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STOPP and START: New Criteria for Drug Therapy in the Elderly

One issue of concern with regard to geriatric drug therapy is the use of potentially inappropriate medications (PIM). Criteria have been developed to identify PIM use in the elderly. The best known of these criteria are the “Beers criteria.” Geriatrician Mark Beers led the research that resulted in these criteria, developed with the aid of an expert panel. These criteria were last updated in 2003.1

The Beers criteria have been used as a starting point for development of similar PIM criteria. Zhan and colleagues published PIM criteria for community-dwelling elderly that were modified from the Beers criteria.2 The Beers criteria also were adapted for inclusion into a quality measure on potentially inappropriate prescribing for the elderly for the Health Plan Employer Data and Information Set (HEDIS).3

The Inappropriate Prescribing in the Elderly Tool (IPET), consisting of a list of 14 common prescription errors, was prepared in 1997 by an expert Canadian consensus panel.4 The use of this tool has been limited primarily to Canada.

In the nursing home setting, Handler and colleagues recently published a list of signals to detect potential adverse drug reactions in nursing homes.5 The signals identified for this purpose were placed into four categories:

  • Laboratory and medication combination signals
  • Medication concentration signals
  • Antidote signals
  • Resident assessment protocol (RAP) signals

The first two types of signals require access to laboratory test results. The fourth type of signal requires access to the Resident Assessment Instrument. Only the third type can be evaluated from the medication list alone. Examples include:

  • Naloxone is given to an individual taking an opioid analgesic.
  • Sodium polystyrene is given to an individual taking a drug that may cause hyperkalemia.
  • Epinephrine is given to an individual taking a drug that may cause an anaphylactic reaction.

Most recently, a panel of European experts has introduced two new sets of criteria related to medication use in the elderly. The panel is comprised of nine physicians in geriatric medicine, three clinical pharmacologists, two senior academic primary care physicians, one geriatric psychiatrist, and three senior hospital pharmacists with an interest in geriatric pharmacotherapy

The STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) criteria are focused on avoiding use of medications that are potentially inappropriate in older adults.6 The criteria are organized by organ system (e.g. cardiovascular system, central nervous system, etc.). A full description of the STOPP criteria is available in an online appendix, along with the full text article.

Examples of the STOPP criteria include:

  • Theophylline as monotherapy for chronic obstructive pulmonary disease
  • NSAID (nonsteroidal anti-inflammatory drug) with heart failure
  • NSAID together with warfarin
  • Vasodilator drugs with postural hypotension
  • Bladder antimuscarinic drugs with dementia

The START (Screening Tool to Alert doctors to the Right Treatment) criteria are focused on identifying undertreatment or prescribing omissions in elderly patients.7 These criteria are also organized by organ system, as shown below (with the number of criteria for each organ system shown in parentheses):

  • Cardiovascular system (8)
  • Respiratory system (3)
  • Central nervous system (2)
  • Gastrointestinal system (2)
  • Locomotor system (3)
  • Endocrine system (4)

In a study conducted in a teaching hospital, 600 elderly patients consecutively admitted from the community for acute illness were evaluated with these criteria. The most common prescribing omissions identified were:

  • Statins in atherosclerotic disease (26%)
  • Warfarin in chronic atrial fibrillation (9.5%)
  • Anti-platelet therapy in arterial disease (7.3%)
  • Calcium/vitamin D supplementation in symptomatic osteoporosis (6%)

Overall, the study authors found that 58% of subjects were not receiving one or more evidence-based appropriate medicines.7

Together, these new STOPP and START criteria provide useful summaries of key prescribing considerations in older adults. Since lack of education among health professionals in geriatric prescribing principles is a key challenge to improving drug use in the elderly, these criteria may serve as useful tools in helping to educate prescribers and others. They also may be useful to incorporate into decision support software for electronic prescribing and dispensing programs. The key challenge here is the need to have comprehensive patient information that includes diagnosis and/or laboratory values


1. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 2003;163:2716-24.

2. Zhan C, Sangl J, Bierman AS et al. Potentially inappropriate medication use in the community-dwelling elderly: Findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001;286:2823-9.

3. Pugh MJ, Hanlon JT, Zeber JE, et al. Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure. J Manag Care Pharm 2006;12(7):537-45.

4. Nauglet CT, Brymer C, Stolee P, et al. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol 2000;7:103-7.

5. Handler SM, Hanlon JT, Perera S, et al. Consensus list of signals to detect potential adverse drug reactions in nursing homes. J Am Geriatr Soc 2008;56:808-15.

6. Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age and Ageing 2008;37:673-9.

7. Barry PJ, Gallagher P, Ryan C, O'Mahony D. START (screening tool to alert doctors to the right treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing 2007;36:632-8.

Some eye-opening facts and figures:

More than 44,000 deaths result each year from medication-related errors, 7,000 of which are due to mistakes in prescribing or dispensing the wrong drugs.

Nearly one in five elderly Americans living in the community is taking at least one drug generally deemed unsuitable for their age group because safer alternative medications are available.

Consultant pharmacists’ services are so important in safeguarding the health and safety of nursing home residents that regular pharmacist reviews of each resident’s drug therapy are mandated by law in federally funded facilities.

In nursing homes alone, patient counseling, medication monitoring, and other services provided by consultant pharmacists save close to $3.6 billion each year in prevented hospitalizations and reduced medication costs.