Medication Appropriateness in Vulnerable Older Adults

Healthy Skepticism of Appropriate Polypharmacy

Terri R. Fried, MD; Marcia C. Mecca, MD


J Am Geriatr Soc. 2019;67(6):1123-1127. 

In This Article

Association of PPO Tools With Clinical Outcomes

Observational studies highlight the narrow therapeutic window of medications included in PPO tools. In one study using implicit chart review to determine the contribution of PIMs identified by the Screening Tool of Older People's Prescriptions (STOPP) and PPOs identified by START with hospitalizations among frail older persons, these medications were assessed to have contributed to 27.1% of admissions. Of these, two-thirds were a result of PIMs and one-third of PPOs. Aspirin was implicated both as a PPO and a PIM.[10] In a second observational study using START/STOPP criteria among a cohort of older persons discharged from the hospital, PIMs were associated with an increased risk of hospital readmission and PPOs with increased mortality.[11] However, a third cohort study suggested that the association between PPOs and mortality is not causal. Among individuals with cardiovascular disease, the likelihood of a PPO identified by START was associated most strongly with frailty. In analysis adjusted for frailty and comorbidity, there was no association of medication underutilization with cardiovascular deaths, but there was an association with competing deaths from noncardiovascular causes.[12] The authors suggest that PPOs are withheld among patients at increased risk of competing adverse outcomes who are least likely to benefit from these medications. There is additional evidence for decreased medication benefits and increased harms in studies of individual medications or classes of medications included in criteria identifying PPOs among older persons who are vulnerable because of disability and/or comorbidity.