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American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults

American Geriatrics Society Updated Beers Criteria forPotentially Inappropriate Medication Use in Older Adults The American Geriatrics Society 2012 Beers Criteria Update Expert Panel Potentially inappropriate medications (PIMs) continue to comes. Estimates from past studies in ambulatory and long- be prescribed and used as first-line treatment for the most term care settings found that 27% of adverse drug events vulnerable of older adults, despite evidence of poor out- (ADEs) in primary care and 42% of ADEs in long-term care comes from the use of PIMs in older adults. PIMs now were preventable, with most problems occurring at the form an integral part of policy and practice and are incor- ordering and monitoring stages of care.1,2 In a study of the porated into several quality measures. The specific aim of 2000/2001 Medical Expenditure Panel Survey, the total esti- this project was to update the previous Beers Criteria using mated healthcare expenditures related to the use of poten- a comprehensive, systematic review and grading of the evi- tially inappropriate medications (PIMs) was $7.2 billion.3 dence on drug-related problems and adverse drug events Avoiding the use of inappropriate and high-risk drugs (ADEs) in older adults. This was accomplished through is an important, simple, and effective strategy in reducing the support of The American Geriatrics Society (AGS) and medication-related problems and ADEs in older adults.
the work of an interdisciplinary panel of 11 experts in Methods to address medication-related problems include geriatric care and pharmacotherapy who applied a modi- implicit and explicit criteria. Explicit criteria can identify fied Delphi method to the systematic review and grading high-risk drugs using a list of PIMs that have been identi- to reach consensus on the updated 2012 AGS Beers Crite- fied through expert panel review as having an unfavorable ria. Fifty-three medications or medication classes encom- balance of risks and benefits by themselves and considering pass the final updated Criteria, which are divided into alternative treatments available. A list of PIMs was devel- three categories: potentially inappropriate medications and oped and published by Beers and colleagues for nursing classes to avoid in older adults, potentially inappropriate home residents in 1991 and subsequently expanded and medications and classes to avoid in older adults with cer- revised in 1997 and 2003 to include all settings of geriatric tain diseases and syndromes that the drugs listed can exac- care.4–6 Implicit criteria may include factors such as thera- erbate, and finally medications to be used with caution in peutic duplication and drug–drug interactions. PIMs deter- older adults. This update has much strength, including the mined by explicit criteria (Beers Criteria) have also use of an evidence-based approach using the Institute of recently been found to identify other aspects of inappropri- Medicine standards and the development of a partnership ate medication use identified by implicit criteria.7 to regularly update the Criteria. Thoughtful application ofthe Criteria will allow for (a) closer monitoring of drug As summarized in two reviews, a number of investiga- use, (b) application of real-time e-prescribing and interven- tors in rigorously designed observational studies have tions to decrease ADEs in older adults, and (c) better shown a strong link between the medications listed in the patient outcomes. J Am Geriatr Soc 60:616–631, 2012.
Beers Criteria and poor patient outcomes (e.g., ADEs,hospitalization, mortality).7–14 Moreover, research has Key words: Beers list; medications; Beers Criteria; shown that a number of PIMs have limited effectiveness in older adults and are associated with serious problems suchas delirium, gastrointestinal bleeding, falls, and frac-ture.8,12 In addition to identifying drugs for which saferpharmacological instances a safer nonpharmacological therapy could be Medication-related problems are common, costly, and substituted for the use of these medications, highlighting often preventable in older adults and lead to poor out- that a “less-is-more approach” is often the best way toimprove health outcomes in older adults.15 Since the early 1990s, the prevalence of PIM usage has From The American Geriatrics Society, New York, New York.
been examined in more than 500 studies, including a Address correspondence to Christine M. Campanelli, The American number of long-term care, outpatient, acute care, and Geriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038.
E-mail: ccampanelli@americangeriatrics.org community settings. Despite this preponderance of informa-tion, many PIMs continue to be prescribed and used as first- 2012, Copyright the AuthorsJournal compilation 2012, The American Geriatrics Society AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA line treatment for the most vulnerable of older adults.16,17 1. Incorporate new evidence on currently listed PIMs and These studies illustrate that more work is needed to address evidence from new medications or conditions not the use of PIMs in older adults, and there remains an impor- addressed in the previous (2003) update.
