Potentially Inappropriate Medication Use in Multimorbid Elderly Inpatients: Differences Between the FORTA, PRISCUS and STOPP Ratings
Potentially Inappropriate Medication Use in Multimorbid Elderly Inpatients: Differences Between the FORTA, PRISCUS and STOPP Ratings
Beate Wickop 0 1 2 3
Steffen Ha¨ rterich 0 1 2 3
Christian Sommer 0 1 2 3
Anne Daubmann 0 1 2 3
Michael Baehr 0 1 2 3
Claudia Langebrake 0 1 2 3
0 Medical Biometry and Epidemiology, University Medical Centre Hamburg Eppendorf , Martinistrasse 52, 20246 Hamburg , Germany
1 Hospital Pharmacy, University Medical Centre Hamburg Eppendorf , Martinistrasse 52, 20246 Hamburg , Germany
2 & Beate Wickop
3 Department for Stem Cell Transplantation, University Medical Centre Hamburg Eppendorf , Martinistrasse 52, 20246 Hamburg , Germany
Background Several classifications to identify and avoid use of potentially inappropriate medications (PIMs) in the elderly have been published. To what extent these classifications match each other and whether there are differences in the prevalence of PIM use at admission, during the inpatient stay and at discharge are largely unreported. Objectives To determine the PIM prevalence in elderly patients at a university hospital, with a special focus on different classification systems and the chronological sequence, and to examine a possible association between PIM use and the reason for admission, as well as severe side effects and consequences of PIM use during hospitalization.
Methods On the basis of the criteria provided by FORTA
(Fit for the Aged), PRISCUS (Latin for ‘time-honoured’)
and STOPP (Screening Tool of Older Persons’ Potentially
Inappropriate Prescriptions), medication in patients over
the age of 65 years was screened retrospectively within
four point prevalence analyses at admission, during the
inpatient stay and at discharge. Evaluation of a possible
association between PIM use and the primary diagnosis or
severe side effects during hospitalization was performed
according to an analysis using the World Health
Organization Uppsala Monitoring Centre system for standardized
case causality assessment.
Results Of 200 patients, 176 (88 %) received at least one
PIM at admission, during the inpatient stay and/or at
discharge (116 patients according to FORTA, 113
according to PRISCUS and 138 according to STOPP).
When the PIM prevalence was compared between the
three different sets of criteria, STOPP identified
significantly more patients receiving PIMs than FORTA
(P = 0.022) and PRISCUS (P = 0.010). At the patient
level and at the drug level, the use of PIMs increased
during the inpatient stay; however, the PIM prevalence
was similar at admission and at discharge, both at the
patient level and at the drug level.
Conclusion Medication is rated significantly differently
by FORTA, PRISCUS and STOPP. In addition, a
significant rise in prescribing of PIMs during the inpatient stay
illustrates that a reduction in PIM use during the inpatient
stay is essential, as it is known that avoiding PIM use in
older adults is one strategy to decrease the risk of adverse
The Author(s) 2016. This article is published with open access at Springerlink.com
Three sets of criteria—FORTA (Fit for the Aged),
PRISCUS (Latin for ‘time-honoured’) and STOPP
(Screening Tool of Older Persons’ Potentially
Inappropriate Prescriptions)—rate drugs as
potentially inappropriate medications (PIMs) quite
differently. A comparison of FORTA, PRISCUS and
STOPP showed that there are significant differences
Especially during the inpatient stay, the prescribing
of PIMs was shown to be high. As it is known that
avoiding PIM use in older adults is one strategy to
decrease the risk of adverse events, a reduction in
PIM use during the inpatient stay is essential.
Polypharmacy has been identified as a risk factor for
use of PIMs, so reducing the total number of
prescribed drugs might be a starting point to reduce
Elderly people often suffer from multiple co-morbidities,
which predispose them to potentially harmful
polypharmacy and inappropriate prescribing. Therapy based on
guidelines can be problematic and is rarely examined in
clinical trials in elderly patients. In addition, alterations in
pharmacokinetics and pharmacodynamics, due to the
advanced age of patients, have to be considered [
]. As a
result, the elderly are particularly vulnerable to certain
drugs—e.g. long-acting benzodiazepines, which might
result in prolonged sedation and increase the risk of falls
]. Therefore, these drugs are classified as potentially
inappropriate medications (PIMs) for the elderly because
they carry an increased risk of adverse drug events and
result in major patient safety concerns. Several
classifications have been published to identify and avoid PIM use. In
the USA, the Beers list is the prevailing one [
]. In Europe,
several sets of criteria have been published. In our study,
the following three screening tools were chosen to identify
PIMs: FORTA (Fit for the Aged) [
], PRISCUS (Latin for
] and STOPP (Screening Tool of Older
Persons’ Potentially Inappropriate Prescriptions) [
because they have been shown to be suitable for the
German pharmaceutical market.
