Drug Rationalization in the Elderly

Core Principles

The American Geriatrics Society recommends a systematic approach to drug rationalization in older adults, prioritizing deprescribing of potentially inappropriate medications and aligning therapy with patient-centered goals, including life expectancy, functional status, and quality of life 1, 2
Comprehensive medication assessment should include all prescription drugs, over-the-counter medications, herbal products, and supplements at every care transition, as recommended by the American Geriatrics Society 1

Medication Review and Deprescribing

The American Geriatrics Society and European Heart Journal suggest applying validated screening tools, such as Beers Criteria or STOPP/START criteria, to identify potentially inappropriate medications 1, 2, 3, 4
Prioritize removal of drugs with unfavorable benefit-risk ratios, such as NSAIDs and benzodiazepines, and medications causing prescribing cascades, as recommended by the American Geriatrics Society and European Heart Journal 1, 2
Discontinue preventive medications exceeding time-to-benefit in patients with limited life expectancy, as suggested by the European Heart Journal 2, 5

Patient-Specific Factors

Evaluate life expectancy vs. time-to-benefit for each medication, and discontinue preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit, as recommended by the European Heart Journal 2
Consider functional and cognitive status, multimorbidity burden, and patient goals of care when making prescribing decisions, as suggested by the American Geriatrics Society and European Heart Journal 1, 2, 6

Polypharmacy Reduction

Target reduction of total medication burden, aiming to reduce polypharmacy and hyperpolypharmacy, as recommended by the American Geriatrics Society 1, 7
Simplify dosing regimens to improve adherence, as suggested by the American Geriatrics Society 1

Implementation Strategies

Conduct medication review at every care transition, including hospital admission, ICU transfer, and hospital discharge, as recommended by the American Geriatrics Society 1
Use a team-based approach, integrating pharmacist-led interventions within comprehensive geriatric assessment teams, as suggested by the American Geriatrics Society 8
Monitor outcomes following medication changes, tracking positive outcomes, persistence of changes, and coordinating across providers, as recommended by the European Heart Journal 2

Common Pitfalls to Avoid

Avoid disease-specific guideline adherence without considering multimorbidity, and prioritize patient-centered goals over achieving multiple disease-specific targets, as recommended by the European Heart Journal 2
Do not ignore drug-drug interactions, and use interaction screening tools systematically, as suggested by the American Geriatrics Society 1
Do not fail to reassess at care transitions, and apply chronological age alone when making decisions, as recommended by the American Geriatrics Society and European Heart Journal 1, 2

Medication Safety in Older Adults

Introduction to Beers Criteria

The American Geriatrics Society (AGS) Beers Criteria is an explicit list of medications that are potentially inappropriate for older adults in most circumstances or in specific situations related to certain diseases or conditions 9, 10
The AGS has been the steward of the criteria since 2011, producing updates on a 3-year cycle with the most recent updates in 2019 and 2023 9
The criteria were first published almost 30 years ago in 1991, making them the longest-running criteria for PIMs in older adults 11

Components of the Beers Criteria

The 2019 AGS Beers Criteria includes five types of recommendations, including medications potentially inappropriate in most older adults, medications to avoid in older adults with certain conditions, medications to use with caution, drug-drug interactions, and medications requiring dose adjustment based on kidney function 10, 11

Clinical Applications of the Beers Criteria

The primary purpose of the Beers Criteria is to improve care of older adults by reducing exposure to PIMs that have an unfavorable balance of benefits and harms compared to alternative treatments 10
The Beers Criteria serves as both an educational tool and a quality measure for healthcare providers, helping clinicians make more informed prescribing decisions for older adults 9, 10

Important Considerations When Using Beers Criteria

The criteria are not meant to be applied in a punitive manner but rather to guide clinical decision-making, and clinical judgment remains essential 10
Prescribing decisions are not always clear-cut, and clinicians must consider multiple factors, including discontinuation of medications no longer indicated 10

Specific Medication Concerns Addressed in Beers Criteria

NSAIDs are associated with increased risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation in older adults 12
Benzodiazepines are linked to increased risk of cognitive impairment, delirium, falls, and fractures 11

Limitations and Proper Use

The criteria support, rather than replace, good clinical decision-making, and individualization is still required when considering patient-specific factors 10
The criteria are not exhaustive and do not address all possible inappropriate prescribing scenarios 10

STOPP/START Criteria for Medication Review in Older Adults

Target Population

The most recent validated version, STOPP/START version 2 (2015), should be applied to all individuals aged ≥ 65 years in ambulatory, acute‑care, and institutional settings. [13][14]15

STOPP Criteria Overview

STOPP version 2 comprises 134 criteria organized by physiological systems to identify potentially inappropriate medications (PIMs) in older adults. [13][16]
The criteria specifically address drug‑disease interactions, drug‑drug interactions, duplicate therapies, and dose adjustments required for reduced renal function. [13][17]
The criteria are structured by physiological system, facilitating a systematic medication review. 17

START Criteria Overview

START version 2 includes 34 criteria that identify potential prescribing omissions (PPOs)—evidence‑based medications that should be considered for common conditions in older adults. [13][16]
The tool highlights the underuse of beneficial medications in this population. 15
Application of START helps ensure that patients receive appropriate therapy aligned with their documented health conditions. 15

Clinical Application Steps

Systematic Medication Review

At every care transition (e.g., hospital admission, ICU transfer, discharge), review all prescribed, over‑the‑counter, herbal, and supplement products. 15

Applying STOPP

Screen for PIMs using the 134 STOPP criteria organized by physiological system. [13][16]

Applying START

Screen for PPOs using the 34 START criteria. [13][16]
Add evidence‑based medications for any documented conditions where omissions are identified. 15

Patient‑Specific Considerations

Evaluate functional status, cognitive status, multimorbidity burden, and individual goals of care when deciding on medication changes. 15
Do not rely solely on chronological age; incorporate functional and cognitive assessments into prescribing decisions. 15

Systematic Medication Screening for Older Adults

Medication Review Process

Clinicians should review all prescription drugs, over‑the‑counter products, herbal remedies, and supplements at every care transition (e.g., hospital admission, intensive‑care transfer, discharge, or outpatient visit) to ensure comprehensive assessment of the medication regimen. 18

Identification of High‑Risk Medications

During the STOPP review, clinicians must flag high‑risk agents—including benzodiazepines (linked to cognitive impairment, delirium, falls, and fractures), non‑steroidal anti‑inflammatory drugs (associated with gastrointestinal bleeding, acute kidney injury, and heart‑failure exacerbation), and anticholinergic drugs—to consider discontinuation or dose adjustment. 18