tant role in policy, research, and practice for an explicit list 2. Grade the strength and quality of each PIM statement of medications to avoid in older adults. Because an increas- based on level of evidence and strength of recom- ing number of interventions have been successful in decreas- ing the use of these drugs and improving clinical 3. Convene an interdisciplinary panel of 11 experts in outcomes,18,19 PIMs now form an integral part of policy geriatric care and pharmacotherapy who will apply a and practice in the Centers for Medicare and Medicaid Ser- modified Delphi method to the systematic review and vices (CMS) regulations and are used in Medicare Part D.
grading to reach consensus on the updated 2012 AGS They are also used as a quality measure in the National Committee for Quality Assurance (NCQA) Healthcare 4. Incorporate needed exceptions into the criteria as Effectiveness Data and Information Set (HEDIS). Several deemed clinically appropriate by the panel. These evi- stakeholders, including CMS, NCQA, and the Pharmacy dence-based exceptions will be designed to make the Quality Alliance (PQA) have identified the Beers Criteria as criteria more individualized to clinical care and more an important quality measure. In addition, a few studies have begun to identify nonpharmacological alternatives toinappropriate medications20 and are incorporating BeersCriteria PIMs into electronic health records as an aid to The 2012 AGS Beers Criteria are intended for use in all An update of the Beers Criteria should include a clear ambulatory and institutional settings of care for popula- approach to reviewing and grading the evidence for tions aged 65 and older in the United States. The primary the drugs to avoid. In addition, the criteria need to be target audience is the practicing clinician. Researchers, regularly updated as new drugs come to the market, as pharmacy benefit managers, regulators, and policy-makers new evidence emerges related to the use of these medica- also use the criteria widely. The intentions of the criteria tions, and as new methods to assess the evidence develop.
include improving the selection of prescription drugs by Being able to update these criteria quickly and transpar- clinicians and patients, evaluating patterns of drug use ently is crucial to their continued use as decision-making within populations, educating clinicians and patients on tools, because regular updates will improve their relevancy, proper drug usage, and evaluating health-outcome, quality dissemination, and usefulness in clinical practice.
of care, cost, and utilization data.
The 2012 update of the Beers Criteria heralds a new The goal of the 2012 AGS Beers Criteria is to improve partnership with the American Geriatrics Society (AGS).
care of older adults by reducing their exposure to PIMs.
This partnership allows for regular, transparent, systematic This is accomplished by their use as an educational tool updates and support for the wider input and dissemination and a quality measure—two uses that are not always in of the criteria by expert clinicians for their use in research, agreement. These criteria are not meant to be applied in a policy, and practice. To keep this tool relevant, the punitive manner. Prescribing decisions are not always clear updated 2012 AGS Beers Criteria must be current with cut, and clinicians must consider multiple factors. Quality other methods for determining best-practice guidelines. A measures must be clearly defined, easily applied, and mea- rigorous systematic review was performed to update and sured with limited information. The panel considered both expand the criteria. As in the past, this update will catego- roles during deliberations. The panel’s review of evidence rize PIMs into two broad groups: medications to avoid in at times identified subgroups of individuals who should be older adults regardless of diseases or conditions and medi- exempt from the criteria or for whom only a specific crite- cations considered potentially inappropriate when used in rion applies. Such a criterion may not be easily applied as older adults with certain diseases or syndromes. A third a quality measure. These applications were balanced with group, medications that should be used with caution, has the needs and complexities of the individual. The panel felt been added. Medications in this group were initially con- that a criterion could not be expanded to include all adults sidered for inclusion as PIMs. In these cases, the consensus aged 65 and older when only individuals with specific view of the panel (described below) was that there were a characteristics may benefit or be at greater risk of harm.
sufficient number of plausible reasons why use of the drugin certain individuals would be appropriate but that thepotential for misuse or harm is substantial and thus merits an extra level of caution in prescribing. In some cases, For this new update, the AGS employed a well-tested these medications were new to the market, and evidence framework that has long been used for development of clinical practice guidelines.6,21–23 Specifically, the frame-work involved the appointment of an 11-member interdis- ciplinary expert panel with relevant clinical expertise andexperience and an understanding of how the criteria have been previously used. To ensure that potential conflicts of Update the previous Beers Criteria using a comprehen- interest are disclosed and addressed appropriately, panel- sive, systematic review and grading of the evidence on ists disclosed potential conflicts of interest with the panel drug-related problems and ADEs in older adults.
at the beginning. Each panelist’s potential conflict of inter- The strategies to achieve this aim are to: ests are provided toward the end of this article. This included in subsequent searches, such as a list of framework also involved a development process that authors whose work was relevant to the goals of the project.
included a systematic literature review and evaluation of When evidence was sparse on older medications, searches the evidence base by the expert panel. Finally, the Institute were conducted on drug class and individual medication of Medicine’s 2011 report on developing practice guide- names and included older search dates for these drugs. The lines,23 which included a period for public comments, co-chairs continually reviewed the updated search results guided the framework. These three framework principles for articles that might be relevant to the project. Panelists are described in greater detail below.
were also asked to forward pertinent citations that might beuseful for revising the previous Beers Criteria or supportingadditions to them.
