{"paper_id":"2d3d6c48-1783-4e43-a590-17bd0057e452","body_text":"Empowering community pharmacists with a STOPP-based tool to prevent medication- related falls in older adults from formulary to frontline | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Empowering community pharmacists with a STOPP-based tool to prevent medication- related falls in older adults from formulary to frontline Eliezer Alemán-Fernández, Dany Siverio-Mota, Liliana Vicet-Muro This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8879598/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Objectives Falls are a leading cause of injury among older adults, with medication use being a well-established, modifiable risk factor. Community pharmacists are strategically positioned to mitigate this risk through medication review. This study aimed to identify and characterize medications in the Cuban Basic Drug List 2025 classified as fall-risk-increasing by STOPP 2023 criteria that are available in community pharmacies for adults aged 60 years and over in Cuba. Methods A descriptive mapping analysis cross-referenced the 12 STOPP 2023 Section K criteria with the Cuban Basic Drug List 2025. Only community pharmacy-dispensable medications were included. Results Twenty distinct medications corresponding to ten STOPP-K criteria were identified. The predominant groups were antipsychotics (5), benzodiazepines (4), and antiepileptics (3). All are accessible for dispensing in the community pharmacy network. Conclusions The Cuban national formulary includes multiple fall-risk-increasing medications readily available at the community level. This study provides a validated, practice-ready screening tool and an operational protocol for implementation in resource-constrained settings. This work translates international evidence into a foundational strategy for scalable, pharmacist-led interventions that enhance safety for the growing older adult population. The discussion includes a framework for implementation and considerations for scalable, technology-supported solutions. Community pharmacy STOPP/START criteria fall-risk-increasing drugs medication safety older adults Cuba Figures Figure 1 1. Introduction Falls among older adults constitute a major global public health challenge, given their high incidence and severe consequences, including fractures, loss of independence, and increased mortality [ 1 ]. In Cuba, this challenge is magnified by a profound demographic shift: recent official data indicates that over a quarter of the population (25.71%) is aged 60 years or older, representing one of the most rapidly aging societies in the region [ 2 ]. Consequently, preventing falls and their modifiable risk factors is not merely a health priority but a critical necessity for the sustainability of the national healthcare system [ 3 ]. The multifactorial nature of falls is well recognized, with recent global guidelines emphasizing inappropriate medication use as a key modifiable risk factor [ 4 ]. The risk of falls in this vulnerable population is significantly amplified by the use of certain medications. A recent systematic review and meta-analysis found that potentially inappropriate prescribing, including FRIDs, is present in 68.6% of individuals who have experienced a fall [ 5 ]. Polypharmacy, particularly involving central nervous system-active drugs, is common in older adults with chronic conditions and is strongly associated with adverse outcomes [ 6 , 7 ]. Therefore, ensuring medication safety for older adults represents a paramount public health imperative in Cuba, directly impacting the well-being of more than a quarter of the nation. Drugs such as psychotropics and cardiovascular agents increase fall risk through mechanisms like sedation, orthostatic hypotension, and impaired coordination [ 8 ]. The STOPP/START criteria provide an evidence-based framework to identify such medications, with the 2023 version including a dedicated section (K) for medications that predispose to falls [ 9 ]. Concurrently, robust evidence demonstrates that pharmacist-led interventions can significantly reduce the use of FRIDs and improve medication appropriateness [ 10 ]. However, patient awareness of these risks remains alarmingly low, underscoring the need for targeted counseling [ 11 ]. In the Cuban healthcare system, community pharmacies are the primary and most accessible point of medication supply for older adults. The Cuban Basic Drug List (CBM) governs medication access. To date, no study has systematically screened the Cuban formulary against the updated STOPP criteria to identify which high-risk drugs are accessible at the community pharmacy level. This gap impedes the development of targeted, evidence-based safety strategies. This study aimed to identify and characterize medications in the CBM 2025 that meet STOPP 2023 Section K criteria and are designated for community pharmacy dispensing. 2. Methods 2.1. Study Design We conducted a descriptive documentary mapping analysis. This design is appropriate for systematically comparing clinical criteria against a national formulary to identify specific medication matches. 2.2. Data Sources 1. STOPP 2023 Criteria: The complete list of the 12 explicit criteria from Section K (Medications that predispose to falls) was used as the reference standard [9]. 2. Cuban Basic Drug List 2025 (CBM 2025): The official national formulary published by the Ministry of Public Health (MINSAP) served as the source for medication availability and dispensing level designation. 2.3. Inclusion and Exclusion Criteria From the CBM 2025, a multi-step filtering process was applied. To focus the analysis on medications with credible potential for systemic effects relevant to fall risk in adults, a sequential three-step filter was applied to the complete CBM 2025: 1. Community Pharmacy Availability: Only medications explicitly designated for dispensing within the community pharmacy network were retained. 2. Adult Use: Medications with primary pediatric indication were excluded, even if used off-label in adults. 3. Systemic Absorption Potential: Medications with minimal systemic absorption (e.g., most topical, ocular, inhalation, or local-acting products) were excluded, based on their pharmacological route and described action in the formulary. This pharmacologically-grounded filtering resulted in a refined analytical list of systemically active medications pertinent to the study's objective. All subsequent mapping was performed against this refined list. 2.4. Analysis Procedure A sequential cross-mapping was performed by two authors. The process involved two stages: 1. Filtering: The CBM 2025 was filtered to create a working list containing only community pharmacy-dispensable medications. 2. Mapping: Each of the 12 STOPP-K criteria was reviewed independently. The specified drug or drug class was searched for within the filtered CBM list. Matching was based on exact generic name (International Nonproprietary Name, INN ) correspondence. Discrepancies were resolved by consensus between the two authors and, if needed, consultation with a third author. For each match, the medication name ( INN ), its precise formulation and strength, and its community pharmacy dispensing level(s) were recorded. It is important to note that the Cuban primary care context, like that of many low- and middle-income countries, lacks a unified national electronic health record accessible to community pharmacies. Therefore, the proposed Detect, Assess, Act protocol and the accompanying operational tool (Supplementary Material 2) are explicitly designed to function without relying on integrated digital patient records. Instead, they leverage the pharmacist's direct patient interview and the pharmacy's own dispensing logs, ensuring feasibility and immediate applicability. 2.5. Ethics Approval Ethical approval was not required for this study as it involved the analysis of publicly available policy documents and clinical guidelines. No patient data or human subjects were involved. 2.6. Preliminary Usability Assessment To ensure clinical face validity and practical utility, the screening tool (Table 2) underwent a preliminary usability assessment (Supplementary Material 1). A convenience sample of eight licensed community pharmacists currently practicing in Cuba were invited to review the tool via a structured electronic form. They rated its perceived clarity on a 5-point Likert scale (1=Very Unclear, 5=Very Clear) and indicated their likelihood of using it in daily practice (Yes/No). Open-ended feedback for improvement was also solicited. 2.7. Development of an Operational Protocol To bridge the gap between the screening tool and routine practice, a detailed, step-by-step operational protocol was developed. This protocol, provided as Supplementary Material 2, elaborates the Detect, Assess, Act framework. It includes practical resources such as scripted questions for patient assessment, templates for prescriber communication, and a documentation form for the pharmacy record, ensuring the intervention is fully actionable. 