By Lucrecia M. Campisi, Pharm. D
Manager Care Transition Population Health
What you need to know
In January 2019, the American Geriatrics Society released the latest version of the Beers Criteria.
A review of medication regimens for patients over 65 years of age found that many patients were on at least one medication that would be considered “potentially inappropriate medication.” Such medications are associated with poor outcomes and can increase fall, confusion and mortality which can lead to increased frequency of emergency room visits and hospitalizations. Using the Beers Criteria to identify potentially inappropriate medications and substituting them with safer alternatives can be the first step towards establishing safer medication regimens for geriatric patients, helping decrease health care costs.
The Five Beers Criteria Updates
- Use caution when prescribing sulfamethoxazole with or without trimethoprim (TMP-SMX) in patients who are taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB), and who have decreased creatinine clearance, to avoid hyperkalemia. decreased kidney function and taking an angiotensin.
- H2-receptor antagonists can be used in patients with dementia, although they should be avoided in patients with delirium. The H2-receptor antagonist drugs were removed from the “avoid” list for in-patients with dementia or cognitive impairment. This decision was due to the weak evidence for adverse cognitive impairment.
- Use caution when recommending aspirin for primary prevention of cardiovascular disease or colorectal cancer in patients age 70 or older (down from previous threshold of 80 years or older), due to emerging evidence of a major increase in the risk of bleeding at a lower age. The Aspirin Reducing Events in the Elderly (ASPREE) trial, found that low – dose aspirin used for primary prevention in older adults did not demonstrate a reduction in mortality, disability-free survival, or cardiovascular events.
- The serotonin-norepinephrine reuptake inhibitors were added to the list of drugs to avoid in patients with a history of falls or fractures.
- Avoid the use of sliding-scale insulin regimens (short- or rapid-acting insulin dosed according to current blood glucose levels), as the risk of hypoglycemia without benefit of improvement in hyperglycemic management. Prescribing for the geriatric population has unique challenges. Special caution is needed due to age-related changes in pharmacokinetics and pharmacodynamics. Pharmacokinetic changes include an increased volume of distribution (e.g., lipophilic drugs such as diazepam or chlordiazepoxide) due to changes in body composition and decreased drug clearance due to the natural decline of patients’ hepatic and renal functions. These pharmacokinetic changes associated with aging are compounded by the use of polypharmacy. Pharmacodynamic changes can result in increased sensitivity to the effects of certain medications such as warfarin. The Beers List Criteria addresses different medication classes that can affect a patient’s renal/hepatic status and therefore by utilizing these guidelines, physicians can optimize medication safety in older adults and help to decrease readmission rates and overall healthcare costs.
Although polypharmacy is common and may often be necessary in older population there are opportunities for optimizing therapy through a practice known as deprescribing which is intended to eliminate unsafe or unnecessary drugs from patient regimens. By using the Beers List Criteria, health care providers can remove medications that are determined to be particularly problematic for older adults.
Today’s technology enables easy access to guidelines via apps such as AGS’s iGeriatrics. This app provides a combination of American Geriatrics Society clinical information and access to a wide range of topics related to older adults all in one place.
It is important to note that the Beers List Criteria is to be used as a tool and not a barrier for optimizing an older adult’s drug regimen. Its main goal is to improve patient safety and wellness, not to overwhelm health care providers with a huge list of restricted medications. The understanding is that each patient is unique clinically and that guidelines can be adjusted to suit each patient’s needs.
When used by health care providers, the Beers List Criteria serves as a starting point, but it is not a substitute for clinical judgment. The criteria cannot account for the complexity of individuals and sub-populations, but it can help the clinician to assess the risk verses benefit analysis for certain medications.
- https://nicheprogram.org/sites/niche/files/2019-02/Panel-2019-Journal of the American Geriatrics Society.pdf
- Whitlock EP, Burdu BU, Williams SB, et al. bleeding risks with aspirin use For primary prevention in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016; 164(12):826-835.
- McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular Events and bleeding in the healthy elderly. N Engl J Med. 2018; 379(16): 1509-1518.
- McNeil JJ, Woods RL, Nelson MR, et al. Effect of aspirin on disability-free Survival in the healthy elderly. N Engl J Med. 2018; 379(16):1499-1508.
- The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in Older adults. J Am Geriatric Soc. 2012; 60:616-631.