which may increase

the risk of adverse drug reactions (Bushardt et al.

2008). Constipation, nausea, headache and excessive

daytime sleepiness are among adverse drug reactions

of dopamine (Pagano et al. 2014; Tholfsen et al.

2015). Other adverse drug reactions such as

hallucinations (both visual and audio), peripheral

edema, heart valve disorders to heart failure have

been reported as an adverse drug reaction of

dopamine agonist therapy (Lockett et al. 2015;

Wood 2010).

There is one incident (10%) of anticholinergics

administered to dementia patients. The provision of

anticholinergic prescriptions should be done

cautiously given the side effects to the elderly.

Adverse drug reactions of anticholinergic will

worsen the state of dementia (O’Mahony et al. 2014;

Gerretsen et al. 2011) . There is one incident (10%)

of antipsychotics given in elderly patients. The

antipsychotic administration was included in the

STOPP Criteria as it may increase the risk of stroke

in the elderly (O’Mahony et al. 2014). In previous

studies, the use of antipsychotics in older adults may

increase the cardiovascular risk to death. The risk

will increase if the elderly develop dementia (Mittal

et al. 2011).

The use of aspirin in the elderly was one incident

(10%). When aspirin was given to uncontrolled

hypertension (> 140 mmHg and > 90 mmHg)

patients, it will increase the risk of bleeding

(O’Mahony et al. 2014; Lip 2011; Pisters et al.

2010).

Glimepiride used with caution in elderly patients

as it may lead to hypoglycemia (Katzung et al.

2012). In this study, there was one incident (10%),

and in previous studies, there was an incidence of

hypoglycemia in 23 patients out of a total of 143

patients (Shihara et al. 2017).

According to the START Criteria, there were

three most potential Omissions

in drug

administration: acetylcholinesterase inhibitor

therapy in dementia patients (23.8%), alpha 1

blocker therapy and 5a reductase inhibitor in patients

with BPH (23.8%), vitamin D and calcium therapy

in geriatric patients with osteoporosis. Study on the

comparison of the use of acetylcholinesterase

inhibitors with placebo found a significant

difference seen from the value of ADAS-Cog (The

Alzheimer’s Disease Assessment Scale–Cognitive

subscale) and MMSE (Mini Mental State Exam)

after patients were given therapy for six months

(Mochammad et al. 2017). Acetylcholinesterase

inhibitors not only improve cognitive function but

can also increase psychological function and habits

(DiSanto et al. 2013).

Alpha 1 blockers administered together with a 5a

reductase inhibitor are the START Criteria in BPH

patients. In elderly who had moderate to severe

prostate disturbance when given a combination of

both drugs resulted in much better improvement

compared with tamsulosin or dutasteride

monotherapy (Roehrborn et al. 2008). Vitamin D

and calcium therapy were PPO in 5 geriatric patients

with osteoporosis. Vitamin D and calcium therapy

are strongly recommended to improve the state of

osteoporosis and prevent fractures (Weaver et al.

2016). In the study had found that the used of

Vitamin D and calcium in osteoporosis patients can

reduce the risk of fracture in the elderly group

(Weaver et al. 2016).

Geriatric patients with blood pressure > 140 /

90mmhg included to the START Criteria for not

MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development

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getting antihypertensive (O’Mahony et al. 2014).

Blood pressure target for elderly (< 140/90mmHg),

the treatment may be based on JNC8 guidelines and

may be combined with expert consensus guidelines

ACCF/AHA 2011 (Arthur et al. 2015).

In this study, xanthine oxidase inhibitor therapy

in gout patients include to the START Criteria.

Febuxostat was recommended if elderly patients

have moderate to severe renal impairment (Fravel et

al. 2011).

Geriatric patients with glaucoma who are not

receiving antiglaucoma therapy (topical

prostaglandin, prostamide or beta-blockers) included

to the STOPP Criteria. Comparison of the

effectiveness of topical prostaglandin (latanoprost

bunod 0.024%) once daily in the afternoon showed

better results than the topical beta blocker (timolol

0.5%) twice daily given to glaucoma patients for

three months (Medeiros et al. 2016).

5 CONCLUSIONS

From the results of this study, it could be concluded

from 560 drugs given to outpatient geriatric patients

at X hospital, there is 1.9% of PIM incidence for

STOPP criteria and 3.8% incidence of PPO for

START criteria.

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