Beers criteria were developed by Mark Beers et al in 199120 and have been updated at regular intervals, most recently by the American Geriatrics Society in 2012.21 The drugs and drug classes included in the Beers criteria should not be prescribed for older patients in most cases, either because the risk of using them outweighs the benefit or because safer alternatives are available. Key components are listed in TABLE 3.21
TABLE 3
Beers criteria:* Drug classes that may be inappropriate for older adults21
| Drug class | Concern |
|---|---|
| Alpha-blockers with peripheral activity | Orthostatic hypotension |
| Anticholinergics | Cognitive impairment, urinary retention |
| Antipsychotics | Increased death rate when used for behavior control in patients with dementia |
| NSAIDs | Renal dysfunction, GI bleeding, fluid retention, exacerbation of heart failure |
| Sedative hypnotics | Cognitive impairment, delirium |
| Tricyclic antidepressants | Cognitive impairment, delirium, urinary retention |
| GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs. *The full Beers criteria contains 53 drugs and drug classes that are generally inappropriate for older adults. The full list is available from the American Geriatrics Society at: www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. | |
One limitation of the Beers criteria has been its all-or-nothing approach, with many of the medications on the list deemed inappropriate for all older adults regardless of their circumstances. The 2012 update does a better job of individualizing recommendations: Medications are now categorized as those that should be avoided in older patients regardless of their diseases or conditions, those that should be avoided only in patients with certain diseases or conditions, and those that may be used for this patient population but require caution.21
STOPP is similar to the Beers criteria, but uses a different approach: Most medications on this list are considered in the context of specific medical problems.22 While the Beers criteria classify digoxin >0.125 mg/d as generally inappropriate for older adults, for example, STOPP criteria state that long-term dosing at that level is inappropriate only for those with impaired renal function.22 A list of medications identified by STOPP as contributing to hospitalization due to adverse drug effects is available at http://ageing.oxfordjournals.org/content/37/6/673.
Both tools address this drug category. Cumulative anticholinergic burden is a concept applied to the use of anticholinergic medications, which are included in both the Beers and STOPP criteria. Although isolated short-term exposure to a drug with anticholinergic properties may be tolerated by a healthy and cognitively intact older patient, repetitive exposure to such drugs, even if separated in time, has negative effects. One study evaluated more than 500 community-dwelling older adults and found that the more exposure an individual had to anticholinergic medications over the course of a year, the greater the impairment in short-term memory and activities of daily living.23 Another study, this one involving more than 13,000 community-dwelling and institutionalized patients, showed that the longer an older patient takes an anticholinergic medication, the more likely there is to be a measurable decline in performance on the Mini-Mental State Examination.24
Programs that flag potential interactions
Drug-drug interactions are a key concern of polypharmacy, and electronic medical records and prescribing systems that flag potential drug-drug interactions when a new medication is ordered are designed to help physicians avoid them. Unfortunately, clinicians only react to 3% to 9% of such notifications, overriding them because computerized systems often fail to distinguish between important and unimportant interactions.25-27 Thus, clinicians often must decide whether to react to or override warnings, an often difficult decision with patient safety and medicolegal implications. The best advice we can offer is to carefully evaluate drug interaction warnings using common sense, and seek consultation with a clinical pharmacist when uncertainty exists. This approach should prevent prescribing medications that have potentially harmful interactions with drugs the patient is already taking.
For physicians who do not have access to an electronic prescribing system that provides such notification, several online resources are available, some by subscription (eg, Lexicomp, www.lexi.com; Micromedex, www.micromedex.com/index.html; and Pepid, www.pepid.com) and others with free access (eg, AARP, healthtools.aarp.org/drug-interactions; Drugs.com (www.drugs.com/drug_interactions.php; and HealthLine, www.healthline.com/druginteractions).
CASE After doing a medication reconciliation for Mrs. R, you find that she is taking tolterodine, an anticholinergic medication for urge urinary incontinence, and donepezil, a procholinergic medication for dementia. This type of drug-drug interaction, in which the action of one drug effectively cancels out the effect of another, should not be ignored.
Overall, you identify 8 of her medications that could be discontinued: The list includes guaifenesin (a nonessential medication of questionable efficacy); naproxen (inappropriate per Beers criteria; inappropriate in patients with heart failure, according to STOPP); alprazolam, zolpidem, and diphenhydramine (duplicate medications that are all on the Beers criteria as inappropriate for chronic use and ill-advised in patients with cognitive impairment); and omeprazole and levothyroxine (for which nothing in the patient’s history suggests a need), as well as tolterodine. Depending on dose, digoxin is yet another candidate for discontinuation.