At the time of the panel’s face-to-face meeting, the co- The literature from December 1, 2001 (the end of the pre- chairs had selected 2,169 unduplicated citations for the full vious panel’s search) to March 30, 2011, was searched to panel review. This total included 446 systematic reviews or identify published systematic reviews and meta-analyses meta-analyses, 629 randomized controlled trials, and 1,094 that were relevant to the project. Search terms included observational studies. Additional articles were found in a adverse drug reactions, adverse drug events, medication manual search of the reference lists of identified articles problems, polypharmacy, inappropriate drug use, subopti- and the panelist’s files, book chapter, and recent review mal drug therapy, drug monitoring, pharmacokinetics, articles, with 258 citations selected for the final evidence drug interactions, and medication errors. Terms were tables to support the list of drugs to avoid.
searched alone and in combination. Search limits includedhuman subjects, English language, and aged 65 and older.
Data sources for the initial search included Medline, theCochrane Library (Cochrane Database of Systematic After consultation with the AGS, the co-chairs identified Reviews), International Pharmaceutical abstracts, and prospective panel members with recognized expertise in references lists of selected articles that the panel co-chairs geriatric medicine, nursing, pharmacy practice, research, and quality measures. Other factors that influenced selec- The initial search identified 25,549 citations, of which tion were the desire to have interdisciplinary representa- 6,505 were selected for preliminary review. The panel co- tion, a range of medical specialties, and representation chairs reviewed 2,267 citations, of which 844 were excluded from different practice settings (e.g., long-term care, ambu- for not meeting the study purpose or not containing primary latory care, geriatric mental health, palliative care and hos- data. An additional search was conducted with the pice). In addition to the 11-member panel, representatives additional terms drug–drug and drug–disease interactions, from CMS, NCQA, and PQA were invited to serve as ex- pharmacoepidemiology, drug safety, geriatrics, and elderly prescribing. An additional search for randomized clinical tri- Each expert panel member completed a disclosure als and postmarketing and observational studies published form that was shared with the entire panel before the pro- between 2009 and 2011 was conducted using terms related cess began. Potential conflicts of interest were resolved by to major drug classes and conditions, delimited by more- the panel co-chairs and were available during the open general topics (e.g., adverse drug reactions, Beers Criteria, comment period. Panel members who disclosed affiliations or financial interests with commercial entities are listed searches were used to develop additional terms to be under the disclosures section of this article.
Table 1. Designations of Quality and Strength of Evidence Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assesseffects on health outcomes (  2 consistent, higher-quality randomized controlled trials or multiple, consistent observationalstudies with no significant methodological flaws showing large effects) Evidence is sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies;generalizability to routine practice; or indirect nature of the evidence on health outcomes (  1 higher-quality trial with > 100participants;  2 higher-quality trials with some inconsistency;  2 consistent, lower-quality trials; or multiple, consistentobservational studies with no significant methodological flaws showing at least moderate effects) limits the strength of theevidence Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplainedinconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack ofinformation on important health outcomes Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits Benefits finely balanced with risks and burden Insufficient evidence to determine net benefits or risks AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA Table 2. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in OlderAdults Anticholinergics (excludes TCAs)First-generation antihistamines anticholinergic effects and toxicity.
DoxylamineHydroxyzinePromethazineTriprolidine antipsychotics; more-effectiveagents available for treatmentof Parkinson disease AntithromboticsDipyridamole, oral short acting* alternatives available; intravenousform acceptable for use in cardiacstress testing inadequate drug concentrationin the urine alternative agents have superiorrisk/benefit profile inotrope and therefore may induceheart failure in older adults;strongly anticholinergic; otherantiarrhythmic drugs preferred general, rate control is preferredover rhythm control for atrialfibrillation associated with no additionalbenefit and may increase risk oftoxicity; slow renal clearance maylead to risk of toxic effects > 25 mg/d or taking concomitantNSAID, angiotensinconverting-enzyme inhibitor,angiotensin receptor blocker, orpotassium supplement Central nervous systemTertiary TCAs, alone or in Doxepin > 6 mg/dImipraminePerphenazine-amitriptylineTrimipramine unlessnonpharmacologicaloptions have failed andpatient is threat to selfor others AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA ButalbitalMephobarbital*Pentobarbital*PhenobarbitalSecobarbital* and risks outweigh benefits inlight of overdose with doses only3 times the recommended dose adults (e.g., delirium, falls,fractures); minimal improvementin sleep latency and duration without improvement inhyperglycemia managementregardless of care setting increases risk of thromboticevents and possibly death in olderadults prolonged hypoglycemia; causessyndrome of inappropriateantidiuretic hormone secretion.
