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Safe Prescribing in the Elderly: Beers Criteria & STOPP/START Explained(With NICE-based Approach & Focus on Anticholinergics)

📌 Introduction

Prescribing in older adults (≥65 years) requires caution due to:

  • 🧠 Increased brain sensitivity

  • 💊 Reduced drug clearance

  • 📚 Polypharmacy

👉 As a result, medications are a common and reversible cause of confusion, falls, and hospitalisation.

To guide safe prescribing, two major tools are used:

  • Beers Criteria

  • STOPP/START Criteria



What These Guidelines Mean

🇺🇸 Beers Criteria

  • A list of potentially inappropriate medications (PIMs)

  • Applies to patients ≥65 years 

  • Focus: What to avoid

🇬🇧 STOPP/START Criteria

  • STOPP → medications to stop

  • START → beneficial medications often missed

👉 Proven to reduce adverse drug events in older adults 

NICE Perspective

NICE does not publish a “Beers-style list” but strongly emphasises:

  • Medication review in elderly

  • Identifying falls-risk-increasing drugs (FRIDs)

  • Avoiding drugs that worsen delirium and cognition 



High-Risk Drug Groups (Common Across Guidelines)

1. Anticholinergics (MOST IMPORTANT)

Examples:

  • Oxybutynin

  • Amitriptyline

  • Diphenhydramine

👉 These are specifically highlighted in Beers due to strong anticholinergic effects 

2. Benzodiazepines

  • Falls, sedation, dependence

3. NSAIDs

  • GI bleeding, renal impairment

4. Cardiovascular drugs

  • Hypotension → falls

5. Sulfonylureas (e.g. glibenclamide)

  • Prolonged hypoglycaemia



Why Anticholinergics Are So Important


Mechanism

👉 Block acetylcholine → affects:

  • Memory

  • Attention

  • Alertness


Effects in elderly

  • Confusion / delirium

  • Falls

  • Constipation

  • Urinary retention

👉 Strong evidence shows anticholinergic drugs are linked to delirium, falls, and even dementia risk 


Anticholinergic Burden

👉 Multiple drugs = additive effect

  • Common in elderly

  • Leads to cognitive decline and functional impairment 



Clinical Presentation (PLAB 2 GOLD)

Patients rarely say “delirium”.

👉 Instead:

  • “I feel foggy”

  • “Not myself”

  • “Funny turns”

  • Falls

👉 Important:

  • Examination may be normal

  • MMSE may be normal

  • Symptoms fluctuate



🧠 Clinical Reasoning

👉 Elderly + new confusion/falls👉 On high-risk drug

➡️ Medication is the diagnosis until proven otherwise



Management (NICE-Aligned + Exam High-Yield)


1. STOP the offending drug (KEY STEP)

👉 Example:

  • Stop Oxybutynin

👉 Beers recommends avoiding anticholinergics due to cognitive risk

👉 Do NOT just reduce if delirium present


2. Rule out other causes (NICE delirium approach)

  • Infection

  • Blood tests (FBC, U&E, glucose)

  • Medication review


3. Supportive care (first-line)

NICE-style delirium management includes:

  • Hydration

  • Reorientation

  • Sleep optimisation

  • Environmental support


4. Avoid worsening

👉 Avoid:

  • Benzodiazepines

  • Strong antipsychotics (especially Parkinson’s)


5. Switch to safer alternatives

👉 For overactive bladder:

  • Mirabegron

👉 NICE principle:

  • Prefer non-anticholinergic options when possible


6. START appropriate medications

STOPP/START reminds us:

👉 Elderly are often undertreated

Examples:

  • Calcium + Vitamin D

  • Statin

  • ACE inhibitor



Practical Clinical Algorithm

👉 Elderly patient with new confusion:

  1. Review medications

  2. Identify high-risk drugs

  3. STOP offending agent

  4. Exclude other causes

  5. Provide supportive care

  6. Switch to safer alternative



PLAB 2 Communication Line

“Some medications can affect memory and balance in older adults. I would like to review and adjust your medications to make them safer.”


Final Takeaway

👉 Beers = what to avoid (USA)👉 STOPP/START = what to stop & start (UK)

👉 Most important concept:➡️ Anticholinergic burden

👉 Most important action:➡️ Recognise → STOP → Support → Switch


📚 References

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