Invited Review

Presenting Turkish Inappropriate Medication Use in the Elderly (TIME) Criteria Set in Turkish


  • Gülistan Bahat
  • Birkan İlhan
  • Tuğba Erdoğan
  • Meltem Halil
  • Sumru Savaş
  • Zekeriya Ülger
  • Filiz Akyüz
  • Ahmet Kaya Bilge
  • Sibel Çakır
  • Kutay Demirkan
  • Mustafa Erelel
  • Kerim Güler
  • Haşmet Hanağası
  • Belgin İzgi
  • Ateş Kadıoğlu
  • Ayşe Karan
  • Işın Baral Kulaksızoğlu
  • Ali Mert
  • Savaş Öztürk
  • İlhan Satman
  • Mehmet Şükrü Sever
  • Tufan Tükek
  • Yağız Üresin
  • Önay Yalçın
  • Nilüfer Yeşilot
  • Meryem Merve Ören
  • Mehmet Akif Karan

Received Date: 18.06.2021 Accepted Date: 30.06.2021 Eur J Geriatric Gerontol 2021;3(2):40-100

Keywords: Elderly, inappropriate medication use, polypharmacy, prescribing, TIME criteria


Older adults are mostly exposed to polypharmacy and inappropriate medication use (IMU) due to the increasing incidence of chronic diseases and geriatric syndromes with aging. Polypharmacy and IMU use are well-known risk factors for adverse drug reactions (1,2).

Although the prevalence and negative consequences of polypharmacy and IMU in older adults have been known for many years, inappropriate drug use in many older adults continues even in first-line treatment. Consideration of pharmacokinetic/pharmacodynamic changes, functional impairment of organs, and the drugs most commonly associated with adverse outcomes can help reduce polypharmacy and inappropriate drug use in older adults. In this context, strategies are developed to prevent inappropriate drug use and polypharmacy in older adults worldwide. Explicit (criteria-based) screening tools and implicit (judgmental) assessment methods are among the tools developed to assist in the management of drug therapy in older adults. Explicit tools provide the user algorithmic approaches that include lists of drugs to avoid or specific indicators of inappropriate drug use (3). They provide information and guidance on optimal drug use. Implicit approaches evaluate the patient with a much broader concept. Research data, clinical conditions, and patient/family preferences are also considered (4). Therefore, implicit assessments offer the most appropriate assessment for the detection of IMU but are difficult to standardize and require much more time, background knowledge, and judgment. For these reasons, explicit rather than implicit approaches have been more widely studied to guide clinicians in the management of the IMU. More than 70 tools from many different countries are described in literature for the assessment of inappropriate prescribing (5-10). Highlights from internationally accepted recommendations to reduce inappropriate drug use include the drug burden index, Beer’s criteria, medication appropriateness index, assessing care of elders project, elderly complex appropriate drug use in patients [criteria to assess appropriate medication use among elderly complex patients (CRIME)] (11) STOPP/START criteria (12) among many others. The most commonly used and studied such criteria are the Beers and STOPP/START criteria.

Prescribing habits differ between the countries and so does the medications available in the market. As such, while the available explicit criteria set for assessing IMU in older adults have provided some important guidance, they had limited benefits due to lack of consideration of circumstances in the countries other than the tool was originated from. To date, there was not any criteria specifically designed from Eastern Europe to aid health care professionals in a better way for optimum prescribing.

Based on this background, we have established Turkish Inappropriate Medication Use in the Elderly (TIME) Criteria with the participation of experienced and expert in the clinical practice of elderly adults in Turkey under the leadership of Rational Drug Use Working Group of the Turkish Academic Geriatrics Society (13). We applied the methodology used to create the STOPP/START tool and classified the criteria as the TIME-to-STOP and TIME-to-START criteria. TIME study group-comprising a national expert group of 49 academics and a national working group of 23 academics conducted the study. The academics were from a wide range of specialties dealing with the care of older adults; 17 members from geriatric medicine; four members from psychiatry; three members each from, general internal medicine, gastroenterology, neurology, cardiology, and pharmacology; two members each from endocrinology, nephrology, urology, physical therapy and rehabilitation; and one member each from clinical pharmacology, pulmonology, infectious diseases, gynecology and ophthalmology. The study was carried out in three phases. In the first phase, STOPP/START v2 and CRIME criteria were combined, and the first draft consisting of 133 criteria was created. At the end of the third phase of the study, 55 new criteria were added, 17 existing criteria were removed, and 60 criteria were modified. Accordingly, the final set of TIME criteria was composed of a total of 153 criteria (112 TIME-to-STOP and 41 TIME-to-START criteria) (13). The fourth phase was the Delphi validation process that validate the tool internationally. An internationally validated TIME criteria set was obtained through a Delphi validation study involving 11 recognized experts who took part in the study from start to finish. The validated TIME list comprised 134 criteria (101 TIME-to-STOP and 33 TIME-to-START criteria) (14). This validation study supports the claim that the TIME set can be regarded as a widened and most up-to-date explicit tool for applications with older adults not only from Turkey and East European region, but also from the other regions across Europe. TIME Criteria mobile application was developed to facilitate the use of Turkish IMU in the elderly criteria in clinics in May 19, 2021. The TIME Criteria application is available now to help health care professionals in reviewing their older patients’ medications in the context of this most update explicit IMU tool.

