Understanding the Need for Geriatric Screening Tools
Older adults, especially those with multiple chronic conditions (multimorbidity), often take a complex combination of medications. The physiological changes that come with aging, such as altered drug metabolism and reduced organ function, make them more vulnerable to adverse drug reactions and serious side effects. This complexity makes standard medication reviews insufficient, necessitating specialized screening tools like the STOPP/START criteria.
The Core Concepts: STOPP and START
The STOPP/START criteria were developed in Europe and are now widely adopted globally to improve medication safety and effectiveness in older adults, particularly those with polypharmacy. This set of criteria provides a systematic framework for healthcare providers to evaluate a patient's medication regimen in two key ways:
What is the STOPP Criteria?
The STOPP criteria (Screening Tool of Older Persons' Potentially inappropriate Prescriptions) focus on identifying medications that are potentially inappropriate or harmful for older patients. The criteria are organized by physiological systems (e.g., cardiovascular, central nervous system) to help clinicians easily navigate potential issues. Examples of conditions identified by STOPP criteria include:
- Drug-Disease Interactions: Prescribing a medication that is contraindicated due to a co-existing medical condition, such as using nonsteroidal anti-inflammatory drugs (NSAIDs) in a patient with heart failure.
- Dosage Problems: Prescribing a medication at an unsafe dose, especially considering renal function, or for a longer duration than recommended.
- Drug-Drug Interactions: Concomitant use of multiple medications that can cause harmful interactions, such as prescribing two drugs with anticholinergic properties.
What is the START Criteria?
The START criteria (Screening Tool to Alert doctors to Right Treatment) address the other side of medication optimization: potential prescribing omissions. This tool ensures that older adults are not missing out on necessary, evidence-based medications that could significantly improve their health outcomes. Examples of prescribing omissions flagged by START include:
- Cardiovascular System: Failing to prescribe antiplatelet therapy for a patient with a history of stroke or myocardial infarction.
- Musculoskeletal System: Omitting calcium and vitamin D supplementation for patients with osteoporosis.
- Endocrine System: Not prescribing a statin for a patient with diabetes and high cardiovascular risk.
The Evolution of STOPP/START
The STOPP/START criteria have been regularly updated to reflect the latest clinical evidence and advancements in geriatric medicine. The most recent version, version 3, published in 2023, represents a significant expansion of the criteria. This updated version includes a greater number of specific criteria, covering more adverse drug–drug and drug–disease interactions encountered in modern clinical practice. This expansion is crucial for keeping pace with the growing pharmacopeia and the expanding evidence base related to geriatric care.
Comparison with Other Geriatric Assessment Tools
While STOPP/START focuses specifically on medication appropriateness, it is often used as part of a broader Comprehensive Geriatric Assessment (CGA). Other tools, like the American Geriatrics Society (AGS) Beers Criteria, also address potentially inappropriate medication use in older adults. A comparison helps illustrate the unique role of STOPP/START.
| Feature | STOPP/START Criteria | AGS Beers Criteria |
|---|---|---|
| Purpose | Addresses both potentially inappropriate prescribing (STOPP) and prescribing omissions (START). | Primarily identifies potentially inappropriate medications (PIMs). |
| Geographic Origin | Developed in Europe. | Developed in the United States. |
| Scope | Expansive list covering a wide range of drug-disease and drug-drug interactions, with explicit, physiological system-based criteria. | Lists PIMs for most older adults, medications to avoid with specific conditions, drug interactions, and dosage adjustments. |
| Key Benefit | Comprehensive and specific for a variety of conditions, proactively addressing under-treatment. | Well-established and widely known, though may be less sensitive for some issues compared to STOPP/START. |
How STOPP/START Improves Patient Outcomes
Using a structured tool like STOPP/START during medication reviews has several important benefits for older adults:
- Reduced Adverse Drug Events: By systematically identifying and removing potentially harmful medications, the risk of side effects, falls, and hospitalizations is lowered.
- Optimized Treatment: The START criteria ensure that patients receive all the necessary, evidence-based treatments for their conditions, addressing common instances of under-treatment.
- Enhanced Patient Safety: Consistent application of these criteria helps healthcare providers deliver safer, more person-centered care, particularly for individuals with multimorbidity and polypharmacy.
- Cost and Resource Savings: By preventing adverse drug events and improving treatment effectiveness, the use of STOPP/START can lead to reduced healthcare costs and resource utilization.
The Role of Comprehensive Geriatric Assessment (CGA)
While STOPP/START provides a crucial focus on medication, it is part of a larger clinical picture known as a Comprehensive Geriatric Assessment (CGA). A CGA is a holistic, multidisciplinary process that evaluates an older person's medical, functional, cognitive, and psychosocial status. Medication review using tools like STOPP/START is a vital component of this broader evaluation, which aims to create an integrated and coordinated care plan. A CGA helps to identify unrecognized needs beyond medication, including issues with nutrition, mobility, mood, and social support.
Conclusion
In the complex landscape of older adult care, specialized screening tools are indispensable for ensuring safety and efficacy. The STOPP/START criteria provide a robust, evidence-based framework for optimizing medication regimens by identifying and addressing both potentially inappropriate prescriptions and essential omissions. While a critical piece of the puzzle, it works best within a broader Comprehensive Geriatric Assessment to provide holistic, patient-centered care. By implementing and regularly updating these tools, healthcare professionals can significantly improve the quality of life and well-being for the older population.
For more detailed information on the latest version of the STOPP/START criteria, you can review the consensus process used by experts Read the full study on the STOPP/START criteria via this PMC link.
