Expanded AGS Beers Criteria offer new info, tools for safer medication use in older adults

The American Geriatrics Society (AGS) has released its second updated and expanded Beers Criteria--lists of potentially inappropriate medications for older adults who are not receiving hospice or palliative care, and one of the most frequently cited reference tools in the field of geriatrics. The Society also unveiled a suite of new companion resources--including a list of alternative therapies for potentially inappropriate medications and more detailed guidance on best practices for implementing AGS recommendations--all published online in the Journal of the American Geriatrics Society and available for free from GeriatricsCareOnline.org.

A panel of 13 experts convened by the AGS identified more than 40 potentially problematic medications or classes of medications organized across five lists. Updated from earlier iterations of the AGS Beers Criteria, two lists detail potentially inappropriate medications for most older adults or for those with specific conditions; an additional list describes certain medications that should be used only with considerable caution. Two new additions to the 2015 AGS Beers Criteria include a specific list of medication combinations that may lead to harmful interactions, as well as a separate synthesis of some medications that should be avoided or dosed differently for people with poor kidney function.

Recognizing that older adults, healthcare professionals, and health plans might benefit from suggestions for evidence-based alternatives to potentially inappropriate medications, the expert panel also unveiled the AGS's first list of certain suggested alternative medications and treatment options outside pharmaceuticals. Used in tandem with the AGS Beers Criteria, this list of alternatives provides additional guidance for clinicians and the older adults they care for, who are prescribed medication more frequently than any other age group in the U.S.

"As we grow older, at least one in six of us is likely to experience serious side effects directly related to the medications we take," explains Todd P. Semla, PharmD, MS, AGSF, co-chair of the AGS Beers Criteria expert panel. Added Donna Fick, PhD, RN, GCNS-BC, FGSA, FAAN, expert panel co-chair: "The AGS Beers Criteria offer guidance to clinicians and the public for talking about medications with risks that may outweigh benefits. It's important to remember that many of these medications are considered potentially inappropriate only in certain circumstances and for certain people. Tools like the AGS Beers Criteria can do much to support medication use that is safe, effective, and responsive to each person's health needs."

The expert panel convened by the AGS reviewed more than 6,700 clinical trials and research studies from a pool of more than 20,000 articles published since the last AGS Beers Criteria update in 2012. The panel's revisions inform specific (though not exhaustive) lists of medications that may be harmful to older adults. As part of the 2015 update, the AGS Beers Criteria now include:

• Separate guidance on avoiding 13 combinations of medications known to cause harmful "drug-drug interactions." Treatments for several conditions common in older adults may be inappropriate when prescribed at the same time because they can increase risks for other health problems--from falls and fractures to urinary incontinence or medication toxicity (the term for a dangerous concentration of medication in the body).
• A specific list of prescriptions to avoid or adjust based on how well a person's kidneys function. The renal system plays a central role in filtering blood, and so impaired kidney function may affect how well medication is processed and absorbed. The 2015 AGS Beers Criteria list 20 potentially problematic medications for older people with moderate to severe kidney impairment, which could elevate risks for everything from nausea and diarrhea to bleeding, problems with the central nervous system, changes in mental well-being, and bone marrow toxicity.
• Three new medications and two new "classes" of medications added to warning lists for most older people or for those with specific health concerns. Noteworthy among these additions are proton-pump inhibitors often prescribed to people living with acid reflux or stomach ulcers. Multiple studies now support a link between these medications and an increased risk for bone loss, fractures, and serious bacterial infections.
• Updates to remove several medications from the AGS Beers Criteria, either because they are no longer available or because the underlying condition or concern they address is no longer limited to older people. Potentially inappropriate medications for those with chronic constipation were dropped from the 2015 AGS Beers Criteria, for example, because constipation is common across the age spectrum and prescribing considerations are not specific to older adults.
• Several modifications to recommendations on potentially inappropriate medications carried over from the 2012 AGS Beers Criteria. With increasing evidence that antipsychotics cause considerable harm without improving care outcomes for people with delirium and dementia, for example, the 2015 AGS Beers Criteria now endorse "avoiding antipsychotics for behavioral problems" altogether unless behavior modification has failed or the older adult poses a physical threat to self or others.
• "For more than 20 years, the Beers Criteria have led to decreased reliance on potentially inappropriate medications and a deeper appreciation for medication safety as a facet of high-quality care for older adults," notes AGS President Steven R. Counsell, MD, AGSF. "Our 2015 update extends the legacy of the late Mark Beers, MD--who led creation of the first list in 1991. Our 2015 update was developed after a review of the latest evidence, and we have created new companion tools intended to help older people, health professionals, and other stakeholders appreciate the AGS Beers Criteria as a resource, not a replacement, for sound clinical judgment on a case-by-case basis," Dr. Counsell said.
• In addition to the highly anticipated list of possible alternate therapies for medications identified as potentially inappropriate, companion tools released with the 2015 AGS Beers Criteria update also include a separate set of guiding principles for implementing prescribing recommendations. Among these core tenets, expert panelists reiterated that:
• Potentially inappropriate medications are just that--potentially inappropriate. They merit special scrutiny but should not be misconstrued as universally unacceptable in all cases or for all people.
• The AGS Beers Criteria should never solely dictate prescribing protocols, nor should they serve as a justification for restricting health coverage. This tool works best as a starting point to address a person's full medication regimen.
• The caveats and rationales informing AGS Beers Criteria recommendations are as important as the recommendations themselves. Appreciating these nuances can help healthcare professionals know why medications are included on the list, and how approaches to prescribing can be adjusted accordingly.

The AGS issued its first revision to the Beers Criteria in 2012, one year after assuming responsibility for the resource. Since that time, the AGS Beers Criteria have played a central role in high-quality care for older adults, influencing everything from research and professional education to care quality measures and health policy decisions.