Glyburide: greater risk of severeprolonged hypoglycemia in olderadults adverse effects; safer alternativesavailable antiemetic drugs; can causeextrapyramidal adverse effects dosages commonly used; maycause neurotoxicity; saferalternatives available selective NSAIDs.)Of all the NSAIDs, indomethacinhas most adverse effects AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA adverse effects, includingconfusion and hallucinations, morecommonly than other narcoticdrugs; is also a mixed agonist andantagonist; safer alternativesavailable The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians andpatients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality ofcare, cost, and utilization data.
* Infrequently used drugs.
CNS = central nervous system; COX = cyclooxygenase; CrCl = creatinine clearance; GI = gastrointestinal; NSAID = nonsteroidal anti-inflammatory drug;TCA = tricyclic antidepressant.
Correction made after online publication February 29, 2012: Table 2 has been updated.
Each panelist independently rated the quality of evidence and strength of recommendation for each criterion using The co-chairs and AGS staff edited the survey used in the the American College of Physicians’ Guideline Grading previous Beers Criteria development process, excluding System24 (Table 1), which is based on the Grades of products no longer marketed. The resulting survey had Recommendation Assessment, Development, and Evalua- three parts: medications currently listed as potentially tion (GRADE) scheme developed previously.25 AGS staff inappropriate for older adults independent of diseases or compiled the panelist ratings for each group and returned conditions, medications currently listed as potentially inap- them to that group, which then reached consensus in con- propriate when used in older adults with certain diseases ference call. Additional literature was obtained and or conditions, and new submissions from the panel. Each included as needed. When group consensus could not be panelist was asked to complete the survey using a 5-point reached, the full panel reviewed the ratings and worked Likert scale ranging from strongly agree to strongly dis- through any differences until they reached consensus. For agree (or no opinion). Ratings were tallied and returned to some criteria, the panel provided a “strong” recommenda- the panel along with each panelist’s original ratings. Two tion even though the quality of evidence was low or mod- conference calls allowed for review of survey ratings, erate. In such cases, the strength of recommendation was based on potential severity of harm and the availability of The panel convened for a 2-day in-person meeting on August 2 and 3, 2011, to review the second draft of thesurvey and the results of the literature search. Panel discus-sions were used to define terms and to address questions of consistency, the inclusion of infrequently used drugs, Fifty-three medications or medication classes encompass the best strategies for evaluating the evidence, and the con- the final updated 2012 AGS Beers Criteria, which are solidation or expansion of individual criterion. The panel divided into three categories (Tables 2–4). Tables were then split into four groups, with each assigned a specific constructed and organized according to major therapeutic set of criteria for evaluation. Groups were assigned as clo- sely as possible according to specific area of clinical exper- Table 2 shows the 34 potentially inappropriate medi- tise (e.g., cardiovascular, central nervous system). Groups cations and classes to avoid in older adults. Notable new reviewed the literature search, selected citations relevant to additions include megestrol, glyburide, and sliding-scale their assigned criteria, and determined which citations should be included in an evidence table. During this Table 3 summarizes potentially inappropriate medica- process, panelists were provided copies of abstracts and full- tions and classes to avoid in older adults with certain dis- text articles. The groups then presented their findings to the eases and syndromes that the drugs listed can exacerbate.
full panel for comment and consensus. After the meeting, Notable new inclusions are thiazolidinediones or glitazones each group met in a conference call to resolve any questions with heart failure, acetylcholinesterase inhibitors with his- or to include additional supporting literature.
tory of syncope, and selective serotonin reuptake inhibitors An independent researcher prepared evidence tables, which were distributed to the four criteria-specific groups.
Table 3. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in OlderAdults Due to Drug–Disease or Drug–Syndrome Interactions That May Exacerbate the Disease or Syndrome Chlorpromazine, thioridazine, andolanzapine options have failed, andpatient is a threat tothemselves or others.