3. Results 3.1. Refined Formulary List and Identified Medications The initial Cuban Basic Drug List (CBM) 2025 contained 651 medications. After applying the sequential three-step filter (community pharmacy availability, adult use, considerable systemic absorption), the refined analytical list comprised 192 medications (Fig. 1 ). A systematic cross-mapping of the STOPP 2023 Section K criteria against this refined list of 192 medications identified twenty distinct medications corresponding to ten different STOPP-K criteria. This represents 10.4% of the systemically active, community-available adult medications in the national formulary. No medications meeting the definitions of the remaining two STOPP-K criteria (K4: Hypnotic Z-drugs; K10: Alpha-blockers for prostatic symptoms) were present in the refined list. The complete list of identified medications is presented in Table 1 . Table 1 Fall-Risk-Increasing Medications from STOPP 2023 Section K Identified in the Cuban Basic Drug List (CBM) 2025 for Community Pharmacy Dispensing No. STOPP 2023 Criterion ATC Code Medication (INN) Presentation / Strength 1 K1: Benzodiazepines N05BA Diazepam Tablets 5 mg 2 N05BA Alprazolam Tablets 0.5 mg 3 N05BA Clonazepam Tablets 1 mg 4 N05BA Chlordiazepoxide Tablets 10 mg 5 K2: Antipsychotics N05AD Haloperidol Tablets 1.5 and 5 mg 6 N05AX Risperidone Tablets 3 mg 7 N05AA Levomepromazine Tablets 25 mg 8 N05AA Chlorpromazine Tablets 100 mg 9 N05AH Olanzapine Tablets 10 mg 10 K3: Vasodilator drugs C04AD Pentoxifylline Tablets 400 mg 11 K5: Anti-epileptic drugs N03AF Carbamazepine Tablets 200 mg 12 N03AG Sodium Valproate Tablets 500 mg 13 N03AX Lamotrigine Tablets 100 mg 14 K6: First generation antihistamines R06AA Diphenhydramine Tablets 25 mg 15 K7: Opioids N02AX Tramadol Tablets 50 mg 16 R05DA Codeine Tablets 30 mg 17 K8: Tricyclic antidepressants N06AA Amitriptyline Tablets 25 mg 18 K9: Alpha blockers as antihypertensives G04CA Terazosin Tablets 5 mg 19 K11: Centrally-acting antihypertensives C02AB Methyldopa Tablets 250 mg 20 K12: Antimuscarinics G04BD Oxybutynin Tablets 5 mg 3.2. Characteristics of the Identified Medications The most frequently represented pharmacological groups were antipsychotics (5 medications), followed by benzodiazepines (4), and anti-epileptic drugs (3). All twenty identified medications are accessible for dispensing in at least one level of the Cuban community pharmacy network. The absence of certain drug classes suggests a deliberate policy to restrict some high-risk agents to institutional use. 3.3. Practice-Ready Outputs To facilitate immediate use in practice, these results were translated into two key outputs: 1. Table 2 . STOPP-K Community Pharmacy Screening Tool: A quick-reference guide for use at the dispensing counter, listing medications, key counseling points, and recommended pharmacist actions. Table 2 STOPP-K Community Pharmacy Screening Tool A quick-reference guide for fall-risk-increasing drugs in the Cuban National Formulary. Use when dispensing to adults ≥ 60 years. STOPP-K Criterion & Drug Class Specific Medication (INN) Key Counseling Point for the Patient Recommended Collaborative Action (Guide) K1. Benzodiazepines Diazepam May cause daytime drowsiness & affect balance. Avoid alcohol. 3 Alprazolam Can cause strong drowsiness, increasing fall risk, especially after taking it. 3 Clonazepam Often causes dizziness and sedation. Can impair coordination. 3 Chlordiazepoxide Long-lasting sedative effect. High risk in older adults. 3 K2. Antipsychotics Haloperidol Watch for stiffness, slowness, dizziness. High risk of movement side effects. 2 Risperidone May cause drowsiness and dizziness. Review indication and dose with prescriber. 3 Levomepromazine Causes strong sedation and low blood pressure. Use is highly restrictive. 2 Chlorpromazine High sedation, anticholinergic effects. Rarely appropriate in primary care. 2 Olanzapine Commonly causes drowsiness and dizziness. Review need for ongoing use. 3 K3. Vasodilator Pentoxifylline May cause dizziness. Clinical benefit in older adults is often unclear. 1 K5. Antiepileptics Carbamazepine Can cause dizziness, blurred vision, unsteadiness. Monitor for interactions. 3 Sodium Valproate Commonly causes drowsiness and tremor. Ask patient about recent falls. 1 Lamotrigine May cause dizziness and double vision. Must be started at a low dose. 1 K6. 1st-Gen Antihistamine Diphenhydramine Strong sedative & anticholinergic effects. Strongly discourage use; suggest safer alternatives. 3 K7. Opioids Tramadol Causes drowsiness and constipation. Use the lowest effective dose for shortest time. 1 Codeine Often causes constipation and drowsiness. Metabolism varies in elderly. 1 K8. Tricyclic Antidepressant Amitriptyline High anticholinergic burden: dry mouth, confusion, fast heart rate. Safer alternatives exist. 2 K9. Alpha-Blocker (for HTN) Terazosin FIRST-DOSE HYPOTENSION. Advise to take first dose at bedtime and rise slowly from sitting/lying. 1 K11. Central-acting Antihypertensive Methyldopa Can cause drowsiness and low blood pressure when standing. 1 K12. Antimuscarinic Oxybutynin Causes dry mouth, confusion, constipation. Can worsen thinking. Review for alternatives. 3 Legend : 1 = Provide direct patient counseling using the key point. 2 = Initiate collaborative communication review with the prescriber to optimize therapy, considering indication, dose, or deprescribing. 3 = Perform both actions (1 and 2). Instructions for Use (Detect, Assess, Act) : DETECT: Screen every prescription for adults ≥ 60 against this list. ASSESS: If a drug is found, briefly assess the patient (ask: Any dizziness or recent falls?). ACT: Perform the indicated action(s) above and document the intervention. To ensure direct clinical application, the findings were translated into a practical screening tool (Table 2 ) and a detailed operational protocol (Supplementary Material 2). 2. Supplementary Material 2. Operational Protocol: A comprehensive guide implementing the Detect, Assess, Act framework, including workflow scripts, communication templates, and a documentation form. 3.4. Usability Assessment Results All pharmacists completed the assessment. The tool received a median clarity score of 4.5 (Interquartile Range: 4–5). All respondents (100%) indicated they would use the tool in their practice. Qualitative feedback unanimously affirmed its practicality and immediate applicability. Recurrent suggestions focused on minor layout adjustments for faster visual scanning, which were incorporated into the final version of Table 2 . 4. Discussion 4.1. Principal Findings This mapping study provides is the first to systematically identify the medications listed in the Cuban national formulary that are recognized by an updated, evidence-based tool (STOPP 2023) as increasing fall risk in older adults and are readily accessible at the community pharmacy level. The identification of 20 such medications across 10 STOPP criteria underscores that this is not an isolated issue but involves a range of commonly prescribed therapeutic classes, posing a significant and modifiable public health risk. The finding that 20 of the 192 systemically active community medications (10.4%) are classified as high-risk underscores a concentrated, actionable target for pharmacist intervention. 4.2. Interpretation in the Context of International Evidence and Geriatric Pharmacotherapy The prominence of psychoactive medications aligns with global literature identifying them as potent contributors to falls. A recent systematic review and meta-analysis confirmed that potentially inappropriate prescribing, including FRID use, is highly prevalent (68.6%) among people who have experienced a fall, with sedatives, opioids, and antidepressants being the most common culprits [ 5 ]. This high prevalence is corroborated by observational studies showing a direct correlation between the number of FRIDs and fall incidence [ 12 ]. Our findings align precisely with this converging evidence, highlighting that the Cuban formulary includes the very agents most frequently implicated in fall events globally. Notably, the work by Saeed et al., 2024 extends beyond identification to the development of a practical, validated screening tool (the Medication-Related Fall [MRF] tool), emphasizing the global push towards actionable clinical instruments for fall prevention [ 13 ]. 4.3. From List to Practice: A Framework for Sustainable Implementation in Cuba A key strength of this framework lies in its pragmatic design for real-world constraints. Developed for a setting without integrated electronic medication records, a common scenario in many healthcare systems, the protocol relies on pragmatic strategies: leveraging the pharmacy's own dispensing history and conducting targeted patient interviews. This makes it a viable, immediately implementable model not only for Cuba but for a wide range of primary care contexts with similar resource profiles. The translational value of this research lies in moving from identification to implementation. The stark evidence of inappropriate prescribing in fallers [ 5 ] presents a clear mandate for systematic medication review. For the Cuban community pharmacist, the generated list (Table 1 ) serves as a foundational tool for structured practice. The critical need for such an intervention is underscored by international studies showing alarmingly low patient awareness of FRIDs [ 11 ]. This knowledge gap represents a crucial point for pharmacist counseling. Robust evidence demonstrates the tangible impact of pharmacist-led interventions, showing significant reductions in polypharmacy, anticholinergic burden, and FRIDs use [ 10 ]. Following this proven model, we propose a feasible Detect, Assess, Act protocol (detailed in Supplementary Material 2). To ensure this intervention can be scaled sustainably, careful consideration must be given to potential electronic support systems. A major implementation challenge is avoiding alert fatigue—a well-documented phenomenon in which clinicians ignore excessive warnings, undermining safety [ 14 ]. A promising solution is demonstrated in a semi-automated system where clinical pharmacists first triaged alerts before physician notification, achieving high physician acceptance (89.8%) and satisfaction (94.5%) [ 15 ]. This potential for adoption is supported by our preliminary usability assessment (Supplementary Material 1), where the tool received high clarity ratings and unanimous acceptance by practicing pharmacists, confirming its design aligns with frontline needs. The accompanying operational protocol (Supplementary Material 2) provides a complete how-to guide, translating the screening list into a structured clinical workflow. This model provides a practical blueprint for Cuba: the community pharmacist, applying their clinical judgment and the proposed protocol, before initiating collaborative communication with the prescriber, could review initial alerts based on the STOPP-K list. This human-in-the-loop design ensures alerts are contextualized and actionable. 