New American Geriatrics Society Beers Criteria
By Jaimie Lazare
The criteria are an important evidence-based tool geriatricians use as a guide when prescribing medications that are potentially inappropriate for use in older adults.
The 2015 American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults was updated by a panel of 13 interdisciplinary experts in the fields of geriatric care and pharmacotherapy. In addition to including a list of potentially inappropriate medications that is also found in the 2012 Beers Criteria, new guidelines have been added. New to the criteria are lists that describe drug-drug interactions and drugs to avoid or drugs that need to be dose-adjusted on the basis of kidney function in older adults.1
Another noteworthy change found in the criteria is the revision to the recommendation that nitrofurantoin should be avoided in patients with a creatinine clearance of less than 60 mL/min. "Based on some evidence that's come up between 2012 and now, [nitrofurantoin] appears to be effective down to a creatinine clearance of 30 mL/min," says Todd Semla, MS, PharmD, BCPS, FCCP, AGSF, cochair of the AGS Beers Criteria expert panel and an associate professor of medicine and psychiatry and behavioral sciences at Northwestern University's Feinberg School of Medicine in Chicago.
"We kept the recommendation to avoid long-term use, particularly for suppression of urinary tract infections, because of the risk of pulmonary, neurological, or hepatic side effects that can occur. So its use is for the acute treatment of urinary tract infections in a person who has a creatinine clearance of 30 mL/min or greater," he says.
A new addition to the criteria is the inclusion of tables that cover drug-drug interactions. "One table is for anticholinergic drugs to avoid and to minimize use when at all possible because of the increased risk of cognitive decline. If you keep adding drugs with anticholinergic effects, then the risk for cognitive impairment or side effects continually increases," Semla says.
Fick notes that the other important companion piece focuses on alternative medications. "It's important to keep in mind that this is the first year that we've done an alternatives list, so it will improve every year. We wanted to move beyond simply saying 'don't give this drug' by giving alternatives for clinicians and patients to use," she says.
"And in most cases, it's best to try to give a nondrug alternative first because we know, for instance, that the No. 1 independent risk factor for having an adverse drug event is the number of medications patients are on. Many times medications are necessary. But if we can get people off certain high-risk medications, then we can help reduce adverse drug events," she adds.
For someone who is taking anticholinergic drugs such as benztropine or trihexyphenidyl for Parkinson's disease, for example, the criteria point out that those are not the best choices, and the preferred starting point would be the carbidopa/levodopa combination (Sinemet) as the best treatment for older people, Semla says.
Using the Beers Criteria to Improve Health Outcomes
"From studies we know that when someone is started on a drug in a hospital, it is often meant to be temporary or to treat symptoms or problems that may arise due to hospitalization. But we know from several different studies that people are often never taken off drugs once they are started. So we need to think about when people are first put on medications and question whether some of these medications can be stopped or tapered off," she says.
"By avoiding the use of certain medications and the prolonged use of medications, you reduce the risk for adverse effects in those medications that require rehospitalization or hospitalization for a different event," Semla says.
For instance, Semla says, an elderly patient may be hospitalized and given a prescription that increases the risk of falling and the medication may not be discontinued at discharge. The patient may fall at home and return to the hospital for a hip fracture when the original hospitalization was for pneumonia. "We certainly want to reduce these types of risks by avoiding these potentially inappropriate medications," he says.
The criteria also offer guidance on the use of antipsychotics in older adults because of increasing evidence about the harms3,4 associated with their use and conflicting data on their effectiveness in treating dementia and delirium. Semla says that when an elderly patient with dementia becomes agitated, there are nonpharmacological approaches that should be considered before prescribing an antipsychotic.
Semla says that the first thing that should be done is to try to determine the underlying reason a person has become agitated. Is it because he or she is hungry, in pain, or has an underlying medical problem such as an infection? The AGS Beers Criteria provides some information for these nonpharmacological approaches.
While many organizations (eg, the Centers for Medicare and Medicaid Services, National Committee for Quality Assurance, and Pharmacy Quality Alliance) use the AGS Beers Criteria for quality measurements, the criteria can also be used in a systems- and in an individual-based approach to help improve health outcomes, Fick says.
"For instance, I use them to do nursing rounds in our local medical center. We've also used them to decrease delirium symptoms in hospitalized older adults. And this is important because our hospital system, like many hospital systems, has very few geriatric specialists," Fick says. "So it's important to bring geriatric care knowledge about potentially inappropriate medications to settings where health care professionals may not have that expertise, especially if an older adult has a change in function."
Health care professionals can also use the criteria on an individual level to communicate with patients about their preferences. Fick recalls a patient consultation in which the patient expressed concern about the number of medications she was taking. The patient was seeing several physicians and was taking 15 different medications—four of which were central nervous system medications that were Beers-specific medications. The patient was concerned about the ways in which the medications were helping her and believed she would be unable to stop taking any of them.
Fick says that after the consultation, her patient went back and worked with her physicians to reduce the number of her medications. She was taken off two medications (zolpidem and lorazepam) and had the dose of a different drug decreased. Fick points out that this patient-centered care approach serves as another way in which the criteria can be used to improve health outcomes.
Complementary Criteria: Beers and STOPP/START
"I don't view the STOPP/START and Beers criteria as competitive. They are complementary, and they both have some things that are very useful. But how they are designed and how they are set up is different. AGS Beers Criteria are more explicit, whereas STOPP/START criteria are more implicit. Both are helpful in guiding prescribers when providing care to older adults," Semla says.
"The Beers Criteria has traditionally been something that had been used both across the desk for a patient and as a quality measure so that CMS or whoever decides to use them can apply them to electronic databases to get an idea of the prevalence of the prescribing of these drugs. STOPP/START is much more individualized in terms of the information that's needed to determine whether or not a drug is correct or not for a patient. It relies more on individualized patient data," he says.
"I would encourage providers and individuals to go to the Health in Aging and Geriatrics Care Online websites and to take a look at all the different materials and ways that information is packaged for different audiences. In particular, look at the three main papers: one is the 2015 AGS Beers Criteria, the second is the alternatives, and then the third is the [one on] how to use the Beers Criteria. There are principles in there that people should really take a look at and think about how they'll use it in their practice," he says.
Fick says that geriatricians should keep in mind that the Beers Criteria is one piece of quality prescribing and that there are other factors to consider such as access to care, medication affordability, and the likelihood of patient adherence in taking medications.
— Jaimie Lazare is a freelance writer based in Brooklyn, New York.
2. Steinman MA, Beizer JL, DuBeau CE, Laird RD, Lundebjerg NE, Mulhausen P. How to use the American Geriatrics Society 2015 Beers Criteria — a guide for patients, clinicians, health systems, and payors [published online October 8, 2015]. J Am Geriatr Soc. doi: 10.1111/jgs.13701.
3. Maust DT, Kim HM, Seyfried LS, et al. Antipsychotics, other psychotropics, and the risk of death in patients with dementia: Number needed to harm. JAMA Psychiatry. 2015;72(5):438-445.
4. Inouye SK, Marcantonio ER, Metzger ED. Doing damage in delirium: The hazards of antipsychotic treatment in elderly persons. Lancet Psychiatry. 2014;1(4):312-315.