Beers Criteria Provide Key
Prescribing Principles

“Start low and go slow.” For years this was the best-known advice for anyone prescribing medications for older adults. Sage advice and easily applied, it was, however, lacking the robust data required for modern discerning clinical practitioners. Decades of pharmaceutical study of medications that specifically excluded older adults led to limited information to guide use in elders. Amid this uncertainty, an astute and visionary geriatrician identified the need for this clarifying practice tool and launched the now legendary tool bearing his name.

In 1991, under the direction of the late Mark Beers, MD, the first Beers Criteria provided awareness of the need for unique caution in prescribing for the elderly. Now widely known and cited, the Beers Criteria are an invaluable resource tool. In 2012, the American Geriatrics Society (AGS) assumed responsibility for it and in October 2015 released the current revision along with several new companion tools to enhance understanding and expand use. I was honored to be a part of the 13-member panel convened to produce the update and companion materials. What I learned during the process gave me a more complete understanding of what the criteria mean and how I can apply them to daily care decisions.

As I joined the panel of seasoned Beers Criteria reviewers, it was clear that I was a newbie. I still called it the Beers List. Far more than a listing of medications to avoid in the elderly, the Beers Criteria are a sophisticated set of guiding principles to assist clinicians in day-to-day decision making.

Each time before I enter a new prescription, as a practicing physician, I try to remember the sobering reminder from our panel cochair and pharmacist, Todd Semla, PharmD: “As we grow older, at least one in six of us is likely to experience serious side effects directly related to the medications we take.” The last thing I want to do to one of my elderly patients is to create more trouble for them from a medication I ask them to take. That risk/benefit decision is at the core of the Beers Criteria.

Our other cochair, Donna Fick, PhD, RN, reminded us often, “The AGS Beers Criteria offer guidance to clinicians and the public for talking about medications with risks that may outweigh benefits. It’s important to remember that many of these medications are considered potentially inappropriate only in certain circumstances and for certain people. Tools like the AGS Beers Criteria can do much to support medication use that is safe, effective, and responsive to each person’s health needs.”

To make this year’s Beers Criteria even more useful for clinical decision making, a separate article, “How to Use the American Geriatrics Society 2015 Beers Criteria — A Guide for Patients, Clinicians, Health Systems, and Payors” was published detailing how to use the criteria. It provides key principles of prescribing for the elderly and application of the Beer’s Criteria. Remember, the criteria are not the be-all and end-all of prescribing decisions. Quality geriatric care requires individualization of decision making, balancing patient-specific circumstances, need, and preferences. The authors equate the criteria with a “warning light” and recommend the following approach:

“A good way to think about the role of the criteria is that when a clinician considers prescribing a Beers Criteria medication, a ‘warning light’ should go off in his or her head. This warning light should remind the clinician of the potentially unfavorable balance of benefits and harms of the medication and prompt consideration of whether other treatment approaches would be better. Questions to address include: Why is the patient taking the drug, and is it truly needed? Are there safer or more effective alternatives for the patient? Does this patient have particular characteristics that increase or mitigate the risk of this medication? This heightened awareness not only should occur at the time the drug is initially prescribed, but should also continue over time and prompt ongoing monitoring to assess whether the therapy is effective or causing adverse effects. In many cases, this heightened awareness should lead to periodic attempts to discontinue or reduce doses of the medication. Even for people who have tolerated Beers Criteria medications, adverse effects or reduced effectiveness can occur years into therapy because of the physiology of aging and other changes in clinical status.”1

Once that warning light goes off, another addition is the companion article, “Alternative Medications for Medications in the Use of High-risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures,” which provides alternatives to medications identified as potentially inappropriate. Consider copying the tables provided with this article2 and having them easily accessible in your practice.

Some additional highlights of the updated information released this year include the following:

• Separate guidance on avoiding 13 combinations of medications known to cause harmful drug-drug interactions: Treatments for several conditions common in older adults may be inappropriate when prescribed at the same time because they can increase risks for other health problems, from falls and fractures to urinary incontinence or medication toxicity.
• A specific list of prescription medications to avoid or adjust based on how well a patient’s kidneys function: The renal system plays a central role in filtering blood. Impaired kidney function can affect how well medication is processed and absorbed. The 2015 AGS Beers Criteria list 20 potentially problematic medications for older people with moderate to severe kidney impairment, which could elevate the risks for everything from nausea and diarrhea to bleeding, problems with the central nervous system, changes in mental well-being, and bone marrow toxicity.
• Three new medications and two new classes of medications have been added to warning lists for most older adults or for those with specific health concerns: Noteworthy among these additions are proton-pump inhibitors, which are often prescribed to people living with acid reflux or stomach ulcers. Multiple studies now support a link between these medications and an increased risk for bone loss, fractures, and serious bacterial infections.
• Updates to remove several medications from the AGS Beers Criteria, either because they are no longer available or because the underlying condition or concern they address is no longer limited to older people: Potentially inappropriate medications for those with chronic constipation were dropped from the 2015 AGS Beers Criteria, for example, because constipation is common across the age spectrum and prescribing considerations are not specific to older adults.
• Several modifications to recommendations on potentially inappropriate medications carried over from the 2012 AGS Beers Criteria: With increasing evidence that antipsychotics cause considerable harm without improving care outcomes for people with delirium and dementia, for example, the 2015 AGS Beers Criteria now endorse “avoiding antipsychotics for behavioral problems” altogether unless behavior modification has failed or the older adult poses a physical threat to himself or others.

Beers Criteria publications can be found at http://geriatricscareonline.org. Available free of charge, there are original documents as well as practice and patient resources to help clinicians use the information.

AGS Clinical Guidelines and Recommendations

The American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults includes the following:

• American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults;
• How to Use the American Geriatrics Society 2015 Beers Criteria — A Guide for Patients, Clinicians, Health Systems, and Payors;
• 2015 AGS Beers Criteria Alternatives List; and
• 2015 AGS Beers Criteria and Evidence Tables.

Related content includes the following:

• Teaching Slides: How to Use the AGS 2015 Beers Criteria;
• Patient Resources: What to Do and What to Ask: If a Medication You Take Is Listed in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Care of Older Adults;
• Patient Resources: Medications to Avoid or Use With Caution;
• Patient Resources: Alternatives for Medications Listed in the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults;
• Patient Resources: Avoiding Overmedication and Adverse Drug Reactions; and
• Beers Criteria Pocketcard.

I hope you will find this updated set of information and resources from the Beers Criteria an asset in your quest to provide high-quality and safe care for older adults. “Start low and go slow” still applies, but we’ve come a long way.

Handouts for your patients can be found at the Health In Aging website. I have referenced this terrific site in prior articles, and I hope you bookmark it. There is a wealth of consumer-focused quality information. Visit www.healthinaging.org/medications-older-adults for The 2015 American Geriatrics Society Updated Beers Criteria: Medications that Older Adults Should Avoid or Use With Caution.

In current medical practice there are a multitude of rules and regulations, quality criteria, and many other sources to encourage or directly alter a clinician’s practice behavior. In some cases these recommendations square with conventional wisdom (eg, antibiotics don’t work for viral upper respiratory infection), while in other cases regulations are out of sync with evidence-based geriatric care (eg, Joint National Committee-VI recommended blood pressures for elderly). In this challenging environment of combining data and population health-level information with clinical experience and individualized patient outcomes, the articles cited herein are focused at this junction of data and a prescribing clinician.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

References

1. 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.
2. Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures [published online October 8, 2015]. J Am Geriatr Soc. doi: 10.1111/jgs.13807.