4.4. The Cuban Context: Medication Shortages as an Unplanned Opportunity An essential contextual factor in Cuba is the frequent medication shortage. Paradoxically, these frequent shortages may create unplanned opportunities for deprescribing or therapeutic review. When a high-risk STOPP-K medication is unavailable, the community pharmacist, in collaboration with the prescriber, can proactively guide the patient toward a safer alternative or re-evaluate the absolute need for the treatment. This approach transforms a logistical problem into a strategic opportunity for therapy optimization, positioning the pharmacist as an active therapy manager in resource-limited settings. A key strength is the practical focus on the community pharmacy setting, aligning with international efforts to create pragmatic solutions [ 13 , 15 ]. The main limitation is its documentary nature. Future research should quantify the prevalence of these medications among Cuban older adults, particularly those with a history of falls [ 5 , 12 ]. Furthermore, the proposed protocol should be piloted as a quality improvement intervention. A logical next step would be to pilot a semi-automated clinical decision support system based on this STOPP-K list, evaluating the feasibility of the pharmacist-led triage model [ 15 ] in the Cuban primary care context. 4.5. Strengths, Limitations and Future Directions A key strength is the practical focus on the community pharmacy setting, aligning with international efforts to create pragmatic solutions [ 13 , 15 ]. The main limitation is its documentary nature. Future research should quantify the prevalence of these medications among Cuban older adults, particularly those with a history of falls [ 5 , 12 ]. Furthermore, the proposed protocol should be piloted as a quality improvement intervention. A logical next step would be to pilot a semi-automated clinical decision support system based on this STOPP-K list, evaluating the feasibility of the pharmacist-led triage model [ 15 ]. in the Cuban primary care context. Furthermore, by design, this tool does not depend on interoperable electronic health records, making it a practical archetype for medication safety interventions in diverse low-resource primary care settings where such digital infrastructure is often absent. The proposed protocol is designed for the current reality of Cuban community pharmacies, where access to a unified patient medication record may be limited. Therefore, the assessment phase emphasizes the use of the pharmacy's own dispensing records and direct patient interview pragmatic strategies that are immediately available to the pharmacist. The logical next step is a pilot implementation study to evaluate feasibility, acceptability, and preliminary effectiveness. To ensure methodological transparency and rigor for this subsequent phase, the Detect, Assess, Act intervention protocol has been formally pre-registered (Supplementary Material 3). The detailed study protocol for a pilot evaluation in a network of Cuban community pharmacies is available from the corresponding author upon reasonable request. This structured progression underscores our commitment to a coherent research program aimed at generating evidence for tangible improvements in medication safety. The identification of fall-risk-increasing drugs at the community pharmacy level takes on added significance in the context of Cuba's demographic structure, where more than one in four citizens is potentially susceptible to this preventable risk. This magnifies the potential public health impact of implementing the proposed screening tool. Looking further ahead, the logical endpoint of this research trajectory is the integration of this validated screening logic into a mobile health (mHealth) application. Such an app could serve as a centralized platform, not only embedding the STOPP-K screening tool and the Detect, Assess, Act protocol but also linking it to context-specific deprescribing guidelines for older adults. This digital tool could provide community pharmacists with instant, point-of-care access to step-by-step deprescribing algorithms, patient education materials, and secure communication channels with prescribers. Developing this app through a formal consensus process with geriatricians, clinical pharmacists, and primary care physicians in Cuba would ensure its clinical validity and adoption. This vision aligns with global moves towards digital clinical decision support and represents a transformative step for medication safety in resource-constrained settings. 5. Conclusion This study identifies twenty medications in the Cuban National Formulary classified as fall-risk-increasing by STOPP 2023 and readily accessible in community pharmacies. This finding moves beyond a simple audit; it provides a validated, context-specific tool to address a significant and quantified public health gap. By translating international evidence into a local checklist, this work directly supports the strategic role of community pharmacists in mitigating a major preventable risk, aligning with data on the proven effectiveness of pharmacist-led medication review. Community pharmacists in Cuba are uniquely positioned to operationalize this list through systematic screening, targeted counseling to bridge patient knowledge gaps, and collaborative deprescribing. For this potential to be realized at scale, we recommend concerted action: (1) integrating intelligently designed, context-aware alerts into pharmacy software to prompt pharmacist review, informed by evidence on preventing alert fatigue; (2) developing standardized protocols for community pharmacist-led falls prevention; and (3) incorporating this competency into continuing education. Ultimately, leveraging the community pharmacy network as a frontline defense against medication-related falls offers a feasible, scalable, and evidence-based strategy for the Cuban healthcare system. It is a logical step towards safeguarding the well-being of its rapidly aging population. Declarations Contributors Eliezer Alemán Fernández wrote the first draft of the manuscript and critically reviewed and provided meaningful edits to the manuscript. Dany Siverio Mota performed all statistical analysis and critically reviewed and provided meaningful edits to the manuscript. Liliana Vicet Murocritically reviewed and provided meaningful edits to the manuscript, had full access to all of the data in the study and takes responsibility for the integrity and accuracy of the data analysis. All authors saw and approved the final version and no other person made a substantial contribution to the paper. Ethics Approval This is a documentary analysis study based on publicly available policy documents and clinical guidelines. No human participants, personal data, or animals were involved. Therefore, ethical approval was not required for this research. Funding This study did not receive any specific grant from funding agencies. Data Availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. The primary source documents, the STOPP 2023 criteria and the Cuban Basic Drug List 2025, are publicly available resources. Conflicts of Interest The authors declare no conflicts of interest. References World Health Organization. Falls. Factsheet. 2021. https://www.who.int/10.1016/news-room/fact-sheets/detail/falls Oficina Nacional de Estadística e Información (ONEI). Anuario Demográfico de Cuba 2024. 2025. https://www.onei.gob.cu/anuario-demografico-de-cuba-enero-diciembre-2024 Ministerio de Salud Pública (MINSAP). Programa Nacional de Atención al Adulto Mayor. 2020. https://especialidades.sld.cu/gerontogeriatria/2021/01/29/el-programa-nacional-de-atencion-integral-al-adulto-mayor-en-cuba-apuesta-por-vejez-activa-y-saludable Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing. 2022;51(9):1–36. https://doi.org/10.1093/ageing/afac205 . O’Reilly T, Gómez Lemus J, Booth L, Clyne B, McCarthy C, Ibrahim K, et al. Potentially inappropriate prescribing and falls-risk increasing drugs in people who have experienced a fall: a systematic review and meta-analysis. Age Ageing. 2025;54(10):afaf300. https://doi.org/10.1093/ageing/afaf300 . Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2023;10:CD008165. https://doi.org/10.1002/14651858.CD008165.pub5 . Fried TR, O’Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health outcomes associated with polypharmacy in community-dwelling older adults. J Am Geriatr Soc. 2014;62(12):2261–72. https://doi.org/10.1111/jgs.13153 . Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. J Am Med Dir Assoc. 2018;19(4):372. https://doi.org/10.1016/j.jamda.2017.12.099 . .e1-372.e8 . O’Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. EurGeriatr Med. 2023;1–8(4):625–32. https://doi.org/10.1007/s41999-023-00777-y . Crawford P, Plumb R, Burns P, Flanagan S, Parsons C. A quantitative study on the impact of a community falls pharmacist role, on medicines optimisation in older people at risk of falls. BMC Geriatr. 2024;24(1):604. https://doi.org/10.1186/s12877-024-05189-6 . Yasmeen A, Syed MH, Meraya AM, Alqahtani SS, Syed NK, Alfaifi AJ, et al. Fall Risk and Knowledge of Fall-Risk-Increasing Drugs Among Saudi Older Adults. Healthc (Basel). 2025;13(13):1549. https://doi.org/10.3390/healthcare13131549 . Murtezani A, Ibrahim Z, Abazi N, Kolgeci D, Shabani D. Association of medication use with falls among older adults. Pharm Pract. 2025;23(2):3260. https://doi.org/10.18549/PharmPract.2025.2.3260 . Saeed D, Carter G, Miller R, Darcy C, Miller K, Madden K, et al. Development and Delphi consensus validation of the Medication-Related Fall screening and scoring tool. Int J Clin Pharm. 