In Turkey, the official language is Turkish. The rate of knowing the English language in the general population is limited. According to the English proficiency index 2020 report, Turkey ranks 69th in the list of 100 countries. With an index score of 465 points, Turkey is among the countries with “low” qualification levels. While the physicians and health care professionals are expected to have better knowledge on the English language due to their education background, a considerable proportion may have problems in following the English text with confidence. Therefore, hereby, we present the TIME criteria in Turkish language to help the healthcare professionals during their application in their everyday practice.

The final list of TIME-to-STOP and TIME-to-START criteria in Turkish is given in Suplementary file 1 and Suplementary file 2, the final list of TIME-to-STOP and TIME-to-START criteria in Turkish with full list of references and accompanying explanations added to some criteria is given in Suplementary file 3 and Suplementary file 4, respectively. The 19 criteria that were not accepted in the international Delphi validation phase are indicated within the supplementary file. Seven criteria were rejected and 12 criteria were neither rejected nor accepted, and were therefore removed. Of note, as can be understood from the panelists’ comments in the survey, some criteria were not accepted because the panelists felt they were not sufficiently familiar with the situation or medication in the criterion in their respective clinical practices and personal experiences.


Optimizing the medication use stands as one of the main goals in geriatrics practice. Explicit IMU criteria are important tools to help managing medication use and polypharmacy in older adults. Turkish Inappropriate Medication Use in the Elderly-(TIME criteria), is an up-to-date explicit IMU tool to guide national and international health care professionals in their everyday practice.


We are grateful to the members of the expert group for their contributions in TIME criteria study. The expert group included the following persons:

Geriatricians: Sibel Akin, Sevgi Aras, Dilek Aydin, Ergun Bozoglu, Asli Curgunlu, Alper Doventas, Berrin Karadag, Selim Nalbant, Sevnaz Sahin, Ilker Tasci, Fatih Tufan, Murat Varli, Burcu Balam Yavuz. Endocrinology: Zeliha Fulden Sarac. Gastroenterology: Nese Imeryuz, Cetin Karaca. Cardiology: Berrin Umman, Huseyin Oflaz. Neurology: Hakan Gurvit. Psychiatry: Eylem Sahin Cankurtaran, Serap Oflaz. Physical therapy and rehabilitation: Nilay Dincer. Urology: Cem Akbal. Pharmacology: Turgay Celik, Zeliha Kerry.


Peer-review: Internally peer-reviewed.

Authorship Contributions

Concept: G.B., M.A.K., Design: G.B., M.A.K., Data Collection or Processing: G.B., B.İ., T.E., M.H., S.S., Z.Ü., F.A., A.K.B., S.Ç., K.D., M.E., K.G., H.H., B.İ., At.K., A.K., I.B.K., A.M., S.Ö., İ.S., M.Ş.S., T.T., Y.Ü., Ö.Y., N.Y., M.M.Ö., M.A.K., Analysis or Interpretation: G.B., B.İ., T.E., M.A.K., Literature Search: G.B., B.İ., T.E., M.H., S.S., Z.Ü., F.A., A.K.B., S.Ç., K.D., M.E., K.G., H.H., B.İ., At.K., A.K., I.B.K., A.M., S.Ö., İ.S., M.Ş.S., T.T., Y.Ü., Ö.Y., N.Y., M.M.Ö., M.A.K., Writing: G.B., B.İ., T.E., M.A.K.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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