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Tools and references

For prescribing clinicians

A short annotated index of the instruments in this field, with what each is actually validated for — which is usually narrower than how it gets used.

Explicit criteria

  • AGS Beers Criteria, 2023 update. The US reference list of potentially inappropriate medications for adults 65 and over, in ambulatory, acute and institutional care, explicitly excluding hospice and end-of-life. There is no 2026 edition. A 2025 Alternatives List is a companion, not a new edition. More.
  • STOPP/START version 3, 2023. The European instrument, in two halves: potentially inappropriate medications, and prescribing omissions. Cite the published correction alongside the article. Its evidence base was independently appraised in 2025 — high-level evidence behind 43% of STOPP and 88% of START criteria, with 8% of STOPP criteria lacking an appropriate supporting reference. More.
  • STOPPFrail version 2. 25 deprescribing criteria for older adults with limited life expectancy approaching end of life, plus a method for identifying that population.

Burden scales

Four are in common use and they are not interchangeable. A systematic review of seven expert-based scales found the ratings inconsistent between them. Any score recorded should name its scale.

InstrumentBasisWhat it was validated against
Anticholinergic Cognitive Burden scaleExpert rating, 0 to 3The most frequently validated against adverse outcomes
Anticholinergic Drug ScaleExpert ratingSerum anticholinergic activity in 297 long-term care residents — explaining under 10% of the variance, which its authors report
Anticholinergic Risk ScaleExpert ratingAnticholinergic adverse effects; adjusted relative risks 1.3 and 1.9 in two cohorts
Drug Burden IndexDose-response, pharmacologicPhysical and cognitive function in 3,075 adults aged 70 to 79; covers sedatives as well as anticholinergics

Deprescribing guidelines

  • Benzodiazepine receptor agonists (2018, GRADE-based). Recommends slow tapering be offered to adults 65 and over regardless of duration of use. Scope limited to primary insomnia or effectively managed comorbid insomnia; explicitly does not apply where anxiety, depression or another sleep disorder is untreated.
  • Proton pump inhibitors (2017, GRADE-based). Strong recommendation on low-quality evidence to reduce dose or move to on-demand use in adults whose upper gastrointestinal symptoms resolved after at least four weeks of treatment. Excludes Barrett’s esophagus, severe grade C or D esophagitis, and documented bleeding ulcer.
  • CDC Clinical Practice Guideline for Prescribing Opioids for Pain, 2022. Replaces the 2016 guideline. Dosage thresholds deliberately removed from the recommendation statements; tapering recommendations substantially expanded. Does not apply to sickle cell disease pain, cancer-related pain, palliative care or end-of-life care.
  • APA practice guideline on antipsychotics for agitation or psychosis in dementia, 2016. A four-week efficacy checkpoint, a taper attempt within four months of response, monthly assessment during and for four months after the taper, and haloperidol excluded as first-line outside delirium.
  • HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics (October 28, 2019). Cited by the CDC 2022 guideline.

Structured approaches to behavior

DICE — Describe, Investigate, Create, Evaluate — was developed and named by a multidisciplinary expert panel as a structured approach to neuropsychiatric symptoms of dementia. The panel’s consensus was that psychotropics should be used only after significant efforts with behavioral, environmental and medical interventions, with three named exceptions: major depression with or without suicidal ideation, psychosis causing or likely to cause harm, and aggression risking harm. Its Investigate step explicitly includes pain and undiagnosed medical conditions.

Evidence syntheses worth having to hand

  • Falls in care facilities (2025 Cochrane, 104 trials, 68,964 participants) — the setting-specific answer on what works and what does not.
  • Potentially inappropriate prescribing (2025, 118 randomized trials, 417,412 patients) — the safety and effect-size baseline.
  • Antipsychotic withdrawal in dementia (2018 Cochrane, 10 studies, 632 participants) — including who relapses.
  • Antipsychotics for agitation and psychosis in dementia (2021 Cochrane, 24 trials, 6,090 participants) — effect sizes and harms.
  • Long-term PPI safety (COMPASS, 17,598 randomized, median 3.01 years).
  • Statins in older people (28 trials, individual participant data) and statin-associated glycemia (19 trials, 123,940 participants).

Back to the clinician track.