2024;46(4):977–86. https://doi.org/10.1007/s11096-024-01734-w . Gani M, Ian Litchfield I, Shukla D, Delanerolle G, Cockburn N, Pathmanathan A. Understanding Alert Fatigue in Primary Care: Qualitative Systematic Review of General Practitioners Attitudes and Experiences of Clinical Alerts, Prompts, and Reminders. J Med Internet Res. 2025;27:e62763. https://www.jmir.org/2025/1/e62763 . Dahmke H, Fiumefreddo R, Schuetz P, De Iacod R, Zaugga C. Tackling alert fatigue with a semi-automated clinical decision support system: quantitative evaluation and end-user survey. Swiss Med Wkly. 2023;153:40082. https://doi.org/10.57187/smw.2023.40082 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial1.doc SupplementaryMaterial2.doc SupplementaryMaterial3.doc Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 12 May, 2026 Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 27 Mar, 2026 Editor assigned by journal 27 Mar, 2026 Editor invited by journal 09 Mar, 2026 Submission checks completed at journal 04 Mar, 2026 First submitted to journal 27 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8879598\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":613432122,\"identity\":\"8676156c-608b-416a-a29c-848aa966e566\",\"order_by\":0,\"name\":\"Eliezer Alemán-Fernández\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Municipal Directorate of Pharmacy, Provincial Directorate of Public Health\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Eliezer\",\"middleName\":\"\",\"lastName\":\"Alemán-Fernández\",\"suffix\":\"\"},{\"id\":613432123,\"identity\":\"842f546f-4f4e-484b-b6a5-fbb3eced4e85\",\"order_by\":1,\"name\":\"Dany Siverio-Mota\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Central University of Las Villas. Villa Clara\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Dany\",\"middleName\":\"\",\"lastName\":\"Siverio-Mota\",\"suffix\":\"\"},{\"id\":613432124,\"identity\":\"a8dcb4ca-95ef-497f-9819-5ed4683c3315\",\"order_by\":2,\"name\":\"Liliana Vicet-Muro\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Central University of Las Villas. Villa Clara\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Liliana\",\"middleName\":\"\",\"lastName\":\"Vicet-Muro\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-14 11:38:38\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8879598/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8879598/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":105744710,\"identity\":\"04451b9a-e18b-42f4-bab6-f6c5da105191\",\"added_by\":\"auto\",\"created_at\":\"2026-03-30 14:02:10\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":544611,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFlow diagram illustrating the medication filtering process\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLegend:\\u003c/strong\\u003e Flow diagram of the medication filtering process. The diagram illustrates the sequential exclusion steps applied to the CBM 2025 (n=651) to derive the final analytical list of systemically active, community-available adult medications (n=192) used for mapping against STOPP-K criteria.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8879598/v1/41cefeff0c1e49e42fe5cea5.png\"},{\"id\":105753687,\"identity\":\"75ab2deb-fdce-4d9e-9c30-a6d6ce75182d\",\"added_by\":\"auto\",\"created_at\":\"2026-03-30 16:10:58\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1425837,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8879598/v1/744fd973-5f59-434c-935c-603740a1b689.pdf\"},{\"id\":105744712,\"identity\":\"4948031c-2b04-4c69-b36d-07a1df535523\",\"added_by\":\"auto\",\"created_at\":\"2026-03-30 14:02:10\",\"extension\":\"doc\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":37376,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial1.doc\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8879598/v1/8a1d3f534067cec8893ab0ae.doc\"},{\"id\":105752100,\"identity\":\"6c18450f-fee8-471e-a337-ca60d0db787a\",\"added_by\":\"auto\",\"created_at\":\"2026-03-30 15:54:50\",\"extension\":\"doc\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":53248,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial2.doc\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8879598/v1/7aad9df5976b1d84dcfaa276.doc\"},{\"id\":105752202,\"identity\":\"cacd4dd4-060f-4788-9614-a03568020b2e\",\"added_by\":\"auto\",\"created_at\":\"2026-03-30 15:55:47\",\"extension\":\"doc\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":42496,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial3.doc\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8879598/v1/2fa22136fe7dfd134ff1d1c6.doc\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Empowering community pharmacists with a STOPP-based tool to prevent medication- related falls in older adults from formulary to frontline\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eFalls among older adults constitute a major global public health challenge, given their high incidence and severe consequences, including fractures, loss of independence, and increased mortality [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. In Cuba, this challenge is magnified by a profound demographic shift: recent official data indicates that over a quarter of the population (25.71%) is aged 60 years or older, representing one of the most rapidly aging societies in the region [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Consequently, preventing falls and their modifiable risk factors is not merely a health priority but a critical necessity for the sustainability of the national healthcare system [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. The multifactorial nature of falls is well recognized, with recent global guidelines emphasizing inappropriate medication use as a key modifiable risk factor [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe risk of falls in this vulnerable population is significantly amplified by the use of certain medications. A recent systematic review and meta-analysis found that potentially inappropriate prescribing, including FRIDs, is present in 68.6% of individuals who have experienced a fall [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Polypharmacy, particularly involving central nervous system-active drugs, is common in older adults with chronic conditions and is strongly associated with adverse outcomes [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Therefore, ensuring medication safety for older adults represents a paramount public health imperative in Cuba, directly impacting the well-being of more than a quarter of the nation. Drugs such as psychotropics and cardiovascular agents increase fall risk through mechanisms like sedation, orthostatic hypotension, and impaired coordination [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe STOPP/START criteria provide an evidence-based framework to identify such medications, with the 2023 version including a dedicated section (K) for medications that predispose to falls [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Concurrently, robust evidence demonstrates that pharmacist-led interventions can significantly reduce the use of FRIDs and improve medication appropriateness [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. However, patient awareness of these risks remains alarmingly low, underscoring the need for targeted counseling [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn the Cuban healthcare system, community pharmacies are the primary and most accessible point of medication supply for older adults. The Cuban Basic Drug List (CBM) governs medication access. To date, no study has systematically screened the Cuban formulary against the updated STOPP criteria to identify which high-risk drugs are accessible at the community pharmacy level. This gap impedes the development of targeted, evidence-based safety strategies.\\u003c/p\\u003e \\u003cp\\u003eThis study aimed to identify and characterize medications in the CBM 2025 that meet STOPP 2023 Section K criteria and are designated for community pharmacy dispensing.\\u003c/p\\u003e\"},{\"header\":\"2. Methods\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003e2.1. Study Design\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe conducted a descriptive documentary mapping analysis. This design is appropriate for systematically comparing clinical criteria against a national formulary to identify specific medication matches.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.2. Data Sources\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e1. STOPP 2023 Criteria: The complete list of the 12 explicit criteria from Section K (Medications that predispose to falls) was used as the reference standard [9].\\u003c/p\\u003e\\n\\u003cp\\u003e2. \\u0026nbsp;Cuban Basic Drug List 2025 (CBM 2025): The official national formulary published by the Ministry of Public Health (MINSAP) served as the source for medication availability and dispensing level designation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.3. Inclusion and Exclusion Criteria\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFrom the CBM \\u003cst1:metricconverter productid=\\\"2025, a\\\" w:st=\\\"on\\\"\\u003e2025, a\\u003c/st1:metricconverter\\u003e multi-step filtering process was applied.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTo focus the analysis on medications with credible potential for systemic effects relevant to fall risk in adults, a sequential three-step filter was applied to the complete CBM 2025:\\u003c/p\\u003e\\n\\u003cp\\u003e1. Community Pharmacy Availability: Only medications explicitly designated for dispensing within the community pharmacy network were retained.\\u003c/p\\u003e\\n\\u003cp\\u003e2. Adult Use: Medications with primary pediatric indication were excluded, even if used off-label in adults.\\u003c/p\\u003e\\n\\u003cp\\u003e3. Systemic Absorption Potential: Medications with minimal systemic absorption (e.g., most topical, ocular, inhalation, or local-acting products) were excluded, based on their pharmacological route and described action in the formulary.\\u003c/p\\u003e\\n\\u003cp\\u003eThis pharmacologically-grounded filtering resulted in a refined analytical list of systemically active medications pertinent to the study\\u0026apos;s objective. All subsequent mapping was performed against this refined list.