In several studies, STOPP and the Beers criteria have
been applied to detect PIM use [
]. One study has
compared PRISCUS with Beers and STOPP [
], and in a
recent study, the overlap between different sets of criteria
was shown to be small [
However, to our knowledge, FORTA, PRISCUS and
STOPP have not been applied to one patient collective
simultaneously. The objective of the present study was to
determine which PIMs are used by elderly patients at the
University Medical Centre Hamburg Eppendorf (UKE) and
how the prevalence of PIM use changes from admission
over the course of the inpatient stay to discharge. In
addition, a possible association between PIM use and the
primary diagnosis/reason for admission, as well as severe
adverse events and consequences of PIM use during
hospitalization, were examined. This information was then
used to develop a practical tool for minimizing PIM use.
2.1 Setting and Participants
The study was conducted at UKE, a university hospital
with 1460 beds. On the basis of the criteria provided by
FORTA, PRISCUS and STOPP, medication use in patients
above the age of 65 years was screened retrospectively
within four point prevalence analyses (distributed equally
over one year in September 2011, December 2011, May
2012 and July 2012) at admission, during the inpatient stay
and at discharge. Patients were included in the study if they
were admitted via the emergency department and had at
least five drugs prescribed at admission. Patients were not
eligible if they were admitted because of a malignant
disease or had undergone solid organ or stem cell
Medication data were recorded using Anatomical
Therapeutic Chemical (ATC) classification codes [
reason for admission and all diagnoses were coded
according to the International Statistical Classification Of
Diseases And Related Health Problems, 10th revision,
German Modification (ICD-10-GM), version 2012 [
Information on medication use at admission was
extracted from the admission form in each electronic
patient record (Soarian Clinicals, Erlangen, Germany). If
it was not recorded there, medication use at day 1 during
the hospital stay was graded as medication use at
admission, leaving out acute medication, such as antibiotics or
analgesics. Information on medication use at discharge was
extracted from the discharge letter. Information on all
drugs used during the hospital stay could be obtained from
the computerized physician order entry (CPOE) ATCHost
(Baxter, Utrecht, the Netherlands). Details of the
medication were recorded in a database and correlated with the
diagnoses and reason for admission.
2.2 Classification Systems for PIMs
The FORTA drug classification system assigns positive and
negative labels (ranging from class A to class D) to 190 of
the substances most frequently used for long-term drug
therapy in older patients, according to the state of evidence
as to risk/benefit and age appropriateness. FORTA was
validated in 2014 [
The PRISCUS list was created for the German
pharmaceutical market on the basis of expert knowledge, using
the Delphi technique. Eighty-three drugs in a total of 18
drug classes are rated as potentially inappropriate for
elderly patients [
STOPP 2008 comprises 65 clinically significant criteria
for potentially inappropriate prescribing in older people.
The STOPP criteria are arranged according to the relevant
physiological systems, for ease of use. Each criterion is
accompanied by a concise explanation as to why the
prescription is potentially inappropriate. Eighteen experts in
geriatric pharmacotherapy were recruited to establish the
content validity of STOPP by a Delphi consensus method
2.3 Data Analysis
Statistical analyses were performed using Microsoft
Office Access 2010, Microsoft Office Excel 2010 and
SAS (Statistical Analysis System) version 9.4 (SAS
Institute Inc., Cary, NC, USA). The two-sided significance level
was set at 5 % (P B 0.05).
The primary objectives of the study (which PIMs are
used by elderly patients at UKE, and how the prevalence of
PIM use changes from admission over the course of the
inpatient stay to discharge) were evaluated using mixed
logistic regression with the binary endpoint of PIM use
(yes or no) and a mixed Poisson regression with the
number of PIMs as the endpoint to examine statistically
significant differences. PIM use was studied in total and
separately on the basis of the FORTA, PRISCUS and
Subgroup analyses were performed concerning age, sex,
previous residential situation, number of prescribed drugs,
length of the hospital stay, and hospital stay in a surgical
ward versus an internal medicine ward. Metric variables
Evaluation of a possible association between PIM use
and the primary diagnosis or severe side effects during
hospitalization (secondary objectives) was performed
according to an analysis using the World Health
Organization Uppsala Monitoring Centre (WHO-UMC) system
for standardized case causality assessment [
causality assessment was performed independently by three
pharmacists. Different ratings were discussed until a
consensus was reached. Severe side effects were rated
according to the US Food and Drug Administration
definition of grade 3: severe or medically significant but not
immediately life threatening; hospitalization or
prolongation of hospitalization indicated; disabling; limiting
selfcare activities of daily living.
