Understanding the Beers Criteria
Developed by the American Geriatrics Society (AGS), the Beers Criteria is a list of potentially inappropriate medications (PIMs) for use in older adults. It was first published by Mark Beers in 1991 and has been regularly updated to reflect new evidence, most recently in 2019.
Core Principles of the Beers Criteria
The Beers Criteria primarily lists specific medications or drug classes to avoid in older adults, either completely or in certain situations, or to use with caution. The criteria are prescriptive, providing a clear list of "dos and don'ts." They are designed to address issues such as an increased risk of adverse drug events (ADEs), drug-disease interactions, and the use of medications for conditions where safer alternatives are available. The framework is straightforward and provides a clear starting point for medication review.
Limitations of the Beers Criteria
While highly influential, the Beers Criteria has limitations. Its primary focus is on what medications to avoid, rather than what to start or continue. Furthermore, its US-centric origin means it is based on medications and practices common in the United States, which may not align perfectly with practices elsewhere.
Delving into the STOPP and START Criteria
In contrast to the Beers Criteria, the Screening Tool of Older Person's Prescriptions (STOPP) and the companion Screening Tool to Alert doctors to Right Treatment (START) were developed in Europe. The STOPP/START criteria, updated in 2014, offer a more comprehensive and proactive approach to medication safety in older adults.
The Dual Focus of STOPP/START
STOPP: This tool lists criteria for potentially inappropriate prescribing (PIP). It identifies instances where a medication is prescribed unnecessarily, at an incorrect dose, or has potential for significant adverse events, much like the Beers Criteria.
START: This is the key distinguishing feature. The START criteria list common instances of prescribing omissions—where an older person has a specific condition for which evidence-based, effective medication is indicated but not prescribed. For example, a patient with heart failure who is not on an ACE inhibitor may be flagged by START.
Advantages of the STOPP/START Criteria
This dual focus addresses both commission (prescribing the wrong drug) and omission (failing to prescribe the right one), providing a more holistic review of a patient's medication regimen. Its European origin and continuous refinement make it a relevant tool for many international settings.
Beers vs. STOPP/START: A Direct Comparison
To highlight the nuances, a side-by-side comparison is helpful.
| Feature | Beers Criteria | STOPP/START Criteria |
|---|---|---|
| Origin | American (American Geriatrics Society) | European (Developed in Ireland) |
| Primary Focus | What to STOP prescribing (avoiding problematic drugs) | What to STOP prescribing AND what to START prescribing (avoiding inappropriate drugs and addressing omissions) |
| Structure | List of specific drugs/drug classes and potential issues | Condition-specific criteria for both inappropriate use (STOPP) and omissions (START) |
| Scope | Broad list of medications for older adults, often drug-centric | Comprehensive, considering both medications and therapeutic omissions, often disease-centric |
| Approach | Primarily reactive (identifies problems) | Proactive (identifies problems and opportunities) |
| Flexibility | Generally more rigid with clear "avoid" statements | More context-driven, considering specific clinical situations |
The Practical Application of Both Sets of Criteria
In practice, healthcare professionals often use both criteria to inform clinical decisions, applying expert clinical judgment to individual patient needs. For instance, the Beers Criteria may be used as a quick screening tool to flag specific medications, while the STOPP/START criteria can guide a more detailed, patient-centered medication review. Neither is a substitute for an in-depth clinical assessment but rather a valuable aid in identifying potential issues.
- Comprehensive Review: During a medication review, a pharmacist or physician can use both lists to cross-reference a patient's drug regimen. First, check for any medications on the Beers list. Second, review the patient's conditions against the STOPP/START criteria to identify both inappropriate prescriptions and potential omissions.
- Case-by-Case Basis: A patient with a specific disease, like heart failure, might have medication issues that only one set of criteria identifies. For example, the STOPP criteria provides more detailed guidance on specific conditions and treatments.
- Deprescribing: Both criteria are integral to the process of deprescribing, which involves systematically reviewing medications with the goal of reducing the number of drugs or reducing the dose, potentially improving patient outcomes and reducing side effects. For further reading on deprescribing, visit the Canadian Deprescribing Network website: https://deprescribing.org/.
Limitations and Synergies of the Criteria
It's important to remember that these are tools, not absolute rules. They are meant to guide, not dictate, clinical judgment. Some studies have shown that STOPP criteria can identify more PIMs than Beers in certain populations, while other studies show significant overlap. This reinforces the idea that using both in combination can provide a more complete picture of a patient's medication appropriateness.
The Importance of a Patient-Centered Approach
Ultimately, the goal is not to simply follow a checklist but to provide patient-centered care. This involves:
- Individualized Risk-Benefit Assessment: Considering the potential benefits versus the risks of continuing a medication for a specific patient.
- Involving the Patient and Caregivers: Ensuring that the patient's and caregiver's preferences and goals are part of the decision-making process.
- Monitoring and Follow-up: Any changes to a medication regimen should be carefully monitored for effectiveness and side effects.
Conclusion
The difference between the Beers and STOPP/START criteria is significant, reflecting their distinct origins, scopes, and approaches to managing medication safety in older adults. While Beers provides a clear, drug-specific list of medications to avoid, STOPP/START offers a more comprehensive, condition-specific assessment that addresses both potentially inappropriate prescriptions and valuable treatment omissions. By understanding and judiciously applying both sets of criteria, healthcare professionals can enhance patient safety, optimize treatment regimens, and support healthier aging.