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.4. Analysis Procedure\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA sequential cross-mapping was performed by two authors. The process involved two stages:\\u003c/p\\u003e\\n\\u003cp\\u003e1. Filtering: The CBM 2025 was filtered to create a working list containing only community pharmacy-dispensable medications.\\u003c/p\\u003e\\n\\u003cp\\u003e2. Mapping: Each of the 12 STOPP-K criteria was reviewed independently. The specified drug or drug class was searched for within the filtered CBM list. Matching was based on exact generic name (International Nonproprietary Name, \\u003cst1:place w:st=\\\"on\\\"\\u003eINN\\u003c/st1:place\\u003e) correspondence. Discrepancies were resolved by consensus between the two authors and, if needed, consultation with a third author.\\u003c/p\\u003e\\n\\u003cp\\u003eFor each match, the medication name (\\u003cst1:place w:st=\\\"on\\\"\\u003eINN\\u003c/st1:place\\u003e), its precise formulation and strength, and its community pharmacy dispensing level(s) were recorded.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is important to note that the Cuban primary care context, like that of many low- and middle-income countries, lacks a unified national electronic health record accessible to community pharmacies. Therefore, the proposed Detect, Assess, Act protocol and the accompanying operational tool (Supplementary Material 2) are explicitly designed to function without relying on integrated digital patient records. Instead, they leverage the pharmacist\\u0026apos;s direct patient interview and the pharmacy\\u0026apos;s own dispensing logs, ensuring feasibility and immediate applicability.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.5. Ethics Approval\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval was not required for this study as it involved the analysis of publicly available policy documents and clinical guidelines. No patient data or human subjects were involved.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.6. Preliminary Usability Assessment\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTo ensure clinical face validity and practical utility, the screening tool (Table 2) underwent a preliminary usability assessment (Supplementary Material 1). A convenience sample of eight licensed community pharmacists currently practicing in \\u003cst1:place w:st=\\\"on\\\"\\u003e\\u003cst1:country-region w:st=\\\"on\\\"\\u003eCuba\\u003c/st1:country-region\\u003e\\u003c/st1:place\\u003e were invited to review the tool via a structured electronic form. They rated its perceived clarity on a 5-point Likert scale (1=Very Unclear, 5=Very Clear) and indicated their likelihood of using it in daily practice (Yes/No). Open-ended feedback for improvement was also solicited.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003e2.7. Development of an Operational Protocol\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTo bridge the gap between the screening tool and routine practice, a detailed, step-by-step operational protocol was developed. This protocol, provided as Supplementary Material 2, elaborates the Detect, Assess, Act framework. It includes practical resources such as scripted questions for patient assessment, templates for prescriber communication, and a documentation form for the pharmacy record, ensuring the intervention is fully actionable.\\u003c/p\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.1. Refined Formulary List and Identified Medications\\u003c/h2\\u003e \\u003cp\\u003eThe initial Cuban Basic Drug List (CBM) 2025 contained 651 medications. After applying the sequential three-step filter (community pharmacy availability, adult use, considerable systemic absorption), the refined analytical list comprised 192 medications (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eA systematic cross-mapping of the STOPP 2023 Section K criteria against this refined list of 192 medications identified twenty distinct medications corresponding to ten different STOPP-K criteria. This represents 10.4% of the systemically active, community-available adult medications in the national formulary. No medications meeting the definitions of the remaining two STOPP-K criteria (K4: Hypnotic Z-drugs; K10: Alpha-blockers for prostatic symptoms) were present in the refined list. The complete list of identified medications is presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eFall-Risk-Increasing Medications from STOPP 2023 Section K Identified in the Cuban Basic Drug List (CBM) 2025 for Community Pharmacy Dispensing\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSTOPP 2023 Criterion\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eATC Code\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMedication (INN)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePresentation / Strength\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eK1: Benzodiazepines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05BA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDiazepam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 5 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05BA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAlprazolam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 0.5 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05BA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eClonazepam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 1 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05BA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eChlordiazepoxide\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 10 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003eK2: Antipsychotics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05AD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eHaloperidol\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 1.5 and 5 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05AX\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRisperidone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 3 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05AA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLevomepromazine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 25 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05AA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eChlorpromazine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 100 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN05AH\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eOlanzapine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 10 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK3: Vasodilator drugs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eC04AD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePentoxifylline\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 400 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eK5: Anti-epileptic drugs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN03AF\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCarbamazepine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 200 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e12\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN03AG\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSodium Valproate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 500 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN03AX\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLamotrigine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 100 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK6: First generation antihistamines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eR06AA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDiphenhydramine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 25 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eK7: Opioids\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN02AX\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTramadol\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 50 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eR05DA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCodeine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 30 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK8: Tricyclic antidepressants\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eN06AA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAmitriptyline\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 25 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e18\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK9: Alpha blockers as antihypertensives\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eG04CA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTerazosin\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 5 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK11: Centrally-acting antihypertensives\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eC02AB\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMethyldopa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 250 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e20\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eK12: Antimuscarinics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eG04BD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eOxybutynin\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTablets 5 mg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.2. Characteristics of the Identified Medications\\u003c/h2\\u003e \\u003cp\\u003eThe most frequently represented pharmacological groups were antipsychotics (5 medications), followed by benzodiazepines (4), and anti-epileptic drugs (3). All twenty identified medications are accessible for dispensing in at least one level of the Cuban community pharmacy network. The absence of certain drug classes suggests a deliberate policy to restrict some high-risk agents to institutional use.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.3. Practice-Ready Outputs\\u003c/h2\\u003e \\u003cp\\u003eTo facilitate immediate use in practice, these results were translated into two key outputs:\\u003c/p\\u003e \\u003cp\\u003e1. