Origins and Development
The American Geriatrics Society (AGS) Beers Criteria originated in the U.S. and has been regularly updated since its inception, with the latest versions continuing to serve as a vital guideline for American healthcare providers. Its initial creation addressed the pressing need to prevent and manage inappropriate drug prescribing in institutionalized older adults. The criteria have since expanded to apply across various healthcare settings. Beers is a product of expert consensus, relying on a systematic review of clinical literature to create a list of medications that should be avoided or used with caution in older adults due to high-risk potential or lack of effectiveness.
In contrast, the STOPP/START criteria were first published in Ireland in 2008 and are widely used across Europe. Their development was motivated by a desire to have criteria specifically adapted to European healthcare systems and prescribing practices. Unlike Beers, STOPP/START is a dual-purpose tool. STOPP focuses on medications that are potentially inappropriate, while START focuses on potentially omitted medications—those that are necessary but not prescribed. The development of STOPP/START also uses an expert consensus and evidence-based approach, but its unique structure provides a more comprehensive review by including both the 'stop' and 'start' aspects of prescribing.
Scope and Focus
A primary difference between Beers and STOPP/START lies in their scope. The Beers Criteria has evolved to include five main categories:
- Medications to avoid in most older adults.
- Medications to avoid in older adults with specific diseases or conditions.
- Medications to be used with caution.
- Clinically important drug-drug interactions.
- Medications that require dose adjustments based on kidney function.
The Beers Criteria focuses solely on the avoidance or careful use of specific drugs. It does not explicitly address the problem of undertreatment, where older adults miss out on beneficial medications. This is a significant limitation that STOPP/START was designed to address.
The STOPP/START criteria provide a more holistic approach. The STOPP section identifies instances of potentially inappropriate prescribing based on common drug classes and physiological systems. The START section, a crucial component often overlooked by other tools, lists instances of potentially omitted medications. For example, a patient with heart failure and no beta-blocker may be flagged by START. This dual focus ensures that a clinician not only considers stopping harmful medications but also reviews the patient's regimen for beneficial but missing treatments, providing a more balanced view of medication appropriateness.
Organizational Structure
Another key distinction is the organization of the criteria. Beers lists medications and medication classes, often with an accompanying rationale, but is not structured by the patient's underlying conditions or physiological systems. A clinician must know which section to consult for a particular drug or condition.
The STOPP/START criteria are organized by physiological systems, such as the cardiovascular, central nervous, and gastrointestinal systems. This structure is often considered more intuitive for clinicians performing a medication review, as it aligns with how they typically assess patients and their comorbidities. It allows for a more focused and systematic review of the patient's drug regimen based on their specific health profile, potentially making the process more efficient and thorough. Furthermore, STOPP criteria often detail more specific instances of inappropriate prescribing, such as the prolonged use of a non-steroidal anti-inflammatory drug (NSAID) for osteoarthritis, which might not be as explicitly detailed in Beers.
Comparison Table
| Feature | Beers Criteria | STOPP/START Criteria |
|---|---|---|
| Origin | United States (American Geriatrics Society) | Europe (Ireland) |
| Primary Focus | Identifies potentially inappropriate medications (PIMs) | Identifies PIMs (STOPP) AND potentially omitted medications (POMs) (START) |
| Scope | Drug-focused, with lists of medications to avoid or use with caution | Patient- and condition-focused, with guidelines for both removal and addition of medications |
| Structure | Organized by medication type and a few condition-specific lists | Organized by physiological system (e.g., cardiovascular, CNS) |
| Geographic Relevance | Highly relevant in the U.S. and North America | Widely used in Europe and increasingly internationally |
| Updates | Regular updates (e.g., 2019, 2023) | Regular updates (e.g., Version 2 in 2014, Version 3 in 2023) |
| Drug Formulary | Reflects typical U.S. drug availability | Reflects European drug availability, sometimes excluding older drugs no longer widely used there |
Practical Application and Efficacy
In clinical practice, both sets of criteria are valuable tools for geriatric specialists, pharmacists, and other healthcare providers. The choice of which tool to use may depend on geographical location and the specific needs of the patient. Some studies suggest that STOPP criteria may be more effective than Beers at detecting certain types of PIMs and predicting adverse drug events. This could be due to its more detailed and condition-specific criteria, as well as its systemic organization. The inclusion of START criteria is a distinct advantage, addressing the equally critical issue of undertreatment in older adults.
For example, a study comparing the criteria found that STOPP identified a higher number of PIMs in a nursing home population than Beers. This highlights that neither tool is perfect, and sometimes a combination of both or a localized version might be most effective. The critical takeaway for practitioners is that these are not substitutes for clinical judgment but rather aids to structure the medication review process. The ongoing evolution of both criteria shows a commitment to improving medication safety in the elderly population.
For a deeper dive into the specific criteria and their evolution, it is recommended to consult the official publications and updates from the respective organizations, such as those found on the American Geriatrics Society website. American Geriatrics Society
Conclusion
While both Beers and STOPP/START criteria are evidence-based tools designed to improve medication prescribing for older adults, they differ fundamentally in their origin, scope, and structure. Beers offers a clear, U.S.-centric list of potentially harmful medications. STOPP/START, from Europe, provides a more comprehensive, dual approach by identifying both inappropriate and omitted medications, organized by physiological system. Clinicians can leverage these distinctions to choose the most appropriate tool for their practice and patients, ultimately enhancing medication safety and optimizing health outcomes for the elderly.
