American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

American Geriatrics Society 2012 Beers Criteria Update Expert Panel

Disclosures

J Am Geriatr Soc. 2012;60(4):616-631. 

In This Article

Discussion

The 2012 AGS Beers Criteria is an important and improved update of previously established criteria widely used by healthcare providers, educators, and policy-makers and as a quality measure. Previously, as many as 40% of older adults received one or more medications on this list, depending on the care setting.[29–31] The new criteria are based upon methods for determining best-practice guidelines that included a rigorous systematic literature review, the use of an expert consensus panel, and grading of the strength of evidence and recommendations.

The updated criteria should be viewed as a guideline for identifying medications for which the risks of their use in older adults outweigh the benefits. The medications that have a high risk of toxicity and adverse effects in older adults and limited effectiveness, and all medications in Table 2 (Independent of Diagnosis or Condition) should be avoided in favor of an alternative safer medication or a nondrug approach. The drug–disease or –syndrome interactions summarized in Table 3 are particularly important in the care of older adults because they often take multiple medications for multiple comorbidities. Their occurrence may have greater consequences in older adults because of age-related decline in physiological reserve. Recent studies in which drug–disease interactions have been shown to be important risk factors for ADEs highlight their importance.[32]

This list is not meant to supersede clinical judgment or an individual patient's values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision-making. The historical lack of inclusion of many older adults in drug trials[33–35] and the related lack of alternatives in some individual instances further complicate medication use in older adults. There may be cases in which the healthcare provider determines that a drug on the list is the only reasonable alternative (e.g., end-of-life or palliative care). The panel has attempted to evaluate the literature and best-practice guidelines to cover as many of these instances as possible, but not all possible clinical situations can be anticipated in such a broad undertaking. In these cases, the list can be used clinically not only for prescribing medications, but also for monitoring their effects in older adults. If a provider is not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation of the medication as potentially inappropriate can serve as a reminder for close monitoring so that ADEs can be incorporated into the electronic health record and prevented or detected early. These criteria also underscore the importance of using a team approach to prescribing, of the use of nonpharmacological approaches, and of having economic and organizational incentives for this type of model.

These criteria have some limitations. First, even though older adults are the largest consumers of medication, they are often underrepresented in drug trials.[33,35] Thus, using an evidence-based approach may underestimate some drug-related problems or lead to a weaker evidence grading. As stated previously, the intent of the updated 2012 AGS Beers Criteria, as an educational tool and quality measure, is to improve the care of older adults by reducing their exposure to PIMs. Second, it does not address other types of potential PIMs that are not unique to aging (e.g., dosing of primarily renally cleared medications, drug–drug interactions, therapeutic duplication). Third, it does not comprehensively address the needs of individuals receiving palliative and hospice care, in whom symptom control is often more important than avoiding the use of PIMs. Finally, the search strategies used might have missed some studies published in languages other than English and studies available in unpublished technical reports, white papers, or other "gray literature" sources.

Regardless, this update has many strengths, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the criteria. Thoughtful application of the criteria will allow for closer monitoring of drug use, application of real-time e-prescribing and interventions to decrease ADEs in older adults, and better patient outcomes. Regular updates will allow for the evidence for medications on the list to be assessed routinely, making it more relevant and sensitive to patient outcomes, with the goal of evaluating and managing drug use in older adults while considering the dynamic complexities of the healthcare system.

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