Understanding the STOPP/START Framework
Polypharmacy, the use of multiple medications, is common among older adults and increases the risk of serious health complications, such as adverse drug events (ADEs), falls, and cognitive decline. To address this challenge, the STOPP/START screening tool was developed in 2008 by a European expert panel and has been subsequently updated to reflect new evidence, most recently in 2023. The tool provides an explicit, evidence-based system to guide medication reviews for seniors with complex health needs.
The Two Core Components: STOPP and START
The tool is comprised of two complementary sets of criteria that address different aspects of prescribing problems:
- STOPP Criteria (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions): These criteria identify medications that are potentially inappropriate for older adults, either because they carry a high risk of adverse effects or because they are not indicated given the patient's condition. Examples include prescribing long-acting sulfonylureas to diabetics with a risk of hypoglycemia or prescribing a benzodiazepine to a patient with a history of falls. The goal is to stop unnecessary or harmful medications.
- START Criteria (Screening Tool to Alert doctors to Right Treatment): These criteria highlight clinically indicated medications that may have been inappropriately omitted. Forgetting to prescribe a necessary medication is just as harmful as prescribing a dangerous one. A common example is omitting a bisphosphonate medication for an osteoporosis patient taking chronic steroids. The goal is to start appropriate, beneficial medications.
The Need for Systematic Medication Review in Geriatric Care
Older adults are uniquely susceptible to medication-related problems due to several factors:
- Physiological Changes: As people age, changes in kidney and liver function can alter how drugs are metabolized and eliminated, potentially leading to higher concentrations and increased toxicity.
- Multimorbidity and Polypharmacy: Many seniors manage several chronic diseases at once, requiring multiple medications. The more medications a person takes, the higher their risk of ADEs and dangerous drug-drug interactions.
- Adverse Drug Reactions: Older adults can be more sensitive to the effects of certain drugs, leading to side effects like confusion, dizziness, and sedation. These can contribute to functional decline, delirium, and falls.
Comparison: STOPP/START vs. Beers Criteria
While both are important tools for medication safety in seniors, they differ in their scope and origin. The Beers Criteria is a US-based tool developed by the American Geriatrics Society, while STOPP/START originated in Europe. The most significant difference is that the Beers Criteria primarily focuses on identifying potentially inappropriate medications to be avoided (PIMs), whereas the STOPP/START tool provides a more comprehensive approach by also identifying potentially omitted medications (POMs).
| Feature | STOPP/START Criteria | Beers Criteria |
|---|---|---|
| Focus | Identifies potentially inappropriate medications (STOPP) and potential prescribing omissions (START). | Primarily identifies potentially inappropriate medications (PIMs) to be avoided. |
| Approach | Explicit, evidence-based criteria based on physiological systems and drug-disease interactions. | Explicit criteria, focusing on drug classes and specific medications to be avoided, used with caution, or with close monitoring. |
| Origin | Europe, with validation by an international panel. | United States, developed by the American Geriatrics Society. |
| Scope | Comprehensive, covering both prescribing sins of commission (STOPP) and omission (START). | Historically focused mainly on medication-related harms, though more recent versions have expanded. |
Implementing the STOPP/START Tool in Clinical Practice
Healthcare providers use the STOPP/START tool as a structured framework during medication reviews. While the criteria provide a clear checklist, the process still requires careful clinical judgment to be applied to the individual patient's specific health context.
Steps for Implementation:
- Comprehensive Review: The provider conducts a thorough review of all medications, including prescriptions, over-the-counter drugs, and supplements.
- STOPP Analysis: They check the patient's medication list against the STOPP criteria to identify any potentially inappropriate drugs.
- START Analysis: They review the patient's medical conditions and compare them against the START criteria to ensure no indicated medications have been omitted.
- Clinical Justification: Based on the review, the provider determines which medications should be discontinued, dose-adjusted, or added. This involves weighing the potential benefits and risks for the individual patient.
Practical Examples of STOPP and START Criteria
To illustrate the tool's application, here are some examples based on common conditions in older adults:
STOPP (Inappropriate Prescriptions)
- Cardiovascular: Use of aspirin with a history of peptic ulcer disease without a proton pump inhibitor (PPI).
- Central Nervous System: Use of benzodiazepines for more than four weeks due to an increased risk of falls and cognitive impairment.
- Gastrointestinal: Prescribing a non-steroidal anti-inflammatory drug (NSAID) to a patient with a history of peptic ulcer disease.
START (Prescribing Omissions)
- Cardiovascular: Failing to prescribe a statin for a patient with established coronary heart disease.
- Endocrine: Omitting a bisphosphonate for a patient on long-term steroid therapy with osteoporosis.
- Central Nervous System: Neglecting to prescribe an antidepressant for a patient with persistent depressive symptoms.
How Families Can Support Medication Safety
Families and caregivers can be invaluable partners in ensuring medication safety for older adults. Here are some actionable tips:
- Keep a Master List: Maintain an up-to-date list of all medications, including dosage, frequency, and the reason for taking them. Share this list with all healthcare providers.
- Report Concerns: Openly discuss any side effects or perceived changes in the senior's condition with their doctor. Sometimes, what seems like a new symptom is actually an ADE.
- Use Adherence Aids: Utilize pill organizers, smartphone apps, or calendars to help ensure medications are taken correctly and on time.
- Proper Storage: Ensure all medications are stored safely and correctly, paying attention to any special instructions.
- Avoid Self-Adjusting: Remind the senior not to stop taking or alter the dose of any prescription drug without consulting a healthcare professional first.
For more tips on safe medication management, visit the National Institute on Aging's guide to taking medicines safely as you age.
Conclusion
The STOPP/START screening tool is a powerful and comprehensive asset in geriatric medicine, providing a structured, evidence-based approach to medication review that goes beyond simply avoiding inappropriate drugs. By also identifying important prescribing omissions, it helps ensure older adults receive the optimal treatment for their complex health needs. While the tool's implementation requires expert clinical judgment, its use represents a significant step forward in promoting medication safety and enhancing the quality of care for the aging population.