Antipsychotics areassociated with anincreased risk ofcerebrovascularaccident (stroke) andmortality in personswith dementia AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA less likely to precipitateworsening ofParkinson's disease First-generation antihistamines assingle agent or part ofcombination products Brompheniramine (various)CarbinoxamineChlorpheniramineClemastine (various)CyproheptadineDexbrompheniramineDexchlorpheniramine (various)DiphenhydramineDoxylamineHydroxyzinePromethazineTriprolidine Anticholinergics andantispasmodics (see Table 9for full list of drugs with stronganticholinergic properties) AntipsychoticsBelladonna alkaloidsClidinium-chlordiazepoxideDicyclomineHyoscyaminePropanthelineScopolamineTertiary TCAs (amitriptyline,clomipramine, doxepin,imipramine, and trimipramine) effective and patientcan takegastroprotectiveagent(proton pumpinhibitoror misoprostol) incontinence (see Table 9for complete list) The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians andpatients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality ofcare, cost, and utilization data.
CCB = calcium channel blocker; AChEI = acetylcholinesterase inhibitor; CNS = central nervous system; COX = cyclooxygenase; NSAID = nonsteroidalanti-inflammatory drug; TCA = tricyclic antidepressant.
Table 4 lists medications to be used with caution in used by healthcare providers, educators, and policy-makers older adults. Fourteen medications and classes were cate- and as a quality measure. Previously, as many as 40% of gorized. Two of these involve recently marketed anti- older adults received one or more medications on this list, thrombotics for which early evidence suggests caution for depending on the care setting.29–31 The new criteria are based upon methods for determining best-practice guide- Table 5 is a summary of medications that were moved lines that included a rigorous systematic literature review, to another category or modified since the last update, and the use of an expert consensus panel, and grading of the Tables 6 and 7 summarize medications that were removed strength of evidence and recommendations.
or added since the last update. Nineteen medications and The updated criteria should be viewed as a guideline medication classes were dropped from the 2003 to the for identifying medications for which the risks of their use 2012 update of the criteria based on consensus of the in older adults outweigh the benefits. The medications that panel and evidence or a rationale to justify their exclusion have a high risk of toxicity and adverse effects in older from the list. In several cases, medications were removed adults and limited effectiveness, and all medications in because they had been taken off the U.S. market since the Table 2 (Independent of Diagnosis or Condition) should 2003 update (e.g., propoxyphene) or because of insuffi- be avoided in favor of an alternative safer medication or a cient or new evidence that was evaluated by the panel nondrug approach. The drug–disease or –syndrome inter- (e.g., ethacrynic acid). Table 8 includes a list of the actions summarized in Table 3 are particularly important antipsychotics included in the statements. Table 9 is the in the care of older adults because they often take multiple list of anticholinergic medications to be avoided in older medications for multiple comorbidities. Their occurrence adults compiled from drugs rated as having strong anticho- may have greater consequences in older adults because of linergic properties in the Anticholinergic Risk Scale,26 age-related decline in physiological reserve. Recent studies Anticholinergic Drug Scale,27 and Anticholinergic Burden in which drug–disease interactions have been shown to be important risk factors for ADEs highlight their impor-tance.32 This list is not meant to supersede clinical judgment or an individual patient’s values and needs. Prescribing The 2012 AGS Beers Criteria is an important and and managing disease conditions should be individualized improved update of previously established criteria widely and involve shared decision-making. The historical lack of AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA Table 4. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications to Be Usedwith Caution in Older Adults Lack of evidence of benefit versus risk in Greater risk of bleeding in older adults; highest-risk older adults (e.g., with priormyocardial infarction or diabetesmellitus) reuptake inhibitorSelective serotoninreuptake inhibitorTricyclic antidepressantsVincristineVasodilators The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians andpatients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality ofcare, cost, and utilization data.
CrCl = creatinine clearance.
