2012 Beers Criteria Update

In an important step forward for efforts to prevent adverse drug events in older adults, the American Geriatrics Society (AGS) has completely revised and expanded the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The 2012 AGS Beers Criteria was published in the online-only edition of the Journal of the American Geriatrics Society (JAGS) in early March and will appear in the April print issue of JAGS. For more than 20 years, the criteria have been the most frequently consulted source of information about safe prescribing for older patients. They identify drugs that pose risks that may outweigh their benefits in this population and are an invaluable resource for those caring for older patients, especially patients who take multiple medications.

Older adults in long-term care are particularly likely to take multiple medications, and, as a result, run a significant risk of side effects, drug-drug interactions, drug-disease interactions, and other adverse drug events. A nationwide study found that nursing home residents took an average of 6.7 regularly scheduled medications, and as many as 2.6 medications on an “as needed” basis.¹

Given the high prevalence of polypharmacy in long-term care, it is not surprising that the Beers Criteria originally focused on safe prescribing for older adults in nursing homes. The criteria were developed by the late Mark Beers, MD, a geriatrician and an editor of The Merck Manuals and The Merck Manual of Geriatrics. With the help of other experts, Dr. Beers first published the criteria in 1991 and updated them in 1997 and 2003, extending their scope to include all adults aged 65 years and older, regardless of where they lived. Last year, in recognition of the important role the criteria have come to play in clinical care, the AGS convened a multidisciplinary panel of experts to both update and expand the criteria. The result is the new American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

This new edition differs from the previous one in several ways. When revising the criteria, the expert panel, in addition to using a modified Delphi process for building consensus, followed the evidence-based approach that the AGS uses when developing clinical practice guidelines (this is the same approach recommended by the Institute of Medicine in its 2011 report, Clinical Practice Guidelines We Can Trust). The AGS also added a public comment period that occurred in parallel with its standard, invited external peer-review process. Finally, the criteria were reviewed internally by AGS leaders, who provided feedback to the panel. In a significant departure from previous versions of the criteria, each recommendation was rated for the quality of both the evidence supporting the panel’s recommendations and the strength of their recommendations. It is important to note that, because medically complex older adults are often excluded from clinical trials, there is a paucity of evidence focused on this specific population.

In another departure from the 2003 criteria, the 2012 AGS Beers Criteria identifies and groups medications that may be inappropriate for older adults into three different categories instead of just two, as had been previously done. The first category includes medications that are potentially inappropriate for older people because they either pose high risks of adverse effects or appear to have limited effectiveness in older patients, and because there are alternatives to these medications. The second category includes medications that are potentially inappropriate for older people who have certain diseases or disorders because these drugs may exacerbate the specified health problems. The newly added third category includes medications to be used with caution in older adults. These medications, while associated with more risks than benefits in older people in general, nonetheless may be the best choice for a particular individual if administered with caution. The addition of this third category is important, emphasizing the necessity of tailoring prescribing to the unique needs of each patient.

The criteria are best known as an invaluable reference for clinicians, but they play a range of other roles. They are widely used in research and in the training of healthcare professionals. They also inform quality measures and healthcare policy. Organizations and agencies such as the National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) turn to the criteria when developing quality measures. The Centers for Medicare & Medicaid Services has also incorporated the criteria into its evaluation of nursing home compliance with medication-related regulations.

The 2012 AGS Beers Criteria can and should be used in patient education as well. When explaining the rationale for prescribing one drug rather than another, healthcare providers can, for example, share information from the criteria with older patients, their caregivers, or both. The AGS Foundation for Health in Aging recently published an easy-to-read version of the criteria to make them more user-friendly for laypeople. The criteria, the version for laypeople, and a variety of supporting professional and public education materials, are available at www.americangeriatrics.org.

Just as there are several ways the 2012 AGS Beers Criteria can and should be used, there are a number of ways it should never be used. First and foremost, the criteria should never be used as the sole basis for prescribing, or to avoid prescribing, a medication. One reason the criteria alone should never dictate prescribing is that they do not take into account all of the varied circumstances older patients may face. The criteria, for example, do not consider the circumstances of older patients receiving palliative or hospice care. After thoughtful consideration, a clinician prescribing for a patient receiving palliative care might, in fact, conclude that a medication on the list of potentially inappropriate drugs is the only appropriate choice for that patient. Because the criteria are not meant to dictate prescribing, but rather to inform prescribing, they should not be used in a punitive manner. Healthcare providers who—after careful deliberation that takes into account available, evidence-based findings and the patient’s individual needs—should not be penalized because they have prescribed a medication listed in the 2012 AGS Beers Criteria.

The AGS has created a compendium of online resources that includes the full text of the 2012 AGS Beers Criteria, a downloadable pocket-card, and resources for patients. A clinical decision-support tool for use with SmartPhones and tablet devices is in the works as well. Visit the AGS Website at www.americangeriatrics.org to access these resources. The society is also offering a special plenary presentation at its 2012 Annual Scientific Meeting that will feature members of the AGS Beers Criteria expert panel. We encourage you to attend this and the many other invaluable sessions concerning older adults in long-term care that are part of the annual meeting, which is slated for May 2 to 5, 2012, in Seattle, WA. u

Reference

1. Tobias DE, Sey M. General and psychotherapeutic medication use in 328 nursing facilities: a year 2000 national survey. Consult Pharm. 2001;16(1):54-64.