What is the role of the Beers criteria in managing medications for older adults, particularly those with dementia or multiple chronic conditions?

Beers Criteria: A Systematic Tool for Identifying and Avoiding Potentially Inappropriate Medications in Older Adults

What the Beers Criteria Are

The American Geriatrics Society Beers Criteria is an evidence-based list of medications that pose greater risks than benefits in older adults, serving as both an educational tool and quality measure to guide prescribing decisions and reduce adverse drug events. 1

The criteria have been continuously refined since 1991, with the American Geriatrics Society stewarding updates on a 3-year cycle (most recently 2019 and 2023), making them the longest-running and most widely validated criteria for potentially inappropriate medications in older adults. 1

Five Core Categories of the Beers Criteria

The 2019 AGS Beers Criteria encompasses five distinct recommendation types that clinicians must systematically review: 2, 1

1. Medications potentially inappropriate in most older adults - 30 individual medications or medication classes to avoid regardless of diagnosis 3

2. Medications to avoid in older adults with certain conditions - Over 40 additional medications requiring caution in specific diseases (e.g., benzodiazepines in fall history, NSAIDs in heart failure) 3

3. Medications to use with caution - Drugs with insufficient evidence for outright avoidance but warranting heightened monitoring (e.g., aspirin for primary prevention ≥70 years, rivaroxaban ≥75 years) 2, 3

4. Critical drug-drug interactions - Combinations documented to cause severe harm (e.g., opioids + benzodiazepines causing respiratory depression and death, opioids + gabapentinoids, warfarin + TMP-SMX) 3

5. Medications requiring dose adjustment based on kidney function - Drugs like ciprofloxacin, TMP-SMX, dofetilide, and edoxaban that accumulate with reduced renal clearance 3

Strength of Evidence Grading System

The criteria use a two-tier strength rating that directly informs clinical decision-making: 2

• Strong recommendation: Harms, adverse events, and risks clearly outweigh benefits - these medications should be actively avoided and deprescribed 2

• Weak recommendation: Harms may not outweigh benefits - clinical judgment and patient-specific factors determine appropriateness 2

High-Priority Medications to Target First

When applying the Beers Criteria, prioritize removal of medications with the highest morbidity and mortality risks: 3

Central Nervous System Agents (Highest Risk Category)

• Benzodiazepines and nonbenzodiazepine hypnotics increase risk of cognitive impairment, delirium, falls, fractures, motor vehicle accidents, and respiratory depression when combined with opioids 2, 3

• Antipsychotics carry an FDA black box warning for increased mortality in dementia patients, plus risks of stroke, falls, fractures, and movement disorders 3, 4

• Tricyclic antidepressants cause anticholinergic effects and orthostatic hypotension 3

Cardiovascular and Metabolic Agents

• NSAIDs increase risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation 1, 3

• Thiazolidinediones worsen fluid retention in heart failure patients 3

Opioids and Gabapentinoids

• Concurrent opioid + benzodiazepine use causes severe respiratory depression and death - this combination must be avoided 3

• Concurrent opioid + gabapentinoid use increases respiratory depression, overdose, and death risk (exception: when transitioning from opioids to gabapentinoids as an alternative) 3

Disease-Specific Medication Avoidance

Apply these disease-specific restrictions systematically: 3

For patients with fall or fracture history, avoid:

• Benzodiazepines
• Nonbenzodiazepine hypnotics
• Antipsychotics
• Opioids
• SNRIs (but SSRIs like sertraline are acceptable) 3

For patients with dementia or cognitive impairment, avoid:

• Anticholinergics
• Benzodiazepines
• Antipsychotics 3

For patients with heart failure, avoid:

• NSAIDs
• Thiazolidinediones
• Calcium channel blockers 3

Acceptable Exceptions and Nuances

The criteria recognize specific clinical scenarios where otherwise inappropriate medications may be justified: 2