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. STOPP-K Community Pharmacy Screening Tool: A quick-reference guide for use at the dispensing counter, listing medications, key counseling points, and recommended pharmacist actions.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSTOPP-K Community Pharmacy Screening Tool A quick-reference guide for fall-risk-increasing drugs in the Cuban National Formulary. Use when dispensing to adults\\u0026thinsp;\\u0026ge;\\u0026thinsp;60 years.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSTOPP-K Criterion \\u0026amp; Drug Class\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSpecific Medication (INN)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eKey Counseling Point for the Patient\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRecommended Collaborative Action (Guide)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eK1. Benzodiazepines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiazepam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMay cause daytime drowsiness \\u0026amp; affect balance. Avoid alcohol.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAlprazolam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCan cause strong drowsiness, increasing fall risk, especially after taking it.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eClonazepam\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOften causes dizziness and sedation. Can impair coordination.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eChlordiazepoxide\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eLong-lasting sedative effect. High risk in older adults.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"4\\\" rowspan=\\\"5\\\"\\u003e \\u003cp\\u003eK2. Antipsychotics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHaloperidol\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eWatch for stiffness, slowness, dizziness. High risk of movement side effects.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eRisperidone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMay cause drowsiness and dizziness. Review indication and dose with prescriber.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLevomepromazine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCauses strong sedation and low blood pressure. Use is highly restrictive.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eChlorpromazine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh sedation, anticholinergic effects. Rarely appropriate in primary care.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOlanzapine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCommonly causes drowsiness and dizziness. Review need for ongoing use.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK3. Vasodilator\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePentoxifylline\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMay cause dizziness. Clinical benefit in older adults is often unclear.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eK5. Antiepileptics\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCarbamazepine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCan cause dizziness, blurred vision, unsteadiness. Monitor for interactions.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSodium Valproate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCommonly causes drowsiness and tremor. Ask patient about recent falls.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLamotrigine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMay cause dizziness and double vision. Must be started at a low dose.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK6. 1st-Gen Antihistamine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDiphenhydramine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStrong sedative \\u0026amp; anticholinergic effects. Strongly discourage use; suggest safer alternatives.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eK7. Opioids\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTramadol\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCauses drowsiness and constipation. Use the lowest effective dose for shortest time.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCodeine\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOften causes constipation and drowsiness. Metabolism varies in elderly.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK8. Tricyclic Antidepressant\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAmitriptyline\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigh anticholinergic burden: dry mouth, confusion, fast heart rate. Safer alternatives exist.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK9. Alpha-Blocker (for HTN)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTerazosin\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFIRST-DOSE HYPOTENSION. Advise to take first dose at bedtime and rise slowly from sitting/lying.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK11. Central-acting Antihypertensive\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMethyldopa\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCan cause drowsiness and low blood pressure when standing.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eK12. Antimuscarinic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eOxybutynin\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCauses dry mouth, confusion, constipation. Can worsen thinking. Review for alternatives.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e\\u003cem\\u003eLegend\\u003c/em\\u003e:\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e1\\u0026thinsp;=\\u0026thinsp;Provide direct patient counseling using the key point.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e2\\u0026thinsp;=\\u0026thinsp;Initiate collaborative communication review with the prescriber to optimize therapy, considering indication, dose, or deprescribing.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e3\\u0026thinsp;=\\u0026thinsp;Perform both actions (1 and 2).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003eInstructions for Use (Detect, Assess, Act)\\u003c/em\\u003e:\\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eDETECT: Screen every prescription for adults\\u0026thinsp;\\u0026ge;\\u0026thinsp;60 against this list.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eASSESS: If a drug is found, briefly assess the patient (ask: Any dizziness or recent falls?).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eACT: Perform the indicated action(s) above and document the intervention.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003eTo ensure direct clinical application, the findings were translated into a practical screening tool (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e) and a detailed operational protocol (Supplementary Material 2).\\u003c/p\\u003e \\u003cp\\u003e2. Supplementary Material 2. Operational Protocol: A comprehensive guide implementing the Detect, Assess, Act framework, including workflow scripts, communication templates, and a documentation form.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3.4. Usability Assessment Results\\u003c/h2\\u003e \\u003cp\\u003eAll pharmacists completed the assessment. The tool received a median clarity score of 4.5 (Interquartile Range: 4\\u0026ndash;5). All respondents (100%) indicated they would use the tool in their practice. Qualitative feedback unanimously affirmed its practicality and immediate applicability. Recurrent suggestions focused on minor layout adjustments for faster visual scanning, which were incorporated into the final version of Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e4.1. Principal Findings\\u003c/h2\\u003e \\u003cp\\u003eThis mapping study provides is the first to systematically identify the medications listed in the Cuban national formulary that are recognized by an updated, evidence-based tool (STOPP 2023) as increasing fall risk in older adults and are readily accessible at the community pharmacy level. The identification of 20 such medications across 10 STOPP criteria underscores that this is not an isolated issue but involves a range of commonly prescribed therapeutic classes, posing a significant and modifiable public health risk. The finding that 20 of the 192 systemically active community medications (10.4%) are classified as high-risk underscores a concentrated, actionable target for pharmacist intervention.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e4.2. Interpretation in the Context of International Evidence and Geriatric Pharmacotherapy\\u003c/h2\\u003e \\u003cp\\u003eThe prominence of psychoactive medications aligns with global literature identifying them as potent contributors to falls. A recent systematic review and meta-analysis confirmed that potentially inappropriate prescribing, including FRID use, is highly prevalent (68.6%) among people who have experienced a fall, with sedatives, opioids, and antidepressants being the most common culprits [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. This high prevalence is corroborated by observational studies showing a direct correlation between the number of FRIDs and fall incidence [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Our findings align precisely with this converging evidence, highlighting that the Cuban formulary includes the very agents most frequently implicated in fall events globally. Notably, the work by Saeed et al., 2024 extends beyond identification to the development of a practical, validated screening tool (the Medication-Related Fall [MRF] tool), emphasizing the global push towards actionable clinical instruments for fall prevention [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e4.3. From List to Practice: A Framework for Sustainable Implementation in Cuba\\u003c/h2\\u003e \\u003cp\\u003eA key strength of this framework lies in its pragmatic design for real-world constraints. Developed for a setting without integrated electronic medication records, a common scenario in many healthcare systems, the protocol relies on pragmatic strategies: leveraging the pharmacy's own dispensing history and conducting targeted patient interviews. This makes it a viable, immediately implementable model not only for Cuba but for a wide range of primary care contexts with similar resource profiles.