To assess severe side effects and consequences of PIM
use during hospitalization, all clinical records of the
patients were checked, e.g. concerning documented falls.
3.1 Study Population
The characteristics of the patients and the number of PIMs
used per patient according to the FORTA, PRISCUS and
STOPP criteria are presented in Table 1. In summary, 200
patients were included in the study, the average age was
78.8 years and 61 % of the patients were female.
FORTA (Fit for the Aged), PIM potentially inappropriate medication,
PRISCUS [Latin for ‘time-honoured’], SD standard deviation,
STOPP (Screening Tool of Older Persons’ Potentially Inappropriate
The most common reasons for hospitalization were
fractures (N = 35), strokes (N = 12), left-ventricular heart
failure (N = 11) and secondary right ventricular heart
failure (N = 10).
Of 200 patients, 176 (88 %) received at least one PIM at
admission, during the inpatient stay and/or at discharge.
The median number of PIMs received by the patients
was 4, ranging from 0 (in 12 % of patients) to 8 (in 1 % of
patients). Most patients received 1 PIM (in 28 %) or 2
PIMs (in 22 %) during the study period (see Table 2).
In total, 116 patients received FORTA PIMs, 113
patients received PRISCUS PIMs and 138 patients
received STOPP PIMs. Eight patients received only
FORTA PIMs, 19 patients received only PRISCUS PIMs
and 23 patients received only STOPP PIMs. Eleven
patients received FORTA ? PRISCUS PIMs, 32 patients
received FORTA ? STOPP PIMs, 18 patients received
PRISCUS ? STOPP PIMs and 65 patients (37 % of all
patients receiving PIMs) received FORTA ? PRISCUS ?
STOPP PIMs (see Fig. 1).
3.2 Primary Objectives
Which PIMs are used by elderly patients at UKE, and how
does the PIM prevalence change from admission to
The PIMs prescribed most often were zopiclone
(N = 63; PRISCUS), acetylsalicylic acid (N = 23;
STOPP), lorazepam (N = 22; FORTA, PRISCUS and
STOPP), amlodipine (N = 21; STOPP) and ibuprofen
(N = 20; FORTA and STOPP). When grouped according
to level 3 ATC codes, drugs from the group of hypnotics
and sedatives were by far the most commonly used
(N = 84).
At admission, 126 patients (63 %) received at least one
PIM. During the inpatient stay, 168 (84 %) received at
Fig. 1 Venn diagram showing the degrees of overlap between the
FORTA, PRISCUS and STOPP tools in terms of potentially
inappropriate medications (PIMs) identified; 65 patients (37 % of
all patients receiving PIMs) received FORTA ? PRISCUS ?
STOPP PIMs. FORTA (Fit for the Aged), PRISCUS [Latin for
‘time-honoured’], STOPP (Screening Tool of Older Persons’
Potentially Inappropriate Prescriptions)
least one PIM. At discharge, 126 (63 %) received at least
one PIM. Multiple classifications were possible (see
Concerning drugs, the PIM proportion of the total
number of medications was 12.5 % (463 of 3717); 12.7 %
of drugs (223 of 1757) at admission, 11.9 % (397 of 3324)
during the inpatient stay and 10.5 % (217 of 2068) at
discharge were regarded as PIMs (see Fig. 2b).
To summarize, at the patient level and at the drug level,
the numbers of PIMs rose during the inpatient stay. At the
patient level, it could be shown that the differences were
significant (P \ 0.0001) between admission and the
inpatient stay, as well as between the inpatient stay and
discharge. At the drug level, the rise in the overall number of
prescribed drugs during the hospital stay has to be
considered. Nevertheless, the numbers of PIMs differed
significantly between admission and the inpatient stay
(P = 0.0087), as well as between the inpatient stay and
discharge (P = 0.0091) (see Fig. 2a, b).
