Patient Safety Tip of the Week

October 20, 2015    Updated Beers List

 

 

The American Geriatrics Society has updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS 2015). Whereas the original 1991 version of Beers Criteria was largely based on expert consensus, the last two updates have attempted to make them more evidence-based. There are actually now two lists, one for most older adults and a second for older adults with specific conditions. The new criteria also include considerations for drug-drug interactions and dosing issues related to impaired renal function.

 

The release also comes with a companion article on how to use the updated Beers criteria (Steinman 2015). It helps clinicians understand that the criteria are not absolute (i.e. that a drug listed as potentially inappropriate may still be appropriate for some patients) and that flexibility is needed. The medications are listed in tables along with the recommendation, rationale, quality of evidence, and strength of recommendation.

 

Also, for the first time, they’ve released a list of suggested alternative medications for drugs appearing on the Beers list (Hanlon 2015). This is much needed since all too often busy clinicians simply prescribe a drug on Beers list because they don’t have the time to research alternative agents to use.

 

One of the principles put forth is that optimal application of the AGS 2015 Beers Criteria involves identifying potentially inappropriate medications and, where appropriate, offering safer nonpharmacological and pharmacological therapies. For example, the updated criteria recommend avoiding antipsychotics for behavioral problems unless behavior modification has failed or the patient is considered a physical threat to self or others.

 

There have been some significant changes from the last update. Of note the nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (eszopiclone, zaleplon, zolpidem) are to be avoided without consideration of duration of use because of their association with harms balanced with their minimal efficacy in treating insomnia. Also added is the avoidance of the use of proton-pump inhibitors beyond 8 weeks without justification.

 

Another important principle is that payers and managed care organizations should not use Beers criteria in a punitive fashion or use excessive restrictions (such as prior authorization) on use of these medications in individual cases. But it does discuss how Beers criteria might be incorporated into CPOE or electronic prescribing systems and how tracking trends and patterns of Beers medications might be used to provide useful feedback to clinicians.

 

The AGS 2015 Beers Criteria also acknowledge that they are complementary to other explicit criteria used to assess medication appropriateness, such as the Screening Tool of Older Persons’potentially inappropriate Prescriptions (STOPP) criteria and the Screening Tool to Alert doctors to the Right Treatment (START) criteria (see our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”).

 

The “how to use” article (Steinman 2015) also has good recommendations on how to discuss Beers criteria medications with patients and other physicians.

 

It also provides a warning that many Beers medications should not be stopped abruptly. A good rule of thumb is that a drug dose is usually safe to taper down at the same rate that it can safely be tapered up. We’ve discussed “deprescribing” in detail in several prior columns (March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”, September 30, 2014 “More on Deprescribing”, May 2015 “Hospitalization: Missed Opportunity to Deprescribe” and July 2015 “Tools for Deprescribing”).

 

The “alternatives” article (Hanlon 2015) lists drugs by class along with suggested alternative medications and references. For example, under chronic kidney disease it lists all nonaspirin nonsteroidal anti-inflammatory drugs and suggests as potential alternative drugs acetaminophen, SNRI, topical capsaicin, or lidocaine patch with links to appropriate reference articles for these. The article also provides discussion and reference to non-pharmacologic alternatives, where appropriate for various conditions, such as transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), cognitive behavioral therapy (CBT), acupuncture, management of delirium or dementia-related behaviors, management of urinary incontinence, and sleep hygiene. This article is an excellent and much needed addition to the tools available to treating clinicians.

 

A timely article in JAMA Internal Medicine’s “Teachable Moment” series just happens to discuss a case of a patient with dementia who goes downhill after a fall with vertebral compression fracture (Larson 2015). The geriatrician doing a home hospice visit on the patient suspected polypharmacy, deprescribed several drugs, instituted several non-pharmacological interventions and educated family about how to respond to the patient, and then used some of the alternative medications you’d find in the Hanlon article. The patient dramatically improved following these measures.

