8.2 STOPP/START Concepts & Anticholinergic Burden in MTM Screening

STOPP/START Concepts & Anticholinergic Burden in MTM Screening

Quick Answer: STOPP finds medicines that may be inappropriate to continue; START finds indicated medicines that may be missing. In older-adult MTM, pair that thinking with anticholinergic burden—the stacked risk from drugs that dry secretions, cloud thinking, and worsen constipation or retention. Technicians screen lists for STOPP-like PIMs, START-like gaps, and multiple anticholinergics, then escalate to the pharmacist.

Chapter 8.1 focused on the U.S.-centric 2023 AGS Beers Criteria. MTM practice and exam items also expect you to understand STOPP/START as a complementary explicit toolset for medication review—and to treat anticholinergic burden as a cross-cutting safety theme that appears whether the reference list is Beers, STOPP, or a local geriatric protocol.

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STOPP vs START: Two Directions of Safety

STOPP/START criteria were developed to support structured review in multimorbid older people. Versions have expanded over time (commonly referenced Version 2 with dozens of STOPP and START items; a later Version 3 further updates content). For the PTCB MTM exam, memorize the concept pair, not every criterion number:

• STOPP-style problems ≈ potentially inappropriate prescribing / safety or indication problems that may need deprescribing or change
• START-style problems ≈ potentially omitted medicines / gaps in therapy that may need initiation after clinical assessment

That duality matches the MRP framework from earlier chapters: you can harm patients by giving the wrong drug or by omitting the right one.

How STOPP/START Relates to Beers

Beers and STOPP overlap on many PIM themes (sedatives, anticholinergics, some diabetes agents, muscle relaxants). START adds explicit attention to underprescribing. In real MTM workflows you may not run a formal STOPP/START checklist on every call, but the mental model improves screening:

1. Scan for drugs that look risky to continue (STOPP / Beers lane).
2. Scan conditions for therapies that appear missing (START / gap lane).
3. Hand both lanes to the pharmacist with clean documentation.

Scenario — STOPP-Style Flag

List: 82-year-old on amitriptyline 50 mg at bedtime for “sleep,” plus oxybutynin for overactive bladder, plus PRN diphenhydramine. STOPP-style concern: Multiple highly anticholinergic agents with high delirium/constipation/retention risk. Tech: Flag stacked anticholinergics and sleep/bladder indications for pharmacist review—do not stop any agent yourself.

Scenario — START-Style Flag

History: 70-year-old with type 2 diabetes and prior myocardial infarction; medication list has metformin only—no statin. START-style concern: Potentially omitted cardiovascular risk-reduction therapy (gap in therapy). Tech: Note missing indicated therapy for pharmacist assessment (guidelines and patient-specific factors belong to the clinician).

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Anticholinergic Burden: Why “One More Drying Drug” Matters

Anticholinergic burden means the cumulative antimuscarinic/anticholinergic effect of a patient’s regimen. Older brains and bodies are more sensitive. Even when each drug seems “low dose,” stacking raises risk for:

• Confusion, delirium, memory complaints
• Dry mouth, blurred vision
• Constipation and fecal impaction risk
• Urinary retention (especially in men with prostate enlargement)
• Falls and sedation
• Worsening cognitive trajectory with higher cumulative burden

Research and practice tools often summarize burden with scores such as the Anticholinergic Cognitive Burden (ACB) scale. A practical teaching threshold you will see in literature and quality projects is that higher total scores (commonly discussed around ≥3) associate with greater cognitive impairment and adverse outcomes. You do not need to become a scoring expert for the exam, but you do need to notice when two or more anticholinergic drugs appear together—or when one strong agent pairs with confusion/falls.

High-Frequency Anticholinergic Contributors in MTM Lists

STOPP criteria sets explicitly call out problems such as concomitant use of two or more drugs with antimuscarinic/anticholinergic properties because toxicity risk climbs with combination use. That is a perfect technician screen: you do not have to name the STOPP code—just count and describe the stack.

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Practical MTM Screening Workflow for Technicians

Step 1 — Build the real list. Include OTC antihistamines, bladder products, and “only at night” tablets. Anticholinergic burden hides in nonprescription items.

Step 2 — Mark STOPP-like candidates. Sedatives, strong anticholinergics, duplicate CNS depressants, chronic muscle relaxants, and other Beers/STOPP-overlapping PIMs.

Step 3 — Mark START-like gaps. Compare major conditions (ASCVD, diabetes, osteoporosis, heart failure, anticoagulation indications, inhaler disease) to the list for obvious missing therapies—then escalate; do not prescribe.

Step 4 — Estimate burden qualitatively. “Three anticholinergic drugs on profile” is enough language for a pharmacist handoff. If your site uses an ACB or similar score in software, capture the score and the contributing drugs.

Step 5 — Attach symptoms. New confusion, falls, severe constipation, urinary retention, or dry mouth so severe the patient sucks on candy all day are clinical amplifiers.

Technician Script — Anticholinergic Stack

Tech to pharmacist queue: “72F CMR prep: amitriptyline 25 mg QHS, oxybutynin XL 10 mg daily, and OTC diphenhydramine most nights. Patient reports increasing constipation and ‘fuzzy’ thinking since oxybutynin started. Flagging high anticholinergic burden / possible STOPP-style inappropriate combination for your review. No therapy changes made.”

Technician Script — START Gap Without Overreach

Tech to patient: “I’m noting that your history includes a prior heart attack and diabetes, and I don’t yet see a cholesterol medicine on your list. I’m going to make sure the pharmacist reviews whether anything is missing—only they and your prescriber decide if a medicine should be added.”

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Connecting Burden Findings to MRP Categories and Documents

Boundary reminder: Scoring tools and criteria lists support pharmacist assessment. Technicians who independently tell patients to stop oxybutynin or start a statin cross the clinical line—even when the screen is obviously important.

Pitfalls That Cost Points on the Exam

• Treating STOPP as the only tool and forgetting START gaps
• Ignoring OTC diphenhydramine when counting anticholinergic burden
• Calling every dry-mouth complaint a penicillin-style allergy
• Assuming “low dose amitriptyline for sleep” is automatically safe in a 80-year-old
• Documenting “polypharmacy” with no detail about which interacting or anticholinergic drugs matter

STOPP/START thinking makes MTM balanced: take away what harms when appropriate, and do not miss what helps. Anticholinergic burden screening turns a cluttered medication list into a clear safety story the pharmacist can act on.