GeriQBank · Paper III · Q2
Rational drug prescribing in older adults
- Chapter
- Pharmacotherapy & Perioperative Medicine
- Years asked
- Not recorded in the source
- Frequency
- Set 1× in Paper III (2009–2025)
As set in the university paper
Rational drug prescribing in older adults.
Paper III · Pharmacology, Prescribing & Perioperative Care · asked ×1 · 7-mark note · see in paper list
Detailed answer
Pro · free in betaAttempt it firstOutline your answer as a 7-mark note before revealing it — definition, causes, evaluation, management and the geriatric angle.Reveal answer
A. Concept and definition
Definition. Rational prescribing means giving the right drug, in the right dose, by the right route, for the right duration, to the right patient, at the lowest cost, with an explicit indication and a plan for review.
Two errors, not one. Inappropriate prescribing includes both over-prescribing / mis-prescribing (potentially inappropriate medications, PIMs) and under-prescribing (potential prescribing omissions, PPOs). Withholding a beneficial drug purely because of age is a form of ageism.
Why it matters. Inappropriate prescribing is associated with ADRs, falls, frailty, disability, hospitalisation and mortality, and should be assessed at every single medical encounter (Pathy, Ch. 10, Key Points).
B. The prescribing sequence
Step 1 — Confirm the diagnosis. Atypical presentation and symptom overlap make this the commonest failure point; treating an undiagnosed symptom is irrational by definition.
Step 2 — Define the therapeutic goal with the patient. Ask what matters to them. Frail elders commonly prioritise function, cognition, independence and relief of suffering over length of life.
Step 3 — Try non-pharmacological treatment first where evidence supports it (exercise, physiotherapy, sleep hygiene and CBT-I, dietary measures, compression stockings, continence training).
Step 4 — Select the drug. Before writing, ask: Efficacy — will this make a real difference, and what is the evidence in this age group? Cost — is there an equally effective cheaper option?
Timing — can a once-daily regimen be used?
Dose — what is the lowest effective dose here?
Side effects — how well will this person tolerate it?
Interactions — any drug–drug or drug–disease contraindication?
Step 5 — Prescribe, educate, document: one drug at a time, written instructions in large print, explanation to patient and caregiver, and an entry in an updated medication record.
Step 6 — Monitor and review. Set a review date and an explicit stopping rule; assess both efficacy and toxicity; periodically deprescribe.
C. Explicit and implicit prescribing tools (Pathy, Table 10.3)
Tool Origin What it does Main limitation
Beers Criteria USA, 1991; AGS Explicit list of PIMs in 5 categories: PIMs in all older Does not address under-steward since adults; PIMs with specific diseases; drugs to use prescribing; US-centric 2011 with caution; harmful drug–drug combinations; formulary; not for hospice/end-of-renal dosing. Plus a table of strongly anticholinergic life care drugs.
STOPP / START Europe, 2008 Organ-system based. STOPP = PIMs, START = Needs fuller medical history; prescribing omissions. Designed to be used suggests no safer alternatives together.
Medication USA, 1992 10 implicit questions per drug (indication, ~10 min per drug; needs Appropriateness Index effectiveness, dose, directions, practicality, drug– expertise; does not prioritise (MAI) drug and drug–disease interaction, duplication, which drug to stop duration, cost); scored A/B/C, max 18.
Pill Pruner New Zealand, Pocket card of 13 commonly prescribed drug Studied only in hospitalised 2009 groups based on STOPP; reduces discharge patients ≥75; no tapering medication counts, sustained at 90 days guidance Drug Burden Index (DBI) 2007 Measures cumulative anticholinergic and Covers only two drug classes sedative exposure; high DBI predicts functional decline and falls TRIM US VA, 2016 EHR-based algorithm using Beers + STOPP to flag Validated only in the US VA PIMs and generate clinician feedback system FORTA Germany, 2008 First tool to give positive and negative labels Requires clinical judgement of together (A–D classification) indication D. Aids to memory in daily practice (Pathy, Table 10.4)
SAIL: keep it Simple — know Adverse effects — identify the Indication — List every drug and dose. TIDE: allot Time at each visit for medicines — Individual response — avoid Drug/drug and drug/disease interactions — Educate the patient.
