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Kia āta kōwhiri Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

Published articles

Tools to guide which medicines should be considered for deprescribing

This page forms part of the Appropriate prescribing toolkit. Use the links in the left hand menu to return to the main toolkit page or access the additional sections. 

Jump to sections:

  1. The American Geriatrics Society (AGS) Beers Criteria (the Beers list)
  2. STOPP/START
  3. NO TEARS
  4. Drug burden index (DBI)
  5. Anticholinergic cognitive burden scale (ACB)/anticholinergic risk scale (ARS)
  6. PRISCUS
  7. Medication appropriateness index (MAI) 
  8. Medication appropriateness tool for co-morbid health conditions in dementia (Match-D)
  9. Australian prescribing indicators tool
  10. References

1. The American Geriatrics Society (AGS) Beers Criteria (the Beers list)

American Geriatrics Society. 2019. Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 67: 674–94. URL: https://bit.ly/2zqCPL8 | Download a copy (170 KB, pdf)

Steinman MA, Fick DM. 2019. Using wisely: A reminder on the proper use of the American Geriatrics Society Beers Criteria. J Am Geriatr Soc 67(4): 644–6. 1-3. URL: https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.15766 | Download a copy (66 KB, pdf)

The American Geriatrics Society Beers Criteria (the Beers list) is widely used. While other lists of medicines that may be problematic in elderly patients have been published, the Beers list is the best known and most commonly used.

The Beers list is an explicit list of potentially inappropriate medicines, developed by Delphi consensus, that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. The Beers list has been updated on a three-year cycle, with the last review in 2019.

Key principles to guide optimal use of the Beers list:
  • Medicines in the 2019 AGS Beers list are potentially inappropriate, not definitely inappropriate.
  • Read the rationale and recommendations statements for each criterion. The caveats and guidance listed there are important.
  • Understand why medicines are included in the Beers list and adjust your approach to those medicines accordingly.
  • Optimal application of the Beers list involves identifying potentially inappropriate medicines and, where appropriate, offering safer non-pharmacologic and pharmacologic therapies.
  • The Beers list should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety.
Is the tool any use?
  • Higher probability of hospitalisation with ≥ 2 potentially inappropriate medicines.[1]
  • Significantly increased risk of ADR in elderly with ≥ 1 potentially inappropriate medication.[2]
  • Increased risk of hospitalisation, death with potentially inappropriate medicines.[3]
  • Increased risk of falling when using potentially inappropriate medicines.[4]
Limitations of the Beers list
  • Does not address drug–drug interactions, duplicate drug class prescriptions and under-prescribing of clinically indicated medicines.
  • Does not include guidance on possible medicine omissions (start criteria).
  • The Beers list is not equally applicable to all countries (eg, some medicines are not available in New Zealand).

2. STOPP/START

(Screening Tool of Older Person’s Prescriptions/Screening Tool to Alert doctors to Right Treatment)

O’Mahony D, O’Sullivan D, Byrne S, et al. 2015. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Aging 44: 213–18. URL: http://ageing.oxfordjournals.org/content/early/2014/11/18/ageing.afu145.full.pdf+html | Download a copy (530 KB, pdf) 

STOPP/START criteria: https://bit.ly/2AfTbqt | Download a copy (146 KB, pdf)

Toolkit NHS Cumbria: https://bit.ly/2XV2HZ7 | Download a copy (1 MB, pdf)

STOPP/START consists of a series of rules/suggestions related to common problems in prescribing for older people, both in terms of reducing medication burden (STOPP) and adding in potentially beneficial therapy (START). The explicit lists were developed by Delphi consensus.

  • Criteria apply to people aged over 65 years.
  • Criteria are arranged according to physiological system and accompanied by an explanation regarding why the prescription is potentially inappropriate (over-prescribing), or should be considered for people with certain conditions (under-prescribing).
Is the tool any use?
  • Applied at a single time point during hospitalisation for acute illness in older people significantly improve medication appropriateness, an effect that is maintained six months post-intervention.[5]
  • STOPP criteria medicines are significantly associated with adverse drug events (ADEs).[6]
  • An Australian study comparing Beers list, the STOPP/START criteria and prescribing indicators in Elderly Australians criteria concluded that the number and scope of drug-related problems identified by pharmacists was best represented by STOPP/START criteria.[7]

3. NO TEARS

Lewis T. 2004. The NO TEARS tool for medication review. BMJ 329: 434. URL: https://www.bmj.com/content/bmj/329/7463/434.full.pdf | Download a copy (53 KB, pdf)

Lewis T. 2005. Medication review for the 10-minute consultation. Welsh Medicines Resource Centre (WeMeReC) Bulletin, November issue. URL: https://www.wemerec.org/Documents/Bulletins/Medication%20Review%20(FINAL).pdf | Download a copy (131 KB, pdf)

Medication review for the 10-minute consultation. The ‘NO TEARS’ structure can be used as a mental prompt to aid medication review. It is a flexible system that can be tailored to an individual practitioner’s consultation style and maximise the potential of the 10-minute consultation.

