The geriatric population is continually growing in the United States, and the number of individuals over the age of 65 is expected to double by the year 2050. Changes in the pharmacokinetic profiles of elderly patients make appropriate medication dosing more challenging for health care providers. The Beers Criteria is a validated, consensus-based screening tool to help identify potentially inappropriate medications in geriatric patients. This article reviews recent updates to the Beers Criteria, as well as other screening tools which have been developed for this purpose.
By the year 2030, one in five adults in the United States is expected to be at least 65 years old. This number is predicted to continually increase such that by 2050 the number of individuals greater than 65 years old will have doubled. Additionally, the geriatric population above the age of 85 is predicted to increase fivefold by 2050.1,2 As adults age, they develop additional medical concerns, such that four in five elderly patients have at least one chronic illness. Outside of chronic medical conditions, it is estimated that 20% of elderly patients have psychiatric disorders that are not part of the normal aging process.3 The continual growth of this age group creates the potential for overwhelming the resources of the current healthcare system.
Elderly patients often use multiple medications to treat various disease states. Reports indicate that 90% of older adults use at least one medication daily, and that the average community dwelling elderly person takes at least three daily medications at any given time, many of which are purchased over-the-counter.4 Unfortunately, studies indicate that approximately 50% of all elderly patients are poorly adherent with prescribed medications, which is likely due to a multitude of causes.4 Notwithstanding the impact of old age on factors such as physical and cognitive impairments, limited resources can also alter an individual's adherence to medications.
Guidelines and published studies to assist in the appropriate use of medications in the elderly population are limited. Specifically, the pharmacokinetic profiles of elderly patients vary as they age, particularly in regards to hepatic metabolism and renal elimination, which makes appropriate dosing more challenging for the health care provider.5,6 Additionally, elderly patients may experience unintended adverse reactions from commonly accepted adult-dosing ranges. 7 Reports indicate that 25% of elderly inpatients and 30% of elderly outpatients will experience an adverse event.8 Unfortunately, many of these events are attributed to the use of multiple medications (polypharmacy).9 Ten to seventeen percent of hospital admissions for the elderly are directly related to adverse drug events and roughly half of the deaths in elderly patients are related to an adverse drug event.8 It is estimated that for each dollar spent on a medication, $1.33 is spent on the treatment of drug-related consequences.10
Screening tools have been developed to help health care providers identify potentially inappropriate medications in the elderly patient. Most recently revised this year (2012), the Beers Criteria is a validated, consensus-based screening tool to help identify potentially inappropriate medications in geriatric patients.11,12 This list includes medications or medication classes considered to be inappropriate for elderly individuals. The Beers Criteria have been adopted by the Centers for Medicare and Medicaid Services as a tool that should be used in nursing homes for assessing quality.11 The 2003 Beers Criteria were evaluated in a systematic review of the literature which examined health care outcomes associated with inappropriate medication use in the elderly patient.13 The authors reported that use of inappropriate medications as defined by the Beers Criteria was associated with increased hospitalizations, emergency room visits, and risk of death. Specifically, an increased risk of falls was noted when individuals were on psychiatric medications.13
Recently, the American Geriatrics Society (AGS) published an update to the 2003 Beers Criteria.13 Compared to the 2003 publication; there have been several modifications that are worth noting. In addition to the previous categories of potentially inappropriate medications in older adults, they also added an additional category for medications that should be used with caution.13 Medications in this group have evidence, but possibly less than other medications, to suggest that their use is inappropriate in certain patients. This additional category was created to promote a heightened level of awareness for prescribers regarding medications that may lead to problems in elderly patients. Fifty-three medications or classes make up the updated Beers Criteria and nineteen medications and/or classes were removed from the 2003 edition (Table 1).13 Additionally, for each of the categories, summary tables are provided of the panel's rationale, recommendations, and strength and quality of the evidence (for a detailed tabulated summaries please refer to American Geriatrics Society Webpage). Specific noteworthy medication added include megestrol, due to the risk of thrombotic events and death outweighs the drugs benefit on weight; and glyburide and sliding scale insulin due to their high risk of hypoglycemia in elderly patients.13 Additionally, new medications listed to avoid in older patients with certain disease states include selective serotonin reuptake inhibitors in patients with a risk of or history of falls and fractures and acetylcholinesterase inhibitors in patients with history of syncope.13 Finally, the panel added fourteen medications or medication classes to the new third category.13 It is important to note that the panel included a table of medications with strong anticholinergic properties that should be avoided or used with caution. These medications were selected based on a variety of risk rating scales including the Anticholinergic Risk Scale, Anticholinergic Drug Scale, and Anticholinergic Burden Scale.13 The updated Criteria are intended to be applicable to all patient care settings for adults aged 65 years and older.13 Over time, new research will be needed to assess whether this update is associated with improved patient outcomes.
In addition to the Beers Criteria, other screening tools have been developed and studied. In Canada, a national consensus panel published the Canadian Criteria14, which gives more consideration to comorbidities, indication and duration of treatment as compared to the Beers Criteria. The Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP)15, developed by Gallagher et al, was shown to be more sensitive than the Beers Criteria in identifying potentially inappropriate medications. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America's health plans to measure performance and is based on the Beers Criteria.16 Also, the Positive Beers Criteria for Preferred CNS Medications in Older Adults was published,17 which describes preferred medications, rather than just listing the inappropriate medications as previously done with the traditional Beers Criteria. However, these tools are less well-known and have less evidence to support their use as compared to the Beers Criteria.
With the expected growth in the geriatric population, it is necessary for healthcare providers to be aware of the challenges surrounding medication use in this population. While many medications may be considered inappropriate in older adults, using resources to identify and prevent adverse outcomes is often not done. Even though the Beers Criteria and other accepted screen tools are accepted and used, each is not without its limitations. These include often a lack of strong published data for or against specific medications due to elderly people being underreported in clinical trials and multiple confounders, including other medical conditions and medications that may affect adverse effects and/or response to specific medications in the elderly population. Appropriate medication use in the elderly patient presents unique challenges and providers need to be cognizant of the potential risks as they engage in individualized treatment of the elderly patient.