The Imperative of Safe Prescribing for Seniors
As individuals age, physiological changes—such as decreased kidney function and altered body fat composition—affect how medications are processed and can increase sensitivity to adverse effects. These changes, combined with a higher prevalence of multiple chronic conditions, make older adults particularly vulnerable to medication-related harm.
To mitigate these risks, healthcare providers rely on specialized screening tools and best practices. These tools provide evidence-based guidance to help clinicians make informed decisions about prescribing for a geriatric population, ensuring that the benefits of a medication outweigh the potential risks and aligning treatment with the patient's overall health goals.
The American Geriatrics Society (AGS) Beers Criteria
The AGS Beers Criteria is one of the most widely used and recognizable screening tools for potentially inappropriate medication (PIM) use in older adults. Originally developed in 1991 by Mark Beers, the list has been periodically updated by an interprofessional expert panel to remain current with new evidence. The most recent version was released in 2023.
What the Beers Criteria Covers:
- Medications to Avoid: A list of drugs that are generally considered potentially inappropriate for most older adults. For example, certain benzodiazepines are associated with a high risk of falls and cognitive impairment.
- Medications to Use with Caution: Drugs that may be used but require careful monitoring due to potential risks, especially in patients with specific health conditions.
- Drug-Disease Interactions: Medications that should be avoided in older adults with certain diseases or syndromes, as they can exacerbate the condition. For instance, using certain anticholinergic drugs in patients with dementia can worsen cognitive function.
- Drug-Drug Interactions: A list of medication combinations that are associated with an increased risk of harmful interactions.
- Renal Function-Based Dosage Adjustments: Guidelines for medications that require dosage adjustments for older adults with reduced kidney function.
How the Beers Criteria is Applied: The Beers Criteria serves as a guideline, not a rigid rule. It encourages healthcare providers to use their clinical judgment, considering each patient's individual health status and goals of care. It is a valuable starting point for medication review in outpatient, acute care, and institutional settings.
The STOPP/START Criteria: A European Initiative
Originating in Ireland and the UK, the Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria represent a complementary approach to medication assessment. The latest version 3, published in 2023, is a comprehensive update validated by a European expert panel.
How the Criteria Are Structured:
- STOPP Criteria: Focuses on potentially inappropriate medications (PIMs). This includes drug-disease and drug-drug interactions, as well as medications that are ineffective or have an unnecessarily high risk for older adults. The criteria are organized by physiological systems, making them highly practical for systematic review.
- START Criteria: Addresses potential prescribing omissions (PPOs), or medications that should be initiated for a specific condition. This highlights situations where a patient is being undertreated, which can be just as harmful as overtreatment. An example is the omission of bisphosphonates in patients with osteoporosis.
Why STOPP/START Is Unique: The inclusion of START criteria to identify prescribing omissions gives this tool a broader scope than Beers Criteria, which primarily focuses on medications to be avoided. Studies have shown that STOPP/START criteria can be more sensitive in detecting prescribing issues in certain populations compared to Beers, although both are valuable.
Comparison of Major Prescribing Tools
| Feature | AGS Beers Criteria | STOPP/START Criteria |
|---|---|---|
| Origin | United States | Europe |
| Primary Focus | Potentially Inappropriate Medications (PIMs) | Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs) |
| Structure | Lists of drugs to avoid, use with caution, specific interactions | Criteria organized by physiological systems |
| Strengths | Widely recognized, regularly updated, excellent for identifying high-risk drugs to avoid | More comprehensive, covers both under- and over-prescribing, systems-based approach is user-friendly |
| Limitations | Primarily focused on avoiding medications, less emphasis on prescribing omissions | Originally developed for a European population, though adapted and validated globally; some criteria may not apply in all settings |
Beyond the List: Best Practices in Medication Management
While screening tools are essential, they are just one component of effective medication management for seniors. A holistic approach is required to ensure optimal outcomes.
The Importance of Medication Reconciliation
Medication reconciliation is a process where a complete and accurate list of all medications (prescriptions, over-the-counter drugs, supplements) is compared with the list used at transition points in care, such as hospital admission or discharge. This practice is critical for preventing medication errors, duplications, and harmful interactions.
The Role of Deprescribing
Deprescribing is the process of tapering or stopping medications that may be causing harm or are no longer beneficial. For older adults, this can improve quality of life, reduce the risk of adverse events, and decrease the burden of taking multiple pills. It should be a collaborative decision between the patient and their healthcare provider, balancing risks and benefits based on the patient's goals and life expectancy.
Prioritizing Patient-Centered Care
Ultimately, medication decisions should be patient-centered. This means involving the patient and their family or caregivers in the conversation, understanding their values and goals of care, and explaining the rationale behind any medication changes. The screening tools should be a guide to facilitate these discussions, not a replacement for clinical expertise and shared decision-making.
For additional resources and detailed guidelines on geriatric pharmacotherapy, the American Geriatrics Society website is an excellent source of information and includes links to the full Beers Criteria and related materials: GeriatricsCareOnline.org.
Conclusion
For those asking "what is the screening tool for older people's prescriptions?", the primary answer includes the AGS Beers Criteria and the STOPP/START criteria. These evidence-based guidelines are vital for protecting seniors from medication-related risks, but they must be applied with sound clinical judgment and a patient-centered approach. By using these tools and following best practices like deprescribing and medication reconciliation, healthcare providers can ensure safer, more appropriate, and more effective medication regimens for the aging population.
