STOPP/START v3: Stronger Criteria, Weaker Evidence in Geriatric Care

The newest Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool too Alert to Right Treatment (START) criteria detect 17% more potential medication omissions and inappropriate prescriptions, respectively.¹ Healthcare providers globally utilize STOPP/START when caring for geriatric patients.

polypharmacy, defined as the concurrent use of five or more medications, is common in older adults.² It increases the risk of adverse drug events, hospitalization, and mortality.³ Older patients are more susceptible to these risks due to age-related physiological changes that affect drug absorption, distribution, metabolism, and excretion.

STOPP/START provides a structured approach to medication review. STOPP identifies possibly inappropriate medications (PIMs) to discontinue, while START highlights potentially omitted medications that could benefit the patient. These tools aren’t rigid rules,but rather prompts for clinical consideration.

Key Updates in the Latest Criteria: The updated STOPP/START criteria (2023) incorporate new evidence and address gaps in the previous versions. Changes include refined criteria for specific conditions like heart failure, dementia, and chronic kidney disease. The criteria also emphasize deprescribing – the process of safely reducing or stopping medications – as a crucial component of geriatric care.

How to Implement STOPP/START:

1. Medication Reconciliation: Obtain a complete and accurate list of all medications the patient is taking, including prescription drugs, over-the-counter medications, and supplements.
2. Apply STOPP Criteria: Systematically review the medication list against the STOPP criteria to identify PIMs.
3. Apply START Criteria: Assess whether any potentially beneficial medications are being omitted based on the START criteria.
4. Clinical Review: Critically evaluate each identified PIM or omission in the context of the patient’s individual health status, goals of care, and preferences.
5. Shared Decision-Making: Discuss potential medication changes with the patient and their caregivers, ensuring they understand the risks and benefits.

Limitations: STOPP/START is a valuable tool, but it has limitations. The criteria are not exhaustive and may not cover all potential medication issues. Clinical judgment remains paramount.furthermore, the criteria were primarily developed and validated in Western populations, and their applicability to other populations may vary.

Using STOPP/START can significantly improve medication safety and quality of life for older adults. By proactively identifying and addressing potentially inappropriate or omitted medications, healthcare providers can optimize treatment regimens and minimize harm.