Table 5. Medications Moved to Another Category or Modified Since 2003 Beers Criteria Amphetamines (excluding methylphenidate hydrochloride and anorexics) Fluoxetine, citalopram, fluvoxamine, paroxetine, and sertraline withsyndrome of inappropriate antidiuretic hormone secretion All barbiturates (except phenobarbital) except when used to control seizures NitrofurantoinNon-cyclooxygenase selective nonsteroidal anti-inflammatory drugs(excludes topical)Oral short-acting dipyridamole; does not apply to the extended-releasecombination with aspirinOxybutyninReserpine in doses >0.25 mg inclusion of many older adults in drug trials33–35 and the also for monitoring their effects in older adults. If a pro- related lack of alternatives in some individual instances vider is not able to find an alternative and chooses to con- further complicate medication use in older adults. There tinue to use a drug on this list in an individual patient, may be cases in which the healthcare provider determines designation of the medication as potentially inappropriate that a drug on the list is the only reasonable alternative can serve as a reminder for close monitoring so that ADEs (e.g., end-of-life or palliative care). The panel has can be incorporated into the electronic health record and attempted to evaluate the literature and best-practice prevented or detected early. These criteria also underscore guidelines to cover as many of these instances as possible, the importance of using a team approach to prescribing, but not all possible clinical situations can be anticipated in of the use of nonpharmacological approaches, and of such a broad undertaking. In these cases, the list can be having economic and organizational incentives for this used clinically not only for prescribing medications, but Table 6. Medications Removed Since 2003 Beers Criteria Antispasmodics and muscle relaxants; CNS stimulants: dextroamphetamine, methylphenidate, methamphetamine, pemoline, with cognitive impairment CNS stimulants: dextroamphetamine, methylphenidate, methamphetamine,pemoline, and fluoxetine with anorexia and malnutrition Clopidogrel with blood clotting disorders or receiving anticoagulant therapy High-sodium content drugs with heart failure Monoamine oxidase inhibitors with insomnia Oxybutynin and tolterodine with bladder outlet obstruction Long-term use of stimulant laxatives: bisacodyl, Pseudoephedrine and diet pills with hypertension cascara sagrada, and neoloid except in thepresence of opiate analgesic useMesoridazine Propoxyphene and combination productsTripelennamine These criteria have some limitations. First, even University, University Park, PA (co-chair); Todd Semla, though older adults are the largest consumers of medica- PharmD, MS, BCPS, FCCP, AGSF, U.S. Department of tion, they are often underrepresented in drug trials.33,35 Veterans Affairs National Pharmacy Benefits Management Thus, using an evidence-based approach may underesti- Services and Northwestern University, Chicago, IL (co- mate some drug-related problems or lead to a weaker chair); Judith Beizer, PharmD, CGP, FASCP, St. Johns evidence grading. As stated previously, the intent of the University, New York, NY; Nicole Brandt, PharmD, updated 2012 AGS Beers Criteria, as an educational tool BCPP, CGP, University of Maryland, Baltimore, MD; Rob- and quality measure, is to improve the care of older ert Dombrowski, PharmD, Centers for Medicare and Med- adults by reducing their exposure to PIMs. Second, it does not address other types of potential PIMs that are Catherine E. DuBeau, MD, University of Massachusetts not unique to aging (e.g., dosing of primarily renally Medical School, Worcester, MA; Nina Flanagan, CRNP, cleared medications, drug–drug interactions, therapeutic CS-BC, Binghamton University, Dunmore, PA; Joseph duplication). Third, it does not comprehensively address Hanlon, PharmD, MS, BCPS, FASHP, FASCP, FGSA, the needs of individuals receiving palliative and hospice AGSF, Department of Medicine (Geriatric Medicine) care, in whom symptom control is often more important School of Medicine, University of Pittsburgh and Geriatric than avoiding the use of PIMs. Finally, the search strate- Education and Research and Clinical Center, Veterans gies used might have missed some studies published in Administration Health System, Pittsburgh, PA; Peter Holl- languages other than English and studies available in mann, MD, AGSF, Blue Cross Blue Shield of Rhode unpublished technical reports, white papers, or other Island, Cranston, RI; Sunny Linnebur, PharmD, FCCP, BCPS, CGP, Skaggs School of Pharmacy and Pharmaceuti- Regardless, this update has many strengths, including cal Sciences, University of Colorado, Aurora, CO; David the use of an evidence-based approach using the Institute Nau, PhD, RPh, CPHQ, Pharmacy Quality Alliance, Inc, of Medicine standards and the development of a partner- Baltimore, MD (nonvoting member); Bob Rehm, National ship to regularly update the criteria. Thoughtful applica- Committee for Quality Assurance, Washington, DC (non- tion of the criteria will allow for closer monitoring of drug voting member); Satinderpal Sandhu, MD, MetroHealth use, application of real-time e-prescribing and interven- Medical Center and Case Western Reserve University tions to decrease ADEs in older adults, and better patient School of Medicine, Cleveland, OH; Michael Steinman, outcomes. Regular updates will allow for the evidence for MD, University of California at San Francisco and San medications on the list to be assessed routinely, making it Francisco Veterans Affairs Medical Center, San Francisco, more relevant and sensitive to patient outcomes, with the goal of evaluating and managing drug use in older adultswhile considering the dynamic complexities of the health- The decisions and content of the 2012 AGS Beers Criteriaare those of the AGS and the panelists and are not neces- sarily those of the U.S. Department of Veterans Affairs.
