The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use
Key Takeaways
- The 2023 American Geriatrics Society (AGS) Beers Criteria identifies Potentially Inappropriate Medications (PIMs) to avoid or use with caution in adults aged 65 and older due to altered pharmacokinetics and heightened adverse drug event (ADE) risks.
- First-generation antihistamines (e.g., diphenhydramine, hydroxyzine) and central anticholinergics carry high anticholinergic burden, causing acute confusion, delirium, dry mouth, constipation, and urinary retention in older adults.
- Skeletal muscle relaxants (e.g., cyclobenzaprine, carisoprodol) and long-acting sulfonylureas (e.g., glyburide) should be avoided due to strong sedating/anticholinergic risks and severe, prolonged hypoglycemia, respectively.
- The STOPP/START criteria provide a dual-action system: STOPP screens for potentially inappropriate prescribing organized by body system, while START alerts providers to prescribing omissions of evidence-based therapies.
The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use
Introduction to Inappropriate Prescribing in Older Adults
Pharmacotherapy in older adults requires a delicate balance between therapeutic efficacy and safety. Age-related alterations in organ function, altered drug distribution, reduced metabolic clearance, and heightened target-organ sensitivity make older adults exceptionally vulnerable to adverse drug events (ADEs), adverse drug reactions (ADRs), and drug-induced functional decline. Two major evidence-based clinical frameworks guide Nurse Practitioners (NPs) in evaluating medication safety: the 2023 American Geriatrics Society (AGS) Beers Criteria and the STOPP/START Criteria (Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment).
A Potentially Inappropriate Medication (PIM) is defined as a drug for which the risk of adverse events outweighs its clinical benefit, particularly when safer, equally effective pharmacological or non-pharmacological alternatives exist.
The 2023 AGS Beers Criteria Framework
Originally developed by Dr. Mark Beers in 1991 and updated periodically by the AGS, the Beers Criteria apply to adults aged 65 and older in community, acute, and institutional settings (excluding decision-aligned palliative/hospice care). The 2023 update incorporates contemporary evidence regarding pharmacogenomics, renal dosing, and drug-disease interactions.
The Beers Criteria are organized into five distinct categories:
- Medications Potentially Inappropriate in Most Older Adults: Drugs that should generally be avoided because they pose substantial risks of toxicity or physical injury without unique clinical superiority.
- Medications to Avoid in Specific Disease States: Drugs that exacerbate underlying conditions (e.g., NSAIDs in heart failure or chronic kidney disease).
- Medications to Be Used with Caution: Drugs requiring heightened clinical vigilance or dose reduction (e.g., SGLT2 inhibitors regarding volume depletion; SSRIs regarding hyponatremia).
- Clinically Significant Drug-Drug Interactions: Drug combinations that dramatically increase toxicity risk (e.g., concurrent use of three or more CNS-active agents).
- Renal Dose Adjustments: Drugs that accumulate in renal impairment, requiring dosage reduction (e.g., gabapentin, DOACs, H2-blockers).
Major High-Risk Drug Classes in the 2023 AGS Beers Criteria
1. Anticholinergic Agents
Anticholinergic medications block muscarinic receptors. Older adults experience an age-related decline in central cholinergic transmission, making them particularly sensitive to anticholinergic toxicity.
- First-Generation Antihistamines: Diphenhydramine, hydroxyzine, and chlorpheniramine possess potent anticholinergic and sedating properties, causing acute confusion, delirium, dry mouth, constipation, urinary retention, blurred vision, and falls.
- OAB Antimuscarinics: Oxybutynin and tolterodine increase cumulative anticholinergic cognitive burden (ACB), worsening executive function and accelerating cognitive decline.
- Tricyclic Antidepressants (TCAs): Amitriptyline and imipramine carry intense anticholinergic, sedating, and orthostatic risks.
2. Sedative-Hypnotics and Anxiolytics
- Benzodiazepines: Both short-acting (alprazolam, lorazepam) and long-acting (diazepam, clonazepam) benzodiazepines increase cognitive impairment, delirium, falls, and fractures. They should be avoided for insomnia, agitation, or anxiety.
- Z-Drugs: Zolpidem, zopiclone, and eszopiclone produce adverse profiles similar to benzodiazepines, with minimal benefit for sleep latency and high fracture risks.
3. Endocrine Agents
- Long-Acting Sulfonylureas: Glyburide, glimepiride, and chlorpropamide carry an unacceptably high risk of severe, prolonged hypoglycemia due to reduced renal clearance. Preferred alternatives include metformin, SGLT2 inhibitors, or GLP-1 agonists.
