What are the 2022 updated STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria for optimizing medication in patients aged 65 years or older?

Updated STOPP/START Criteria for Elderly Patients

Current Version and Target Population

The most current validated version is STOPP/START version 2 (2015), which should be applied to all patients aged 65 years and older across ambulatory, acute care, and institutional settings. 1, 2, 3

STOPP Criteria (Version 2,2015)

STOPP version 2 contains 134 criteria organized by physiological systems to identify potentially inappropriate medications (PIMs) that should be avoided in older adults. 1

Key Components of STOPP:

• 65 clinically significant criteria for potentially inappropriate prescribing, each accompanied by a concise explanation of why the practice is inappropriate 4
• Addresses drug-disease interactions, drug-drug interactions, duplicate medications, and medications requiring dose adjustment based on kidney function 1
• Organized according to physiological systems for systematic review 1
• Inter-rater reliability kappa coefficient of 0.75, indicating substantial agreement among clinicians 4
• Pharmacists demonstrate excellent inter-rater reliability (kappa 0.88-0.89) when applying STOPP criteria 5

Most Common PIMs Identified by STOPP:

• Benzodiazepines (increased risk of falls, cognitive impairment, delirium, fractures) 2, 6
• Proton pump inhibitors (often used without clear indication) 6
• NSAIDs (gastrointestinal bleeding, acute kidney injury, heart failure exacerbation) 2, 6
• Aspirin for primary prevention in patients ≥70 years (bleeding risk outweighs benefit) 3
• Duplicate drug classes 6

START Criteria (Version 2,2015)

START version 2 contains 34 criteria identifying potential prescribing omissions (PPOs)—evidence-based medications that should be considered for commonly encountered diseases in older adults. 1

Key Components of START:

• 22 evidence-based prescribing indicators for commonly encountered diseases in older people 4
• Identifies underuse of potentially beneficial medications 1
• Inter-rater reliability kappa coefficient of 0.68-0.91, indicating substantial to almost perfect agreement 4, 5
• Helps ensure patients receive appropriate treatment aligned with their conditions 1

Most Common PPOs Identified by START:

• Cardiovascular medications (antiplatelet therapy, ACE inhibitors, beta-blockers post-MI) 6
• Antihypertensive medications 6
• Osteoporosis treatment (calcium, vitamin D, bisphosphonates) 6
• Diabetes medications 6
• Lipid-lowering therapy 6

Prevalence of Inappropriate Prescribing

Community-Dwelling Elderly:

• PIMs: 26-31% weighted average 6
• PPOs: 24-47% weighted average 6

Hospitalized Patients:

• PIMs: 47% weighted average 6
• PPOs: 50% weighted average 6

Nursing Home Residents:

• PIMs: 59% weighted average 6
• PPOs: 49% weighted average 6

Clinical Application Algorithm

Step 1: Systematic Medication Review

• Review ALL medications at every care transition (hospital admission, ICU transfer, discharge) including prescription drugs, over-the-counter medications, herbal products, and supplements 1, 2

Step 2: Apply STOPP Criteria

• Screen for PIMs using the 134 STOPP criteria organized by physiological system 1
• Prioritize removal of drugs with unfavorable benefit-risk ratios (NSAIDs, benzodiazepines, medications causing prescribing cascades) 2

Step 3: Apply START Criteria

• Screen for PPOs using the 34 START criteria 1
• Consider adding evidence-based medications for documented conditions where omissions are identified 1

Step 4: Consider Patient-Specific Factors

• Evaluate life expectancy versus time-to-benefit for each medication 2
• Discontinue preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit 2
• Assess functional status, cognitive status, multimorbidity burden, and patient goals of care 1, 2

Step 5: Implement Changes

• Use team-based approach with pharmacist-led interventions 2
• Monitor outcomes following medication changes (track positive outcomes, persistence of changes, coordinate across providers) 2

Clinical Outcomes from STOPP/START Application

Applying STOPP/START criteria improves medication appropriateness, reduces polypharmacy, reduces adverse drug reactions, leads to fewer falls, and lowers medication costs in single-center trials. 7

Critical Pitfalls to Avoid

• Do not apply disease-specific guidelines without considering multimorbidity—prioritize patient-centered goals over achieving multiple disease-specific targets 2
• Do not ignore drug-drug interactions—use interaction screening tools systematically 2
• Do not fail to reassess at care transitions 2
• Do not apply chronological age alone when making decisions—consider functional and cognitive status 1, 2
• Do not use STOPP/START punitively—clinical judgment remains essential and individualization is required 2

Validation and Reliability

The STOPP/START criteria were validated using Delphi consensus technique with an 18-member expert panel from academic centers in Ireland and the United Kingdom, demonstrating favorable inter-rater reliability. 4

Portuguese translation and validation (2022) confirmed substantial intra-rater reliability (kappa 0.70 for STOPP, 0.60 for START) and almost perfect inter-rater reliability (kappa >0.93). 8