Rational Use of Analgesic Agents in Elderly Patients: Implications of the Beers Criteria and STOPP/START Algorithms

Pain affects approximately 30% of community-dwelling older adults and more than half of nursing-home residents but remains undertreated because age-related pharmacokinetic and pharmacodynamic changes render standard analgesic dosing hazardous. This review synthesises the evidence on rational analgesic prescribing in older adults, comparing the American Geriatrics Society 2023 Beers Criteria with STOPP/START version 3.

In this structured narrative review, PubMed/MEDLINE, Embase and the Cochrane Library were searched (January 2000-May 2026), combining analgesic-class terms with the Beers Criteria, STOPP/START, potentially inappropriate medications, deprescribing and older age. Systematic reviews, meta-analyses, randomised trials, large observational studies and guidelines in English were eligible; studies confined to patients younger than 65 years were excluded.

Analgesics are principal drivers of inappropriate prescribing: STOPP/START version 3 identified at least one potentially inappropriate medication in 73% of geriatric outpatients versus 56% under version 2, NSAIDs and aspirin being the most prevalent new criteria. The Beers Criteria designate meperidine, non-selective oral NSAIDs, anticholinergic tricyclic antidepressants, and opioid-benzodiazepine or opioidgabapentinoid combinations as highest risk; meperidine is most strongly associated with unplanned hospitalisation (OR 2.37).

The instruments are complementary, not interchangeable: the Beers Criteria offer broader drug-disease coverage but are aligned with the United States formulary, whereas STOPP/START is bidirectional and more prescriptive on dose and renal thresholds. Neither has been shown to reduce falls, hospitalisation or mortality in adequately powered trials.

Stepwise multimodal analgesia beginning with paracetamol and topical agents, initiated at low doses and titrated slowly, with comprehensive geriatric assessment and regular medication review, remains the evidence-based standard of care.