What is the role of Beers criteria in prescribing medications to older adults?

The Role of Beers Criteria in Prescribing Medications to Older Adults

The Beers Criteria serves as an essential clinical tool for identifying potentially inappropriate medications (PIMs) that should typically be avoided in older adults due to their unfavorable balance of benefits and harms compared to alternative treatment options. 1

What is the Beers Criteria?

• The American Geriatrics Society (AGS) Beers Criteria® is an explicit list of medications that are potentially inappropriate for older adults in most circumstances or in specific situations related to certain diseases or conditions 1
• Since 2011, the AGS has been the steward of the criteria, producing updates on a 3-year cycle with the most recent updates in 2019 and 2023 1, 2
• The criteria were first published almost 30 years ago in 1991, making them the longest-running criteria for PIMs in older adults 1
• The criteria are developed through a comprehensive, systematic review and grading of evidence on drug-related problems and adverse events in older adults 1, 3

Components of the Beers Criteria

The 2019 AGS Beers Criteria® includes five types of recommendations:

1. Medications potentially inappropriate in most older adults - A list of 30 individual criteria of medications or medication classes to be avoided in older adults 1
2. Medications to avoid in older adults with certain conditions - 16 criteria specific to more than 40 medications or medication classes that should be avoided in certain diseases or conditions 1
3. Medications to use with caution - Medications that may be appropriate but require careful monitoring 1
4. Drug-drug interactions - Combinations of medications that should be avoided 1
5. Medications requiring dose adjustment based on kidney function - Medications that should be avoided or have dosage reduced based on renal function 1

Clinical Applications of the Beers Criteria

• Primary purpose: To improve care of older adults by reducing exposure to PIMs that have an unfavorable balance of benefits and harms compared to alternative treatments 1
• Dual function: Serves as both an educational tool and a quality measure for healthcare providers 1
• Warning system: Acts as a "warning light" to identify medications with unfavorable benefit-harm profiles in many older adults 4
• Clinical guidance: Helps clinicians make more informed prescribing decisions for older adults 1

Important Considerations When Using Beers Criteria

• Not punitive: The criteria are not meant to be applied in a punitive manner but rather to guide clinical decision-making 1
• Clinical judgment remains essential: Prescribing decisions are not always clear-cut, and clinicians must consider multiple factors, including discontinuation of medications no longer indicated 1, 4
• Exceptions exist: There are situations where medications included in the criteria may be appropriate for specific patients 1, 4
• Target population: The criteria apply to adults 65 years and older in all ambulatory, acute, and institutionalized settings except hospice and end-of-life care 2

Specific Medication Concerns Addressed in Beers Criteria

• Anticholinergic medications: Older adults experience a decline in acetylcholine physiology with aging, making them more susceptible to anticholinergic side effects 5
• NSAIDs: Associated with increased risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation in older adults 1
• Benzodiazepines: Linked to increased risk of cognitive impairment, delirium, falls, and fractures 1
• Antidepressants: Certain antidepressants like tricyclic antidepressants (TCAs) and paroxetine have significant anticholinergic effects and are considered potentially inappropriate 5, 6

Impact and Evolution of Beers Criteria

• Quality improvement: The criteria have become an integral part of policy and practice and are incorporated into several quality measures 3
• Regular updates: The criteria undergo regular updates based on new evidence, with modifications, additions, and removals of criteria as appropriate 1, 2
• Expanded scope: The criteria have evolved from the original focus on nursing home residents to cover all care settings for older adults 2, 7
• Increased specificity: Recent updates have enhanced the criteria's usability and provided more nuanced guidance for specific clinical scenarios 2

Limitations and Proper Use

• Not a substitute for clinical judgment: The criteria support, rather than replace, good clinical decision-making 4
• Individualization still required: While identifying PIMs, clinicians must still consider patient-specific factors 1
• Not exhaustive: The criteria do not address all possible inappropriate prescribing scenarios 1
• Misinterpretation risks: The criteria can be misinterpreted and implemented in ways that cause unintended harms if applied too rigidly 4

The Beers Criteria remain a valuable resource for improving medication safety in older adults when used appropriately as part of a comprehensive approach to geriatric pharmacotherapy.