The Purpose of the Beers Criteria: Screening for Potential Risks
The American Geriatrics Society (AGS) Beers Criteria, first developed by Dr. Mark Beers in 1991, provides evidence-based guidance for healthcare professionals to improve medication selection and reduce adverse drug events (ADEs) in older adults. It functions as a screening tool to identify potentially inappropriate medications (PIMs), or those where the risks of taking them may be greater than the potential benefits for patients aged 65 or older. The criteria apply across various care settings—including ambulatory, acute, and institutionalized care—but are not intended for use in hospice or palliative care.
The rationale behind this screening is rooted in the physiological changes that occur with age, which alter how the body processes and responds to medications. Reduced renal and hepatic function, changes in body composition, and increased sensitivity to drug effects can all make older adults more susceptible to medication-related problems. By highlighting specific drugs or drug classes with unfavorable risk-benefit profiles in older patients, the Beers Criteria provides a structured framework for careful evaluation.
The Five Categories of the Beers Criteria
For a comprehensive medication review, the Beers Criteria classifies potentially inappropriate medications and prescribing scenarios into five distinct categories. Healthcare providers screen patient medication lists against these categories to identify areas of concern.
Medications to avoid in most older adults
This list includes drugs that should generally be avoided in adults aged 65 or older because they pose a high risk of adverse effects, or because safer, more effective alternatives are available. Examples include certain long-acting benzodiazepines, anticholinergics, and nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic use.
Medications to avoid in older adults with specific diseases or syndromes
For patients with certain health conditions, some medications can worsen their specific disease state. A provider would screen for drugs that exacerbate conditions like heart failure, delirium, or a history of falls. For instance, certain anticholinergics should be avoided in patients with a history of falls or fractures.
Medications to be used with caution
These medications present a high-risk scenario and require careful monitoring. There is less expert consensus on the balance of benefits versus harms, necessitating close observation by the healthcare team. This category may include medications like aspirin or specific antipsychotics.
Medication combinations with harmful drug-drug interactions
This category identifies combinations of medications that can be particularly harmful when taken concurrently by an older person. Screening for these interactions is crucial for patients with polypharmacy. For example, combining opioids with benzodiazepines or gabapentinoids significantly increases the risk of severe respiratory depression.
Medications requiring dose adjustment based on kidney function
Many medications are processed and eliminated by the kidneys. As kidney function naturally declines with age, dosages may need adjustment to prevent accumulation and toxicity. The Beers Criteria includes a list of medications that should be avoided or dosed differently in individuals with reduced kidney function.
The Role of the Beers Criteria in Managing Polypharmacy
Polypharmacy, defined by the AGS as taking five or more medications, is a significant issue for older adults and is strongly linked to adverse drug reactions and hospitalizations. The Beers Criteria serves as a vital tool for clinicians to address this issue by facilitating the process of 'deprescribing'. Deprescribing involves systematically reviewing a patient's medication regimen to reduce or discontinue medications that are no longer necessary or may be causing more harm than benefit. It is an essential component of medication reconciliation, which ensures a patient's medication list is accurate and appropriate.
Clinical Application of the Beers Criteria
When applying the Beers Criteria, clinicians use it as a guide to prompt thoughtful discussion and shared decision-making, rather than a rigid set of rules. A decision to prescribe a potentially inappropriate medication might still be made if, after a thorough risk-benefit analysis, it is deemed the best option for an individual patient's specific circumstances. However, the criteria encourage a more cautious approach and closer monitoring in such cases.
Comparison of Screening Tools: Beers Criteria vs. STOPP/START
| Feature | Beers Criteria | STOPP/START Criteria |
|---|---|---|
| Focus | Identifies potentially inappropriate medications (PIMs) to avoid or use with caution in older adults. | Screening Tool of Older People's Potentially Prescribing and Screening Tool to Alert Risk of Treatment. Identifies both potentially inappropriate medications (STOPP) and omissions of necessary medications (START). |
| Scope | Explicit list of drugs and drug classes to avoid, use with caution, or adjust based on renal function or drug-drug interactions. | Criteria-based lists focusing on disease-specific interactions and common prescribing errors, in addition to omissions. |
| Use Case | Most commonly used tool in the United States for medication reviews in older adults. | Widely used in Europe and can be a complementary tool to the Beers Criteria. |
| Primary Goal | To reduce exposure to potentially harmful medications by improving selection. | To improve prescribing by identifying both inappropriate medications and potential underuse. |
Limitations and Nuances
While an invaluable tool, the Beers Criteria has limitations. It doesn't capture all cases of inappropriate prescribing, such as under-prescribing or over-treating. Additionally, since it's updated periodically (by the AGS every three years), it may not include the very latest medications. Most importantly, it is a population-based tool and does not replace individualized clinical judgment, as patient goals of care and unique health status must always be considered. The AGS reiterates that it is a starting point for a discussion, not a mandate.
Conclusion: Promoting Safer Prescribing Practices with the Beers Criteria
In conclusion, the Beers Criteria is used for screening medications in adults 65 years and older to identify those that may be potentially inappropriate due to a higher risk of adverse effects. It is a critical component of geriatric pharmacology, providing a structured, evidence-based approach to medication safety. By systematically screening for PIMs, harmful drug-drug interactions, and inappropriate dosing, the criteria helps healthcare professionals mitigate risks associated with polypharmacy and age-related physiological changes. Ultimately, this leads to improved medication management and safer, more effective care for a vulnerable population. For more information, healthcare professionals can consult resources provided by the American Geriatrics Society.