Within FORTA, PRISCUS and STOPP, significant
changes could be found at the patient level from admission
to the inpatient stay, as well as from the inpatient stay to
discharge, concerning FORTA PIMs (P = 0.0071 and
P = 0.0007, respectively) and PRISCUS PIMs (both
P \ 0.0001). For STOPP PIMs, the difference was
significant only between admission and the inpatient stay
(P = 0.0214). The difference between admission and
discharge was not significant in any classification system. At
the drug level, a significant difference in prescribing of
PRISCUS PIMs could be shown between admission and
the inpatient stay (P = 0.0060) and between the inpatient
stay and discharge (P = 0.0005); for STOPP PIMs, a
a Patient level
b Drug level
12.7 %: 223 of 1757 drugs
98 (44 %)
55 (25 %)
163 (73 %)
11.9 %: 397 of 3324 drugs
157 (40 %)
161 (41 %)
224 (56 %)
10.5 %: 217 of 2068 drugs
88 (41 %)
58 (27 %)
158 (73 %)
significant difference could be shown between admission
and the inpatient stay (P = 0.0023).
When FORTA, PRISCUS and STOPP were compared
with each other, significant differences in the numbers of
PIMs could be shown at admission and at discharge
between all sets of criteria at the patient level and at the
drug level. During the inpatient stay, no significant
difference concerning the numbers of PIMs was found
between FORTA and PRISCUS (see Table 3).
Concerning individual PIMs, it can be stated that at
admission, acetylsalicylic acid (N = 19; STOPP), followed
by amlodipine (N = 15; STOPP) and prednisolone
(N = 12; FORTA and STOPP) were the PIMs prescribed
FORTA (Fit for the Aged), NS not significant, PRISCUS [Latin for ‘time-honoured’], STOPP (Screening Tool of Older Persons’ Potentially
During the inpatient stay, zopiclone was classified as a
PIM (N = 60; PRISCUS) most often (at admission, N = 8
only), followed by amlodipine (N = 22; STOPP) and
lorazepam (N = 17; FORTA 17, STOPP 6 and PRISCUS 3).
At discharge, amlodipine (N = 20), followed by
acetylsalicylic acid (N = 16) and risperidone (N = 12),
were the PIMs prescribed most often, all according to the
STOPP rating, as was risperidone, according to the FORTA
rating. Zopiclone (N = 7; PRISCUS) was ranked only
When grouped according to level 3 ATC codes, drugs
classified as hypnotics and sedatives were by far the most
commonly used (N = 84). At admission, they were
prescribed less frequently (N = 13). Antithrombotic agents
(N = 28; STOPP 26 and PRISCUS 2), antipsychotics
(N = 26; STOPP 23, FORTA 19 and PRISCUS 5) and
antidepressants (N = 20; FORTA 15, STOPP 8 and
PRISCUS 7) were the PIMs prescribed most often at
admission (see Table 4).
During the inpatient stay, hypnotics and sedatives were
prescribed most often (N = 80; PRISCUS 80, FORTA 11
and STOPP 7), followed by antipsychotics (N = 39;
FORTA 30, STOPP 30 and PRISCUS 6) and selective
calcium channel blockers with mainly vascular effects
(N = 33; STOPP 30 and PRISCUS 6).
At discharge, drugs classified as antipsychotics were
prescribed most often (N = 26; STOPP 23, FORTA 19
and PRISCUS 3), followed by selective calcium channel
blockers with mainly vascular effects (N = 24; STOPP 23
and PRISCUS 2) and antidepressants (N = 23;
FORTA 18, STOPP 10 and PRISCUS 9).
Subgroup analyses exhibited significant differences in:
STOPP concerning sex (P = 0.0324). More women
were receiving STOPP PIMs.
PRISCUS (P = 0.0435) and STOPP (P = 0.0384)
concerning the previous residential situation. Patients
living at home were prescribed more PIMs according to
PRISCUS but fewer PIMs according to STOPP, in
comparison with patients living in nursing homes.
FORTA (P = 0.0034) and PRISCUS (P \ 0.0001)—as
well as the total (P = 0.0092)—concerning the number
of prescribed drugs. The more drugs were prescribed,
the more PIMs were prescribed as well.
PRISCUS (P = 0.0298) concerning the length of the
hospital stay. A longer hospital stay was related to
prescription of more PIMs.
