A Critical Tool for Geriatric Care
In the field of pharmacology, managing medication for older adults presents a unique challenge. As people age, their bodies undergo significant physiological changes that affect how medications are absorbed, metabolized, and eliminated. These changes can increase sensitivity to drugs and raise the risk of adverse drug events (ADEs), such as confusion, falls, and bleeding. The Beers criteria were created specifically to address this issue, providing healthcare providers with a crucial reference for safe prescribing practices for patients aged 65 and older.
The History and Evolution of the Beers Criteria
The concept of the Beers criteria was first developed by Dr. Mark Beers and his colleagues in 1991. The initial list identified medications that were potentially inappropriate for use in older adults residing in nursing homes. The original goal was to reduce the prevalence of adverse drug reactions in this vulnerable population. The American Geriatrics Society (AGS) took over the maintenance of the criteria in 2011, establishing a process of regular updates by an expert panel. The criteria have since been expanded and revised, with the most recent version released in 2023. Each update incorporates new evidence from clinical trials and research, refining the list of potentially inappropriate medications (PIMs) to ensure the guidelines remain relevant and accurate.
The Five Categories of the Beers Criteria
The AGS Beers criteria are organized into five distinct categories to help healthcare professionals identify potential risks related to medication use in older adults. This categorization allows for a nuanced approach to prescribing, considering various patient factors.
- Medications to avoid in most older adults (excluding hospice or palliative care settings): These drugs have a high risk of adverse effects in older adults and should generally not be used. Safer alternatives or non-pharmacological therapies are typically available. Examples include certain anticholinergics like diphenhydramine and benzodiazepines like diazepam, which can cause cognitive impairment and falls.
- Medications to avoid among older adults with certain diseases or syndromes: For some medications, the risk is not universal but becomes elevated in the presence of specific health conditions. For instance, certain NSAIDs can worsen heart failure, and anticholinergic agents can exacerbate confusion and delirium.
- Medications to be used with caution: These drugs may be the best choice for some individuals, but their use requires careful monitoring due to potential side effects. The criteria recommend a risk-versus-benefit assessment before prescribing. For example, some antipsychotics might increase the risk of stroke or death in older adults with dementia.
- Potentially inappropriate drug-drug interactions: This category lists combinations of medications that can lead to harmful interactions in older adults. A notable example is the increased risk of severe sedation and respiratory depression when opioids are combined with benzodiazepines.
- Medications that should be dosed differently or avoided in patients with reduced kidney function: As kidney function naturally declines with age, the body's ability to clear certain drugs diminishes. This can lead to drug accumulation and toxicity. The criteria identify drugs like certain anticoagulants (rivaroxaban) and antibiotics (ciprofloxacin) that may require dosage adjustments based on renal function.
Why Older Adults are at a Higher Risk
Physiological changes that occur with aging significantly alter how the body interacts with medications. These changes are a primary reason for the increased risk of ADEs in older adults.
- Changes in Pharmacokinetics: This refers to what the body does to a drug. Older adults often experience a decrease in liver and kidney function, leading to slower drug metabolism and elimination. This means medications stay in the system longer, increasing the risk of toxicity. Changes in body composition, such as a higher percentage of fat and lower percentage of total body water, can also affect drug distribution.
- Changes in Pharmacodynamics: This refers to what the drug does to the body. Older adults can have altered sensitivity to certain drug effects. For example, some medications that affect the central nervous system, like sedatives, can have a more pronounced effect, increasing the risk of confusion and falls.
- Polypharmacy: The common practice of taking multiple medications for various chronic conditions is known as polypharmacy. This increases the likelihood of drug-drug interactions, leading to adverse effects and potential harm.
Comparison of High-Risk vs. Lower-Risk Medications
The Beers criteria help clinicians compare the risks of potentially inappropriate medications with the benefits of safer alternatives. The following table provides examples of such comparisons:
| Drug Class | High-Risk Example (Beers list) | Associated Risks in Older Adults | Safer/Alternative Options | Rationale for Safer Alternative |
|---|---|---|---|---|
| First-Generation Antihistamines | Diphenhydramine (Benadryl) | High anticholinergic effects leading to confusion, sedation, and dry mouth | Loratadine (Claritin) or Cetirizine (Zyrtec) | Second-generation antihistamines have minimal to no anticholinergic effects and are less sedating. |
| Benzodiazepines | Diazepam (Valium) | Increased risk of cognitive impairment, falls, and sedation | Non-pharmacological therapies for insomnia or anxiety; short-acting hypnotics with caution | Promotes safer management without the high risks of long-acting benzodiazepines. |
| Oral NSAIDs | Ibuprofen (Advil), Naproxen (Aleve) | Increased risk of GI bleeding, kidney injury, and elevated blood pressure | Acetaminophen (Tylenol) for mild to moderate pain; careful, short-term NSAID use with gastric protection | Acetaminophen is safer for GI and renal systems; requires careful monitoring. |
| Antipsychotics (for dementia) | Haloperidol (Haldol) | Increased risk of stroke, cognitive decline, and death in patients with dementia | Non-pharmacological approaches to manage behavioral symptoms | Reduces risk of serious adverse events associated with antipsychotic use in this population. |
| Long-Acting Anticoagulants | Warfarin (Coumadin) | Higher risk of major bleeding (especially intracranial) compared to newer oral anticoagulants | Direct oral anticoagulants (DOACs) such as apixaban or dabigatran | DOACs offer better bleeding safety profiles for initiation of therapy in most older adults. |
Using the Beers Criteria Wisely
The AGS stresses that the Beers criteria are a guide, not a rigid set of rules. Healthcare providers must use their clinical judgment and consider individual patient factors, such as overall health, comorbidities, and personal preferences, through a process of shared decision-making. A medication on the Beers list might still be the most appropriate choice for a particular patient if the benefits outweigh the risks in that specific circumstance.
For patients and their caregivers, understanding the Beers criteria empowers them to have informed conversations with their healthcare team. Asking questions about the purpose of each medication, potential risks, and safer alternatives is a vital step toward proactive health management. The interprofessional team, including nurses and pharmacists, plays a crucial role in implementing these guidelines and helping patients and families navigate their medication regimens. Resources from organizations like the AGS provide valuable information for both clinicians and the public on how to apply these recommendations wisely.
Conclusion
The Beers criteria serve as a cornerstone of safe medication management for older adults in the fields of medications and pharmacology. By systematically identifying potentially inappropriate medications, the criteria help mitigate the increased risk of adverse drug events caused by age-related changes and polypharmacy. While not a prescriptive law, this comprehensive guideline, updated regularly by the American Geriatrics Society, equips healthcare professionals with the evidence-based knowledge needed to optimize prescribing. For older adults and their families, it is an essential tool for engaging in shared decision-making, ultimately leading to improved health outcomes and a higher quality of life. For more information, visit the American Geriatrics Society website.
