Drugs Aging
DOI 10.1007/s40266-016-0371-4
LETTER TO THE EDITOR
The FORTA (Fit fOR The Aged) List 2015: Update of a Validated
Clinical Tool for Improved Pharmacotherapy in the Elderly
Farhad Pazan1 • Christel Weiss2 • Martin Wehling1 • FORTA
Ó Springer International Publishing Switzerland 2016
Multimorbidity and polypharmacy represent a major
problem for older people. Patients aged 65 years and older
may take five or more drugs in 44 % (male) and 57 %
(female) of cases and ten or more drugs in 12 % of cases
[1]. Critical amendment of medication schemes is impor-
tant to avoid both under- and overtreatment; listing
approaches are considered to be potentially useful aids,
given the limited paid consultation time in general prac-
tices. Most listing approaches (e.g. Beers in the USA,
PRISCUS in Germany [2, 3]) are explicit—thus not
requiring intricate knowledge about patients—and mainly
state what not to give to older patients. Their interventional
clinical impact is still controversial; they are mostly used
for epidemiological studies on the prevalence of potentially
inappropriate medications [4]. A list of alternative medi-
cations has recently been published to replace high-risk
medications [5], which, however, does not cover wide
therapeutic areas and does not provide cross-therapeutic
prioritization guidance. The FORTA (Fit fOR The Aged)
List 2012 was published in Drugs & Aging [6] as the first
drug list combining positive and negative labeling of drugs
chronically prescribed to older patients. Its labels range
from A (indispensable) to B (beneficial), C (questionable)
The complete list of ‘‘FORTA’’ members are listed in the
Acknowledgments section.
& Martin Wehling
martin.wehling@medma.uni-heidelberg.de
1
Department of Clinical Pharmacology, Center for Geriatric
Pharmacology in Mannheim at the University of Heidelberg,
Mannheim, Germany
2
Department of Medical Statistics, Biomathematics and
Information Processing, Medical Faculty Mannheim at the
University of Heidelberg, Mannheim, Germany
and D (avoid), depending on the state of evidence for
safety, efficacy and age appropriateness [7]. The START
criteria [8], as the main competing listing approach posi-
tively stating what to do in given clinical situations,
describe packages of treatments and may lead to additive
prescriptions if several criteria are met; in contrast, FORTA
allows for cross-therapeutic prioritization. Meanwhile, the
clinical utility, implementability and teachability of the
FORTA List 2012 have been validated in controlled clin-
ical trials [9, 10], demonstrating a profound effect on
medication quality (reduction of over- and undertreatment)
and adverse drug reactions. As its application aims to
improve both over- and undertreatment, the FORTA score
has been developed as the sum of individual errors in both
segments; typically, negatively labeled drugs (C/D) may
represent overtreatment, while beneficial drugs (A/B) are
often omitted (undertreatment).
As drug therapy in older people has gained increased
interest in recent years, new evidence and experiences with
the list have necessitated an update of the FORTA List,
which followed the same two-step Delphi process [6] as
was followed for its first version. Twenty-one raters
assessed the proposal of four initiators (see ‘‘Acknowl-
edgments’’). The metrics of the changes are given in
Table 1; the new list just published at http://www.umm.
uni-heidelberg.de/ag/forta (with free access) now contains
273 entries in 29 indications. A general trend toward more
negative labels was observed for oncological and psychi-
atric disorders. The entries for the treatment of diabetes
mellitus type II, as well as for Parkinson’s disease, were
relabeled in both directions. The mean consensus coeffi-
cient for three psychiatric disorders improved significantly;
finally, over 95 % (249 items) of the proposed items (261
items) received a consensus coefficient over 0.8 after the
 F. Pazan et al.

Table 1 Metrics of changes between the 2012 and 2015 versions of the FORTA list
Top 6 indications ranked by Number of entries Number of Number of Number Examples of Examples of downgraded
changes of entries [%] with a new upgraded downgraded of new upgraded entries
classification/total entries entries entries entries
number [%]

Behavioral and psychological 3/3 [100] 0 3 0 – SNRI (serotonin-

symptoms of dementia noradrenaline-reuptake-
(BPSD): depression inhibitors): venlafaxine,
duloxetine
B?D
Oncological diseases: solid 21/21 [100] 0 21 0 – Gastric cancer: ECF regime
tumors (epirubicin, cisplatin,
5-fluorouracil)
A?B
Oncological diseases 6/6 [100] 0 6 6 – MDS (myelodysplastic
Hematological neoplasias syndrome): azacytidine
A?B
Incontinence 2/3 [66.6] 0 2 3 – Trospium chloride
Drug therapy for urge B?C
incontinence
Parkinson’s disease 5/8 [62.5] 3 2 2 L-DOPA Amantadine
B?A C?D
Type II diabetes mellitus 5/10 [50] 2 3 1 DPP4 3rd generation sulfonylureas
(dipeptidyl- (for example, glimepiride)
peptidase) A?C
inhibitors
C?A
Indications with the highest increase in the mean 2012 mean consensus 2015 mean consensus p value (t test)
consensus coefficient (mean B0.80) coefficient (range) coefficient (range)
BPSD: paranoia, hallucination 0.659 (0.500–0.800) 0.891 (0.833–0.976) p \ 0.05
Dementia 0.784 (0.700–0.900) 0.947 (0.650–1) p \ 0.05
BPSD: restlessness, agitation (aggressiveness) 0.785 (0.625–0.947) 0.922 (0.880–0.976) p \ 0.05

first round of the Delphi process, indicating improved
coherence between raters and initiators. The FORTA List
2015 now reflects recent advances in drug treatment for
older people, backed by a wider consensus among experts,
thereby increasing its validity for clinical use further. It
represents a tool to improve the quality of drug prescription
in older patients by identifying inappropriate and omitted
drugs, and thus both over- and undertreatment.
