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There are a variety of medications that are particularly prone to be problematic in older adults. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we discussed the STOPP and START tools and our October 2018 What's New in the Patient Safety World column “STOPP/START/STRIP” discussed the STRIP tool. But the granddaddy of all tools for inappropriate prescribing in older adults is Beers List (aka “Beers Criteria”) which we’ve discussed in many columns over the years (listed below). With the last several updates, Beers Criteria have become much more evidence-based. The American Geriatrics Society (AGS) updates Beers Criteria roughly every 3 years since 2011. The last update had been in 2015. But the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults has now been published (AGS 2019).
The AGS notes that a panel of 13 experts reviewed more than 1,400 clinical trials and research studies published between 2017 and the last update in 2015. Across its five lists, the 2019 AGS Beers Criteria® includes:
· 30 individual medications or medication classes to avoid for most older people.
· 40 medications or medication classes to use with caution or avoid when someone lives with certain diseases or conditions.
· Several changes to medications previously identified as potentially inappropriate. Twenty-five medications or medication classes were dropped outright from the last update to the AGS Beers Criteria® in 2015, while several others were moved to new categories or had guidance revised based on new evidence.
The Beers Criteria update was developed by a consensus expert panel who reviewed the evidence base developed since the last update and used a Delphi process to arrive at the current recommendations. Recommendations are grouped into several tables which include with each drug a rationale for the recommendation, the recommendation itself, and the quality of the evidence and strength of recommendation. It is important to remember that PIM’s (potentially inappropriate medications) are not absolutely to be avoided. Sound clinical judgement must be used in weighing potential benefits of any drug against potential adverse effects. A companion article “How to Use the Beers Criteria” (Steinman 2019) published along with the update emphasizes this point.
High on the list of drugs to avoid in the elderly are those with strong anticholinergic properties. The update has added two such drugs to that list, pyrilamine and methscopolamine.
Changes to criteria on cardiovascular drugs include minor updates to the rationale and a minor change to clarify the recommendation for avoiding digoxin as first-line therapy for atrial fibrillation and heart failure.
The rationale to avoid sliding scale insulin was revised to clarify its meaning and intent and glimepiride was added to the list of sulfonylureas with a greater risk of severe prolonged hypoglycemia.
The duration of use of metoclopramide was added to be consistent FDA labeling.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) have been added to the list of drugs to avoid in patients with a history of falls or fractures.
While we usually refer to inappropriate prescribing for a population, such as those age 65 and older, don’t forget that there is also inappropriate prescribing based upon certain conditions a patient may have. A classic one is Parkinson’s Disease (see our prior columns for August 2011 “Problems Managing Medications in Parkinson’s Disease”, December 2012 “More on Hospitalized Parkinson’s Disease Patients”, June 2015 “More Risks for Parkinson Inpatients” and our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing”). Beers Criteria has also looked at Parkinson’s Disease. After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. Note that the Beers Criteria also recommend avoiding benztropine and trihexyphenidyl for prevention or treatment of available for treatment of Parkinson’s.
The Beers Criteria has a nice table with recommendations on PIM use in older adults due to drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome. That table includes Parkinson’s Disease but also includes heart failure, syncope, dementia/cognitive impairment, delirium, history of falls or fractures, chronic kidney disease, urinary incontinence, and lower urinary tract symptoms.
The update also contains a table with medications “to be used with caution” in older adults with heart failure who are asymptomatic (ie, excellent control of heart failure signs and symptoms). The NOAC’s dabigatran and rivaroxaban make that list to use with caution table for adults 75 years or older. The list also notes that trimethoprim-sulfamethoxazole should be used with caution when used concurrently with an ACEI or ARB in the presence of decreased creatinine clearance because of an increased risk for hyperkalemia.
Two of the tables we find most useful are those for “Drug-Drug Interactions” and for “PIM’s Based on Kidney Function”. These recommendations really need to be wired into your CPOE and e-Prescribing systems so that useful alerts can make you aware of the PIM’s.
So, what do you do when you come across a PIM or a drug to be used with caution on Beers List in an elderly patient? As pointed out in the companion article (Steinman 2019), presence of a drug on Beers List is not an absolute contraindication to using that drug in a specific patient. You need to assess both the risks and potential benefits of the drug and consider whether safer alternatives are available. So, you need a system in place to alert you at the time of initial prescribing. If your patient is already taking a medication on Beers List, you need to consider deprescribing. See our numerous columns, listed below, on deprescribing.
Endsley (Endsley 2018) notes that deprescribing can be accomplished in four steps:
1. Conduct a “brown bag” review. Ask the patient to bring in all medications they are taking, even over-the-counter drugs or supplements, to get an accurate record.
2. Identify inappropriate, unnecessary, and harmful medications. With the patient, review the list to determine which medications are providing benefits and which are not. Ask the patient if there are any medications he or she would like to quit because of negative side effects or whether any medications have complex dosing regimens that could be simplified.
3. Decide with the patient when and how to stop selected medications. Patients may be resistant to stopping a medication because they’re concerned about their condition worsening or they don’t want to contradict the original prescriber. To get them on board, consider discontinuing one medication at a time or tapering medications if necessary. Also, assure patients you will closely monitor them for worsening conditions or withdrawal effects.
4. Regularly review medications. On at least an annual basis, take another look at the patient’s medication list in case they accumulate additional medications from other providers.
