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Adjusting the START/STOPP to Nursing Home Patients

Medication Appropriateness for Elderly Nursing Home Residents With a Limited Life Expectancy: Adjusting the START/STOPP criteria by means of a Delphi consensus study

Karin Pouw, Martin Smalbrugge, Jacqueline Hugtenburg, Rob van Marum, Cees Hertogh

De abstractcommissie heeft op verzoek van de congrescommissie 5 abstracts geselecteerd die tijdens het Verenso najaarscongres 'Specialist ouderengeneeskunde in the lead' op 30 november 2017 middels een flitspresentatie gepresenteerd worden. Onderstaande abstract is daar een van.


Nursing home (NH) residents are generally (very) old. They suffer from multi-morbidity and often use a large number of drugs. The Screening Tool to Alert to Right Treatment (START) and Screening Tool of Older Persons’ Prescriptions (STOPP) are commonly used tools to enable physicians to assess medication appropriateness. However, these may not be applicable for frail NH elderly with a limited remaining life expectancy as they were developed for all older patients.


To adjust the current START/STOPP criteria to elderly NH patients with a limited remaining life expectancy. 


Online Delphi consensus study with an international expert panel .


The study was based on the 2015 START/STOPP criteria.1 Successive online rounds were submitted to the panel using SurveyMonkey between January and August 2017. We invited international pharmacists or pharmacologists, geriatricians, elderly care physicians, general practitioners, and researchers with clinical and/or research expertise on the subject. The START and STOPP criteria were presented with the indication and treatment goal. The experts considered for each medication(group) whether it would be appropriate to start this for patients from the target group (NH residents with a maximum life expectancy of 1.5-2 years) and if not, whether it would be appropriate to stop it (on 4-point Likert Scales). They also provided written comments on their decision. Consensus was defined as ≥70% of the participants answering (very)inappropriate or (very)appropriate. Participants were also asked to offer suggestions for additions or adjustments to the STOPP criteria. In the subsequent rounds, the panel gave their opinion on criteria for which consensus had not yet been achieved.

(Preliminary) Results

23 participants from 11 different countries participated in the study. During the first round, 16 of the 37 presented START items were considered (very) appropriate by consensus, against three (very) inappropriate. Furthermore, participants offered suggestions for alterations and additions to the STOPP criteria. The final results are expected at the end of August 2017.


The results will be used to develop adjusted START/STOPP criteria, which may assist physicians with appropriate prescribing. These adjusted criteria will be applied in the IMPETUS cluster randomized controlled trial, aimed at increasing mediation appropriateness of NH residents with a limited remaining life expectancy in the Netherlands. 


  • C.A.M. Pouw, Msc, aioto ouderengeneeskunde, VUmc – afdeling huisartsgeneeskunde & ouderengeneeskunde, Amsterdam
  • M. Smalbrugge, VUmc – afdeling huisartsgeneeskunde & ouderengeneeskunde, Amsterdam
  • J.G. Hugtenburg, VUmc – afdeling klinische farmacologie @apotheek, Amsterdam
  • R.J. van Marum, VUmc – afdeling huisartsgeneeskunde & ouderengeneeskunde, Amsterdam
  • C.M.P.M. Hertogh, VUmc – afdeling huisartsgeneeskunde & ouderengeneeskunde, Amsterdam


  1. O'mahony D, O'sullivan D, Byrne S, O'connor MN, Ryan C, Gallagher P: STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age and Ageing 2015.
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