Making Use of the 2012 Beers Criteria
Among older adults, drug side effects, drug-drug interactions and other adverse drug events (ADEs) are common, but often preventable. Research suggests that more than a quarter of ADEs that occur in primary care and almost half of those in long-term care could be avoided.1,2 The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults have been an important resource for preventing ADEs since the late Mark Beers, MD, and a team of experts first published them in 1991; Dr. Beers led efforts to update the criteria in 1997 and 2003. In 2011, the American Geriatrics Society (AGS), recognizing the need to maintain an up-to-date list, convened a multidisciplinary panel to revise, expand, and enhance the criteria. The result—the AGS Updated Beers Criteria for Potentially Inappropriate Mediation Use in Older Adults—is even more clinically useful than before. The AGS Beers Criteria was published in the online-only edition of the Journal of the American Geriatrics Society in early March, and will appear in the April print edition. I recommend this resource to everyone who cares for older patients.
In developing the criteria, the AGS made several changes to the process that Dr. Beers had used, in order to align the development process with AGS’ internal clinical practice guideline development processes and with the recommendations in the Institute of Medicine’s 2011 report, Clinical Practice Guidelines We Can Trust.3 As a result, the 2012 AGS Beers Criteria are based on a systematic literature review and evaluation of the evidence, and are informed by invited organizational peer review and an open public comment period. In addition, the panel used a modified Delphi process to reach consensus on the criteria’s recommendations, rated the quality of the evidence supporting each recommendation, and rated the strength of each recommendation. It is important to note that, in a number of instances, there is a paucity of research specific to the geriatric population given that they are routinely excluded from clinical trials.
The panel also determined that the AGS should expand the applicability of the Beers Criteria to a wider range of patient circumstances, per the suggestions of critics of previous iterations. In addition to the two categories of potentially problematic drugs included in earlier versions—medications that may pose more risks than benefits for older adults, and drugs that can exacerbate certain health problems in later life—the AGS Beers Criteria includes a new, third category. This is comprised of medications that, while they appear to be inappropriate for older patients in general, may nevertheless be the best choice for individual patients, and, in those cases, should be used with particular caution.
Like its predecessors, the AGS Beers Criteria are especially useful when clinicians are confronted with a medication list for an older adult that includes multiple drugs that may be interacting, and raises questions as to whether to continue these drugs, substitute others, or consider nonpharmacologic approaches. Medication review is an integral component of caring for older adults, and given the complexity of drug regimens in this population, regular medication reviews—at least once every 6 months and always after a hospitalization or transition in care—are essential. The percentage of adults taking five or more prescription medications nearly doubled between 2000 and 2008, and we know that the risk of adverse reactions increases with the number of drugs taken. We also know that older people can safely cut back on the number of drugs they take.4 This “less is more approach” is especially pertinent for older adults with possible medication-related problems. This issue becomes even more important when drugs that are indicated in the Beers Criteria as potentially inappropriate are used in the context of a comorbid chronic condition that may significantly increase adverse events due to that medication.
Although the AGS Beers Criteria are an essential aid in prescribing, they should never substitute for clinical judgment and the individualized decision-making that must take place in consultation with patients, their caregivers, or both. Among many reasons, the criteria should not replace clinical judgment because they do not apply to all of the circumstances patients face. They do not, for example, apply to patients receiving palliative care. For these patients, care may appropriately include the use of medications identified as potentially inappropriate in the criteria. In such situations, clinicians will need to more closely monitor these patients so that potential adverse drug events can be prevented or detected early.
The AGS Beers Criteria should neither dictate prescribing nor be used in a punitive manner to penalize individual prescribers who may have very valid reasons for prescribing medications classified as potentially inappropriate to an individual patient. Again, such medications may be the best choice for a given patient with specific needs and values. Just as the criteria should inform, but not dictate prescribing, they should not be the sole basis for formulary decisions regarding which drugs will or will not be covered by public or private health insurance.
I encourage you to familiarize yourselves with the 2012 AGS Beers Criteria. I also encourage you to use them in your daily interactions with patients, physicians, and other healthcare professionals, and, when applicable, in quality and medical management and review aimed at enhancing the safety and quality of prescribing for older people. The AGS has pulled together a wealth of resources for clinicians and patients related to the updated AGS Beers Criteria. To access these materials, visit the AGS Website at www.americangeriatrics.org. The AGS is also hosting a plenary session at its 2012 Annual Scientific Meeting that is focused on the Beers Criteria and will feature members of the expert panel. I encourage you to attend the Annual Meeting, which will be held May 2 to 5, 2012, in Seattle, WA, as this and other sessions will help you to improve your knowledge and skills in caring for older adults.
Finally, we invite you to respond to our online poll question at www.clinicalgeriatrics.com: Do you utilize the Beers Criteria when making prescribing decisions for patients over the age of 65? Look for poll results in an upcoming journal e-newsletter to find out how your colleagues responded. We also welcome your feedback on this topic, which may be published as a letter to the editor in an upcoming issue of Clinical Geriatrics®. You can send your letter to Allison Musante, Assistant Editor, at firstname.lastname@example.org.
1. Gurwitz JH, Fields TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116.
2. Gurwitz JH, Fields TS, Judge J, et al. The incidence of adverse drug events in 2 large academic long-term care facilities. Am J Med. 2005;118(3):251-258.
3. Graham R, Mancher M, Wolman D, et al; Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Institute of Medicine. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press, 2011.
4. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med. 2010;170(18):1648-1654.
Dr. Spivack is Medicare Medical Director, OptumHealth Care Solutions, United Healthcare, Westport/Trumbull, CT; Founder, Connecticut Geriatrics Society; Consultant in Geriatric Medicine, Greenwich Hospital, Greenwich, CT, and Stamford Hospital, Stamford, CT.
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