The Beers Criteria

Pharmacists who practice inlong-term care are very familiarwith the Beers criteria.Many other pharmacists remainunaware that a national expert panelidentified many medications or classesof medication—48, to be exact—that adults aged 65 years and oldershould avoid. Although unenlightenedpharmacists might think these drugsare available by prescription only orare labeled with clear warnings, manyof them are easily available as OTCmedications and widely marketed toand used by seniors. In this update toan article published in PharmacyTimes (June 2006), the focus is onfacts pharmacists should know aboutthe Beers criteria, originally publishedin 19911 and updated in 19972 andagain in 2003.3

Obtaining a Copy

All iterations of the Beers criteriafor potentially inappropriate medicationuse in older adults have beenpublished in the Archives of InternalMedicine. After the Centers forMedicare & Medicaid Services incorporatedan adaptation of the Beerscriteria into federally mandated nursinghome regulatory guidelines, theiravailability increased. Many facilitieshave created summary documents ormodifications based on the criteria,like those posted on the Internet byDuke University's Center for Clinicaland Genetic Economics, available atwww.dcri.duke.edu/ccge/curtis/beers.html. Although helpful, theselists should not replace a carefulreview of the original document.Fortunately, it, too, is available free ofcharge on the Internet at archinte.ama-assn.org/cgi/content/full/163/22/2716#ACK. It is well-organized andvery easy to follow.

Development of the Criteria

Critics will hasten to point out thatthe Beers criteria are not an evidence-based guideline. Instead, theyare a type of consensus documentthat was developed by a team ofexperts specializing in geriatric medicineand pharmacology from acrossthe United States. Their specificexpertise included geriatric care, clinicalpharmacology, and psychopharmacology.Expert consensus for thesecriteria was developed using extensiveliterature reviews with a bibliographyand a questionnaire evaluatedusing a modified Delphi technique.

Donna Fick, PhD, RN, the leadauthor and facilitator of the expertpanel, indicates that some drugs onthe list generated concern from someclinicians after they were published,but she reminds us that, "All criteriashould be questioned and improved,and ultimately decisions about prescribingor stopping a medicationshould be based on the individualpatient's whole clinical picture." Shealso indicates that any controversygenerated heightens awareness ofthe complexities of medication use inolder adults, and this is good.

Seniors at Greatest Risk

Comorbidities, polypharmacy, andpoor lifestyle choices increase risk inseniors, just as they do in youngerpeople. Members of the Beers panel,in addition to creating a list of potentiallyinappropriate medications, haveidentified conditions that increase apatient's risk for adverse drug eventsand certain drugs that should beavoided in those specific conditions.The 2003 revision added cognitiveimpairment, depression, Parkinson'sdisease, anorexia, malnutrition, andobesity to the list.

Drug or Condition InclusionCriteria

Seniors are at an increased risk formedication-related problems thatoften manifest as depression, confusion,or falls. They (and clinicians whotreat them) are apt to attribute theseproblems to normal aging, when inreality they may be side effects ofOTC or prescription medicines. Somedrugs on the list can contribute to orcause early mortality, although moredata are needed to elucidate exactlyhow dangerous these drugs can be.

Randomized controlled trials (RCTs)to identify a drug's adverse-eventsprofile are often not feasible or ethical,and industry funding is scarceonce the drug is marketed—especiallyafter drugs become available asgenerics. Further, it is common knowledgethat drug trials often consideronly seniors with the fewest comorbiditieseligible to participate; the mostvulnerable are excluded. Frequently,adverse events are only identifiedyears after drugs are marketed. Thebest aspect of the Beers criteria is thatresearchers have begun to use themas a starting point for better research.

What exactly do completed studiesshow? An Italian study by Onder andassociates evaluated the impact ofinappropriate druguse on all-cause mortality,adverse drugreactions, and lengthof stay among in-hospitalpatients.4 Sevenof the 48 drugs on theBeers criteria are notapproved in Italy,which is a serious limitation.During hospitalization,1475(28.6% of the studysample) patients receivedone or moreinappropriate drugs.They found no relationshipbetween use of potentiallyinappropriate drugs and mortality,adverse events, or length of stay. Theyacknowledge, however, that in differentsettings, using additional healthoutcomes and alternate measures ofinappropriate drug use, the findingsmay be different.

Other studies, like that of Barnett etal in US veterans5; Fu, et al and Lau etal in long-term care residents6,7; andHanlon et al in community-dwellingelderly8 have found that seniors takingpotentially inappropriate drugs arelikely to have poorer self-rated health,a decline in function, and increasedhospitalizations. Good RCTs are neededto evaluate individual drugs on thelist to determine if specific outcomescan be linked to their use.