ARMOR: Assess → Review pharmacokinetics/pharmacodynamics → Minimise → Optimise doses → Reassess. Focused on function and quality of life; useful in post-acute and long-term care.
ERASE: Evaluate diagnoses by considering Resolved conditions, Ageing normally, and Selecting appropriate targets, to Eliminate unnecessary diagnoses — i.e. "un-diagnosing to prevent over-prescribing".
AVOID TOO MANY: Alternatives, Vague symptoms, OTC drugs, Interactions, Duration, Therapeutic vs preventive, Once daily, Other doctors, Money, Adverse effects, Needs still?, Yes/no — is the patient actually taking it?
E. Barriers and system measures
Treatment burden — the effort the patient must expend to follow the regimen — is reduced by shared decision-making and by involving pharmacists, nurses and social workers.
Prescribing inertia (continuing a drug simply because it is on the list) and multiple prescribers are the two commonest system failures; medication reconciliation at every transition of care is the antidote.
Latest Updates (2023–Present)
STOPP/START version 3 (European Geriatric Medicine, 2023) is the current version: 190 criteria — 133 STOPP and 57 START, a 66.7% increase over version 2's 114 criteria. Validated by an 11-member Delphi panel from 8 European countries. Criteria are now presented by drug class rather than individual drug name to improve international applicability. Roughly 41% of STOPP.v3 and 42% of START.v3 criteria are new.
AGS Beers Criteria 2023 remains the current US standard (see Q1 for key changes), with the 2025 Alternatives companion supplying safer substitutes.
Trial evidence is mixed on hard outcomes. Single-centre trials of STOPP/START showed reduced polypharmacy, ADRs, falls and cost; but the large multicentre SENATOR, OPERAM and OPTICA trials did not show significant reductions in ADRs, mortality, drug-related readmissions or quality of life (Expert Review of Clinical Pharmacology, 2023). Usability work has produced a validated 3-page single-entry table of STOPP/START v3 for bedside use (European Geriatric Medicine, 2025), addressing the criticism that 190 criteria are impractical in a busy clinic. STOPPFrail remains the tool of choice for frail patients with limited life expectancy, where standard criteria are inappropriate.
Current Practice Update
Textbook position Current evidence and practice (2023–2026)
STOPP/START version 2 (2015), 114 criteria (80 STOPP + Version 3 (2023): 190 criteria (133 + 57), class-based rather than drug-34 START). based, with expanded cardiovascular, diabetes and COPD sections.
STOPP/START application within 72 hours of admission These single-centre findings were not replicated in SENATOR, OPERAM reduces ADRs by ~9% and length of stay by ~3 days. or OPTICA. Present the tools as improving prescribing quality, with hard clinical endpoints still unproven.
Beers criteria give no alternatives. 2025 AGS Alternatives list now covers 21 conditions and emphasises non-pharmacological options.
Tools presented as broadly interchangeable. Current practice is tool-plus-judgement: an explicit tool (Beers/STOPP) to screen, an implicit tool (MAI) to judge, and a patient-centred goals discussion to decide.
Examiner's Tip
Open with the two-sided definition: "Rational prescribing corrects both over-prescribing and under-prescribing — STOPP addresses the first, START the second."
Quote the current numbers: "STOPP/START version 3 (2023) contains 190 criteria — 133 STOPP and 57 START." Name at least four tools with their country and year; this single sentence often separates a distinction answer. Add the honest caveat: "These tools reliably improve prescribing quality; large multicentre trials have not yet shown a mortality benefit."
Always mention time-to-benefit and life expectancy as determinants of rationality.
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References
- PAPERS-2-3-4_COMBINED.pdf — page 911
- GeriQBank source PDF — p. 911
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