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

References

  1. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
  2. By the 2025 AGS Alternative Treatments Panel. Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria. Journal of the American Geriatrics Society. 2025;73(9):2657–2677. PMID 40697073 · DOI 10.1111/jgs.19500.
  3. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine. 2023;14(4):625–632. PMID 37256475 · DOI 10.1007/s41999-023-00777-y. See also the published correction, Eur Geriatr Med. 2023;14(4):633, PMID 37326916.
  4. Boland B, Sibille FX, Mouzon A, et al. Appraisal of the references supporting the STOPP/START.version 3 criteria. European Geriatric Medicine. 2026;17(3):1193–1200 (published online 2025-12-26). PMID 41452533 · DOI 10.1007/s41999-025-01386-7.
  5. Curtin D, Gallagher P, O’Mahony D. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age and Ageing. 2021;50(2):465–471. PMID 32997135 · DOI 10.1093/ageing/afaa159.
  6. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatrics. 2015;15:31. PMID 25879993 · DOI 10.1186/s12877-015-0029-9.
  7. Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of Anticholinergics on the Aging Brain: A Review and Practical Application. Aging Health. 2008;4(3):311–320. DOI 10.2217/1745509X.4.3.311. Not indexed in PubMed; verified through Crossref. Cite by DOI.
  8. Carnahan RM, Lund BC, Perry PJ, Pollock BG, Culp KR. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. Journal of Clinical Pharmacology. 2006;46(12):1481–1486. PMID 17101747 · DOI 10.1177/0091270006292126.
  9. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Archives of Internal Medicine. 2008;168(5):508–513. PMID 18332297 · DOI 10.1001/archinternmed.2007.106.
  10. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Archives of Internal Medicine. 2007;167(8):781–787. PMID 17452540 · DOI 10.1001/archinte.167.8.781.
  11. Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician. 2018;64(5):339–351. PMID 29760253.
  12. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Canadian Family Physician. 2017;63(5):354–364. PMID 28500192. No DOI is assigned to this article; cite by PMID/PMCID.
  13. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
  14. Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. The American Journal of Psychiatry. 2016;173(5):543–546. PMID 27133416 · DOI 10.1176/appi.ajp.2015.173501.
  15. U.S. Department of Health and Human Services. HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. October 28, 2019. hhs.gov. 2019. https://nida.nih.gov/nidamed-medical-health-professionals/opioid-crisis-pain-management/hhs-guide-clinicians-appropriate-dosage-reduction-or-discontinuation-long-term-opioid.
  16. Kales HC, Gitlin LN, Lyketsos CG; Detroit Expert Panel. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal of the American Geriatrics Society. 2014;62(4):762–769. PMID 24635665 · DOI 10.1111/jgs.12730.
  17. Dyer SM, Kwok WS, Suen J, et al. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. 2025;8(8):CD016064. PMID 40832852 · DOI 10.1002/14651858.CD016064.
  18. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.
  19. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.
  20. Mühlbauer V, Möhler R, Dichter MN, Zuidema SU, Köpke S, Luijendijk HJ. Antipsychotics for agitation and psychosis in people with Alzheimer’s disease and vascular dementia. Cochrane Database of Systematic Reviews. 2021;12(12):CD013304. PMID 34918337 · DOI 10.1002/14651858.CD013304.pub2.
  21. Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of Proton Pump Inhibitors Based on a Large, Multi-Year, Randomized Trial of Patients Receiving Rivaroxaban or Aspirin. Gastroenterology. 2019;157(3):682–691.e2. PMID 31152740 · DOI 10.1053/j.gastro.2019.05.056.
  22. Cholesterol Treatment Trialists’ (CTT) Collaboration. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. The Lancet. 2019;393(10170):407–415. PMID 30712900 · DOI 10.1016/S0140-6736(18)31942-1.
  23. Cholesterol Treatment Trialists’ (CTT) Collaboration. Effects of statin therapy on diagnoses of new-onset diabetes and worsening glycaemia in large-scale randomised blinded statin trials: an individual participant data meta-analysis. The Lancet Diabetes & Endocrinology. 2024;12(5):306–319. PMID 38554713 · DOI 10.1016/S2213-8587(24)00040-8.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.