STOPP (P = 0.0010) concerning the hospital stay in a
surgical ward versus an internal medicine ward. More
STOPP PIMs were prescribed for patients staying in
3.3 Secondary Objectives
Is there a possible association between PIM use and the
primary diagnosis/reason for admission, as well as severe
side effects and consequences of PIM use during
Following an analysis using the WHO-UMC system for
standardized case causality assessment, an association with
the reason for admission could be found for amlodipine (in
10 of 15 patients) most often, followed by risperidone (in 6
of 9 patients), lorazepam (in 4 of 6 patients) and diclofenac
(in 2 of 5 patients). These PIMs had severe side effects
during the inpatient stay, such as falls following
amlodipine, lorazepam and risperidone intake, and gastrointestinal
bleeding following non-steroidal anti-inflammatory drug
Applying both the results reported herein and an
analysis of the available literature, a standardized workflow
could be established to minimize the prescription of PIMs.
This tool, designated as GERAS (Geriatrische
Arzneimitteltherapie-Sicherheit [German for ‘geriatric medication
safety’]), is used in routine clinical practice at UKE.
GERAS consists of five items, is illustrated on just one
page and is more a guidance for clinical situations than a
list of single substances. For example, in item 4
(‘Procedure for insomnia’), it is recommended that in patients
aged over 65 years, the dosage of zopiclone should be
limited to 3.75 mg. GERAS is provided in the Electronic
In the present study, FORTA, PRISCUS and STOPP were
applied simultaneously to one collective of patients for the
first time. These three sets of criteria were chosen because
they have been shown to be suitable for the German
An overall PIM prevalence of 88 % was found. In
Germany, the PIM prevalence in elderly patients found in
other investigations has ranged between 16 and 67 %
]. Most studies have been conducted in the
community/outpatient setting. Siebert et al. [
] found a
PIM prevalence of 43 % according to the PRISCUS rating
and 67 % according to the STOPP rating in a geriatric
rehabilitation clinic. In particular, drugs from the group of
hypnotics and sedatives, as well as antidepressants, have
been identified as PIMs in many studies [
8, 10, 16
]. This is
in accordance with the results of the present study. The
reason for the observed high PIM prevalence might be that
the study inclusion criteria included multimorbid patients
receiving polypharmacy. In addition, if the PIM ratings
according to FORTA, PRISCUS and STOPP are
considered, it should be noted that the three sets of criteria rate
drugs as PIMs quite differently. This also contributed to the
high PIM prevalence in the present study. The intersections
between the different sets of PIM criteria were quite small,
which resulted in a greater number of medications being
identified as PIMs.
Significant differences could be found at both the patient
level and the drug level. Whereas PRISCUS primarily rates
drugs from the group of hypnotics and sedatives as PIMs,
FORTA and STOPP particularly rate antipsychotics and
NSAIDs as PIMs. NSAIDs were striking in an
investigation by Gallagher and O’Mahony [
] as well. Gallagher and
] and Dormann et al. [
] also rated
amlodipine as negative or as being associated with adverse
events. In the present study, amlodipine was evaluated as a
‘vasodilator drug’ in accordance with STOPP and ranked
as a PIM in all patients who were admitted to hospital
because of a fall (even if postural hypotension could not
always be identified as its cause), because of the
retrospective design of the study. This possibly led to an
increased negative rating but ensured a consistent rating
within the study.
In the present study, a significant rise in use of PIMs
during the inpatient stay was detected. A similar finding
was also reported by Siebert et al. [
] and might be
explained by the increased (temporary) use of hypnotics
and sedatives during the inpatient stay. The increased use
of potentially inappropriate analgesics during the inpatient
stay also adds to this point.
The significant rise in PIM use from admission to the
inpatient stay and the significant decrease from the
inpatient stay to discharge illustrate that a reduction in
prescribing of PIMs during the inpatient stay is essential, as it
is known that avoiding PIM use in older adults is one
strategy to decrease the risk of adverse events.
Reducing the total number of prescribed drugs might be
a starting point, as a subgroup analysis of this study
revealed that an increase in the number of prescribed drugs
had a significant effect on the number of PIMs prescribed.
Polypharmacy is a risk factor for PIM use. This has also
been reported in several other studies [
7, 9, 18, 20–28
Concerning the causality between PIM use and the
reason for admission, amlodipine and risperidone were the
prevailing ones. These drugs were also associated with
adverse events in the study by Dormann et al. [
]. As they
used PRISCUS to identify PIMs, amlodipine and
risperidone were rated as non-PIMs in that study. Concerning
PRISCUS PIMs, acetyldigoxin, diazepam, tetrazepam and
zolpidem were associated with falls in the study by
Dormann et al. [
]. In the study by Gallagher and O’Mahony
], which used the STOPP criteria, overt digoxin toxicity
with high-dose digoxin and renal impairment, upper
gastrointestinal bleeding with inappropriate NSAID use, and
falls with inappropriate psychotropic use could be
identified as causal or contributory to admission. In the present
study, NSAIDs were also found to be potentially causal for
During the inpatient stay, use of lorazepam, risperidone,
mirtazapine, zopiclone and dimenhydrinate was associated
with falls. Therefore, hypnotics and sedatives seem to be of
Nevertheless, it has to be stated that PIMs are only
potentially (not definitely) inappropriate, and that detailed
clinical judgment is always needed, based on a full review
of the medical record.
