A Closer Look at STOPP/START
The most widely recognized screening tool of older people's prescriptions is the STOPP/START criteria. This tool is a two-pronged approach to optimizing pharmacotherapy for older adults. It helps clinicians address two major prescribing problems: polymedicine and age-related physiological changes that can lead to adverse drug events (ADEs).
The STOPP Criteria
STOPP, the Screening Tool of Older Persons' Prescriptions, is a set of explicit, evidence-based rules for identifying potentially inappropriate medications (PIMs) in older adults. The criteria are organized by physiological system, making them easier for clinicians to apply during medication reviews. By highlighting drugs that carry a higher risk of adverse effects in older people, STOPP helps healthcare providers avoid dangerous prescribing practices. This includes avoiding medications that are contraindicated for certain conditions prevalent in older populations, like a history of falls or specific organ dysfunction. The latest version, STOPP v3 (2023), expanded the number of criteria to reflect new research and clinical evidence.
Examples of medications and scenarios flagged by STOPP:
- Long-acting benzodiazepines, which increase the risk of falls.
- Non-steroidal anti-inflammatory drugs (NSAIDs) in patients with a history of heart failure or renal impairment.
- Anticholinergic drugs in patients with dementia or delirium, as they can worsen cognitive function.
- Tricyclic antidepressants, which carry a risk of orthostatic hypotension and sedation.
The START Criteria
START, the Screening Tool to Alert doctors to Right Treatment, complements STOPP by identifying potential prescribing omissions (PPOs). While STOPP focuses on what to stop prescribing, START focuses on what might need to be started to improve patient care. Just like STOPP, the START criteria are organized by physiological system and are based on clinical evidence. Identifying prescribing omissions is just as crucial as identifying inappropriate prescriptions, as undertreatment is a significant issue in older adults with multiple comorbidities.
Examples of prescribing omissions flagged by START:
- Not prescribing a statin for a patient with established coronary artery disease.
- The absence of osteoporosis treatment (e.g., bisphosphonates) in a patient on long-term corticosteroid therapy.
- Failure to prescribe a laxative for a patient on long-term opioid treatment.
- The omission of a proton pump inhibitor in patients using chronic NSAIDs, especially those with a history of gastrointestinal issues.
How Healthcare Professionals Use STOPP/START
Healthcare providers, including geriatricians, pharmacists, and general practitioners, can use the STOPP/START criteria to perform a structured medication review. The process typically involves comparing a patient's current medication list against the comprehensive list of criteria, often organized by physiological system. This systematic review helps identify and rectify potential drug-related problems. A key part of the process is balancing the tool's recommendations with individual patient needs, considering their health literacy, preferences, and overall goals of care. This practice of adjusting medication regimens to ensure appropriateness is sometimes referred to as 'deprescribing'. Electronic clinical decision support systems have also been developed to integrate STOPP/START criteria, helping clinicians flag potential issues more efficiently.
STOPP/START vs. Beers Criteria
While STOPP/START is widely used, particularly in Europe, the Beers Criteria developed by the American Geriatrics Society (AGS) is another prominent tool used mainly in the United States. Both tools aim to improve medication safety for older adults, but they have key differences.
| Feature | STOPP/START Criteria | Beers Criteria |
|---|---|---|
| Origin | European consensus-based tool. | US-based tool from the American Geriatrics Society. |
| Focus | Identifies both potentially inappropriate medications (STOPP) and potential prescribing omissions (START). | Primarily focuses on potentially inappropriate medications (PIMs) to be avoided. |
| Structure | Organized by physiological systems (e.g., cardiovascular, central nervous system) for structured review. | Lists drugs or drug classes by category (e.g., drug-drug, drug-disease interactions). |
| Update Cycle | Periodically updated; latest is version 3 (2023). | Regularly updated by an expert panel; latest is 2023. |
| Advantages | More sensitive in detecting a wider range of prescribing issues, including both over- and undertreatment. | Long-established, familiar to many US clinicians, and widely adopted. |
Conclusion
The Screening Tool of Older People's Prescriptions (STOPP), in combination with the START criteria, represents a vital, evidence-based approach to optimizing medication management for the elderly. By providing a structured framework for clinicians to identify potential prescribing issues—both inappropriate prescriptions and omissions—these criteria help mitigate the risks associated with polypharmacy and age-related physiological changes. While not a one-size-fits-all solution, when used alongside sound clinical judgment, the STOPP/START tool can significantly improve medication appropriateness, reduce adverse drug events, and ultimately enhance patient safety and well-being. As the population ages, the systematic application of such tools will become increasingly critical for ensuring high-quality, person-centered geriatric care.
Authoritative Outbound Link: Learn more about STOPP/START criteria from the National Institutes of Health
