International Journal of Clinical Pharmacy

, Volume 34, Issue 3, pp 481–489 | Cite as

Prescribing omissions in elderly patients admitted to a stroke unit: descriptive study using START criteria

  • Elisabete Pinto BorgesEmail author
  • Manuel Morgado
  • Ana Filipa Macedo
Research Article


Background Underuse of medication considered beneficial is particularly common in elderly patients. A new Screening Tool to Alert Doctors to the Right Treatment (START) has been published to identify potential prescribing omissions. Objective To quantify and characterize potential prescribing omissions of cardiovascular risk management therapy using START criteria. Setting This study was conducted in the Stroke Unit of the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, located in the Eastern Central Region of Portugal. Method During 6 months, the medical files of all elderly patients (age ≥ 65 years) admitted with acute cardiovascular disease were reviewed and the START criteria applied to the information of medication, at admission and at the time of discharge from the hospital Stroke Unit. Main outcome measure Potential prescribing omissions of cardiovascular and endocrine pharmacological therapy were identified and the difference in the potential prescribing omissions between admission and discharge from hospital Stroke Unit was also evaluated. Results At the time of admission to the Stroke Unit, 101 potential prescribing omissions were found in 68.1 % (n = 91) of elderly (average 1.11 omissions per patient), of which 84.2 % (n = 85) were corrected at the time of discharge. In 14 patients, 16 omissions found at admission were not corrected during hospitalization, and in 5 patients 5 new omissions were detected. Conclusion Prescribing omissions of beneficial drugs are highly prevalent in acutely ill admitted to a Stroke Unit. START criteria represent a simple, evidence-based and easy-to-use tool to screen underuse of cardiovascular risk management therapy in elderly patients.


Adverse drug reaction Cardiovascular disease Drug prescriptions Elderly Portugal START criteria Stroke 



The authors would like to acknowledge the support of Professor Miguel Castelo-Branco (MD, PhD), the Director of the Stroke Unit of Cova da Beira Hospital Centre, where the study was conducted.


The authors did not receive any financial support for the research, authorship, and/or publication of this article.