Unlike the explicit approaches mentioned above, its
application requires detailed (‘implicit’) knowledge of the
patient, as it supports matching of the diagnoses, severity of
disease and current status of therapeutic success with cor-
responding drugs [11]. As a living document, the list needs
frequent updates, as gerontopharmacology progresses
rapidly. Further studies and development of electronic aids to
promote the principle and the list are under way.
Acknowledgments FORTA List Initiators and Their Affiliations
Martin Wehling, MD; Center for Geriatric Pharmacology, Institute
of Experimental and Clinical Pharmacology, University of Heidel-
berg, Maybachstrasse 14, 68169 Mannheim, Germany
Heinrich Burkhardt, MD; Geriatric Medicine, 4th Department of
Medicine, University Medical Centre Mannheim, Theodor-Kutzer-
Ufer 1–3, 68167 Mannheim, Germany
Stefan Schwarz, MD; Central Institute of Mental Health, J5,
68159 Mannheim, Germany
Ulrich Wedding, MD; Clinic for Internal Medicine II, University
Hospital, Bachstrasse 18, 07743 Jena, Germany
Expert Panel Members (Raters) and Their Affiliations
Jürgen Bauer, MD; Geriatrics Centre Oldenburg, University of
Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, Germany
Heiner K. Berthold, MD; Department of Internal Medicine and
Geriatrics, Bielefeld Evangelical Hospital (EvKB), Schildescher
Strasse 99, 33611 Bielefeld, Germany
Michael Denkinger, MD; AGAPLESION Bethesda Klinik Ulm,
University Hospital Ulm, Zollernring 26, 89073 Ulm, Germany
Peter Dovjak, MD; Department of Acute Geriatric Medicine,
Gmunden Hospital, Miller-von-Aichholz-Strasse 49, 4810 Gmunden,
Austria
Helmut Frohnhofen, MD; Essen-Mitte Hospital, Knappschafts
Hospital, Teaching Hospital at the University of Duisburg in Essen,
Am Deimelsberg 34a, 45276 Essen, Germany; and Faculty of Health,
University of Witten-Herdecke, Witten, Germany
Thomas Frühwald, MD; Geriatric Department, Hietzing Hospital,
Wolkersbergenstrasse 1, 1130 Vienna, Austria
2015 Update of the FORTA List
Christoph Gisinger, MD; Haus der Barmherzigkeit, Danube
University Krems, Seeböckgasse 30a, 1160 Vienna, Austria
Manfred Gogol, MD; Geriatric Department, Lindenbrunn Hospital,
Lindenbrunn 1, 31863 Coppenbruegge, Germany
Markus Gosch, MD; Medical Clinic 2, Geriatric Department,
University Hospital of the Paracelsus Medical University, Nürnberg
Hospital North, Prof.-Ernst-Nathan-Strasse 1, 90419 Nürnberg,
Germany
Hans Gutzmann, MD; Clinic for Psychiatry, Psychotherapy and
Psychosomatic Medicine, Hedwigshöhe Hospital, Höhensteig 1,
12526 Berlin, Germany
Isabella Heuser, MD; Department of Psychiatry and Psychother-
apy, Charité University Hospital Berlin, University Medicine Berlin,
Campus Benjamin Franklin, Eschenallee 3, 14050 Berlin, Germany
Michael Hüll, MD; Center for Geriatric Medicine and Gerontology
Freiburg, University Clinic Freiburg, Lehener Strasse 88,
79106 Freiburg, Germany
Bernhard Iglseder, MD; Department of Geriatric Medicine,
Christian-Doppler-Klinik, Paracelsus Medical University, Ignaz-
Harrer-Strasse 79, 5020 Salzburg, Austria
Siegfried Kasper, MD; Department of Psychiatry and Psychother-
apy, Medical University of Vienna, AKH, Währinger Gürtel 18–20,
1090 Vienna, Austria
Anja Kwetkat, MD; Department of Geriatric Medicine, Jena
University Hospital, Bachstrasse 18, 07740 Jena, Germany
Wolfgang von Renteln-Kruse, MD; Albertinen Hospital/Albertinen
House nonprofit company (GmbH), Center for Geriatric Medicine and
Gerontology, Scientific Institution at the University of Hamburg,
Sellhopsweg 18–22, 22459 Hamburg, Germany
