Beers revised: Drugs not to use in older adults

2019 AGS Beers Criteria for older adults

Updated Beers Criteria: A more comprehensive guide to medication safety in older adults

Inappropriate medications are often used in older adults despite their unfavourable risk-to-benefit profile. Although many of the medications in the American Geriatrics Society (AGS) Beers list are potentially inappropriate because of their anticholinergic properties, little is known regarding the nature and extent of potentially inappropriate anticholinergic medication use in older adults. To determine the prevalence of, and factors associated with, potentially inappropriate anticholinergic medication use in the older population. A retrospective, cross-sectional study was conducted, involving older adults (aged 65 years and older), using 2009-2010 Medical Expenditure Panel Survey (MEPS) data. The 2012 AGS Beers Criteria were used to define potentially inappropriate anticholinergic medications on the basis of the list of medications to avoid using in older adults irrespective of the diagnosis. Descriptive analyses were used to examine the nature and extent of potentially inappropriate anticholinergic medication use. Multivariable logistic regression within the conceptual framework of the Andersen Behavioral Model was used to identify the factors associated with potentially inappropriate anticholinergic use in older adults. According to the MEPS, there were 78.60 million older adults in the USA; an estimated 7.51 million (9.56 %) of these older adults used potentially inappropriate anticholinergic medications in 2009-2010. The most frequently used potentially inappropriate anticholinergics were cyclobenzaprine, promethazine, amitriptyline, hydroxyzine and dicyclomine. Multivariable regression analyses revealed that female sex, residing in the South and the presence of anxiety disorder increased the likelihood of receiving potentially inappropriate anticholinergic medications, whereas older adults aged 75-84 or ≥ 85 years, and those with over 15 years of education, had a decreased likelihood of receiving potentially inappropriate anticholinergic medications. The study found that approximately one in ten older adults used potentially inappropriate anticholinergic medications. Several predisposing, enabling and need factors were associated with the use of potentially inappropriate anticholinergic medications. Concerted efforts are needed to optimize potentially inappropriate anticholinergic medication use in older adults.

LOS ANGELES — The American Geriatrics Society (AGS) released a new version of the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults in early 2019, and care professionals immediately began poring over its updated recommendations — anything but an easy task. “The Beers list can be cumbersome and tedious to read. But we need to remember that [medication-related] adverse events are a serious situation,” especially in the geriatric population, said Vanessa J. Mandal, MD, MS, CMD, a geriatrician based near Sacramento, CA. Dr. Mandal updated colleagues about the new Beers Criteria (J Am Geriatr Soc 2019;67:674–694) at the annual meeting of the California Association of Long Term Care Medicine, which serves physicians, medical directors, nurses, pharmacists, administrators, and other professionals. Researchers estimated that tens of thousands of people in the United States die each year due to adverse medication-related events. The number could be as high as 106,000, making it the nation’s fourth-leading cause of death, the Food and Drug Administration has reported, and that number doesn’t take incidents at nursing homes into account (FDA, “Preventable Adverse Drug Reactions,” Mar. 6, 2018; http://bit.ly/307goCj). The newly updated Beers Criteria removes 25 medications for various reasons such as lack of current availability or adverse effects that are not unique to older adults (65 and older). Several drugs, however, have been added to the list. Dr. Mandal highlighted several drugs and medication classes that should be used with caution. Digoxin: Avoid this heart drug as a first-line treatment for atrial fibrillation or heart failure, and beware of multiple potential drug interactions. “If we see this is the only agent on board, it behooves us to contact the cardiologist to ask why this is the case,” Dr. Mandal said. “We also have to avoid doses greater than 0.125 mg. I don’t see it that much, but it still occurs and should be questioned. We need to be cautious not only because of its own effects but because of how it interacts with other medications.” Cilostazol: Avoid this vasodilator drug in any type of heart failure. “Generally, I don’t use this medication in older adults anymore,” Dr. Mandal said. “But we see it prescribed in patients from the hospital.” Aspirin: Note that the guidelines regarding aspirin’s use as primary protection against cardiovascular disease and colorectal cancer have changed. Now the Beers list says aspirin should be used for these purposes with “extra caution” starting at age 70, not 80. H2-receptor antagonists: The Beers list has updated recommendations regarding these drugs and no longer says they should be avoided in patients with dementia or cognitive impairment. But they should still be avoided in the context of delirium. Anticholinergics: The Beers Criteria include numerous drugs with anticholinergic properties that should be avoided. Two medications — the antihistamine pyrilamine (also known as mepyramine) and the peptic ulcer drug methscopolamine (Pamine) — are new to the list. Alpha blockers: Avoid doxazosin (Cardura), prazosin (Minipress), and terazosin (Hytrin) — all prostate enlargement/blood pressure medications — for hypertension due to risk of reduced blood flow to the brain. Antipsychotics: Do not use these drugs to control behavioral problems due to dementia or delirium. Instead, Dr. Mandal suggested, try alternative strategies that don’t involve drugs. Look for ideas, she said, by visiting the Nursing Home Toolkit (www.nursinghometoolkit.com), the Hospital Elder Life Program (www.hospitalelderlifeprogram.org), and Positive Approach to Care (www.teepasnow.com). Antidepressants: Avoid amitriptyline (Elavil), amoxapine, clomipramine (Anafranil), desipramine (Norpramin), doxepin (>6 mg/day), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), protriptyline, and trimipramine (Surmontil), which are highly anticholinergic and sedating. Also according to new guidelines, avoid serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta) and venlafaxine (Effexor) in patients who have a history of falls or fractures. Benzodiazepines and Z drugs: Avoid these drugs except in certain situations because of their risk of dementia and cognitive impairment. On this front, “there’s a lot of awareness [of the risks] of anticholinergics and antipsychotics” Dr. Mandal said, but fewer people know about benzodiazepines and Z drugs such as several common types of sleeping pills. Sliding-scale insulin: Avoid the use of “insulin regimens that include only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin,” according to the new criteria. Opioids: Per the FDA’s black-box warning, avoid using opioids concurrently with benzodiazepines and gabapentinoids. Although the Beers list doesn’t provide rules, its guidelines are very helpful, Dr. Mandal said. “We can consider it a very useful tool for us to look at potentially avoidable adverse events.” Randy Dotinga is a San Diego-based freelance writer.