The following individuals were members of the AGS Panel Sue Radcliff, Independent Researcher, Denver, Colo- to update the 2012 AGS Beers Criteria: Donna Fick, PhD, rado, provided research services. Susan E. Aiello, DVM, RN, FGSA, FAAN, School of Nursing and College of ELS, provided editorial services. Christine Campanelli and Medicine, Department of Psychiatry, Pennsylvania State Elvy Ickowicz, MPH, provided additional research and AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA Table 7. Medications Added Since 2003 Beers Criteria Aspirin for primary prevention of cardiac events First- and second-generation antipsychotics Urinary incontinence (all types) in women Lower urinary tract symptoms andbenign prostatic hyperplasia Nondihydropyridine calcium channel blockers Serotonin-norepinephrine reuptake inhibitors SIADH = syndrome of inappropriate antidiuretic hormone secretion.
administrative support. The development of this paper was Table 8. First- and Second-Generation Antipsychotics supported in part by an unrestricted grant from the John The following organizations with special interest and expertise in the appropriate use of medications in older adults provided peer review of a preliminary draft of this guideline: American Academy of Family Physicians; Ameri- can Academy of Nurse Practitioners; American Academy of Nursing; American College of Clinical Pharmacy; Amer- ican College of Obstetrics and Gynecology; American College of Physicians; American College of Surgeons; American Medical Association; American Medical Direc- tors Association; American Society of Anesthesiologists; American Society of Consultant Pharmacists; Centers for Medicare and Medicaid Services; Gerontological Advanced Practice Nurses Association; Gerontological Society of Committee for Colorado Access (a health plan serving Table 9. Drugs with Strong Anticholinergic Properties indigent children and adults and Medicare members). Dr.
Nau works for the PQA, which has received demonstra- tion project grants from Pfizer, Inc., Merck & Co, Inc, sa- nofi-aventis, and GlaxoSmithKline. He also has held shares with CardinalHealth in the past 12 months. Dr. Semla receives honoraria from the AGS for his contribution as an author of Geriatrics at Your Fingertips and for serving as a Section Editor for the Journal of the American Geriatrics Society. He is a past President and Chair of the AGS Board of Directors. His spouse is an employee of Abbott Laboratories. He serves on the Omnicare Pharmacy and Therapeutics Committee. He is an author and editor for Author Contributions: All panel members contributed to the concept, design, and preparation of the manuscript.
Sponsor’s Role: AGS staff participated in the final technical preparation and submission of the manuscript.
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8. Stockl KM, Le L, Zhang S et al. Clinical and economic outcomes associ- Conflict of Interest: Drs. Dombrowski, Flanagan, ated with potentially inappropriate prescribing in the elderly. Am J ManagCare 2010;16:e1–e10.
Hanlon, Hollmann, Rehm, Sandhu, and Steinman indi- 9. Dimitrow MS, Airaksinen MS, Kivela SL et al. Comparison of prescribing cated no conflicts of interest. Dr. Beizer is an author and criteria to evaluate the appropriateness of drug treatment in individuals editor for LexiComp, Inc. She is on the Pharmacy and aged 65 and older: A systematic review. J Am Geriatr Soc 2011;59:1521– Therapeutics Committee for Part D at Medco Health Solu- 10. Jano E, Aparasu RR. Healthcare outcomes associated with Beers’ Criteria: tions. Dr. Brandt is on the Pharmacy and Therapeutics A systematic review. Ann Pharmacother 2007;41:438–447.