Information for thePharmacist

A brief review of the list is an excellentway to brush up on pharmacotherapyand drugs/disease states.The list makes no absolute sanctions,banning any particular medication;instead, it tempers recommendationswith dose ranges considered detrimentalor comorbidities that increaserisk. Their thorough review of the literaturehas created a high-quality referencedocument for general concerns.

Many of the concerns noted in theBeers criteria do not apply solely toseniors. The authors note that agingis an individualized process, andsome robust seniors can take theidentified medications with no problems.Some populations age poorly,however, and these medications maybe inappropriate for individuals whoage prematurely or have multiplecomorbidities as well. The concernsdescribed in the Beers criteria wouldmerit consideration, for example, inpsychiatric facilities or incarceratedpopulations, where patients havehigh rates of lifelong poor nutritionand dual diagnoses.

Final Thought

Rates of potentially inappropriatedrug use among the elderly are stillhigh, with estimates generally in therange of 25% to 30% in community-dwellingand institutionalized seniors,but may be considerably higher.9-14 Wecan do better. Pharmacists can helpdecrease these rates by reviewing thepublished criteria carefully and applyingthem appropriately. Counselingolder adults who need OTC sleep aidsor analgesics can be directed to betteralternatives than anticholinergics ornonsteroidal anti-inflammatory drugs.Nonpharmacologic interventions forsleep often have fewer side effectsand can be used over time.15 Workingto improve institutional formularies toexclude potentially inappropriatemedications is helpful as well.

Dr. Fick indicates that one issue thecriteria present is that they need regularupdates (every 3 to 4 years),given the pace of evidence and newlyapproved drugs. At this time, noupdate is planned, but pharmacists,nevertheless, should watch forupdates.

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.

References

1. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria fordetermining inappropriate medication use in nursing home residents. UCLA Division of GeriatricMedicine. Arch Intern Med. 1991;151:1825-1832.

2. Beers MH. Explicit criteria for determining potentially inappropriate medication use by theelderly: an update. Arch Intern Med. 1997;157:1531-1536.

3. Fick DM, Cooper JW, Wade WE, Walter JL, Maclean JR, Beers MH. Updating the Beerscriteria for potentially inappropriate medication use in older adults: results of a US consensuspanel of experts. Arch Intern Med. 2003;163:2716-2724.

4. Onder G, Landi F, Liperoti R, Fialova D, Gambassi G, Bernabei R. Impact of inappropriatedrug use among hospitalized older adults. Eur J Clin Pharmacol. 2005;61:453-459.

5. Barnett MJ, Perry PJ, Langstaff JD, Kaboli PJ. Comparison of rates of potentially inappropriatemedication use according to the Zhan criteria for VA versus private sector Medicare HMOs. JManag Care Pharm. 2006;12:362-370.

6. Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in theelderly. J Am Geriatr Soc. 2004;52:1934-1939.

7. Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG. Hospitalization and death associatedwith potentially inappropriate medication prescriptions among elderly nursing home residents.Arch Intern Med. 2005;165:68-74.

8. Hanlon JT, Fillenbaum GG, Kuchibhatla M, et al. Impact of inappropriate drug use onmortality and functional status in representative community dwelling elders. Med Care.2002;40:166-176.

9. Cannon KT, Choi MM, Zuniga MA. Potentially inappropriate medication use in elderly patientsreceiving home health care: a retrospective data analysis. Am J Geriatr Pharmacother.2006;4:134-143.

10. Christian JB, Vanhaaren A, Cameron KA, Lapane KL. Alternatives for potentiallyinappropriate medications in the elderly population: treatment algorithms for use in the FleetwoodPhase III study. Consult Pharm. 2004;19:1011-1028.

11. Roth MT, Ivey JL. Self-reported medication use in community-residing older adults: a pilotstudy. Am J Geriatr Pharmacother. 2005;3:196-204.

12. Rigler SK, Jachna CM, Perera S, Shireman TI, Eng ML. Patterns of potentially inappropriatemedication use across three cohorts of older Medicaid recipients. Ann Pharmacother.2005;39:1175-1181.

13. Rigler SK, Perera S, Jachna C, Shireman TI, Eng M. Comparison of the association betweendisease burden and inappropriate medication use across three cohorts of older adults. Am JGeriatr Pharmacother. 2004;2:239-247.

14. Viswanathan H, Bharmal M, Thomas J 3rd. Prevalence and correlates of potentiallyinappropriate prescribing among ambulatory older patients in the year 2001: comparison of threeexplicit criteria. Clin Ther. 2005;27:88-99.

15. McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol forhospitalized older patients. J Am Geriatr Soc. 1998;46:700-705.