STOPP START Criteria: A Caregiver's Guide to Medication Screening

Your parent is on nine medications and you suspect some of them are doing more harm than good. But how do you know which ones? Two clinical screening tools — the STOPP/START criteria and the Beers Criteria — give doctors (and informed caregivers) a systematic way to flag potentially inappropriate medications in patients over 65.

What the STOPP/START Criteria Do

STOPP stands for Screening Tool of Older Persons' Prescriptions. START stands for Screening Tool to Alert to Right Treatment. Together, they work in two directions:

• STOPP identifies medications that should potentially be stopped — drugs where the risks outweigh the benefits for older adults.
• START identifies medications that should potentially be started — evidence-based treatments being omitted.

Version 3 (2023) expanded the criteria by 66.7%, from 114 to 190 total criteria. The update introduced dedicated sections for coagulation and renal systems, reflecting how critical kidney function monitoring is before and during therapy.

Key STOPP Rules Caregivers Should Know

The renal-function rules are particularly important because kidney decline is universal in aging:

If your parent hasn't had kidney function tested recently, this alone is worth a conversation with their doctor. A simple blood test measuring eGFR (estimated glomerular filtration rate) determines whether their current medications are still safe.

The Beers Criteria 2023: What Changed

The American Geriatrics Society Beers Criteria is the US counterpart to STOPP/START. The 2023 update made several significant changes:

Rivaroxaban (Xarelto) moved from "use with caution" to "avoid." Observational data showed higher rates of major gastrointestinal bleeding in older adults compared to apixaban (Eliquis). If your parent takes rivaroxaban for atrial fibrillation, ask their doctor whether switching to apixaban makes sense.

Aspirin for primary prevention is now flagged. Starting aspirin to prevent a first heart attack or stroke in older adults carries a high bleeding risk with no net clinical benefit. If your parent was put on daily aspirin years ago "just in case," it warrants a review.

All sulfonylureas are now listed (glimepiride, glyburide, glipizide), not just long-acting ones. These diabetes medications carry risks of prolonged hypoglycemia, cardiovascular death, and ischemic stroke in older adults.

Proton pump inhibitors (PPIs) like omeprazole carry updated warnings for pneumonia, C. difficile infection, bone loss, and fractures with long-term use.

How to Use These Tools as a Caregiver

You don't need to memorize 190 clinical criteria. What you need is enough knowledge to ask the right questions:

1. Get your parent's current medication list and their most recent eGFR result. Cross-reference the kidney function against the STOPP renal rules above.
2. Look for the highest-risk drug classes. Anticholinergics, benzodiazepines, NSAIDs, and first-generation antihistamines appear most frequently on both the Beers and STOPP lists.
3. Ask the doctor directly. "We noticed Mom is on [drug]. The 2023 Beers Criteria lists this as potentially inappropriate for patients over 65. Can we discuss whether it's still the best option?" Framing it in clinical terms — referencing the specific guideline — bypasses defensiveness.
4. Request a formal medication review. Mention that you'd like the review to specifically screen against the STOPP/START and Beers criteria.

The Understanding and Managing Polypharmacy toolkit includes a high-risk drug screener based on both the STOPP/START v3 and Beers 2023 criteria, along with fillable worksheets to prepare for these conversations with your parent's medical team.