Committees at Omnicare and receives grants from Talyst 11. Chang CM, Liu PY, Yang YH et al. Use of the Beers Criteria to predict (research grant), Econometrics (research grant), Health adverse drug reactions among first-visit elderly outpatients. Pharmacother- Resources and Services Administration (educational grant), 12. Chrischilles EA, VanGilder R, Wright K et al. Inappropriate medication and the State of Maryland Office of Health Care Quality use as a risk factor for self-reported adverse drug effects in older adults. J (educational grant). Dr. Dubeau serves as a consultant for Pfizer, Inc. (urinary incontinence) and the New England 13. Dedhiya SD, Hancock E, Craig BA et al. Incident use and outcomes associ- Research Institute (nocturia). Dr. Fick is partially sup- ated with potentially inappropriate medication use in older adults. Am JGeriatr Pharmacother 2010;8:562–570.
ported by the National Institute of Health (NIH) for 14. Passarelli MC, Jacob-Filho W, Figueras A. Adverse drug reactions in an National Institute of Nursing Research grants R01 elderly hospitalised population: Inappropriate prescription is a leading NR011042 and R01NR012242. Dr. Hanlon is supported cause. Drugs Aging 2005;22:767–777.
in part by National Institute on Aging grants and contracts 15. Garfinkel D, Mangin D. Feasibility study of a systematic approach for dis- continuation of multiple medications in older adults: Addressing polyphar- macy. Arch Intern Med 2010;170:1648–1654.
K07AG033174, R01AG034056), a National Institute of 16. Fick D, Semla T. Improving medication use in gerontological nursing: Now Nursing Research grant (R01 NR010135), and Agency for is the time for interdisciplinary collaboration and translation. J Gerontol Healthcare Research and Quality grants (R01 HS017695, 17. Morandi A, Vasilevskis EE, Pandharipande PP et al. Inappropriate medica- R01HS018721). Dr. Linnebur receives an honorarium for tions in elderly ICU survivors: Where to intervene? Arch Intern Med serving as a member of the Pharmacy and Therapeutics AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA 18. Agostini JV, Zhang Y, Inouye SK. Use of a computer-based reminder to 26. Rudolph JL, Salow MJ, Angelini MC et al. The Anticholinergic Risk Scale improve sedative-hypnotic prescribing in older hospitalized patients. J Am and anticholinergic adverse effects in older persons. Arch Intern Med 19. Hume AL, Quilliam BJ, Goldman R et al. Alternatives to potentially inap- 27. Carnahan RM, Lund BC, Perry PJ et al. The Anticholinergic Drug Scale as propriate medications for use in e-prescribing software: Triggers and treat- a measure of drug-related anticholinergic burden: Associations with serum ment algorithms. BMJ Qual Saf 2011;20:875–884.
anticholinergic activity. J Clin Pharmacol 2006;46:1481–1486.
20. McCurry SM, Pike KC, Vitiello MV et al. Increasing walking and bright 28. Boustani M, Campbell N, Munger S et al. Impact of anticholinergics on light exposure to improve sleep in community-dwelling persons with Alz- the aging brain: A review and practical appllication. Aging Health heimer’s disease: Results of a randomized, controlled trial. J Am Geriatr 29. Curtis LH, Ostbye T, Sendersky V et al. Inappropriate prescribing for 21. American Geriatrics Society Panel on Pharmacological Management elderly Americans in a large outpatient population. Arch Intern Med of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009;57:1331– 30. Fick DM, Mion LC, Beers MH et al. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health 22. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the updated American 31. Laroche ML, Charmes JP, Nouaille Y et al. Is inappropriate medication Geriatrics Society/British Geriatrics Society clinical practice guideline use a major cause of adverse drug reactions in the elderly? Br J Clin Phar- for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148– 32. Hanlon JT, Sloane RJ, Pieper CF et al. Association of adverse drug reac- 23. Graham R, Mancher M, Wolman DM et al. Institute of Medicine: Clinical tions with drug-drug and drug-disease interactions in frail older outpa- Practice Guidelines We Can Trust. Washington, DC: National Academies tients. Age Ageing 2011;40:274–277.
33. Applegate WB, Curb JD. Designing and executing randomized clinical tri- 24. Qaseem A, Snow V, Owens DK et al. The development of clinical practice als involving elderly persons. J Am Geriatr Soc 1990;38:943–950.
guidelines and guidance statements of the American College of Physicians: 34. Cherubini A, Del Signore S, Ouslander J et al. Fighting against age discrim- Summary of methods. Ann Intern Med 2010;153:194–199.
ination in clinical trials. J Am Geriatr Soc 2010;58:1791–1796.
25. Atkins D, Best D, Briss PA et al., for the GRADE Working Group. Grad- 35. Hutchins LF, Unger JM, Crowley JJ et al. Underrepresentation of patients ing quality of evidence and strength of recommendations. BMJ 2004;328: 65 years of age or older in cancer-treatment trials. N Engl J Med

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