Brandt Helps Revise Beers Criteria

List of medications tells clinicians and health care professionls which medications to avoid prescribing or to use with caution in older people

By Becky Ceraul
May 31, 2012

Nicole Brandt, PharmD, CGP, BCPP, FASCP, an associate professor of pharmacy practice and science, at the School of Pharmacy, recently served on a panel of 11 experts in nursing, geriatric medicine, and pharmacotherapy that revised the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

The Beers Criteria is a list of medications to avoid prescribing or to use with caution in older persons. It was created by the late Mark Beers, MD, a geriatrician and editor of The Merck Manual of
Geriatrics, and a panel of experts in 1991. The criteria helped practitioners, researchers, and policymakers evaluate potentially inappropriate medications for adults over the age of 65, who may be
especially vulnerable to their side effects.

“The Beers Criteria had been a valuable source for 20 years and served as a model for similar guidelines around the world, but it had not been updated since 2003, and practitioners wanted a more current, evidence-based guide,” Brandt says. “The American Geriatrics Society [AGS] felt strongly about the value of the Beers Criteria as a clinical tool and sponsored its update and expansion in 2011.”

The Beers Criteria is now known as the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The goal of the AGS Updated Beers Criteria is to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIM), those drugs whose risks may outweigh their therapeutic benefits. Clinicians need special prescribing guidelines for persons over 65 because older adults typically have different reactions to medications than younger people do, and these reactions can be more serious. “As we age, the way our bodies break down and eliminate drugs changes and takes longer, and our risk for certain conditions, such as dementia, increases,” says Brandt, who directs clinical programs at the Peter Lamy Center on Drug Therapy and Aging at the School of Pharmacy, and has worked with older adults with dementia and Alzheimer’s disease.

Older adults also have more health problems and are more likely to take multiple medications for a variety of chronic illnesses, such as diabetes, hypertension, high cholesterol, and heart disease. Because of this, PIM use is a major source of drug-related problems in the elderly, and drug-to-drug interactions and adverse drug events are common.

“Using inappropriate medications can lead to side effects or drug interactions that cause lightheadedness, blurry vision, confusion, gastrointestinal bleeding, and drops in blood pressure [that can lead to falls and resulting fractures], which are especially dangerous for the elderly,” says Brandt. “Inappropriate medication use can also blunt the effects of ‘good’ medications that are working, rendering them less effective.”

PIM use by older adults also impacts the U.S. health care system by causing unnecessary and costly emergency room visits and hospitalizations. In 2001, a U.S. government Medical Expenditure Panel Survey estimated that health care expenditures related to PIM use in the elderly were $7.2 billion.

The AGS Updated Beers Criteria covers 53 drugs or drug classes that are divided into three broad groups. The first group is potentially inappropriate drugs and drug classes to generally avoid prescribing to older adults—regardless of their diagnosis. “These drugs have the highest likelihood of poor outcomes and may have limited effectiveness in older persons,” Brandt says.

The second group is potentially inappropriate drugs and drug classes to avoid in older adults with certain syndromes and diseases, which the drugs can make worse (such as Parkinson’s disease, heart failure, dementia, cognitive impairment, and a history of ulcers).

The third category is drugs to use with caution in older persons. “The latter group includes several drugs that are new to the market where evidence of their effects on and risks to older adults is still emerging,” Brandt notes.

The AGS Updated Beers Criteria differs from previous Beers iterations in a number of ways. It was created using the Institute of Medicine’s recommendation that guidelines be evidence-based,
and Beers committee members rated each recommendation for quality of evidence as well as the committee’s assessment of the strength of each recommendation.

The primary audience for the AGS Updated Beers Criteria is the practicing clinician, but others who work in health care and policy will find it a useful reference. “It is a great tool for those in academia and who educate health professionals. I know that I have used it as an educator of pharmacy students,” says
Brandt. “Policymakers rely on it as well. The Centers for Medicare & Medicaid Services has incorporated the Beers into Medicare Part D policy, and the Agency for Healthcare Research and Quality consults the Beers Criteria when developing quality measures addressing the pharmacological care of older adults.”

The AGS Updated Beers Criteria was released in April 2012 and is scheduled to be updated every three years. The AGS website posts the full AGS Updated Beers Criteria, including evidence tables, as well as a guide for consumers and caregivers who want to learn more about medications and aging.