The evidence base
STOPP/START is the European counterpart to Beers, and it differs in one structurally important way: it is two lists. STOPP identifies medications that may be inappropriate. START identifies treatments that should be there and are not.
The half that gets left out
Almost every discussion of prescribing in older adults is about too much. START exists because undertreatment is as real and as consequential. A US national survey analysis of 6,336 community-dwelling adults aged 65 and over found that only 44.3% of those with heart failure received an ACE inhibitor or ARB plus a beta blocker, and only 54.0% of those with albuminuria received an ACE inhibitor or ARB.
An older adult can be simultaneously over-prescribed and under-treated, and usually is. A review that only subtracts is doing half the job.
The current version
Version 3, published in 2023, developed through a four-round Delphi consensus process with an eleven-member European expert panel, over a literature review covering April 2014 to March 2022. A published correction accompanies the article and should be cited alongside it. Earlier versions appeared in 2008 and 2015.
A note on counts: criteria totals from superseded versions circulate widely and are frequently attached to the wrong version. The number is not the clinically meaningful fact and this site does not publish one.
The audit of its own evidence base
An independent group has appraised all 454 references cited in support of version 3, classifying the best available evidence behind each criterion. The result is worth knowing before treating the tool as settled: high-level evidence supported 43% of the STOPP criteria against 88% of the START criteria; 35% of STOPP criteria rested on evidence at levels III to V; and ten criteria — 8% of STOPP, none of START — were found to “lack appropriate supporting reference.”
The authors conclude that “fewer than half of the STOPP criteria are supported by high-level evidence” and that “a reassessment of many STOPP criteria and their references is warranted.” The tool’s own authors have published a reply, and earlier critique-and-reply exchanges exist. This is a live methodological conversation in the peer-reviewed literature, not a fringe objection.
The asymmetry is itself informative. The evidence for adding a treatment is stronger than the evidence for removing one, which is what you would expect: treatments get randomized trials, withdrawals mostly do not.
STOPPFrail
A separate instrument for older adults with limited life expectancy who are approaching the end of life. Version 2 supplies 25 deprescribing criteria plus a method for identifying that population, and foregrounds shared decision-making. New content in version 2 covers antihypertensives, anti-anginals and vitamin D.
Applied to a real population it finds a great deal. A retrospective study of 464 applications for long-term nursing care in Cork, Ireland found 274 (64.3%) met STOPPFrail eligibility, median age 83, and that 250 of those (91.2%) had at least one potentially inappropriate medication. The three commonest were medications without a clear indication (47.0%), long-term high-dose proton pump inhibitors (31.4%) and statins (29.6%). Time to benefit.
Common questions
Is STOPP/START better than the Beers Criteria?
They are different tools for different systems, built from partly different evidence, and they disagree in places. STOPP/START adds the prescribing-omissions half that Beers does not cover. Beers is the US reference and is what US quality reporting is built around. Using one does not make the other wrong. The Beers Criteria.
How solid is the evidence behind these criteria?
Uneven, and the field has audited itself. High-level evidence supports 43% of STOPP criteria and 88% of START criteria, with 8% of STOPP criteria lacking an appropriate supporting reference altogether. That does not make the tool useless — it makes it a prompt for clinical judgment rather than a substitute for it. What deprescribing trials measure.
References
- 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.
- 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.
- 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.
- Lavan AH, O’Mahony D, Gallagher P. STOPPFrail (Screening Tool of Older Persons’ Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care. European Journal of Clinical Pharmacology. 2019;75(5):723–731. PMID 30685856 · DOI 10.1007/s00228-019-02630-3.
- Pan S, Li S, Jiang S, et al. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011–2020. The Journals of Gerontology Series A. 2024;79(7):glae108. PMID 38644631 · DOI 10.1093/gerona/glae108.
- 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.
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.