\\u003c/p\\u003e \\u003cp\\u003eThe translational value of this research lies in moving from identification to implementation. The stark evidence of inappropriate prescribing in fallers [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e] presents a clear mandate for systematic medication review. For the Cuban community pharmacist, the generated list (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e) serves as a foundational tool for structured practice. The critical need for such an intervention is underscored by international studies showing alarmingly low patient awareness of FRIDs [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. This knowledge gap represents a crucial point for pharmacist counseling. Robust evidence demonstrates the tangible impact of pharmacist-led interventions, showing significant reductions in polypharmacy, anticholinergic burden, and FRIDs use [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eFollowing this proven model, we propose a feasible Detect, Assess, Act protocol (detailed in Supplementary Material 2). To ensure this intervention can be scaled sustainably, careful consideration must be given to potential electronic support systems. A major implementation challenge is avoiding alert fatigue\\u0026mdash;a well-documented phenomenon in which clinicians ignore excessive warnings, undermining safety [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. A promising solution is demonstrated in a semi-automated system where clinical pharmacists first triaged alerts before physician notification, achieving high physician acceptance (89.8%) and satisfaction (94.5%) [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThis potential for adoption is supported by our preliminary usability assessment (Supplementary Material 1), where the tool received high clarity ratings and unanimous acceptance by practicing pharmacists, confirming its design aligns with frontline needs. The accompanying operational protocol (Supplementary Material 2) provides a complete how-to guide, translating the screening list into a structured clinical workflow.\\u003c/p\\u003e \\u003cp\\u003eThis model provides a practical blueprint for Cuba: the community pharmacist, applying their clinical judgment and the proposed protocol, before initiating collaborative communication with the prescriber, could review initial alerts based on the STOPP-K list. This human-in-the-loop design ensures alerts are contextualized and actionable.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e4.4. The Cuban Context: Medication Shortages as an Unplanned Opportunity\\u003c/h2\\u003e \\u003cp\\u003eAn essential contextual factor in Cuba is the frequent medication shortage. Paradoxically, these frequent shortages may create unplanned opportunities for deprescribing or therapeutic review. When a high-risk STOPP-K medication is unavailable, the community pharmacist, in collaboration with the prescriber, can proactively guide the patient toward a safer alternative or re-evaluate the absolute need for the treatment. This approach transforms a logistical problem into a strategic opportunity for therapy optimization, positioning the pharmacist as an active therapy manager in resource-limited settings.\\u003c/p\\u003e \\u003cp\\u003eA key strength is the practical focus on the community pharmacy setting, aligning with international efforts to create pragmatic solutions [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. The main limitation is its documentary nature. Future research should quantify the prevalence of these medications among Cuban older adults, particularly those with a history of falls [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Furthermore, the proposed protocol should be piloted as a quality improvement intervention. A logical next step would be to pilot a semi-automated clinical decision support system based on this STOPP-K list, evaluating the feasibility of the pharmacist-led triage model [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e] in the Cuban primary care context.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e4.5. Strengths, Limitations and Future Directions\\u003c/h2\\u003e \\u003cp\\u003eA key strength is the practical focus on the community pharmacy setting, aligning with international efforts to create pragmatic solutions [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. The main limitation is its documentary nature. Future research should quantify the prevalence of these medications among Cuban older adults, particularly those with a history of falls [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Furthermore, the proposed protocol should be piloted as a quality improvement intervention. A logical next step would be to pilot a semi-automated clinical decision support system based on this STOPP-K list, evaluating the feasibility of the pharmacist-led triage model [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. in the Cuban primary care context. Furthermore, by design, this tool does not depend on interoperable electronic health records, making it a practical archetype for medication safety interventions in diverse low-resource primary care settings where such digital infrastructure is often absent.\\u003c/p\\u003e \\u003cp\\u003eThe proposed protocol is designed for the current reality of Cuban community pharmacies, where access to a unified patient medication record may be limited. Therefore, the assessment phase emphasizes the use of the pharmacy's own dispensing records and direct patient interview pragmatic strategies that are immediately available to the pharmacist.\\u003c/p\\u003e \\u003cp\\u003eThe logical next step is a pilot implementation study to evaluate feasibility, acceptability, and preliminary effectiveness. To ensure methodological transparency and rigor for this subsequent phase, the Detect, Assess, Act intervention protocol has been formally pre-registered (Supplementary Material 3). The detailed study protocol for a pilot evaluation in a network of Cuban community pharmacies is available from the corresponding author upon reasonable request. This structured progression underscores our commitment to a coherent research program aimed at generating evidence for tangible improvements in medication safety.\\u003c/p\\u003e \\u003cp\\u003eThe identification of fall-risk-increasing drugs at the community pharmacy level takes on added significance in the context of Cuba's demographic structure, where more than one in four citizens is potentially susceptible to this preventable risk. This magnifies the potential public health impact of implementing the proposed screening tool.\\u003c/p\\u003e \\u003cp\\u003eLooking further ahead, the logical endpoint of this research trajectory is the integration of this validated screening logic into a mobile health (mHealth) application. Such an app could serve as a centralized platform, not only embedding the STOPP-K screening tool and the Detect, Assess, Act protocol but also linking it to context-specific deprescribing guidelines for older adults. This digital tool could provide community pharmacists with instant, point-of-care access to step-by-step deprescribing algorithms, patient education materials, and secure communication channels with prescribers. Developing this app through a formal consensus process with geriatricians, clinical pharmacists, and primary care physicians in Cuba would ensure its clinical validity and adoption. This vision aligns with global moves towards digital clinical decision support and represents a transformative step for medication safety in resource-constrained settings.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"5. Conclusion\",\"content\":\"\\u003cp\\u003eThis study identifies twenty medications in the Cuban National Formulary classified as fall-risk-increasing by STOPP 2023 and readily accessible in community pharmacies. This finding moves beyond a simple audit; it provides a validated, context-specific tool to address a significant and quantified public health gap. By translating international evidence into a local checklist, this work directly supports the strategic role of community pharmacists in mitigating a major preventable risk, aligning with data on the proven effectiveness of pharmacist-led medication review.\\u003c/p\\u003e \\u003cp\\u003eCommunity pharmacists in Cuba are uniquely positioned to operationalize this list through systematic screening, targeted counseling to bridge patient knowledge gaps, and collaborative deprescribing. For this potential to be realized at scale, we recommend concerted action: (1) integrating intelligently designed, context-aware alerts into pharmacy software to prompt pharmacist review, informed by evidence on preventing alert fatigue; (2) developing standardized protocols for community pharmacist-led falls prevention; and (3) incorporating this competency into continuing education.\\u003c/p\\u003e \\u003cp\\u003eUltimately, leveraging the community pharmacy network as a frontline defense against medication-related falls offers a feasible, scalable, and evidence-based strategy for the Cuban healthcare system. It is a logical step towards safeguarding the well-being of its rapidly aging population.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eContributors\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEliezer Alem\\u0026aacute;n Fern\\u0026aacute;ndez wrote the first draft of the manuscript and critically reviewed and provided meaningful edits to the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDany Siverio Mota performed all statistical analysis and critically reviewed and provided meaningful edits to the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eLiliana Vicet Murocritically reviewed and provided meaningful edits to the manuscript, had full access to all of the data in the study and takes responsibility for the integrity and accuracy of the data analysis.