Mark Beers created a list of PIMs (Potentially Inappropriate Medications) in older adults in the early 1990’s that became known as the Beers List. I first met Dr. Beers in about 1995 when he presented on this subject at our annual CMDA (California Medical Directors Association, the predecessor to CALTCM) CME meeting. He and his colleagues subsequently expanded this list to include potentially inappropriate meds in chronic diseases and when in combination with other drugs. These criteria unfortunately do not help the prescriber see safer or better options versus whether there may be no better option. Since Mark’s death in 2009, the American Geriatrics Society (AGS) has taken over updating the Beers Criteria with the last update in 2023. Prescribing in our SNF patient population can be difficult, as noted by the example below.

Recently, I was covering for another physician whose patient qualified for hospice for Lewy Body Dementia complicating Parkinson’s disease. On our SNF unit, she developed late afternoon agitation and screaming that extended until the end of the evening shift. Her hospice began lorazepam 0.5 mg q 4 hr as needed, which put her to sleep (3 doses between late afternoon and 11p.m), but she was more confused during the day with reduced quality of life. Lorazepam and other benzodiazepines are on the Beers List for increasing the risk for delirium, falls, and compromised oral intake. Her daughter on an extended visit several months ago noticed increased paranoia and frightening dreams despite taking aripiprazole 2 mg daily. With this information, this medication was increased to twice daily dosing and Morphine elixir 5 mg SL was added as needed for her times of distress. Over the course of the next week, she improved with return of daytime alertness, easy engagement with staff, ability to safely navigate the facility in her wheelchair, and reduced need for prn lorazepam.

In May of this year, the same AGS oversight committee developed the “Alternatives to AGS Beers criteria.” They constructed Tables pairing Medical Conditions with Relevant PIMs recommendations and then added columns for Alternatives to Consider (Meds & Non-Pharm approaches) and another column for Patient and Caregiver Education. The latter is especially important when deprescribing since our patients, families, and caregivers are more likely to adhere to recommendations when provided reasons they can understand. I particularly appreciate the links to helpful web resources throughout this document.

On August 14, the GeriPal Podcast featured the Co-Chairs of this work (Drs. Todd Semla & Mike Steinman) who provided clinical examples of the benefits of this new tool. The show notes give full access to the tool and links to other helpful resources. They strongly encouraged listeners to visit the Canadian website http://deprescribing.org/ for deprescribing assistance.

When clinical problems develop, a comprehensive assessment provides the basis for potential care interventions. This tool can assist providers and IDT implement evidence-based interventions aimed at stabilizing or improving challenging clinical problems with reduced risk of adverse drug events.

This tool is now on my work SNF computer readily available at the point of care. I hope you will become familiar with its contents and discover its value for your staff and residents.