Clinical Context

Clinicians are generally aware that medications can result in more severe adverse events among older adults, and the Beers Criteria have helped define those drugs that are best avoided in this population. But is there a link between taking potentially harmful drugs and a higher risk for hospitalization among older adults? Varga and colleagues addressed this issue in a November 2017 issue of the British Journal of Clinical Pharmacology.^[1]

Researchers assessed an Italian database that contained health information on 1,480,137 older adults. They evaluated the rates of potentially inappropriate medications (PIMs) among this population, and they performed an adjusted analysis to determine the risk for hospitalization associated with these medications.

More than half of study subjects used at least 1 PIM, and subjects were exposed to a PIM 10.9% of the time during the study period. Nonsteroidal anti-inflammatory drugs were the most common class of PIM, and ketorolac was the PIM associated with the highest rate of hospitalization. The crude rates of hospitalization during time exposed and not exposed to a PIM were 228.1 and 152.1 per 1000 person-years, which translated to an adjusted hazard ratio of 1.16 (95% CI, 1.14-1.18) for hospitalization while receiving a PIM.

The current document updates the Beers criteria for clinicians.

Study Synopsis and Perspective

The American Geriatrics Society (AGS) has released the 2019 update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The update was published online January 29 in the Journal of the American Geriatrics Society.^[2]

"Medications play an important role in health and well-being for many older people," Donna M. Fick, PhD, RN, co-chair of the expert panel responsible for the 2019 AGS Beers Criteria, said in a news release. "With this new update, we hope the latest information on what makes medications appropriate for older people can play an equally important role in decisions about treatment options that meet the needs of older adults while also keeping them as safe as possible."

The Beers Criteria are intended to improve medication selection, reduce adverse drug events, and provide a tool to assess cost, patterns, and quality of care of drugs used for people aged 65 years or older. It lists drugs that should be avoided in the treatment of older adults, either generally or in patients with specific diseases or conditions. Clinicians, researchers, educators, healthcare administrators, and regulators use the criteria, which were first published in 1991 and have been updated every 3 years since 2011.

The 2019 criteria include 30 medications or medication classes to be avoided in older adults in general, and 40 medications or medication classes that should be used with caution or avoided in certain patients with certain diseases or conditions. Two criteria were added in response to the worsening opioid crisis: not prescribing opioids with benzodiazepines or gabapentinoids.

The criteria dropped 8 seizure medications, 8 drugs for insomnia, and vasodilators for syncope. Some of these drugs were dropped because the problems associated with their use are not unique to older patients. Two (ticlopidine and pentazocine) were dropped because they are no longer available in the United States.

Removed From the Criteria

H2-receptor antagonists were removed from the criteria for dementia because the evidence that they harm people with dementia is weak. These drugs, which relieve gastric reflux, can continue to be used with caution in patients with high risk dementia but should be avoided in older adults with or at high risk of delirium because of potential of inducing or worsening delirium.

The chemotherapeutic drugs carboplatin, cisplatin, vincristine, and cyclophosphamide were removed from the criteria because the panel considered them to be "highly specialized" and outside the scope of the criteria.

"Use With Caution"

Dextromethorphan/quinidine should be used with caution because it has limited efficacy in alleviating behavioral symptoms of dementia in patients without pseudobulbar affect and because it potentially increases the risk for falls and drug-drug interactions.

Rivaroxaban is to be used with caution for venous thromboembolism or atrial fibrillation in patients older than 75 years because of the risk for gastrointestinal bleeding.

Trimethoprim and sulfamethoxazole can elevate risk for hyperkalemia in patients with decreased kidney function who are receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

Carbamazepine, mirtazapine, oxcarbazepine, serotonin, norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants, and tramadol should be used with caution because they may exacerbate or cause what is known as syndrome of inappropriate antidiuretic hormone secretion. Sodium levels should be monitored closely when using these drugs.

Aspirin should be used with caution for primary protection against cardiovascular disease or colorectal cancer in patients older than 70 years, not 80 years, because new data show that the age at which the risk of bleeding is elevated has fallen.

Serotonin and norepinephrine reuptake inhibitors should be prescribed with caution for patients at risk of falling or sustaining fractures.

