It’s that time again.
The American Geriatrics Society (AGS) Beers Criteria® were updated recently, as they are every three years, by an interdisciplinary panel of geriatric experts.
The Beers Criteria are a unique set of evidence-based recommendations tailored specifically for older adults (65 years and older) in all care settings, except hospice or palliative care. This list of potentially inappropriate medications (PIMs) provides guidance on how to optimize medication selection in older adults, and it can help meet a variety of healthcare needs:
- Clinicians: The criteria are an excellent tool to refer to before starting, increasing, or switching medications, or when simply performing a comprehensive medication review for geriatric patients
- Health systems: The criteria can be a tool in creating clinical decision support systems
- Patients: The criteria can be an educational tool to engage patients who want to learn more about the potential risks and benefits of their medications
Focusing primarily on that first group – clinicians – it is important to review key changes and updates to recommendations in the latest publication of the Beers Criteria to help ensure those treating geriatric patients are aware of the most current best practices for medication efficacy and safety.
Why we need beers
Older adults respond differently than younger adults to medications due to changes in medication absorption, distribution, metabolism, and elimination that occur over time. Older adults can also have more or less sensitivity to medications. These unpredictable age-related changes often increase risk for adverse effects and drug interactions.
To help navigate these challenges, the Beers Criteria panel evaluates controlled clinical trials, observational studies, systematic reviews and meta-analyses with a special emphasis on adverse drug events or reactions to update its recommendations.
In addition to metabolic and physical age-related challenges, the criteria also help clinicians address other obstacles associated with treating geriatric populations:
- Polypharmacy: One study estimates that approximately 50% of ambulatory older adults take 5 or more medications. A higher medication burden is often accompanied with a higher risk of adverse effects and drug interactions and potentially a problematic prescribing cascade
- Fewer efficacy and safety data: Because older adults are often underrepresented in clinical trials, there are fewer safety data and treatment guidelines available
Notable beers updates in 2019
While it is worthwhile for those treating geriatric patients to review the complete Beers Criteria, these updates stood out as notable changes that might impact prescribers’ and pharmacists’ routine decision making at the point of care.
Dementia and H2 blockers
In 2015, proton-pump inhibitors were added to the Beers Criteria PIM list to generally avoid for long-term use in older adults (unless a patient is high-risk). Because H2-receptor antagonists were also on the PIM list to avoid in patients with dementia or cognitive impairment due to potential adverse cognitive effects, some prescribers felt they had to choose between the lesser of two evils when treating patients with gastroesophageal reflux, or choose a less effective treatment option. Due to weak evidence, the H2-receptor antagonists were removed from the PIM list to avoid in patients with dementia or cognitive impairment, but they are still PIMs to avoid in patients with or at high-risk of delirium.
Notable new guidelines on drug-drug interactions include:
- Trimethoprim-sulfamethoxazole should be used with caution when combined with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in patients with decreased creatinine clearance due to an increased risk of hyperkalemia
- Avoid prescribing warfarin with antibiotics ciprofloxacin, macrolides (except azithromycin) or trimethoprim-sulfamethoxazole whenever possible due to an increased bleeding risk. International normalized ratio (INR) should be monitored closely if warfarin is used concurrently with any of these antibiotics
- Two clinically important opioid interactions were added to the criteria, which are particularly relevant as opioid-related deaths in older adults have increased over the years:
- The combination of opioids and benzodiazepines should generally be avoided due to an increased risk of overdose. The recommendation is very clinically relevant, as a 2015 study found that benzodiazepine use in the United States tends to increase with age, particularly in women
- The combination of opioids and gabapentinoids (e.g., gabapentin and pregabalin) should generally be avoided due to an increased risk of sedation, respiratory depression, and potentially death. This recommendation excludes when switching from an opioid to a gabapentinoid
Direct oral anticoagulants
Rivaroxaban joined dabigatran as a direct oral anticoagulant that should be used with caution for atrial fibrillation or venous thromboembolism treatment in adults 75 years and older. This recommendation is due to an increased risk of gastrointestinal bleeding compared with warfarin and other direct oral anticoagulants.
Fall and fracture avoidance
Serotonin-norepinephrine reuptake inhibitors (SNRIs) were added as PIMs to avoid in older adults with a history of falls or fractures, unless alternatives are unavailable. This recommendation is due to an increased risk of unsteadiness, syncope, and additional falls, and it also applies to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. This recommendation helps emphasize the importance of using a “start low and go slow” approach, particularly if one of these antidepressants is indicated in older adults with a history of falls.
Monitoring for SIADH
Tramadol was added to the list of PIMs to use with caution in older adults due to an increased risk of hyponatremia or syndrome of inappropriate antidiuretic hormone secretion (SIADH). Sodium levels should be monitored with medication initiation and adjustments, especially if combined with other medications with the same risk, including diuretics, SNRIs, and SSRIs.
Aspirin for primary prevention
The criteria previously recommended exercising caution when using aspirin for primary prevention of cardiovascular disease in people 80 years or older. The cautionary age now includes people 70 years or older after a 2016 systematic review showed an increased risk of bleeding in this age group, with a potentially higher risk with older age and in men. Recent studies also showed no significant difference in primary prevention of cardiovascular disease or in disability-free survival, but an increased risk of bleeding in older adults when compared with placebo.
You might notice…
In an effort to tailor the Beers Criteria specifically for older adults, some universal medication recommendations were removed from this latest edition. One example is removal of PIMs to avoid in older adults with chronic seizures. Although these PIMs are still relevant, the recommendations are not unique to older adults.
One of many tools
The AGS notes that the Beers Criteria should be thought of as a “warning light” to help identify potentially inappropriate medications, and medication decisions should be individualized and based on shared decision making between the healthcare team, patients, and caregivers.
In this world of polypharmacy, the Beers Criteria are one of the essential tools that can be used to help guide safer medication use in older adults. Other helpful tools include the STOPP-START criteria, deprescribing guidelines and algorithms, and AGS action steps to help guide patient-centered care for older adults with multimorbidity.
Christine Holman, PharmD, BCGP, BCPS, is a clinical pharmacy specialist in geriatrics with a decade of experience providing specialized care to veterans in the Veterans Affairs (VA) Healthcare System. She received her PharmD from the University of Utah College of Pharmacy and completed a PGY1 pharmacy residency at the VA Medical Center in Salt Lake City, Utah.