• Antipsychotics in Parkinson disease psychosis: Quetiapine, clozapine, and pimavanserin are exceptions to the general avoidance recommendation, though none is ideal in efficacy or safety 2

• Haloperidol acceptable uses: Short-term use during chemotherapy as antiemetic, treatment of schizophrenia, and acute delirium management in controlled settings (but avoid for long-term behavioral management in dementia) 4

• Gabapentinoids with opioids: Acceptable only when transitioning from opioids to gabapentinoids as an alternative analgesic 3

Implementation Strategy: When and How to Apply

Apply the Beers Criteria systematically at every care transition: hospital admission, ICU transfer, hospital discharge, nursing home placement, and outpatient medication reconciliation. 1, 3

Step-by-Step Application Algorithm

1. Conduct comprehensive medication assessment including all prescription drugs, over-the-counter medications, herbal products, and supplements 1

2. Screen using validated tools - Apply both Beers Criteria and STOPP/START criteria to identify potentially inappropriate medications 1, 3

3. Prioritize deprescribing targets - Remove medications with highest morbidity/mortality risks first: benzodiazepines, opioids, antipsychotics, NSAIDs 3

4. Evaluate patient-specific factors:

   • Life expectancy vs. time-to-benefit for each medication 1
   • Functional and cognitive status 1
   • Multimorbidity burden 1
   • Patient goals of care 1

5. Check for critical drug-drug interactions using interaction screening tools systematically 1

6. Adjust doses based on kidney function for renally cleared medications 3

7. Simplify dosing regimens to improve adherence 1

8. Monitor outcomes following medication changes and coordinate across providers 1

Role in Patients with Dementia

For older adults with dementia, the Beers Criteria plays a particularly critical role in reducing exposure to medications that worsen cognitive function and increase mortality: 3, 4

• Avoid antipsychotics for behavioral management due to increased mortality risk (FDA black box warning), stroke risk, and worsening delirium 4

• Prioritize non-pharmacological approaches first: redirection techniques and environmental modifications for behavioral symptoms 4

• If antipsychotic use is unavoidable, use the shortest possible duration and conduct regular medication review to identify deprescribing opportunities 4

• Avoid anticholinergics and benzodiazepines which directly worsen cognitive impairment and increase delirium risk 3

Role in Patients with Multiple Chronic Conditions

The Beers Criteria prevents the common pitfall of disease-specific guideline adherence without considering multimorbidity: 1

• Target reduction of total medication burden (polypharmacy and hyperpolypharmacy) rather than achieving multiple disease-specific targets 1

• Discontinue preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit 1

• Prioritize patient-centered goals over disease-specific targets - quality of life and functional status take precedence 1

• Use team-based approach integrating pharmacist-led interventions within comprehensive geriatric assessment teams 1

Critical Pitfalls to Avoid

Do not apply the criteria punitively - they support rather than replace clinical decision-making, and individualization remains essential when considering patient-specific factors. 1

Do not ignore the criteria as merely suggestions - while clinical judgment is required, the evidence-based nature of the criteria (using Institute of Medicine standards and GRADE methodology) demands systematic application. 2

Do not fail to reassess at care transitions - medication appropriateness changes with clinical status, and each transition is an opportunity to optimize therapy. 1

Do not apply chronological age alone when making decisions - functional status, cognitive status, and life expectancy are more relevant than age in years. 1

Do not screen for drug-drug interactions haphazardly - use interaction screening tools systematically, particularly for the critical combinations identified in the criteria. 1

Quality Measure and Educational Applications

The Beers Criteria serves dual purposes beyond direct clinical application: 1, 5

• Quality measure: Incorporated into several healthcare quality metrics and policy initiatives to monitor prescribing practices 5

• Educational tool: Helps clinicians make more informed prescribing decisions and understand the evidence behind medication risks in older adults 1

• Real-time e-prescribing interventions: Can be integrated into electronic health records to provide point-of-care alerts and decrease adverse drug events 5