4. Drug burden index (DBI)

Hilmer SN, Mager DE, Simonsick EM, et al. 2007. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 167(8): 781–7. URL: https://www.ncbi.nlm.nih.gov/pubmed/17452540/ | Download a copy (167 KB, pdf)

  • The DBI measures the cumulative exposure to anticholinergic and sedative medicines.
  • The DBI demonstrates that exposure to anticholinergic and sedative medicines is associated with poorer physical function, poorer balance and increased risk of falls and frailty, poorer cognition and memory, increased GP visits, increased hospitalisations and increased mortality.
  • Increasing DBI is associated with a higher likelihood of a hip fracture.[8]
  • Each additional unit of drug burden has a negative effect on physical function similar to that of three additional physical comorbidities.
  • A practical limitation of the DBI is that there does not appear to be a published list of DBI values and you need to calculate your own.

5. Anticholinergic cognitive burden scale (ACB)/anticholinergic risk scale (ARS)

Boustani M, Campbell N, Munger S et al. 2008. Impact of anticholinergics on the aging brain; a review and practical application. Aging health 4(3): 311–20 | Download a copy (360 KB, pdf)

Rudolph JL, Salow MJ, Angelini MC, et al. 2008. The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons. Arch Intern Med 168(5): 508–13 | Download a copy (85 KB, pdf)

6. PRISCUS

(Latin for old, ancient and venerable)

Holt S, Schmiedl S, Thürmann P. 2010. Potentially Inappropriate Medications in the Elderly: The PRISCUS List. Dtsch Arztebl Int 107(31–32): 543–51. URL: www.ncbi.nlm.nih.gov/pmc/articles/PMC2933536/ | Download a copy (250 KB, pdf)

Suggests potentially inappropriate medicines. Designed for the German health care system, for a given medicine (or group of medicines). It lists the main concerns, possible therapeutic alternatives and recommended precautions to be taken when the potentially inappropriate medicine is used (eg, monitoring required).

7. Medication appropriateness index (MAI)

Hanlon JT. 2019. Use of the Medication appropriateness index (MAI). Undated 1/17/2019. Personal communication, 8 June 2019 | Download a copy (473 KB, pdf)

Hanlon JT, Schmader KE, Smasa GP, et al. 1992. A method for assessing drug therapy appropriateness. J Clin Epidemiol 45(10): 1045–51 | Download a copy (421 KB, pdf)

Fitzgerald LS, Hanlon JT, Shelton PS, et al. 1997. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother 31: 543–8 | Download a copy (500 KB, pdf)

  • The MAI uses 10 questions per medicine on a three-point Likert scale (appropriate, marginally appropriate, inappropriate) to assess the appropriateness of medicine use: indication, effectiveness, dosage, correct directions, practical directions, drug–drug interactions, drug–disease interactions, duplication, duration and expense.[10]
  • Uses implicit (judgement-based) criteria that are not drug- or disease-specific. Consequently, they rely on the clinician’s knowledge.[11]
  • When the answer to a question indicates inappropriateness, a weighted score is assigned to the medicine. For example, lack of effectiveness scores 3 points; drug–drug interactions score 2 points and duplication of medicine scores 1 point. A MAI score for each drug, the ‘drug score’, is calculated by adding the weighted scores.
  • The higher the score the more inappropriate the medicine and the more reason there is to review, stop or change it. Generally, a score ≥ 3 indicates an inappropriate medicine[12] and greater probability of hospitalisation.[13, 14]
  • Somers et al[15] adapted the original producing an eight-question MAI index: three questions from the original MAI were not included (practical directions, duplication of therapy and cost), one question was rephrased (ie, ‘effectiveness’ was changed to ‘right choice’) and one question about adverse drug reactions was added.
  • The MAI is time-consuming to apply, taking about 10 minutes per medicine. It is mainly used as a research tool.[16]

8. Medication appropriateness tool for co-morbid health conditions in dementia (Match-D)

Page AT, Potter K, Clifford R, et al. 2016. Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel. Intern Med J 46(10): 1189–97. URL: https://bit.ly/3hn8y11 | Download a copy (345 KB, pdf)

