What criteria should be used to identify potential inappropriate medication use in older adults?

Oct 15, 2025 3 min read •

senior care Geriatric Health Medication Management

According to the CDC, adverse drug events lead to over 600,000 emergency room visits by older adults each year. Understanding what criteria should be used to identify potential inappropriate medication use in older adults is a critical component of safe, effective senior care.

Quick Summary

Several comprehensive frameworks exist, such as the American Geriatrics Society's Beers Criteria and the STOPP/START criteria, that provide explicit guidelines for evaluating medication appropriateness based on age-related physiological changes, drug-disease interactions, and the overall benefit-to-risk ratio for older adults.

Key Points

Beers Criteria: The American Geriatrics Society provides a comprehensive list, regularly updated, of medications and drug classes to avoid or use with caution in older adults, considering specific health conditions and drug interactions.
STOPP/START Criteria: This European-developed tool addresses both the overuse (STOPP) and underuse (START) of medications, offering a broader evaluation of medication appropriateness.
Medication Appropriateness Index (MAI): The MAI uses ten implicit criteria to evaluate individual prescriptions, allowing for a patient-centered, in-depth assessment of each medication.
Individualized Assessment: Effective identification goes beyond standard lists, requiring a holistic assessment of the patient's overall health, comorbidities, and life expectancy to determine the true benefit-to-risk ratio of a medication.
Deprescribing: A crucial strategy for senior care, deprescribing involves the systematic process of reducing or stopping medications when the risks or burdens outweigh the benefits, often guided by the patient's own health goals.
Inclusion of OTC and Supplements: A complete medication review must include all prescriptions, over-the-counter drugs, and herbal supplements, as all can contribute to harmful drug interactions and side effects.
Patient and Caregiver Involvement: Ensuring patient and caregiver understanding and acceptance of a medication plan is a key criterion for appropriateness and helps increase adherence and safety.

Understanding the Problem: Why Is Inappropriate Medication a Concern for Older Adults?

As people age, their bodies undergo significant physiological changes that affect how medications are absorbed, distributed, metabolized, and eliminated. This can lead to an increased risk of adverse drug events (ADEs), which can have severe consequences, from falls and cognitive impairment to hospitalization and even death. Factors contributing to this risk include multiple comorbidities, polypharmacy (the use of multiple medications), and altered drug sensitivity. Clinicians, caregivers, and older adults themselves must use specific, evidence-based criteria to mitigate these risks and ensure medication regimens are appropriate and safe.

Key Criteria and Tools

Several validated tools and criteria are used to identify potentially inappropriate medication (PIM) use in older adults. These frameworks help healthcare providers evaluate medication regimens based on age-related factors, comorbidities, and potential drug interactions.

The American Geriatrics Society (AGS) Beers Criteria

The AGS Beers Criteria is a widely recognized tool that lists medications and drug classes potentially inappropriate for older adults. It provides categories to guide clinical decisions, including medications to avoid in most older adults, those to avoid with specific conditions, medications to use with caution, significant drug-drug interactions, and drugs requiring dosage adjustment based on kidney function.

The STOPP/START Criteria

The STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria offer a complementary approach. STOPP identifies potentially inappropriate prescribing (overuse), while START highlights potential prescribing omissions (underuse) of beneficial medications. This dual approach provides a more comprehensive review of medication appropriateness.

Comparing Beers and STOPP/START Criteria


Feature	Beers Criteria	STOPP/START Criteria
Primary Focus	Overuse of potentially inappropriate medications (PIMs).	Both overuse (STOPP) and underuse (START) of medications.
Geographic Origin	United States (American Geriatrics Society).	Ireland/Europe (international application).
Approach	Explicit list of specific drugs or drug classes to avoid, with specific caveats.	Explicit lists, but is often seen as more clinically prescriptive and disease-specific.
Key Strength	Widely known and regularly updated. Excellent for identifying drugs with unfavorable risk profiles.	Comprehensive, addressing both medication errors of commission and omission.
Limitation	Primarily focused on what to stop, not what might be missing from a patient's regimen.	Less known in the US, requiring more familiarity from clinicians.

The Medication Appropriateness Index (MAI)

The Medication Appropriateness Index (MAI) offers an implicit, patient-centered approach using 10 criteria to evaluate the appropriateness of each medication. These criteria cover indication, effectiveness, dosage, directions, drug interactions, drug-disease interactions, duration, cost, duplication, and patient acceptance.

The Role of Deprescribing

Deprescribing is a crucial process involving the planned reduction or discontinuation of medications that may no longer be beneficial or could be causing harm. This requires a collaborative discussion with the patient and caregivers to align medication regimens with individual health goals and priorities. Key steps include reviewing all medications, assessing patient goals, identifying candidates for deprescribing, planning a gradual taper, and monitoring for effects.

Conclusion: A Multi-faceted Approach

Identifying inappropriate medication use in older adults requires a comprehensive approach utilizing tools like the Beers Criteria, STOPP/START criteria, and MAI, combined with deprescribing principles. This ensures medication regimens are optimized to minimize risks and improve the quality of life for older adults.

An excellent resource for patients and caregivers seeking to better understand this issue is the Health in Aging Foundation, specifically their resource on Medications that Older Adults Should Avoid or use with Caution.

Frequently Asked Questions

The most well-known and widely used criteria is the American Geriatrics Society's (AGS) Beers Criteria. It provides a list of potentially inappropriate medications (PIMs) for older adults, which is regularly updated to reflect new research.

Polypharmacy, defined as the use of multiple medications, significantly increases the risk of drug-drug interactions, side effects, and medication burden. Each new medication adds to the complexity and potential for an inappropriate prescribing cascade.

The STOPP/START criteria are explicit, evidence-based tools used to address both potentially inappropriate prescribing (STOPP) and potential prescribing omissions (START), which is when a beneficial medication has been omitted from a patient's regimen.

No. While authoritative lists like the Beers Criteria are invaluable tools for clinicians, they should not replace a healthcare provider's clinical judgment. The criteria are a guide, and individual circumstances, patient goals, and overall health status must always be considered.

Older adults often have reduced kidney function, which can slow the body's ability to clear medications. The Beers Criteria specifically addresses this by listing medications that should be avoided or have their dosage adjusted in individuals with varying levels of renal impairment.

Deprescribing is the supervised process of reducing or stopping medications that are no longer beneficial or may be causing harm. It is a patient-centered approach that helps reduce polypharmacy and its associated risks, improving overall quality of life.

Caregivers can help by maintaining a comprehensive list of all medications, including OTCs and supplements, noting any adverse side effects or changes in the senior's health, and accompanying them to appointments to facilitate communication with healthcare providers.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.