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- Potentially Inappropriate Prescribing in Elderly: Application of STOPP/START Criteria in Portuguese PatientsPublication . Candeias, Catarina Diogo; Alves, Gilberto Lourenço; Ferreira, Amílcar Celta Falcão Ramos; Rodrigues, Márcio José de Abreu MarquesThe ageing of the population is a multifactorial phenomenon, primarily resulting from low birth rates and an increase in average life expectancy. While the increase in life expectancy reflects the success of public health measures, population ageing leads to greater morbidity and an increased incidence of chronic diseases. This raises concerns about the sustainability of patient management and health systems. Chronic diseases are more prevalent in older people (those aged 65 or over) and result in multimorbidity, which leads to the simultaneous use of several drugs. Polypharmacy — defined as the use of five or more drugs — is associated with an increased risk of adverse drug reactions, drug-related problems, and potentially inappropriate prescribing. Adverse drug reactions are responsible for hospital admissions, health costs, morbidity and mortality, even though more than half of them are preventable. The management of these patients with an increasingly complex pharmacotherapeutic profile requires a careful approach, particularly when transitioning care, requires the definition and monitoring of an individual intervention plan for each patient. In Portugal, where the average life expectancy is slightly higher than the European average, the National Network for Integrated Continuing Care (RNCCI) was created in 2006 by the Ministries of Labour and Social Solidarity, and Health. The RNCCI comprises a group of public and private institutions that provide long-term healthcare and social support to the patients leaving hospital or joining from the community who are dependent and require assistance with mental, social and/or physical limitations. Although this support is independent of age, a significant proportion of patients are elderly. The RNCCI has more than 10,000 inpatient beds, which are distributed across several Units for Integrated Continuous Care (UCCI) nationwide. However, research into the medication of these patients is still lacking, particularly on polypharmacy and potentially inappropriate prescribing. This is also associated with the occurrence of adverse drug reactions, the risk of hospitalisation and readmission, high costs, a lower quality of life and even higher mortality. Potentially inappropriate prescribing is a growing concern in terms of potentially inappropriate medication (PIM), overprescribing (prescribing medication without a clear clinical indication) and incorrect prescribing (prescribing an indicated medication when the risk outweighs the benefit, or when a safer or more effective alternative is available); it also refers to potential prescribing omissions (PPO), or underprescribing (failing to prescribe a beneficial medication for which there is a clear clinical indication). Various tools have been developed in the context of clinical practice to identify potentially inappropriate prescriptions. One of the first to be developed was the Beers list, which has been widely used. However, as many of the medicines included in this list are not marketed in most European countries, its applicability is limited. The STOPP/START criteria (Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment) can identify PIM and PPO, both of which can have harmful consequences for patients. The updates of the criteria have been shown to cover PIM with greater clinical significance. Despite the relevance of these criteria, they are rarely applied in Portugal and are practically non-existent in specific contexts, such as UCCI. Therefore, this study aimed to address several gaps in Portuguese research, particularly regarding UCCI patients, by analysing the prescriptions of 180 patients from eight different UCCI. Firstly, the relationship between demographic and clinical characteristics and medication use patterns, including polypharmacy was analysed. On average, eight drugs were prescribed per patient, and around 90% of patients were polymedicated. Multivariate logistic regression revealed that polypharmacy was significantly associated with UCCI when two institutions were compared, as well as with the Charlson Comorbidity Index (CCI). The CCI is an index resulting from the sum of age weighting (one point for each decade over the age of 50, up to a maximum of four points) and a weighting assigned to various diseases (from one to six). It predicts the 10-year survival rate of patients with multiple comorbidities: higher scores indicate more serious health conditions and, consequently, a worse prognosis. Then, the prevalence of PIM and PPO in elderly patients was determined by applying the STOPP/START criteria, after which potential predictors were investigated. PIM was found to have a prevalence of 85.1%, mainly involving drugs that act on the central nervous system and psychotropic drugs. PPO had a prevalence of 81.4%, mainly involving drugs that act on the musculoskeletal and cardiovascular systems. Logistic regression analysis showed that the predictors of PIM were female gender, hospital admission and the number of medications taken. In turn, PPO was significantly associated with CCI and a recent history of fractures. Finally, we explored differences in the prevalence and associated factors of PIM and PPO between the patients aged 75–84 years and the oldest-old patients (i.e., aged 85 or over). The oldest-old patients were more dependent on activities of daily living and had a higher CCI. However, patients aged 75–84 patients took more daily drugs and had higher oral doses; additionally, patients in this age group were more likely to have been hospitalized and to be obese. Although PIM was lower in older patients (≥85 years), the prevalence of PIM and PPO did not differ significantly between the two age groups. The most prevalent cases of PIM and PPO were the same, but older patients with a history of falls were more likely to have a PPO associated with an omitted vitamin D prescription. Logistic regression analysis showed that the number of medications was a common predictor of PIM. For PPO, male gender and risk of falls were predictors in the 75–84 age group, while number of comorbidities was a predictor in the group aged 85 or over. This study aims to improve the quality of healthcare provided to the elderly by highlighting the need to optimise drug therapy with a holistic but individualised approach. The dynamic interaction between ageing, multimorbidity, polypharmacy and inappropriate prescribing can result in significant harm, both economically and, more importantly, in terms of patients' lives. Adopting good prescribing practices alongside the early identification of PIM and PPO could reduce risks and improve patients' health outcomes. Furthermore, identifying predictors of inappropriate prescribing could provide valuable information for the development of future health policies and clinical practices tailored to Portugal's growing elderly population.