Stronger Criteria, Weaker Evidence: Evaluating STOPP/START Version 3 for Geriatric Care

Compared with the previous version, the newest Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria can detect 17% more potential omissions and inappropriate medications, respectively.¹ Health care providers around the world use STOPP/START to care for their geriatric patients.

Despite the common use of STOPP/START version 3 (SS.v3), some providers question the unwieldy length of recommendations and how the authors developed them in the first place. Study results published in the European Journal of Geriatric Medicine sought to investigate the sources of recommendations used by the creators of SS.v3 and the strength of evidence supporting them.²

The authors completed their research by having 2 clinical pharmacist-geriatricians and a geriatrician expert evaluate all references from SS.v3. The research group categorized the level of evidence for each reference, ranging from systematic review of randomized controlled trials at the top down to expert opinion at the bottom.²

The results highlight some underlying weaknesses in SS.v3, with one-third of all references rated as low evidence. Nearly half (45%) of low-evidence resources supported the STOPP criteria, compared to the START criteria at 19%. The authors suggest the addition of evidence ranking within the criteria to increase transparency with providers who use SS.v3 as a tool in their practice. Additionally, within the STOPP criteria, 10 had no valid reference to support the recommendation. The authors found it alarming that the unsupported recommendations are about common medications such as anticoagulants, corticosteroids, and opioids.²

Among their concerns, the authors noted that randomized controlled trials about efficacy are easier to come by than safety. Additionally, underlying evidence has the power to strengthen or weaken guidance to providers, and the high proportion of narrative reviews, expert opinion, and other feeble evidence weakens SS.v3.²

Tools are only as good as we make them. This is not to say that providers can’t use STOPP/START version 3; it serves an important purpose to support decisions around geriatric medicine. Providers use SS.v3 to keep their geriatric patients safe, but decisions about medication appropriateness ultimately come down to the patient and provider.

REFERENCES

1. Szoszkiewicz M, Deskur-Śmielecka E, Styszyński A, Urbańska Z, Neumann-Podczaska A, Wieczorowska-Tobis K. Potentially inappropriate prescribing identified using STOPP/START version 3 in geriatric patients and comparison with version 2: a cross-sectional study. J Clin Med. 2024;13(20):6043. doi:10.3390/jcm13206043

2. Boland B, Sibille FX, Mouzon A, et al. Appraisal of the references supporting the STOPP/START.version 3 criteria. Eur Geriatr Med. 2025. doi:10.1007/s41999-025-01386-7