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The STOPP/START criteria are a two-part, physiological-systems-based tool for reviewing prescriptions in older adults. STOPP (Screening Tool of Older People’s Prescriptions) flags medications that are potentially inappropriate; START (Screening Tool to Alert to Right Treatment) flags clinically indicated medications that are missing from the regimen. Both halves are applied together, as one review, not as separate checklists.
STOPP/START was developed in Ireland by geriatrician Denis O’Mahony and pharmacist Paul Gallagher, then both at University College Cork, and first published in the International Journal of Clinical Pharmacology and Therapeutics in February 2008. It is the European counterpart to the American Geriatrics Society’s Beers Criteria, and the two tools are frequently confused or treated as interchangeable — they are not. The differences matter for how each is built into a medication-review workflow, and are covered in detail below.
The two-part structure: STOPP and START
STOPP/START’s defining feature is that it screens for two distinct kinds of prescribing problems in the same pass:
- STOPP (potentially inappropriate medications, PIMs) — medications whose risk of harm, in a given clinical context, is likely to outweigh their benefit in an older patient. This is the “what to stop” half, and it is the half that overlaps most directly with what the Beers Criteria also does.
- START (potential prescribing omissions, PPOs) — clinically indicated medications that are absent from the patient’s regimen even though the patient’s diagnoses and clinical picture call for them. This is the “what’s missing” half. It is the more distinctive part of STOPP/START, because it screens for under-treatment rather than only over-treatment — a direction of error the Beers Criteria does not have an equivalent structured mechanism for catching.
Both STOPP and START criteria are organized by physiological system (cardiovascular, central nervous system and psychotropics, gastrointestinal, respiratory, musculoskeletal, urogenital, endocrine, and a cross-cutting section on drugs that predictably increase fall risk and analgesic/anticholinergic burden), rather than by drug class or by disease state the way the Beers Criteria is organized. A reviewer works through the patient’s active problem list system by system, checking both what should probably come off the regimen and what is probably missing from it.
Version history
STOPP/START has gone through three major versions, each expanding the criteria set as the evidence base and the available pharmacopeia for older adults grew:
| Version | Published | Criteria count | Journal |
|---|---|---|---|
| Version 1 | February 2008 | Original STOPP/START set (O’Mahony & Gallagher, University College Cork) | International Journal of Clinical Pharmacology and Therapeutics |
| Version 2 | 2015 | 114 criteria | Age and Ageing |
| Version 3 (current) | August 2023 | 190 criteria | European Geriatric Medicine |
Version 3 is the current edition. It was expanded and validated by an international European panel of experts in geriatric pharmacotherapy, based on a systematic review of literature published between April 2014 and March 2022, with the explicit aim of adding clinically important new PIM and PPO criteria and retiring criteria the panel judged outdated. The near-doubling in criteria count from version 2 to version 3 reflects both an expanded pharmacopeia and a larger clinical-trials evidence base for older adults since 2015 — it is not a sign that earlier versions were unreliable, and hospitals still using version 2 tooling are working from a defensible, published edition, just not the current one.
How hospitals use it
STOPP/START is designed to be applied as part of a structured medication review, not as a one-off screen at admission. Typical points of use for hospital patient-safety, quality, and pharmacy teams:
- Admission and discharge medication review — applying STOPP/START alongside medication reconciliation at transitions of care, when the full medication list is being actively re-verified anyway.
- Geriatric and multidisciplinary team review — pharmacists, geriatricians, and ward teams working through a patient’s list system by system, often alongside frailty and cognitive screening such as the Clinical Frailty Scale or the MoCA, since polypharmacy risk and cognitive/functional status compound each other.
- Formulary and clinical decision-support work — some institutions encode a subset of STOPP/START logic into EHR alerting or use it to inform formulary and non-formulary decisions, though the criteria were written for clinician judgment during a review, not for blanket automated hard-stops.