Christoph Schindler, MD; CRC-MHH Core Facility, Clinical
Research Center Hannover, Feodor-Lynen-Strasse 15, 30625 Han-
nover, Germany
Matthias Schuler, MD; Diakonissenkrankenhaus Mannheim,
Speyerer Strasse 91–93, 68163 Mannheim, Germany
Ralf-Joachim Schulz, MD; Geriatric Clinic at the St.-Marien
Hospital, Kunibertkloster 11–13, 50668 Köln, Germany
Ulrike Sommeregger, MD; Hietzing Hospital and Neurological
Center Rosenhügel, Wolkersbergenstrasse 1, 1130 Vienna, Austria
Andrej Zeyfang, MD; University of Ulm, Institute of Epidemiology
and Medical Biometry, Albert-Einstein-Allee 41, 89081 Ulm, Ger-
many; AGAPLESION Bethesda Krankenhaus Stuttgart, Hohenheimer
Strasse 21, 70184 Stuttgart, Germany
Compliance with Ethical Standards
Martin Wehling was employed by AstraZeneca R&D (Mölndal,
Sweden) as the Director of Discovery Medicine [=Translational
Medicine] from 2004 to 2006 while on sabbatical leave from his
professorship at the University of Heidelberg. Since returning to this
position in January 2007, he has received lecturing and consulting
fees from Sanofi-Aventis, Bayer, Boehringer Ingelheim, Novartis,
Takeda, Roche, Pfizer, Bristol-Myers Squibb, Daichii-Sankyo, Lilly,
LEO Pharma, Novo-Nordisk, Shire and Pro Bono Bio Entrepreneur
Ltd. Farhad Pazan and Christel Weiss have no conflicts of interest that
are directly relevant to the content of this letter.
References
1. Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of
medication use in the ambulatory adult population of the United
States: the Slone Survey. JAMA. 2002;287:337–44.
2. American Geriatrics Society 2015 Beers Criteria Update Expert
Panel. American Geriatrics Society 2015 updated Beers criteria
for potentially inappropriate medication use in older adults. J Am
Geriatr Soc. 2015;2015(63):2227–46.
3. Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate
medications in the elderly: the Priscus list. Dtsch Ärztebl Int.
2010;107:543–51.
4. Tommelein E, Mehuys E, Petrovic M, Somers A, Colin P,
Boussery K. Potentially inappropriate prescribing in community-
dwelling older people across Europe: a systematic literature
review. Eur J Clin Pharmacol. 2015;71:1415–27.
5. Hanlon JT, Semla TP, Schmader KE. Alternative medications for
medications in the use of high-risk medications in the elderly and
potentially harmful drug–disease interactions in the elderly
quality measures. J Am Geriatr Soc. 2015;63:e8–18.
6. Kuhn-Thiel AM, Weiss C, Wehling M, The FORTA Authors/
Expert Panel Members. Consensus validation of the FORTA (Fit
fOR The Aged) list: a clinical tool for increasing the appropri-
ateness of pharmacotherapy in the elderly. Drugs Aging.
2014;31:131–40.
7. Wehling M. Multimorbidity and polypharmacy: how to reduce
the harmful drug load and yet add needed drugs in the elderly?
Proposal of a new drug classification: Fit fOR The Aged. J Am
Geriatr Soc. 2009;57:560–1.
8. Barry PJ, Gallagher P, Ryan C, O’Mahony D. START—an evi-
dence-based screening tool to detect prescribing omissions in
elderly patients. Age Ageing. 2007;36:632–8.
9. Michalek C, Wehling M, Schlitzer J, Frohnhofen H. Effects of
‘‘Fit fOR The Aged’’ (FORTA) on pharmacotherapy and clinical
endpoints—a pilot randomized controlled study. Eur J Clin
Pharmacol. 2014;70:1261–7.
10. Wehling M, Burkhardt H, Kuhn-Thiel AM, Pazan F, Throm C,
Weiss C, Frohnhofen H. VALFORTA—a randomized trial to
validate the FORTA (‘‘Fit fOR The Aged’’) classification. Age
Ageing. 2016;45(2):262–7. doi:10.1093/ageing/afv200.
11. Wehling M. How to use the FORTA (‘‘Fit fOR The Aged’’) list to
improve pharmacotherapy in the elderly. Drug Res.
2016;66:57–62.