Use of STOPP Toolkit: background and review of application in practice at
East Parade surgery October 2015.
Background
‘STOPP’ stands for Screening Tool of Older People’s potentially inappropriate Prescriptions. This
was originally devised in 2008, and has been thoroughly reviewed and updated in 2014:
http://ageing.oxfordjournals.org/content/early/2014/10/16/ageing.afu145
The medications included in the STOPP criteria are significantly associated with adverse drug
reactions. Applying STOPP criteria during acute hospital admission has been shown to significantly
improve medication appropriateness 6 months post intervention and reduce adverse drug reactions.
The tool is validated for patients over 65, but is specifically recommended in patients considered to
be ‘frail’. The tool identifies markers of frailty and reviews medications, giving recommendations on
reviewing these for interactions, and side effects and drugs to consider stopping or dose reduction.
There is a second tool used in conjunction with ‘STOPP’ called ‘START’ which gives recommendations
on suitable drugs that should be considered. This does not form part of the STOPP tool kit on
System One so has not been assessed.
Frailty is currently a ‘hot topic’ with the British Geriatric Society in conjunction with the RCGP having
published their ‘Fit for Frailty’ Best Practice Guidance for the care of older people living with frailty
in community and outpatient settings in 2014:
http://www.bgs.org.uk/index.php/resources-6/bgscampaigns/fit-for-frailty
Conducting a personalised, evidence based medication review is one of the key recommendations of
the guidance. The STOPP/START tool is recommended as one way to assist with this.
Trial of System One STOPP protocol at East Parade
22 residents of a local nursing home were chosen for the initial trial of the tool. This group was
picked because they all fulfil the criteria for frailty.
STOPP Alerts were generated in 15 of the 22 patients. No concerns were identified in the
remaining 7 patients.
Single alerts (12 patients)
Alert
Review use of PPI for uncomplicated
peptic ulcer disease or erosive peptic
oesophagitis at full therapeutic
dosage for > 8 weeks (dose reduction
or earlier discontinuation indicated)
Number of
patients
4 patients
Review drugs likely to cause
constipation in patients with chronic
constipation.
2 patients
Review hypnotics
Review use of acetylcholinesterase
inhibitors is a patient with known
heart block OR on concurrent
treatment with drugs that reduce
heart rate
Review antimuscarinics for OAB in
patients with concurrent dementia /
cognitive impairment / narrow angle
glaucoma or chronic prostatism
Review loop diuretic in patient
without heart failure diagnosis
Review loop diuretic in patient with
urinary incontinence
Review use of vasodilating drugs in
patient with persistent postural
hypotension
1 patient
1 patient
Action Taken
Stopped completely for one patient as
no clear indication.
Dose reduced to maintenance level for
the 3 other patients who were all on
concurrent anti-coagulation (NICE CKS
recommends low dose PPI in patients at
high risk of GI side effects
http://cks.nice.org.uk/antiplatelettreatment#!scenariorecommendation )
No changes made as little scope to do so
(one patient required current level of
opiate pain relief, and the other had iron
deficiency anaemia so iron therapy was
appropriate)
Attempt made to tackle this again
Betablocker stopped as this patient had
ongoing hypotension and falls.
1 patient
Stopped, with review of symptoms
planned.
1 patient
Stopped as no obvious indication to
remain on this
Continued as required diuretics for
symptomatic treatment for heart failure.
Continued because her BP had recently
been monitored on and off treatment on
ongoing use considered appropriate
1 patient
1 patient
Multiple alerts (3 patients)
Alerts
3 Alerts:
Long term use of PPI.
Number of
patients
1 patient
Reduce lansoprazole to 15mg (on
warfarin).
Regular use of cyclizine reviewed, but
continued as still needed and appears
to be effective.
Stop repeat of codeine as rarely using.
Use of first generation antihistamine.
Constipating agents.
5 Alerts:
Action Taken
1 patient
Loop diuretics and incontinence
Continue furosemide 40mg as HF
symptoms better with this dose.
Continue prn codeine as cannot tolerate
other pain relief.
Try lower dose amitriptyline with a view
to stopping.
Reduce lansoprazole to 30 mg od
initially, with a view to cutting down to
15mg.
Reduce dose bisoprolol as BP tends to be
low
Constipating agents
Tricyclics – avoid first line for
depression
Long term PPI
Vasodilators / postural hypotension
3 Alerts:
Tricyclics in patient with dementia
Hypnotics
Constipating agents
1 patient
Reduce amitriptyline back to 25mg with
a view to further reductions.
Discuss lower dose zopiclone once
amitriptyline tackled.
Quantities of tramadol on repeat
reduced.
Overall 5 drugs were stopped completely and dose reductions were made for another 8 drugs, with
plans to review further for 3 of these. 7 drugs were reviewed and continued use felt justified.
Conclusions
The STOPP protocol appears to be a useful tool in helping to identify inappropriate prescribing that
might otherwise have been overlooked. In particular, avoiding long term used of treatment dose PPI
has been a useful learning outcome, and there appears to be scope for wider application of this
prescribing point, which was flagged up in 6 out of 22 patients. This tool is most likely to be useful
when GPs are doing annual reviews or medication reviews of care home patients, care plan patients,
and any other patients with identified frailty.
Further Actions
Follow up audit planned in 2 months time to review any adverse outcomes of cessation of
medication, and any items that have been recommenced.
Emma Huskins, salaried GP, October 2015