Farrell (Farrell 2019) notes five steps to individualize deprescribing practices to each patient:
(1) to identify potentially inappropriate medications
(2) to determine if the medication dosage can be reduced or the medication stopped
(3) to plan tapering
(4) to monitor (for discontinuation symptoms or the need to restart) and support the patient
(5) to document outcome
Years ago, we set up an alert for prescribers about avoiding use of amitriptyline in the elderly (amitriptyline has both anticholinergic side effects and may cause orthostatic hypotension and may cause drowsiness and increase the risk of falling in the elderly). New starts of amitriptyline dropped substantially. But we found that the prescribers almost never stopped the drug in patients for whom they had already prescribed it.
Why is it so difficult to get healthcare professionals to deprescribe? One is an inherent cognitive bias to continue doing something one started. In human factors research, continuation bias is the unconscious cognitive bias to continue with the original plan in spite of changing conditions. There’s an equivalent of this often taught in executive leadership training. That is where a simulated exercise shows people seldom back off a position they have previously declared publicly – like the problem leading to the Challenger disaster.
One very important point when advising how to avoid PIM’s on Beers List or to facilitate deprescribing is to be able to suggest alternatives. Keep in mind that those alternatives are not always pharmacological ones. Nonpharmacological alternatives may be very important, particularly to facilitate deprescribing. That’s especially true for conditions like insomnia, where promotion of good sleep hygiene may obviate the need for any sleep medications. Our numerous columns on prevention and management of delirium have also emphasized nonpharmacological approaches. The 2015 Beers Criteria update was accompanied by an article suggesting both pharmacological and nonpharmacological alternatives (Hanlon 2015). Though that article has not yet been updated to include changes in the 2019 Beers Criteria update, it still has very useful suggestions.
Of course, Beers Criteria also includes drugs that may be inappropriately continued beyond the recommended durations, such as proton pump inhibitors (PPI’s). In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we discussed the problem of "legacy prescribing", which refers to the prescribing of drugs for a longer period than is typically needed to treat a condition. Canadian researchers (Mangin 2018) noted that commonly prescribed drugs with legacy prescribing potential include antidepressants, bisphosphonates, and proton pump inhibitors (PPIs),
In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we noted that, fortunately, there are evidence-based algorithms available for deprescribing many medications. One website, deprescribing.org, has links to algorithms for deprescribing several drugs, including PPI’s, benzodiazepine receptor agonists, antipsychotics, cholinesterase inhibitors and memantine, and antihyperglycemics. In addition to the algorithm for deprescribing PPI’s available on that website, there is also a toolkit for deprescribing PPI’s on the Choosing Wisely Canada website (Wintemute 2017).
There have also been several recent guidelines and/or algorithms for deprescribing benzodiazepine receptor agonists (Croke 2019, Pottie 2018, Scrandis 2018), deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia (Croke 2018), and deprescribing cholinesterase inhibitors and memantine in patients with dementia (Reeve 2018a, Reeve 2018b). A systematic review also identified many tools for deprescribing in frail older persons and those with limited life expectancy (Thompson 2018). The Farrell article noted above (Farrell 2019) also contains links to good resources for deprescribing.
While you are focusing on deprescribing, that is also an opportunity to determine whether patients are missing medications they should be taking (for their comorbidities). We addressed “optimizing” medications in our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly”.
And, lastly, don’t forget that sometimes medications are inadvertently continued when we think we have discontinued them. See our columns listed below on this problem.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
· November 27, 2018 “Focus on Deprescribing”
Some of our past columns on deprescribing:
· November 27, 2018 “Focus on Deprescribing”
Some of our other columns on failed discontinuation of medications:
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019
Steinman MA, Fick DM. Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. J Amer Geriatr Soc 2019; First published: 29 January 2019
Endsley S. Deprescribing Unnecessary Medications: A Four-Part Process. Fam Pract Manag 2018; 25(3): 28-32
Farrell B, Mangin D. Deprescribing Is an Essential Part of Good Prescribing. Am Fam Physician 2019; 99(1): 7-9
Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use ofHigh-Risk Medications in the Elderly and Potentially HarmfulDrug–Disease Interactions in the Elderly Quality Measures. J Amer Geriatr Soc 2015; 63(12): e8-e18 First published October 8, 2015
Mangin D, Lawson J, Cuppage, J, et al. Legacy Drug-Prescribing Patterns in Primary Care. Ann Fam Med 2018; 16(6): 515-520
Wintemute K. Bye, bye, PPI: a toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings. Version 1.2. Toronto, Ontario: Choosing Wisely Canada; July 2017.
Croke LM. AFP Practice Guideline. Deprescribing Benzodiazepine Receptor Agonists for Insomnia in Adults. Am Fam Physician 2019; 99(1): 57-58
Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists. Evidence-based clinical practice guideline. Canadian Family Physician 2018, 64 (5) 339-351
Scrandis DA, Duarte AC. Deprescribing benzodiazepines. The Nurse Practitioner 2019; 44(2): 12-14
Croke LM. AFP Practice Guideline. Deprescribing Antipsychotics for Behavioral and Psychological Symptoms of Dementia and Insomnia. Am Fam Physician 2018; 98(6): 394-395
Linda Brookes L. Deprescribing Cholinesterase Inhibitors and Memantine in People With Dementia. A Sensitive Issue. Medscape 2018; March 06, 2018
Reeve E, Farrell B, Thompson W, et al. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine. Sydney: The University of Sydney; 2018
Reeve E, Farrell B, Thompson W, et al. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine: Recommendations. Sydney: The University of Sydney; 2018
Thompson W, Lundby C, Graabæk T, et al. Tools for Deprescribing in Frail Older Persons and Those With Limited Life Expectancy. A Systematic Review. J Am Geriatr Soc 2019; 67(1): 172-180
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