AGS Spotlight

New Year, New Guidelines: Resolving to Optimize Geriatric Care in 2013 With the AGS Updated Beers Criteria

Barney S. Spivack, MD, FACP, AGSF, CMD Associate Physician Editor, Clinical Geriatrics®

Nearly a year ago, the American Geriatrics Society (AGS) updated and expanded the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults—one of the leading sources of information about safely prescribing medications to older people. The criteria had previously been revised in 2003, just a few years before the death of Mark Beers, MD, the geriatrician and former editor of the Merck Manuals who first published the criteria bearing his name. Recognizing the need for the update and expansion, the AGS convened a multidisciplinary panel of experts to undertake both. The society published the result of this collaboration in March 2012 in the Journal of the American Geriatrics Society. Since then, I’ve been using the new criteria on a daily basis. These criteria are now called the 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, and I’ve been very impressed with their value and utility. 

The Beers Criteria have been enhanced in a number of ways. Among many things, the 2012 AGS Beers Criteria are based on updated research. The panel that undertook the update followed enhanced protocols when evaluating this research. The panelists followed the evidence-based approach recommended by the Institute of Medicine when developing clinical practice guidelines. In addition, the panel used a modified Delphi process for building consensus and rated each recommendation in the new criteria, evaluating both the strength of each of the panelists’ recommendations and the quality of the evidence supporting each of these recommendations. Providing separate evaluations for the quality of the evidence and for the strength of each recommendation helps those of us using the criteria identify stronger recommendations based on the evidence. 

Making the criteria even more helpful for clinicians, researchers, and others involved in geriatric healthcare, the AGS Beers Criteria assign medications that appear to be potentially inappropriate for older adults into three more nuanced categories, instead of just two, as previous versions of the criteria did. The first of these three categories includes drugs that are potentially inappropriate for older adults, not only because they pose high risks of adverse effects or appear to have limited efficacy in older adults, but also because there are reasonable alternatives to these medications. The second category lists drugs that may be inappropriate for aging patients because they can exacerbate certain health problems. The third and newest category includes medications that should be used with caution because these drugs, while linked to more risks than benefits in older people in general, may nevertheless be an appropriate choice for a given individual if administered with particular caution. Throughout, the content is highly credible and reflects the strong leadership role that the AGS plays in improving the health and quality of life of older people. 

As a medical director with a responsibility to support nurse care managers and care management programs, I use the information in the AGS Beers Criteria regularly to identify potentially inappropriate drugs and enhance recommendations for medication management. The rationale and additional content accompanying each recommendation in the AGS Beers Criteria are clear and based on the evidence. Our team of healthcare professionals also uses additional public education materials about safe prescribing in older adults developed by the AGS’ Foundation for Health in Aging. These resources, which are available for free at www.healthinaging.org, can help older patients and their family members better communicate with their primary care physicians and other clinicians. These materials can assist us with making important decisions about our patients’ care and helping them to understand these decisions. 

The AGS has developed a number of extremely helpful resources for clinicians to easily and conveniently employ the criteria in their daily practice, such as a printable pocket guide and a smartphone application that includes tables, which are a significant aid in geriatric prescribing. The slideshow presentation about the criteria can be helpful in teaching and in sharing this knowledge, given its easily adapted educational content. You can learn more about and access these free resources at http://bit.ly/AGS_Beers_Guidelines

Other professionals and organizations, including the National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA), have also incorporated information from the new criteria into their work. Following publication of the AGS Beers Criteria, the NCQA and PQA revised their own quality measures based in part on the updated criteria. 

When treating older adults, certain issues, such as the use of benzodiazepines, arise often. The AGS Beers Criteria advise that older adults avoid these mediations because they are associated with increased risks of falls, fractures, motor vehicle accidents, delirium, and cognitive impairment. The criteria also note that, in many cases, nonbenzodiazepine hypnotics (known as the Z drugs) should also be avoided due to evidence that they can similarly increase risks of adverse events and have limited efficacy. Since the publication of the AGS Beers Criteria, there have been additional reports highlighting the risks of benzodiazepines and calling for even greater attention to this opportunity to further improve prescribing. 

In short, the AGS Beers Criteria is a must-read source of current, high-quality, evidence-based information that can guide prescribing for often vulnerable and clinically complex older adults, many of whom have multimorbidity. As new medications continue to be developed and
marketed and as studies continue to shed light on the efficacy and safety of the currently available medications, it is imperative that we continue to revise the criteria and incorporate new findings into this valuable guide. The AGS is committed to revising the AGS Beers Criteria on a regular basis, which will ensure the enduring value and appropriate clinical use of this important resource as we continue to improve the health and well-being of older adults.