- Sliding-Scale Insulin: Short-acting insulin dosed strictly by blood glucose without basal coverage increases hypoglycemia risk without improving control.
4. Cardiovascular Agents
- Centrally Acting Alpha-Blockers: Clonidine and methyldopa carry high risks of CNS adverse effects, bradycardia, and orthostatic hypotension.
- Digoxin: Doses exceeding 0.125 mg/day provide no added benefit and increase digoxin toxicity risk due to decreased renal clearance.
5. Gastrointestinal and Pain Medications
- Nonselective Oral NSAIDs: Indomethacin, ibuprofen, naproxen, and ketorolac increase risks of upper GI bleeding, peptic ulcer disease, acute kidney injury, fluid retention, and heart failure exacerbation.
- Proton Pump Inhibitors (PPIs): Scheduled use for >8 weeks without compelling indication increases risks of C. difficile infection, bone loss, fractures, and Vitamin B12 deficiency.
6. Skeletal Muscle Relaxants
Cyclobenzaprine, carisoprodol, and methocarbamol are poorly tolerated due to anticholinergic effects, sedation, and fracture risk.
2023 AGS Beers Criteria High-Risk Medication Table
| Medication Class | Exemplar Drugs | Primary Clinical Risks & Adverse Effects | Recommended Clinical Action / Safer Alternative |
|---|---|---|---|
| 1st-Gen Antihistamines | Diphenhydramine, Hydroxyzine | Delirium, urinary retention, dry mouth, constipation, falls | Avoid. Use saline spray or 2nd-gen non-sedating agents. |
| Benzodiazepines & Z-Drugs | Diazepam, Alprazolam, Zolpidem | Delirium, balance impairment, falls, fractures, accidents | Avoid. Utilize non-pharmacological CBT-I; taper slowly. |
| Long-Acting Sulfonylureas | Glyburide, Glimepiride | Severe, prolonged hypoglycemia from drug accumulation | Avoid. Prefer Metformin, DPP-4 inhibitors, or GLP-1 agonists. |
| Centrally Acting Alpha-Blockers | Clonidine, Methyldopa | Orthostatic hypotension, severe CNS depression, bradycardia | Avoid for hypertension. Use thiazides, ACE-I/ARBs, or CCBs. |
| Nonselective Oral NSAIDs | Indomethacin, Naproxen, Ketorolac | GI bleeding, peptic ulcers, AKI, fluid retention, HFrEF flare | Avoid chronic use. Prefer topical NSAIDs or acetaminophen. |
| Skeletal Muscle Relaxants | Cyclobenzaprine, Carisoprodol | Anticholinergic toxicity, sedating CNS depression, fall risk | Avoid. Utilize physical therapy or topical analgesics. |
The STOPP/START Criteria Framework
European geriatricians developed the STOPP/START Criteria to provide a systems-based, comprehensive prescribing review.
STOPP (Screening Tool of Older Persons' Prescriptions)
STOPP criteria identify potentially inappropriate prescribing organized by body systems (Cardiovascular, CNS, GI, Respiratory, Endocrine, Urogenital). STOPP explicitly identifies redundant drug combinations, inappropriate treatment duration, and severe drug-disease contraindications.
START (Screening Tool to Alert to Right Treatment)
The START criteria directly addresses prescribing omissions (underprescribing) of evidence-based therapies. Examples include:
- Initiating an ACE inhibitor or ARB in chronic heart failure or diabetic nephropathy.
- Prescribing a statin for secondary prevention in documented cardiovascular disease.
- Initiating bone-density therapy (bisphosphonates, Vitamin D, calcium) in osteoporosis.
- Starting oral anticoagulation in non-valvular atrial fibrillation with elevated stroke risk.
Integrating Beers and STOPP/START in Primary Care
Combining Beers with STOPP/START enables NPs to eliminate high-risk PIMs while ensuring patients receive indicated, goal-aligned pharmacotherapies.
Which of the following medications is classified as a potentially inappropriate medication (PIM) in older adults under the 2023 AGS Beers Criteria primarily due to its potent anticholinergic properties and risk of acute confusion?
An older adult patient with type 2 diabetes mellitus presents with recurrent episodes of severe nocturnal hypoglycemia. Which antidiabetic medication is most likely responsible and explicitly recommended to be avoided on the Beers Criteria?
In contrast to the Beers Criteria, the primary unique feature of the START (Screening Tool to Alert to Right Treatment) criteria is that it specifically identifies:
A 74-year-old patient with a history of heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease stage 3b presents for knee pain. Which pain medication class should be strictly avoided due to risks of fluid retention and acute renal decompensation?