 

And just a reminder – drugs appearing on Beers list may not be the ones most responsible for patient visits to the emergency department or hospitalizations. Though we focus heavily on the drugs appearing on Beers’ List, many of the adverse drug events (ADE’s) experienced by the elderly (and the not-so-elderly) are related to commonly prescribed drugs that are not on the list. In our November 12, 2013 Patient Safety Tip of the Week “More on Inappropriate Meds in the Elderly we noted a study from Australia (Miller 2013) that looked at occurrence of ADE’s in adults aged 45 and older. They found that 11.6% of all patients experienced at least one ADE in the previous 6 months. While most ADE’s were mild or moderate, 11.8% were severe and 5.4% resulted in hospitalizations. Thirteen commonly prescribed drug classes accounted for 58% of all ADE’s and the list bore little resemblance to Beers’ List. Opioids were the most frequently implicated (8.2% of all ADE’s) and accounted for over 14% of the hospitalizations. ADE’s from salicylates and NSAID’s accounted for 12.2% of hospitalizations related to ADE’s.

 

In our December 2011 What’s New in the Patient Safety World column “Beers’ Criteria Update in the Works” we also noted multiple studies which demonstrated drugs not on Beers’ List are frequent causes of ADE’s. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we noted that the literature has been mixed on the ability of Beers’ List to predict adverse drug events (ADE’s). The STOPP criteria, on the other hand, identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and such ADE’s are extremely common (Hamilton 2011). Another study (Budnitz 2011) on emergency hospitalizations related to ADE’s concluded that drugs on Beers’ list account for only a small percentage of hospitalizations. In that study, 6.6% of the ADE-related hospitalizations were related to potentially inappropriate medications on Beers’ list and if digoxin is excluded this is reduced to only 3.17%. On the other hand, two thirds of the hospitalizations were related to only four medications or medication categories: warfarin/anticoagulants, antiplatelet agents, insulins, and oral hypoglycemia agents.

 

And, lastly, a recent article showed that the medications most likely to harm the elderly are…

…antibiotics!!! At least for patients in primary care in New Zealand. Not the drug category we’d have suspected. We would have predicted opiates, anticoagulants, or diabetes drugs as the most likely offenders. But a new study from New Zealand found medications to be the number one cause of harm to ambulatory patients age 65 and older and antibiotics the most common offenders (Wallis 2015). There is actually only one anti-infective drug on the most recent Beers list.

 

All the latter studies don’t mean we should downgrade the importance of Beers criteria. The new updated Beers criteria and the 2 companion articles are extremely valuable tools that can be used wisely in clinical decision making and help protect our patients. We find the article on alternative medications (Hanlon 2015) to be an especially useful addition that may make it easier for clinicians to move patients from potentially inappropriate drugs to safer drugs or non-pharmacological interventions.

 

 

 

Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:

 

 

 

 

References:

 

 

American Geriatrics Society. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015

http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

 

 

Steinman MA, Beizer JL, DuBeau CE, et al. How to Use the American Geriatrics Society 2015 Beers Criteria - A Guide for Patients, Clinicians, Health Systems, and Payors. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015

http://onlinelibrary.wiley.com/doi/10.1111/jgs.13701/full

 

 

Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. J Amer Geriat Soc 2015; Article first published online 8 Oct 2015

http://onlinelibrary.wiley.com/doi/10.1111/jgs.13807/full

 

 

Larson CK, Kao H. Hospice Diagnosis: PolypharmacyA Teachable Moment

JAMA Intern Med 2015; Published online September 28, 2015. doi:10.1001/jamainternmed.2015.5253

http://archinte.jamanetwork.com/article.aspx?articleid=2443370

 

 

Wallis KA. Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients. Ann Fam Med 2015; 13(5): 472-474

http://annfammed.org/content/13/5/472.full

 

 

Miller GC, Valenti L, Britt H, Bayram C. Drugs causing adverse events in patients aged 45 or older: a randomised survey of Australian general practice patients. BMJ Open 2013; 3:e003701 Published 10 October 2013 doi:10.1136/bmjopen-2013-003701

http://bmjopen.bmj.com/content/3/10/e003701.full?g=w_qualitysafety_open_tab

 

 

Hamilton H, Gallagher P, Ryan C, et al. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med 2011; 171(11): 1013-1019

http://archinte.ama-assn.org/cgi/content/short/171/11/1013

 

 

Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. NEJM 2011; 365: 2002-2012

http://www.nejm.org/doi/full/10.1056/NEJMsa1103053?query=featured_home

 

 

Wallis KA. Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients. Ann Fam Med 2015; 13(5): 472-474

http://annfammed.org/content/13/5/472.full

 

 

 

 

 

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