Key recommendations
Use explicit criteria to support — not replace — shared decision-making about medicines with older people; they are not meant to be applied punitively.
Intent of criteriaAmerican Geriatrics Society 2023
Judge each medicine in the context of the whole regimen and the person's goals of care: harm comes from how drugs act together, not only from single drugs.
Applying the criteria to policy and practiceAmerican Geriatrics Society 2023
The aim is not simply to swap one drug for another — a non-drug treatment, or no treatment, is often preferable.
Applying the criteria to policy and practiceAmerican Geriatrics Society 2023
Review both sides of prescribing: potentially inappropriate medicines that could be stopped (STOPP) and potentially beneficial medicines that have been omitted (START).
Computer-generated alerts need interpretation by a trained clinician: in the OPERAM trial, more than half of the STOPP/START recommendations generated by software were judged not clinically relevant for the individual patient.
Diagnosis
Not covered in this summary — see the original guideline.
Investigations
STOPP criteria are arranged by physiological system, with extra sections for people at risk of falls, people taking opioids, and drugs with anticholinergic properties; START criteria are arranged the same way.
Before prescribing a fall-risk-increasing drug, check for a history of falls and a high risk of falling.
DiscussionEuGMS Task and Finish Group on Fall-Risk-Increasing Drugs 2021
STOPPFall lists 14 fall-risk-increasing medication classes agreed by expert consensus — mostly psychotropics, but also diuretics, alpha-blockers, centrally acting antihypertensives, sedating antihistamines, cardiac vasodilators, opioids, antiepileptics, anticholinergics and medicines for overactive bladder.
ResultsEuGMS Task and Finish Group on Fall-Risk-Increasing Drugs 2021
Treatment
Deprescribing is more than telling someone to stop: plan for communication, the person's fears about stopping, coordination between prescribers, tapering, withdrawal symptoms, and telling the pharmacy that the drug has stopped.
DeprescribingAmerican Geriatrics Society 2023
Stepwise withdrawal is generally needed for benzodiazepines and related drugs, antipsychotics, opioids and antidepressants; for several other classes, such as antiepileptics, diuretics and sedating antihistamines, the panel advised considering it.
Table 2EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs 2021
After deprescribing, monitor for falls and for return of the original symptoms — for example anxiety and insomnia after a benzodiazepine, pain after an opioid, or recurrent depression after an antidepressant.
Table 2EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs 2021
Deprescribing fall-risk-increasing drugs should be part of a multifactorial falls-prevention strategy, not a stand-alone intervention.
DiscussionEuGMS Task and Finish Group on Fall-Risk-Increasing Drugs 2021
Antipsychotics for behavioural symptoms of dementia or delirium should be a last resort, after behavioural approaches and a search for modifiable triggers, and agreed through shared decision-making with the person and their care partners.
Results: noteworthy changesAmerican Geriatrics Society 2023
Important geriatric considerations
Two people of the same age can have very different risks of drug harm: advanced age, cognitive and physical impairment, multimorbidity, frailty, kidney impairment and extensive polypharmacy all raise the risk.
Applying the criteria to policy and practiceAmerican Geriatrics Society 2023
The Beers criteria apply to adults aged 65 and over in all care settings except hospice and end-of-life care.
Intent of criteriaAmerican Geriatrics Society 2023
For frail older people approaching the end of life, STOPPFrail version 2 provides 25 deprescribing criteria and emphasises shared decision-making.
The Beers criteria are designed for the United States; clinicians elsewhere need to adapt them to the medicines available locally.
Strengths and limitationsAmerican Geriatrics Society 2023
Older people, especially the frailest, remain under-represented in trials, so apply trial results to individual multimorbid patients with caution.
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Not covered in this summary — see the original guideline.
Red flags
Not covered in this summary — see the original guideline.
Recent updates
2023: STOPP/START version 3 grew to 190 criteria (133 STOPP and 57 START), up from 114 in version 2.
2023 Beers update: avoid starting aspirin for primary prevention of cardiovascular disease in older adults, and consider deprescribing it in people already taking it.
Results: noteworthy changesAmerican Geriatrics Society 2023
2023 Beers update: avoid all sulfonylureas as first- or second-line therapy; if one must be used, a short-acting agent is preferred because long-acting ones carry a higher risk of prolonged hypoglycaemia.
Results: noteworthy changesAmerican Geriatrics Society 2023
2023 Beers update: rivaroxaban moved to “avoid” for long-term treatment of atrial fibrillation and venous thromboembolism, and warfarin should be avoided as initial therapy unless DOACs are contraindicated or there are substantial barriers to their use.
Results: noteworthy changesAmerican Geriatrics Society 2023
2023 Beers update: the drug–drug interaction table now highlights combined use of several anticholinergic drugs and of three or more CNS-active drugs, which now include skeletal muscle relaxants.
Results: noteworthy changesAmerican Geriatrics Society 2023