Optimizing Medication Use in Older Adults

Influence of Studies Published by the Journal of the American Geriatrics Society: Top 20 Articles from 2000-2015.

Commentary on the New American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Geriatric people particularly those with multiple co-morbid condition may result in polypharmacy which can be associated with use of potentially inappropriate medication. This study aims to understand about prescription pattern and to find out inappropriate medication used in geriatric patients using Beer's criteria 2012. A cross sectional study was conducted from May 2018 to Aug 2018 in Koshi Zonal Hospital in Biratnagar. Data of all elderly patients greater above or equal to 60 years those were admitted to General Medical Ward during this period was analyzed. Eighty-six percent of the prescriptions were appropriate and 14% were inappropriate. Seventy-seven percent of drugs belong to Group I of Beer's criteria (Potentially inappropriate medication use in older adults), 23% of drugs belong to Group III (Potentially inappropriate medication to be used with caution in older adults) and no drugs fall under Group II (Potentially inappropriate medication use in older adults due to Drug-Disease or Drug-Syndrome interactions that may exacerbate the disease or syndrome) of Beer's criteria. Potentially inappropriate medication was found out to be 14%. The use of inappropriate medications can be avoided using Beer's criteria 2012 which is important clinical tool that can be used by physicians, pharmacist and other health care professionals.

Updated 2012 Beers Criteria: What’s Noteworthy and Cautionary?

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society's Beers Criteria and the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents.

There is a paucity of data describing the prevalence of and factors associated with the use of potentially inappropriate medications (PIMs) among older adults in Northern Nigeria. This study evaluates the prevalence and predictors of PIMs used among older adults attending outpatient clinics. This cross-sectional study involved patients aged ≥ 65 years attending outpatient clinics in two public hospitals and was conducted from June to September 2016. PIMs were detected using the American Geriatrics Society (AGS) 2015 updated Beers criteria and the Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP) [version 2] criteria. A total of 244 older adults (mean age 71.1 ± 6.1 years) were included. The prevalence of PIM measured using Beers (67.2%) and STOPP criteria (40.2%) varied significantly (p = 0.047). Both Beers and STOPP criteria identified at least one PIM in 73 patients (29.9%). Nonsteroidal anti-inflammatory drugs (NSAIDs) and α-methyldopa were the most common PIMs identified using the Beers criteria. Concurrent use of an angiotensin-converting enzyme inhibitor and amiloride was observed in 32.4% of older adults. “Glibenclamide and glimepiride” and “NSAIDs with concurrent antiplatelet without proton pump inhibitor” were the most common PIMs detected by the STOPP criteria. The number of medications being taken and the hospital attended were significant predictors of PIM. The prevalence of PIMs among ambulatory older adults was relatively high. A higher number of medications and the hospital attended were associated with a greater risk of PIMs. The 2015 Beers criteria detected significantly higher PIMs than the STOPP criteria (version 2). These observations highlight the need for interventions to improve the use of medications in older adults.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674-694, 2019.

Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults. To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults. We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6months prior to the intervention) and final (12months after) prevalence of PIM use using a test of proportions. There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%). This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.