One of the tools most widely used by pharmacists is the Medication Appropriateness Index (MAI). This tool was introduced in 1992 and modified in 2010.26‐29 It regards each medication individually, assessing 10 important aspects of medication use using a Likert scale to rate appropriateness and providing a single score to help identify inappropriate medications that can be targeted for deprescribing. The 10 items addressed are as follows:
1 Recognize if there is a clear indication for such medication.
2 Gauge the effectiveness of such medication for the condition.
3 Address if the dosage is correct.
4 Confirm that the directions are correct.
5 Assess if such directions are practical and doable to put into practice.
6 Evaluate for clinically significant drug–drug interactions.
7 Evaluate for clinically significant drug–disease or condition interactions.
8 Assess if there is unnecessary duplication with another treatment.
9 Evaluate if the duration of the therapy is acceptable.
10 Assess if such medication is the least expensive alternative compared to others of equal utility.
The answers lead to three rating choices (three‐point Likert scale):
A = appropriate
B = marginally appropriate
C = inappropriate
A maximum score of 18 is related to a level of ‘maximum inappropriateness’. While this tool is very comprehensive and well‐validated and has been shown to identify more problematic medications than the Beers Criteria, it is time‐consuming, requires more clinical expertise than other tools, and does not help the clinician prioritize drugs for deprescribing. For this reason, it is most often used in research settings or for teaching clinical trainees learning how to conduct reviews of complex drug regimens in a stepwise manner.27,28
The Pill Pruner checklist was introduced in 2009 and designed to be ‘a simple medication guide based on STOPP criteria’.30 It consists of a list of 13 commonly prescribed medications printed on a pocket‐sized card for use in assessing medication appropriateness in frail, hospitalized older adults:
1 Loop diuretics (‘only for patients with heart failure, not venous insufficiency’)
2 Thiazides (‘not in patients with hyponatremia, gout, or venous insufficiency’)
3 Calcium antagonists (‘not in patients with heart failure/constipation/postural hypotension’)
4 Alpha blockers / labetalol (‘not in patients with postural hypotension/falls/turns’)
5 Anti‐platelet drugs (‘not in patients with GI bleeding or funny turns without focal neurology’)
6 Tricyclic antidepressants (‘not in patient with confusion, constipation, postural hypotension, urinary retention’)
7 Benzodiazepines (‘not in patients with confusion, falls’)
8 Anticholinergics (‘not in patients with confusion, falls, constipation’)
9 Antihistamines (‘not in patients with confusion, falls’)
10 SSRIs (‘not in patients with confusion, hyponatremia, falls’)
11 Antipsychotics (‘not in patients with parkinsonism, epilepsy, falls’)
12 NSAIDS (‘not! Avoid if at all possible’)
13 Proton pump inhibitors (‘not unless clear history of reflux, ulcers’)
Research showed that the routine use of the Pill Pruner tool safely limits the number of medications taken by older patients on admission to the hospital, reduces the number of medications on hospital discharge, and reminds about the need to communicate medication changes to the patient’s primary practitioner by ensuring that the hospital discharge summary accurately reflects the medications changes made in the hospital.30 In the original study, patients were followed up at 90 days post‐hospital discharge, and the changes made while in the hospital were maintained as an outpatient.
The Drug Burden Index (DBI) was introduced in 200731 and is designed to measure cumulative exposure to anticholinergic and sedative medications, including its impact on physical and cognitive function.32,33 Despite its limitations (see Table 10.3), the DBI is useful for predicting the risk of ADRs, as a high DBI has been correlated with an increased risk for functional decline in community‐dwelling older adults and an increased risk of falls in residents of long‐term care facilities.33‐35
The Tool to Reduce Inappropriate Medications (TRIM) was developed in 2016 at the US Veterans Affairs (VA) Medical Center.36 TRIM uses a computer algorithm based on Beers and STOPP criteria to identify PIMs and provide recommendations for medication discontinuation. The computer programme extracts information from the electronic health record related to age, medications, and chronic medical conditions, identifying high‐risk patients and providing feedback reports to clinicians for evaluating the medication regimen. These algorithms identify medication regimen discrepancies, poor treatment adherence, potential overtreatment of diabetes and hypertension, inappropriate drug renal dosing, and a list of patient‐reported medication‐related adverse reactions.36 While TRIM has only been validated in the