Also New

For Parkinson's disease, the general advice to avoid all antipsychotics has been revised to except quetiapine, clozapine, and pimavanserin.

For heart failure, nondihydropyridine and calcium channel blockers should not be prescribed for patients with low ejection fractions, and nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, thiazolidinediones, and dronedarone should be prescribed with caution in patients who have no symptoms of heart failure.

Macrolides (except azithromycin) or ciprofloxacin should not be prescribed with warfarin because of bleeding risk.

Ciprofloxacin and theophylline should not be prescribed because of increased theophylline toxicity.

For patients with reduced kidney function, use of ciprofloxacin is associated with increased risk for tendon rupture and increased central nervous system effects. Use of trimethoprim-sulfamethoxazole is associated with worsening renal failure and hyperkalemia.

"The AGS Beers Criteria are an essential evidence-based tool that should be used as a guide for drugs to avoid in older adults. However, they are not meant to supplant clinical judgment or an individual patient's preferences, values, care goals, and needs, nor should they be used punitively or to excessively restrict access to medications," the authors conclude.

Limitations of the criteria are that consideration was given only to studies published in English, including observational studies, and consideration was not given to subpopulations of patients.

In an accompanying editorial, panel members Michael A. Steinman, MD, from the Division of Geriatrics, the University of California, San Francisco, and Donna Fick, PhD, RN, from the College of Nursing and the College of Medicine, Pennsylvania State University, Hershey, remind readers that the drugs that were deemed unsafe for older patients in the 2019 criteria are potentially inappropriate, not definitely inappropriate, and advise close reading of the details.^[3]

"Optimal application of the AGS Beers Criteria involves identifying potentially inappropriate medications and where appropriate offering safer nonpharmacologic and pharmacologic therapies," they write. Clinicians should view the criteria as a starting point for individual prescribing.

"[Ensuring] the safe and effective use of medications by older adults is a cornerstone of high-quality medical care and a superb arena for interprofessional practice.... Use the AGS Beers Criteria well, and use them wisely," Dr Steinman and Dr Fick conclude.

For the 2019 update, an expert panel reviewed evidence published since the last update to evaluate whether to add, remove, or change specific criteria. The 13 members of the panel were physicians, pharmacists, or nurses who had participated in the 2015 update.

The panel fully reviewed 1422 articles. Of those, 377 were abstracted into evidence tables; these articles included 29 controlled clinical trials, 281 observational studies, and 67 systematic meta-analyses and/or reviews. Comments were collected from August 13, 2018, to September 4, 2018, and included 79 comments from 47 individuals, 10 comments from six pharmaceutical companies, and 155 comments from 22 peer organizations.

One coauthor consults for Wolters-Klewer. Another coauthor consults for Institute for HealthCare Improvement, is section editor for SLACK Inc, and received a grant from IMPAQ on MTM. Another coauthor consults for the Colorado Access Pharmacy and Therapeutics Committee. Another coauthor is an editor for Lexi-Comp. Another coauthor reviews physicians for CVS/Caremark. The remaining authors have disclosed no relevant financial relationships. Dr Fick consults for SLACK Inc and Precision Health Economics. Dr Steinman consulted for iodine.com.

J Am Geriatr Soc. Published online January 29, 2019.

Clinical Implications

• A previous study found that more than half of older adults used at least 1 PIM, and participants were exposed to a PIM during more than 10% of the study period. Nonsteroidal anti-inflammatory drugs were the most common class of PIM. Use of a PIM was independently associated with a higher risk for hospitalization.
• The current update to the Beers Criteria includes warnings regarding glimepiride, trimethoprim-sulfamethoxazole, ciprofloxacin, rivaroxaban and nonsteroidal anti-inflammatory drugs; as well as the deletion of multiple drugs from the list due to availability. There is a clear warning for the avoidance of dextromethorphan/quinidine in the treatment of behavioral symptoms of dementia.
• Implications for the Healthcare Team: The healthcare team should proactively reconcile medications for older adults and eliminate PIMs when possible. Health care professionals should engage in active communication with each other and across care transitions to enable appropriate selection of medication for the elderly. The beers guideline should be utilized as an essential tool to identify and improve medication appropriateness and safety.

Post-Assessment Question