(Colour version): Page AT, Potter K, Clifford R, Met al. 2016 Medication appropriateness tool for comorbid health conditions in dementia (MATCH-D). URL: https://bit.ly/3hckRx3 | Download a copy (3.2 MB, pdf)

  • Provides guidance (67 statements) for medicines optimisation in people with dementia across three sub-classes of early-stage, mid-stage and late-stage dementia, including what medicines to start/continue using and which to discontinue.
  • The statements are in the broad themes of preventative medication, symptom management, disease progression, psychoactive medication, treatment goals, principles of medication use, side-effects and medication reviews.
  • Used a Delphi consensus study to define appropriate medication management of co-morbidities for people with dementia.
  • Includes those statements that the Delphi experts did not agree with, so are not recommended practice for people with dementia.
  • For further information, see the Western Australia Centre for Health and Aging, MATCH-D at: www.match-d.com.au/.

9. Australian prescribing indicators tool

Basger BJ, Chen TF, Moles RJ. 2012. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method. BMJ Open 2(50): e001431. URL: https://bit.ly/3cO6paV | Download a copy (277 KB, pdf)

  • Uses 41 medicine assessment criteria to identify medicine-related problems for commonly occurring medicines and medical conditions in older (≥ 65 years old) patients.
  • Developed for the Australian health care system.
  • The criteria were based on the most frequent medicines prescribed to Australians, and the most frequent medical conditions for which older Australians (≥ 65 years old) consult medical practitioners.

10. References

  1. Ruggiero C, Dell'Aquila G, Gasperini B, et al. 2010. Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project. Drugs Aging 27(9): 747–58.
  2. Passarelli MC, Jacob-Filho W, Figueras A. 2005. Adverse drug reactions in an elderly hospitalised population: Inappropriate prescription is a leading cause. Drugs Aging 22: 767–77.
  3. Dedhiya SD, Hancock E, Craig BA, et al. 2010 Incident use and outcomes associated with potentially inappropriate medication use in older adults. Am J Geriatr Pharmacother 8(6): 562–70.
  4. Gallagher PF, O’Connor MN, O’Mahony D. 2011. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 89: 845–54.
  5. Ibid.
  6. Hamilton H, Gallagher P, Ryan C, et al. 2011. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 171: 1013–19.
  7. Curtain CM, Bindoff IK, Westbury JL, Peterson GM. A comparison of prescribing criteria when applied to older community-based patients. Drugs Aging. 2013; 30: 935-943.
  8. Jamieson HA, Nishtala PS, Scrase R, et al. 2018. Drug burden index and its association with hip-fracture among older adults: a national population-based study. J Gerontol A Biol Sci Med Sci 74(7): 1127–33. DOI: 10.1093/gerona/gly176.
  9. Boustani M, Campbell N, Munger S, et al. 2008. Impact of anticholinergics on the aging brain; a review and practical application. Aging health 4(3): 311–20.
  10. Hanlon JT, Schmader KE, Smasa GP, et al. 1992. A method for assessing drug therapy appropriateness. J Clin Epidemiol 45(10): 1045–51.
  11. O’Connor MN, Gallagher P, O’Mahony D. 2012. Inappropriate prescribing. Criteria, detection and prevention. Drugs Aging 29(6): 437–52.
  12. Gillespie U, Alassaad A, Hammarlund-Udenaes M, et al. 2013. Effects of Pharmacists' Interventions on Appropriateness of Prescribing and Evaluation of the Instruments' (MAI, STOPP and STARTs') Ability to Predict Hospitalization–Analyses from a Randomized Controlled Trial. PLoS ONE 8(5): e62401. DOI: 10.1371/journal.pone.0062401.
  13. Gillespie U, Alassaad A, Hammarlund-Udenaes M, et al. 2013. Effects of Pharmacists' Interventions on Appropriateness of Prescribing and Evaluation of the Instruments' (MAI, STOPP and STARTs') Ability to Predict Hospitalization–Analyses from a Randomized Controlled Trial. PLoS ONE 8(5): e62401. DOI: 10.1371/journal.pone.0062401.
  14. Schmader KE, Hanlon JT, Landsman PB, et al. 1997. Inappropriate prescribing and health outcomes in elderly veteran outpatients. The Annals of Pharmacotherapy 31(5): 529–33.
  15. Somers A, Mallet L, van der Cammen T, et al. 2012. Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients. Am J Geriatr Pharmacother 10: 101–9.
  16. O’Connor MN, Gallagher P, O’Mahony D. 2012. Inappropriate prescribing. Criteria, detection and prevention. Drugs Aging 29(6): 437–52.
Last updated: 5th April, 2022