- CONDITION CENTERS
Pharmacists who practice in long-term care are very familiar with the Beers criteria. Many other pharmacists remain unaware that a national expert panel identified many medications or classes of medication48, to be exactthat adults aged 65 years and older should avoid. Although unenlightened pharmacists might think these drugs are available by prescription only or are labeled with clear warnings, many of them are easily available as OTC medications and widely marketed to and used by seniors. In this update to an article published in Pharmacy Times (June 2006), the focus is on facts pharmacists should know about the Beers criteria, originally published in 19911 and updated in 19972 and again in 2003.3
Obtaining a Copy
All iterations of the Beers criteria for potentially inappropriate medication use in older adults have been published in the Archives of Internal Medicine. After the Centers for Medicare & Medicaid Services incorporated an adaptation of the Beers criteria into federally mandated nursing home regulatory guidelines, their availability increased. Many facilities have created summary documents or modifications based on the criteria, like those posted on the Internet by Duke University's Center for Clinical and Genetic Economics, available at www.dcri.duke.edu/ccge/curtis/beers.html. Although helpful, these lists should not replace a careful review of the original document. Fortunately, it, too, is available free of charge on the Internet at archinte.ama-assn.org/cgi/content/full/163/22/2716#ACK. It is well-organized and very easy to follow.
Development of the Criteria
Critics will hasten to point out that the Beers criteria are not an evidence-based guideline. Instead, they are a type of consensus document that was developed by a team of experts specializing in geriatric medicine and pharmacology from across the United States. Their specific expertise included geriatric care, clinical pharmacology, and psychopharmacology. Expert consensus for these criteria was developed using extensive literature reviews with a bibliography and a questionnaire evaluated using a modified Delphi technique.
Donna Fick, PhD, RN, the lead author and facilitator of the expert panel, indicates that some drugs on the list generated concern from some clinicians after they were published, but she reminds us that, "All criteria should be questioned and improved, and ultimately decisions about prescribing or stopping a medication should be based on the individual patient's whole clinical picture." She also indicates that any controversy generated heightens awareness of the complexities of medication use in older adults, and this is good.
Seniors at Greatest Risk
Comorbidities, polypharmacy, and poor lifestyle choices increase risk in seniors, just as they do in younger people. Members of the Beers panel, in addition to creating a list of potentially inappropriate medications, have identified conditions that increase a patient's risk for adverse drug events and certain drugs that should be avoided in those specific conditions. The 2003 revision added cognitive impairment, depression, Parkinson's disease, anorexia, malnutrition, and obesity to the list.
Drug or Condition Inclusion Criteria
Seniors are at an increased risk for medication-related problems that often manifest as depression, confusion, or falls. They (and clinicians who treat them) are apt to attribute these problems to normal aging, when in reality they may be side effects of OTC or prescription medicines. Some drugs on the list can contribute to or cause early mortality, although more data are needed to elucidate exactly how dangerous these drugs can be.
Randomized controlled trials (RCTs) to identify a drug's adverse-events profile are often not feasible or ethical, and industry funding is scarce once the drug is marketedespecially after drugs become available as generics. Further, it is common knowledge that drug trials often consider only seniors with the fewest comorbidities eligible to participate; the most vulnerable are excluded. Frequently, adverse events are only identified years after drugs are marketed. The best aspect of the Beers criteria is that researchers have begun to use them as a starting point for better research.
What exactly do completed studies show? An Italian study by Onder and associates evaluated the impact of inappropriate drug use on all-cause mortality, adverse drug reactions, and length of stay among in-hospital patients.4 Seven of the 48 drugs on the Beers criteria are not approved in Italy, which is a serious limitation. During hospitalization, 1475 (28.6% of the study sample) patients received one or more inappropriate drugs. They found no relationship between use of potentially inappropriate drugs and mortality, adverse events, or length of stay. They acknowledge, however, that in different settings, using additional health outcomes and alternate measures of inappropriate drug use, the findings may be different.
Other studies, like that of Barnett et al in US veterans5; Fu, et al and Lau et al in long-term care residents6,7; and Hanlon et al in community-dwelling elderly8 have found that seniors taking potentially inappropriate drugs are likely to have poorer self-rated health, a decline in function, and increased hospitalizations. Good RCTs are needed to evaluate individual drugs on the list to determine if specific outcomes can be linked to their use.
Information for the Pharmacist
A brief review of the list is an excellent way to brush up on pharmacotherapy and drugs/disease states. The list makes no absolute sanctions, banning any particular medication; instead, it tempers recommendations with dose ranges considered detrimental or comorbidities that increase risk. Their thorough review of the literature has created a high-quality reference document for general concerns.
Many of the concerns noted in the Beers criteria do not apply solely to seniors. The authors note that aging is an individualized process, and some robust seniors can take the identified medications with no problems. Some populations age poorly, however, and these medications may be inappropriate for individuals who age prematurely or have multiple comorbidities as well. The concerns described in the Beers criteria would merit consideration, for example, in psychiatric facilities or incarcerated populations, where patients have high rates of lifelong poor nutrition and dual diagnoses.
Rates of potentially inappropriate drug use among the elderly are still high, with estimates generally in the range of 25% to 30% in community-dwelling and institutionalized seniors, but may be considerably higher.9-14 We can do better. Pharmacists can help decrease these rates by reviewing the published criteria carefully and applying them appropriately. Counseling older adults who need OTC sleep aids or analgesics can be directed to better alternatives than anticholinergics or nonsteroidal anti-inflammatory drugs. Nonpharmacologic interventions for sleep often have fewer side effects and can be used over time.15 Working to improve institutional formularies to exclude potentially inappropriate medications is helpful as well.
Dr. Fick indicates that one issue the criteria present is that they need regular updates (every 3 to 4 years), given the pace of evidence and newly approved drugs. At this time, no update is planned, but pharmacists, nevertheless, should watch for updates.
Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. The views expressed are those of the author and not those of any government agency.
1. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991;151:1825-1832.
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15. McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46:700-705.