The 2019 Beers Criteria: What You Need to Know

Linda Brookes, MSc

Disclosures

February 22, 2019

The Beers Criteria[1] may well be one of the best-kept secrets in geriatrics. While widely cited in prescribing guidelines for older adults, some geriatricians, at least anecdotally, report that many primary care physicians either don't know about them or don't use them, even though 90% of older adults take at least one prescription drug.[2] And about one third of these older patients have been prescribed at least one drug on the Beers Criteria warning list.[3]

The Beers Criteria do more than guide decisions about what drugs to use in older patients. They also tell us what not to do—that is, what drugs are potentially good candidates for deprescribing.[4]

Issued by the American Geriatrics Society (AGS), the latest version of the Beers Criteria was released in January 2019. These updated criteria, which apply to all clinical settings except hospice and palliative care, list 30 individual medications or medication classes to be avoided. The criteria list more than 40 additional drugs or drug classes that should be used with caution or avoided altogether in certain diseases or conditions.

Medscape spoke with Michael A. Steinman, MD, co-chair of the AGS committee, about these updates and their implications.

What's Changed?

The 2019 update drops 25 medications or medication classes included in earlier versions because they are no longer available in the United States or because concerns with the drugs are not limited to the older population alone.

Otherwise, the new recommendations do not differ extensively from those of 2015.[5] "That reflects the stability of our recommendations and a maturity in the evidence for many of the drugs," Steinman contended. He did caution, however, that "the literature isn't as robust as we would like for some of these medications."

The rationale for each recommendation, the quality of supporting evidence, and the graded strength of the recommendation are clearly noted. For example, the criteria list 15 first-generation antihistamines as drugs to avoid, noting, among other reasons, that they are highly anticholinergic and that clearance is reduced with advanced age. While the quality of evidence is determined to be moderate, the Beers committee grades the recommendation as strong. Another example: proton-pump inhibitors. These drugs are associated with a risk for Clostridium difficile infection as well as bone loss; evidence is high. But the strong recommendation to avoid is more nuanced, noting that scheduled use for more than 8 weeks should be avoided except for certain high-risk patients.

However, the Beers Criteria are not intended to be taken as gospel. In an accompanying editorial,[6] Steinman and his AGS panel co-chair Donna Fick, PhD, RN, caution against strict adherence to the criteria without considering individual patient circumstances.

In practice, the quality of the evidence is probably not the primary driver of clinician decision-making, Steinman believes. "It's a question of doing the best with the evidence that is out there. The vast majority of recommendations in most guidelines do not have a strong evidence base to support them."

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