\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors saw and approved the final version and no other person made a substantial contribution to the paper.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics Approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis is a documentary analysis study based on publicly available policy documents and clinical guidelines. No human participants, personal data, or animals were involved. Therefore, ethical approval was not required for this research.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study did not receive any specific grant from funding agencies.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. The primary source documents, the STOPP 2023 criteria and the Cuban Basic Drug List 2025, are publicly available resources.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no conflicts of interest.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWorld Health Organization. Falls. Factsheet. 2021. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.who.int/10.1016/news-room/fact-sheets/detail/falls\\u003c/span\\u003e\\u003cspan address=\\\"https://www.who.int/10.1016/news-room/fact-sheets/detail/falls\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOficina Nacional de Estad\\u0026iacute;stica e Informaci\\u0026oacute;n (ONEI). Anuario Demogr\\u0026aacute;fico de Cuba 2024. 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.onei.gob.cu/anuario-demografico-de-cuba-enero-diciembre-2024\\u003c/span\\u003e\\u003cspan address=\\\"https://www.onei.gob.cu/anuario-demografico-de-cuba-enero-diciembre-2024\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMinisterio de Salud P\\u0026uacute;blica (MINSAP). Programa Nacional de Atenci\\u0026oacute;n al Adulto Mayor. 2020. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://especialidades.sld.cu/gerontogeriatria/2021/01/29/el-programa-nacional-de-atencion-integral-al-adulto-mayor-en-cuba-apuesta-por-vejez-activa-y-saludable\\u003c/span\\u003e\\u003cspan address=\\\"https://especialidades.sld.cu/gerontogeriatria/2021/01/29/el-programa-nacional-de-atencion-integral-al-adulto-mayor-en-cuba-apuesta-por-vejez-activa-y-saludable\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMontero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. 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J Am Geriatr Soc. 2014;62(12):2261\\u0026ndash;72. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1111/jgs.13153\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/jgs.13153\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSeppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. J Am Med Dir Assoc. 2018;19(4):372. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jamda.2017.12.099\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jamda.2017.12.099\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e.e1-372.e8\\u003c/span\\u003e\\u003cspan address=\\\"http://.e1-372.e8\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eO\\u0026rsquo;Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. EurGeriatr Med. 2023;1\\u0026ndash;8(4):625\\u0026ndash;32. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s41999-023-00777-y\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s41999-023-00777-y\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCrawford P, Plumb R, Burns P, Flanagan S, Parsons C. A quantitative study on the impact of a community falls pharmacist role, on medicines optimisation in older people at risk of falls. BMC Geriatr. 2024;24(1):604. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1186/s12877-024-05189-6\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/s12877-024-05189-6\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYasmeen A, Syed MH, Meraya AM, Alqahtani SS, Syed NK, Alfaifi AJ, et al. Fall Risk and Knowledge of Fall-Risk-Increasing Drugs Among Saudi Older Adults. Healthc (Basel). 2025;13(13):1549. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3390/healthcare13131549\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/healthcare13131549\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMurtezani A, Ibrahim Z, Abazi N, Kolgeci D, Shabani D. Association of medication use with falls among older adults. Pharm Pract. 2025;23(2):3260. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.18549/PharmPract.2025.2.3260\\u003c/span\\u003e\\u003cspan address=\\\"10.18549/PharmPract.2025.2.3260\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSaeed D, Carter G, Miller R, Darcy C, Miller K, Madden K, et al. Development and Delphi consensus validation of the Medication-Related Fall screening and scoring tool. Int J Clin Pharm. 2024;46(4):977\\u0026ndash;86. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s11096-024-01734-w\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s11096-024-01734-w\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGani M, Ian Litchfield I, Shukla D, Delanerolle G, Cockburn N, Pathmanathan A. Understanding Alert Fatigue in Primary Care: Qualitative Systematic Review of General Practitioners Attitudes and Experiences of Clinical Alerts, Prompts, and Reminders. J Med Internet Res. 2025;27:e62763. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.jmir.org/2025/1/e62763\\u003c/span\\u003e\\u003cspan address=\\\"https://www.jmir.org/2025/1/e62763\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDahmke H, Fiumefreddo R, Schuetz P, De Iacod R, Zaugga C. Tackling alert fatigue with a semi-automated clinical decision support system: quantitative evaluation and end-user survey. Swiss Med Wkly. 2023;153:40082. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.57187/smw.2023.40082\\u003c/span\\u003e\\u003cspan address=\\\"10.57187/smw.2023.40082\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)\",\"snPcode\":\"12982\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/12982/3\",\"title\":\"Discover Public Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Community pharmacy, STOPP/START criteria, fall-risk-increasing drugs, medication safety, older adults, Cuba\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8879598/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8879598/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjectives\\u003c/h2\\u003e \\u003cp\\u003eFalls are a leading cause of injury among older adults, with medication use being a well-established, modifiable risk factor. Community pharmacists are strategically positioned to mitigate this risk through medication review. This study aimed to identify and characterize medications in the Cuban Basic Drug List 2025 classified as fall-risk-increasing by STOPP 2023 criteria that are available in community pharmacies for adults aged 60 years and over in Cuba.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA descriptive mapping analysis cross-referenced the 12 STOPP 2023 Section K criteria with the Cuban Basic Drug List 2025. Only community pharmacy-dispensable medications were included.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eTwenty distinct medications corresponding to ten STOPP-K criteria were identified. The predominant groups were antipsychotics (5), benzodiazepines (4), and antiepileptics (3). All are accessible for dispensing in the community pharmacy network.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eThe Cuban national formulary includes multiple fall-risk-increasing medications readily available at the community level. This study provides a validated, practice-ready screening tool and an operational protocol for implementation in resource-constrained settings. This work translates international evidence into a foundational strategy for scalable, pharmacist-led interventions that enhance safety for the growing older adult population. The discussion includes a framework for implementation and considerations for scalable, technology-supported solutions.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Empowering community pharmacists with a STOPP-based tool to prevent medication- related falls in older adults from formulary to frontline\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-30 14:01:54\",\"doi\":\"10.21203/rs.3.rs-8879598/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-12T17:46:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-26T12:10:33+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"295335457437157865628633536958967937549\",\"date\":\"2026-04-14T06:36:02+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-04T19:05:29+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"44001172671097458324123912930552764822\",\"date\":\"2026-03-30T13:50:34+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-03-27T12:19:29+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-27T12:18:55+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-03-09T07:33:50+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-04T10:55:16+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Discover Public Health\",\"date\":\"2026-02-27T12:16:13+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"discover-public-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"\",\"sideBox\":\"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)\",\"snPcode\":\"12982\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/12982/3\",\"title\":\"Discover Public Health\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Discover Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"b9f53884-c099-42f2-bfa6-1fd8fc9428b4\",\"owner\":[],\"postedDate\":\"March 30th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-05-12T17:46:07+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-12T17:54:38+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-30 14:01:54\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8879598\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8879598\",\"identity\":\"rs-8879598\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}