Over my career, I and other clinicians have often assumed the side effects of a medication represent a subtle new disease which commonly leads to more tests and more medications, resulting in a prescribing cascade which can be quite harmful. At a CALTCM meeting in the early 1990’s (we were then called The California Association of Medical Directors) , I had the privilege of attending a presentation by Dr. Mark Beers on “Potentially Inappropriate Medications” (PIMS) in older adults. This list became known as the Beers List. After his untimely death in 2009 the AGS (American Geriatrics Society) began updating the criteria for PIMS about every 4 years with the last update released in May 2023. A summary table can be found at: https://www.guidelinecentral.com/guideline/340784/
Prescribing medications in older adults is a complicated process, because there are so many chronic conditions that impact drug metabolism, heighten sensitivity to side effects, and with so many meds/patient, increase drug-drug interactions This complexity is nicely categorized in the latest set of criteria and is worth a close read by all our nurses, NPs, PAs, and physicians.
Personally, I have keyed in on medicines that have considerable risk for serious adverse effects. Neuropathic pain in various forms has been the bane of many patients and often is not curable or adequately relieved. One of the most effective medicines for this problem is amitriptyline (Elavil). The PIM on this medicine discourages its use because it is highly anticholinergic and can cause serious “brain fog” (delirium). Knowing this, I still did attempt to use the lowest dose (10 mg at bedtime) for severe post herpetic neuralgia in cognitively intact older adults but became discouraged from doing this after seeing in follow up visits, patients with unawareness of significant cognitive impairment.
This year, while the interim medical director of a PACE program, I discovered that our seasoned and excellent clinic RNs were not aware of the Beer’s Criteria or the PIM for Benadryl (highly anticholinergic). They and the rest of our clinical staff welcomed access to these criteria.
Later, as a part-time SNF attending, I became the physician for an older adult with dementia who was in our unit for rehab of another medical condition. I was surprised that his long standing Amitriptyline 50 mg at bedtime (for peripheral sensory neuropathy) had not been recognized as a potential PIM. When I asked his nurse, who is an excellent clinician, whether this medicine might be inappropriate, she was not aware that this medication could be a reversible part of his dementia syndrome. Again, she welcomed access to the Beer’s Criteria.
If you are an AGS member, you have access to the full printed/pdf version through access to JAGS (Journal of the American Geriatric Society) at: GeriatricsCareOnline.org . If you were at our 2023 CALTCM summit, you heard an excellent presentation on the 2023 update by our CALTCM President, Dr. Janice Hoffman.
For those who are not AGS members, the full criteria are available for purchase in the JAGS May 2023 issue. This update is available to read but not download or print, at: https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.18372
Similarly, the pocket card update is free for AGS members and for a small cost to non-members at: https://geriatricscareonline.org/ProductAbstract/2023-ags-beers-criteria-pocketcard/PC0015
For those who prefer an app, the AGS Beers Criteria app is available for $9.99/yr. The app is easy to use and provides access to timely information when assessing a patient.
For AGS members, free teaching slides for the 2019 update (readily adaptable to the 2023 update) are available at: How to Use the 2023 AGS Beers Criteria® (geriatricscareonline.org)
In our area of medicine focused on patients with medical complexity, knowing the major PIMs may reduce the harm we previously have unknowingly caused. In addition, these criteria should become a part of our medication reviews as well as our thought process when prescribing new medications.
I hope you and your team provide a safe and healing environment of care by reducing the risk of adverse medication events.
Always grateful for the observations and insights you share here. I would like to add one more from the perspective of a non-prescriber. I can't tell you how many times I had patients (and family members!) ask me to explain why their loved one was on a particular medication. The typical preface was, "When XYZ was at home, the doc had him/her on this med. Why can't s/he still use it?" The Beers List became a huge help-mate in sharing about drug-interactions, potential benefits of different meds, and risks of the "old ones". In the LTC setting, there is ample opportunity to share the why's and wherefore's for using (or not using) a particular med. This is less so in a community setting, where multiple prescribers may or may not be aware. The challenge continues!