4.1 Comparison of FORTA, PRISCUS and STOPP
Negative lists such as PRISCUS, which provide an explicit
listing of drugs, independent of the diagnosis, are easy to
use—the main advantage being good practicability. On the
other hand, constant updates are needed, and such lists
carry the risk of an assumption that drugs not listed would
be appropriate in every case. As an example, the NSAID
indometacin is listed, but diclofenac is not. In particular,
the STOPP criteria have the advantage of greater flexibility
due to a waiver of indexing certain drugs, so international
transferability is assured, and an adaption to current market
conditions is not necessary. In addition, contraindications
and duplicate prescriptions can also be identified using
STOPP. As a critical note regarding STOPP, it can be
stated that use of the criteria is sophisticated, and a gradual
rating is not possible. FORTA allows a disease-related
evaluation revealing over-treatment and under-treatment,
and substances rated negatively as class D can be replaced
by more suitable substances in class A or class B.
The three sets of criteria have in common that they refer
to long-term medication. Drugs frequently used during the
inpatient stay, such as antibiotics, are hardly taken into
account. The only antibiotic listed by PRISCUS is
The superiority of more complex criteria, such as
STOPP, to negative lists has already been demonstrated by
Hamilton et al. [
] with respect to adverse events and
resulting hospital admissions.
In the present study, in 176 of 200 patients, at least one
PIM in their medication was found: in 116 patients according
to FORTA, in 113 patients according to PRISCUS and in 138
patients according to STOPP. So, the largest number of PIMs
were identified by STOPP. It is striking that medication is
rated quite differently by the three sets of criteria. A
comparison between FORTA, PRISCUS and STOPP showed that
there are significant differences between them. Thus, the
present study confirms the superiority of STOPP to purely
negative lists, as has also previously been shown by
Gallagher and O’Mahony [
] and Hamilton et al. [
compared the STOPP and Beers criteria.
Looking at PIM use related to the reason for admission,
FORTA identified 30 possible and 50 unlikely
relationships, PRISCUS identified 9 possible and 19 unlikely
relationships, and STOPP identified 50 possible and 66
unlikely relationships. In percentage terms, FORTA
identified 38 % possible PIM–adverse drug event associations,
PRISCUS identified 32 % and STOPP identified 43 %.
With the implementation of the new practical tool
GERAS in routine clinical practice at UKE, the rate of
zopiclone 7.5 mg being the most frequently prescribed
PIM in the present study could be reduced from 30 to 7 %
Because of the retrospective design of the study, only
events documented in the patient record were considered,
so the rate of adverse events might have been higher in
reality. In addition, only possible associations following
the WHO-UMC causality categories of PIMs and adverse
events could be stated. Moreover, only the medication
documented in the electronic patient record could be
considered. The study population was quite small, and so
larger, randomized, multicentre studies are needed to
confirm the findings of the present study.
The three sets of criteria—FORTA, PRISCUS and
STOPP—rate drugs as PIMs quite differently. A
comparison between FORTA, PRISCUS and STOPP showed that
there are significant differences between them. In addition,
especially during the inpatient stay, prescribing of PIMs was
shown to be common. As it is known that avoiding PIM use
in older adults is one strategy to decrease the risk of adverse
events, a reduction in PIM use during the inpatient stay is
essential. Polypharmacy was identified as a risk factor for
PIM use, and so reducing the total number of prescribed
drugs might be a starting point to reduce PIM use.
Compliance with Ethical Standards
Conflicts of Interest Beate Wickop, Steffen Ha¨rterich, Christian
Sommer, Anne Daubmann, Michael Baehr and Claudia Langebrake
declare no conflict of interest.
Funding No funding was received for this work.
Ethical Approval Ethical approval was obtained from
Ethikkommission der A¨ rztekammer Hamburg.
Open Access This article is distributed under the terms of the
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License (http://creativecommons.org/licenses/by-nc/4.0/), which
permits any noncommercial use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons
license, and indicate if changes were made.
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