Conflicts of interest



  1. 1.
    Hashimoto K, Tabata K. Population aging, health care and growth. J Popul Econ. 2010;23:571–93.CrossRefGoogle Scholar
  2. 2.
    Preventing Chronic Diseases. A Vital Investment: WHO Global Report. Geneva: World Health Organization, 2005. pp 200. CHF 30.00. ISBN 92 4 1563001. Int J Epidemiol. 2006; 35(4):1107.Google Scholar
  3. 3.
    Instituto Nacional de Estatística, Revista de Estudos Demográficos, no 46, Novembro 2009; [on-line] Available at URL: Accessed on Jan 2012, ISSN 1645-5657.
  4. 4.
    Hajjar ER, Cafiero AC, Halon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–55.PubMedCrossRefGoogle Scholar
  5. 5.
    Hughes CM. Medication non-adherence in the elderly: how big is the problem? Drugs Aging. 2004;21(12):793–811.PubMedCrossRefGoogle Scholar
  6. 6.
    Halon JT, Lindblad CI, Hajjar ER, McCarthy TC. Update on drug-related problems in the elderly. Am J Geriatr Pharmacother. 2003;1:38–43.CrossRefGoogle Scholar
  7. 7.
    Wright RM, Sloane R, Pieper CF, Ruby-Scelsi C, Twersky J, Schmader KE, Hanlon JT. Underuse of indicated medications among physically frail older US veterans at the time of hospital discharge: results of a cross-sectional analysis of data from the Geriatric Evaluation and Management Drug Study. Am J Geriatr Pharmacother. 2009;7(5):271–80.PubMedCrossRefGoogle Scholar
  8. 8.
    Lindley CM, Tully MP, Paramsothy V, Tallis RC. Inappropriate medication is a major cause of adverse drug reactions in the elderly patients. Age Ageing. 1992;21(4):294–300.PubMedCrossRefGoogle Scholar
  9. 9.
    Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention, ADE Prevention Study Group. JAMA. 1995;274(1):29–34.PubMedCrossRefGoogle Scholar
  10. 10.
    Barry PJ, Gallagher P, Ryan C. Inappropriate prescribing in geriatric patients. Curr Psychiatry Rep. 2008;10:37–43.PubMedCrossRefGoogle Scholar
  11. 11.
    Spinewine A, Schamader KE, Barbr N, Hughes C, Lapane KL, Swine C, Halon JT. Prescribing in elderly people 1 Appropriate prescribing in elderly people: how well can it be measured and optimized? Lancet. 2007;370(9582):173–84.PubMedCrossRefGoogle Scholar
  12. 12.
    Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing homes. Arch Intern Med. 1991;151(9):1825–32.PubMedCrossRefGoogle Scholar
  13. 13.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use in elderly: an update. Arch Intern Med. 1997;157(14):1531–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Naugler CT, Brymer C, Stolee P, Arcese ZA. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol. 2000;7(2):103–7.PubMedGoogle Scholar
  15. 15.
    Halon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, Cohen HJ, Feussner JR. A method assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045–51.CrossRefGoogle Scholar
  16. 16.
    Wenger NS, Shekelle PG. ACOVE investigators, assessing care of vulnerable elders: ACOVE project overview. Ann Intern Med. 2001;135(8):642–6.PubMedGoogle Scholar
  17. 17.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening tool of older person’s prescriptions) and START (Screening tool to alert doctors to the right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.PubMedGoogle Scholar
  18. 18.
    Barry PJ, Gallagher P, Ryan C, O’Mahony D. START (screening tool to alert doctors to the right treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36:632–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice, European guidelines on cardiovascular disease prevention in clinical practice: executive summary. Eur Heart J. 2007; 28(19):2375–2414.Google Scholar
  20. 20.
    Szadkowska I, Stanczyk A, Aronow WS, Kowalski J, Pawlicki L, Ahmed A, Banach M. Statin therapy in the elderly: a review. Arch Gerontol Geriatr. 2010;50:114–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Guerra LC, Moreno MCF, Suero JA. Secondary stroke prevention in the elderly: new evidence in hypertension and hyperlipidemia. Eur J Intern Med. 2009;20:586–90.CrossRefGoogle Scholar
  22. 22.
    Deedwania P, Stone PH, Bairey Merz CN, Cosin-Aguilar J, Koylan N, Luo D, et al. Effects of intensive versus moderate lipid-lowering therapy on myocardial ischemia in older patients with coronary heart disease: results of the Study Assessing Goals in the Elderly (SAGE). Circulation. 2007;115(6):700–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Diamond GA, Kaul S. Prevention and treatment: a tale of two strategies. J Am Coll Cardiol. 2008;51:46–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Ryan C, O’Mahony D, Kennedy J, Weedle P, Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68(6):936–47.Google Scholar
  25. 25.
    Kuijpers MAJ, van Marum RJ, Egberts ACG, Jansen PAF, The OLDY (OLd people Drugs & dYsregulations) study group. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol. 2007;65(1):130–3.PubMedCrossRefGoogle Scholar
  26. 26.
    Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516–23.PubMedCrossRefGoogle Scholar
  27. 27.
    Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;6:845–54.CrossRefGoogle Scholar
  28. 28.
    Broeiro P, Maio I, Ramos V. Polifarmacoterapia Estratégias de Racionalização, Dossier: prescrição em medicina geral e familiar. Rev Port Clin Geral. 2008;24:625–31.Google Scholar
  29. 29.
    Pyszka LL, Seys Ranola TM, Milhans SM. Identification of inappropriate prescribing in geriatrics at a Veterans Affairs hospital using STOPP/START screening tools. Consult Pharm. 2010;25(6):365–73.PubMedCrossRefGoogle Scholar
  30. 30.
    Amarenco P, Labreuche J, Lavalle P, Touboul PJ. Statins in stroke prevention and carotid atherosclerosis systematic review and up-to-date meta-analysis. Stroke. 2004;35:2902–9.PubMedCrossRefGoogle Scholar
  31. 31.
    European Stroke Organization (ESO) Executive Committee, ESO Writing Committee. Guideline for management of ischaemic stroke and transient ischaemic attack. 2008. Cerebrovasc Dis. 2008;25(5):457–507.CrossRefGoogle Scholar
  32. 32.
    Smith SC, Allen J, Blair SN, Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease, 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113(19):2363–72.PubMedCrossRefGoogle Scholar
  33. 33.
    Williams MA, Fleg JL, Ades PA, Chaitman BR, Miller NH, Mohiuddin SM, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients >75 years of age). An American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation and Prevention. Circulation. 2002;105(14):1735–43.PubMedCrossRefGoogle Scholar
  34. 34.
    Erdmann E. Safety and tolerability of beta-blockers: prejudices and reality. Eur Heart J Suppl. 2009; 11(Suppl A):A21–A25.Google Scholar
  35. 35.
    Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation. 2003;107(1):149–58.PubMedCrossRefGoogle Scholar
  36. 36.
    Fox K, Garcia MA, Ardissino D, Buzzman P, Camici PG, Crea F, et al. Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006;27(11):1341–81.PubMedCrossRefGoogle Scholar
  37. 37.
    Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–52.PubMedCrossRefGoogle Scholar
  38. 38.
    Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. Guidelines for the management of arterial Hypertension. Eur Heart J. 2007;28(12):1462–536.PubMedGoogle Scholar
  39. 39.
    Gage BF, Boechler M, Doggette AL, Fortune G, Flaker GC, Rich MW, Radford MJ. Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. Stroke. 2000;31(4):822–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for practice guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace. 2006;8(9):651–745.PubMedCrossRefGoogle Scholar
  41. 41.
    Sirois C, Moisan J, Poirier P, Grégoire J-P. Underuse of cardioprotective treatment by the elderly with type 2 diabetes. Diabetes Metab. 2008;34(2):169–76.PubMedCrossRefGoogle Scholar
  42. 42.
    Sigal R, Malcolm J, Meggison H. Prevention of cardiovascular events in diabetes. Clin Evid. 2005;14:501–21.Google Scholar
  43. 43.
    Rydén L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J. 2007;28(1):88–136.PubMedCrossRefGoogle Scholar
  44. 44.
    Antithrombotic Trialists’ (ATT) Collaboration, Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373(9678):1849–60.PubMedCrossRefGoogle Scholar
  45. 45.
    Moynihan R, Smith R. Too much medicine? BMJ. 2002;324(7342):859–60.PubMedCrossRefGoogle Scholar
  46. 46.
    Janssen PG, Gorter KJ, Stolk RP, Rutten GE. Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study. Br J Gen Pract. 2009;59(558):43–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Elisabete Pinto Borges
    • 1
    Email author
  • Manuel Morgado
    • 2
  • Ana Filipa Macedo
    • 2
  1. 1.Faculty of Health SciencesUniversity of Beira InteriorCovilhãPortugal
  2. 2.CICS-UBI, Health Sciences Research CentreUniversity of Beira InteriorCovilhãPortugal

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