- Feeding adverse-drug-event and fall-prevention work — a STOPP flag on an existing medication is a natural input into ADE surveillance and causality tools like the Naranjo algorithm when an event has already occurred, and into fall-prevention risk-tiering (many STOPP criteria target fall-risk-increasing drugs directly, and fall-risk assessment tools like the Morse Fall Scale are natural companions).
As with any explicit prescribing-review tool, STOPP/START criteria are meant as a structured starting point for clinical judgment, not a substitute for it. A STOPP flag identifies a medication worth a second look in this patient’s context — not an automatic instruction to discontinue — and a START flag identifies an omission worth discussing, which may still be clinically inappropriate for a specific patient (limited life expectancy, patient preference, or a competing risk the tool doesn’t capture).
STOPP/START vs. the Beers Criteria
Hospitals that operate across US and European clinical literature, or that are simply choosing which tool to standardize on, need to know where the two overlap and where they genuinely differ. See CASRAI’s full Beers Criteria guide for the American tool in depth.
| STOPP/START | Beers Criteria | |
|---|---|---|
| Origin | Ireland (University College Cork), 2008 | United States (Mark H. Beers, UCLA), 1991 |
| Steward | International European geriatric-pharmacotherapy panel | American Geriatrics Society (since 2010) |
| Current edition | Version 3, 2023 (190 criteria) | 2023 update (seventh overall revision) |
| Organizing structure | Physiological body system | Drug/drug class and disease-state interactions |
| Omission detection | Yes — the START half explicitly screens for missing, clinically indicated medications | No equivalent structured mechanism; Beers focuses on what to stop or avoid, not what’s missing |
| Primary audience | European clinical practice, increasingly used internationally | US clinical practice; underlies two NCQA HEDIS quality measures |
The practical takeaway for a hospital patient-safety or pharmacy team: Beers is the more familiar reference in a US clinical setting and is directly wired into US payer quality measures, but it only screens in one direction. STOPP/START’s START half gives a review process a structured way to catch under-treatment — a beneficial medication that was never started, or was stopped and never restarted — which is a real gap in a Beers-only review. Some institutions run both, using Beers for the US-quality-measure-aligned PIM screen and START specifically to catch prescribing omissions Beers has no mechanism to flag.
Limitations
STOPP/START, like any explicit criteria list, has documented limits worth stating plainly rather than glossing over:
- It was developed and validated primarily in a European (and specifically Irish/UK-adjacent) clinical and formulary context; drug availability, brand names, and prescribing norms outside that setting don’t map onto it perfectly.
- Applying it well requires clinical judgment about the individual patient’s diagnoses, prognosis, and preferences — a mechanical pass through the criteria list without that context will generate flags that don’t actually apply to the patient in front of you.
- It reviews the medication list as presented; it does not replace a full medication reconciliation process for catching list inaccuracies, duplications introduced across care transitions, or dosing errors that aren’t about drug-appropriateness per se.
Frequently asked questions
What does STOPP stand for?
Screening Tool of Older People’s Prescriptions — the half of the criteria that flags potentially inappropriate medications (PIMs) for an older patient.
What does START stand for?
Screening Tool to Alert to Right Treatment — the half of the criteria that flags potential prescribing omissions (PPOs), i.e., clinically indicated medications that are missing from the patient’s regimen.
Is STOPP/START the same as the Beers Criteria?
No. Both are explicit prescribing-review tools for older adults, but STOPP/START is European (Irish in origin), organized by physiological system, and includes the START omission-detection half that Beers does not have. Beers is American, organized by drug/drug class and disease-state interaction, and is directly tied to US payer quality measures. See the comparison table above.
What is the current version of STOPP/START?
Version 3, published in European Geriatric Medicine in August 2023, with 190 criteria — up from 114 in version 2 (2015) and the original 2008 set.
Who created STOPP/START?
Geriatrician Denis O’Mahony and pharmacist Paul Gallagher, both then at University College Cork, Ireland, who published the original criteria in 2008. Later versions were developed and validated by an expanded international European panel of geriatric-pharmacotherapy experts.
