Adverse drug reactions are the 4th leading cause of death ahead of diabetes, pulmonary disease and accidents, with 350,000 events occurring annually in nursing home residents.(1) These events are potentially preventable up to 50 percent of the time and common serious manifestations include falls, orthostatic hypotension, heart failure, and delirium. The American Geriatric Society (AGS) updated Beers Criteria is a useful toolbox for physicians in addressing medication appropriateness, identifying potentially inappropriate medications and de-prescribing to reduce avoidable adverse drug events.

AGS has assumed responsibility for the criteria in 2011 with updates on the 3 year cycle since 2012, with the most recent occurring in January 2019. The interdisciplinary expert panel was comprised of 13 clinicians – physicians, pharmacists and nurses, experts with experience in ambulatory care, home care, acute hospital care, skilled nursing facility and long-term care. The Panel reviewed 1,422 articles, and abstracted 377 into evidence tables.  The abstracted evidence included 29 controlled clinical trials, 281 observational studies and 67 systematic meta-analyses and/or reviews. The primary target is practicing clinicians and the criteria are intended for use in adults age 65 and older in ambulatory, acute and institutionalized settings. The overarching goal is to improve medication selection; educate clinicians and patients; reduce adverse drug events; serve as a tool for evaluating quality of care, cost and patterns of drug use of older adults. Five types of criteria from the 2015 updates were retained in the 2019 update.

1. Medications that are potentially inappropriate in most older adults- 30 medications or medication classes

2. Medications that should be avoided due to certain medical conditions- 40 medications or medication classes.

3. Medications to be used with caution

4. Drugs that posed risk for drug-drug interaction

5. Drugs which require dose adjustment based on renal function

The panel allowed for comments from August 2018 to September 2018 and received 79 comments from 47 individuals, 10 comments from pharmaceutical companies and 155 comments from 22 peer organizations. Notable changes in the 2019 Beers Criteria are summarized as follows. The recommendation of not prescribing opioids with benzodiazepines or gabapentinoids. Ticlopidine and pentazocine were dropped because they’re no longer available in the United States.  Seizure medications, drugs for insomnia and vasodilators for syncope were dropped because the problems with the use were not unique to older patients. H2 receptor antagonists were removed from criteria for dementia, but the recommendation that these drugs continue to be used with caution in DELIRIUM still remains. The less stringent criteria for H2 receptor antagonists is because of weaker evidence and because of need to have treatment options for patients who need a safer option to proton pump inhibitors.

The list of medications to be used with caution includes: Dextromethorphan/quinidine because of limited efficacy in alleviating behavioral symptoms of dementia in patients without pseudobulbar affect. Rivaroxaban cautioned in patients older than 75 for venous because of risk for gastrointestinal bleeding. Trimethoprim/sulfamethoxazole cautioned in patients on ACE inhibitors or angiotensin receptor blockers because of risk for hyperkalemia. Tramadol and SNRIs cautioned because they may exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion. Aspirin cautioned for primary prevention of cardiovascular disease or colorectal cancer in patients older than 70 years because new data shows risk for bleeding at a younger age. Serotonin and non-epinephrine reuptake inhibitors cautioned because of risk for fall and fracture. Non-dihydropyridine and calcium channel blockers use not recommended in patients with heart failure due to low ejection fraction. In patients with impaired renal function, ciprofloxacin is associated with increased risk for tendon rupture and has increased central nervous system effects.

Beer Criteria are not rules; rather they are useful tools for promoting medication appropriateness and screening for potentially inappropriate medications.  Adverse drug events are the leading cause of death in older adults. Patient centered care in frail older adults means assessing potential harm versus benefit when making decisions about adding new medications to a patient’s regimen. CALTCM presentation of updated Beers Criteria 2019 reviews the updates and puts this in context with a drug disease interaction, drug-drug interaction and patient preference.  The Patient Driven Payment Model (PDPM) goes into effect October 1, 2019 and a key component of this program is understanding of the patient’s clinical conditions. Attention to potentially inappropriate medications is essential in reducing adverse drug events in skilled nursing facilities. Outcome of cost and quality of care are both impacted by judicious medication prescribing. The AGS Beers Criteria 2019 are an essential tool kit to providers in the acute, post-acute in primary care setting.

References: 

1. Preventable Adverse Drug Reactions: A Focus on Drug Interactions. https://www.fda.gov/drugs/developmentapprovalprocess/developmentresources/druginteractionslabeling/ucm110632.htm

2. Updated Beers Criteria Guide Drug Use in Elders - Medscape - Feb 01, 2019.