American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug–drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13‐member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence‐based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults.     

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

The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High‐Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug–Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence‐based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug‐therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug‐therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.     

American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3‐year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674–694, 2019.     

American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2023 update, an interprofessional expert panel reviewed the evidence published since the last update (2019) and based on a structured assessment process approved a number of important changes including the addition of new criteria, modification of existing criteria, and formatting changes to enhance usability. The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. Although the AGS Beers Criteria® may be used internationally, it is specifically designed for use in the United States and there may be additional considerations for certain drugs in specific countries. Whenever and wherever used, the AGS Beers Criteria® should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making.     

American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults

Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. PIMs now form an integral part of policy and practice and are incorporated into several quality measures. The specific aim of this project was to update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults. This was accomplished through the support of The American Geriatrics Society (AGS) and the work of an interdisciplinary panel of 11 experts in geriatric care and pharmacotherapy who applied a modified Delphi method to the systematic review and grading to reach consensus on the updated 2012 AGS Beers Criteria. Fifty-three medications or medication classes encompass the final updated Criteria, which are divided into three categories: potentially inappropriate medications and classes to avoid in older adults, potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate, and finally medications to be used with caution in older adults. This update has much strength, including the use of an evidence-based approach using the Institute of Medicine standards and the development of a partnership to regularly update the Criteria. Thoughtful application of the Criteria will allow for (a) closer monitoring of drug use, (b) application of real-time e-prescribing and interventions to decrease ADEs in older adults, and (c) better patient outcomes.     

Possible Medication Errors in Home Healthcare Patients

OBJECTIVE: To determine the frequency of possible medication errors in a population of older home healthcare patients according to expert panel objective criteria. DESIGN: A cross-sectional survey. SETTING: Two of the largest urban home healthcare agencies in the United States. PARTICIPANTS: Home healthcare patients age 65 and older admitted to selected offices of these agencies between October 1996 and September 1998. MEASUREMENTS: We used two sets of consensus-based expert panel criteria to define possible medication errors. The Home Health Criteria identify patients with patterns of medication use and signs and symptoms that indicate sufficient likelihood of a medication-related problem to warrant reevaluating the patient. The Beers criteria identify medications that experts have deemed generally inappropriate for older patients. RESULTS: The 6,718 study subjects took a median of five drugs; 19% were taking nine or more medications. A possible medication error was identified for 19% of patients according to Home Health Criteria, 17% according to the Beers criteria, and 30% according to either. Possible errors increased linearly with number of medications taken. When patients taking one to three medications were compared with those taking nine or more drugs, the percentages with possible errors were, respectively, 10% and 32% for the Home Health Criteria, 8% and 32% for the Beers criteria, and 16% and 50% for both. CONCLUSION: Nearly one-third of the home healthcare patients surveyed had evidence of a potential medication problem or were taking a drug considered inappropriate for older people. More-effective methods are needed to improve medication use in this vulnerable population.     

Tools to reduce polypharmacy

The reduction in polypharmacy and avoidance of inappropriate medications is a common goal in the care of older persons, regardless of setting. While multidisciplinary teams and regular medication reconciliation and review can identify and reduce medication-related problems, tools to decrease the use of high-risk/low benefit medications can help the individual clinician to improve prescribing. Numerous criteria, tools, algorithms, and scoring systems have been developed for use in a wide range of areas from long-term care to the outpatient setting, and some may not be applicable to individual situations. Not all medication review instruments have been adequately validated, and the tools we have presented have varying levels of evidence to support their use. Clinicians also need to be aware of regulatory, policy, and guideline issues that may impact the use of certain criteria for optimum prescribing. Ultimately, optimizing prescribing by reducing polypharmacy and avoiding inappropriate medications is a highly individualized process for each patient, and clinicians will have to use extensive clinical judgment in using the tools presented here.     

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

BACKGROUND: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. METHODS: This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. RESULTS: This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. CONCLUSIONS: This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.     

Potentially inappropriate medications in older individuals with diabetes: A population-based study in Quebec,Canada

AimTo study the population-based prevalence of potentially inappropriate medication (PIM) among older individuals with diabetes, and to identify factors associated with their use.MethodsWe used the Quebec Integrated Chronic Disease Surveillance System (QICDSS) database to conduct a population-based cohort study of individuals with diabetes ≥66 years between April 1st, 2014 and March 31st, 2015. PIMs were defined according to the 2015 Beers Criteria. Factors associated with PIM use were identified using robust Poisson regression models. Risk ratios (RR) and 99% confidence intervals (99%CI) were calculated.ResultsMore than half (56%) of the 286,962 older individuals with diabetes used at least one PIM over a year. Benzodiazepines (41%), proton pump inhibitors (27%) and endocrine medication (mainly glibenclamide) (25%) were the most common PIMs used. Factors associated with PIM use included female sex (RR: 1.17; 99%CI: 1.16–1.18), and comorbidities such as schizophrenia (1.48; 1.45–1.51), anxiety disorders (1.34; 1.33–1.35) and Alzheimer's disease (1.14; 1.13–1.25). Risks of using PIMs increased both with increasing comorbidities and number of medications.ConclusionPIM use is highly prevalent among older individuals with diabetes. Interventions to promote optimal medication use should particularly target individuals with comorbidities and polypharmacy who are most vulnerable to adverse drug events.     

老年人不宜使用的药物

不适当药物的使用是导致老年人发病和死亡的一个重要原因。文章介绍了国际上广泛应用的两个老年人用药指南。Beers标准介绍了48种药物在老年人中应避免使用或限量使用和20种老年人特定病症不宜使用药物的理由及危害等级。加拿大标准介绍了38种药物在老年人中应避免使用,并对老年人不适当处方行为提出了替代治疗方案。推广两个指南的应用,将有利于改善老年人不适当药物应用的局面,使老年人少受药物不良反应的危害。     

斋堂社区老年人潜在不适当用药及其相关因素

目的使用不同潜在不适当用药(PIM)标准调查乡镇社区门诊PIM现状,分析PIM与医师处方、患者自身疾病及认知功能障碍等因素的关系,帮助提高乡镇门诊老年人合理用药水平。方法采取横断面研究,纳入北京市门头沟区斋堂社区卫生服务中心门诊长期就诊老年患者264例,收集患者年龄、共病情况[疾病数量、查尔森共病指数(CCI)]、口服药、认知功能状态等资料。分别以中国老年人潜在不适当用药判断标准2017版(标准1)、美国Beers标准2019版(标准2)、联合使用中国老年人潜在不适当用药判断标准和美国Beers标准(标准3)确定PIM。将患者分为PIM组和非PIM组,调查不同标准PIM检出率,对比2组患者年龄、共病情况、认知功能状态等差异。应用SPSS 23.0软件包进行统计分析,分别应用χ2检验、独立样本t检验、非参数检验、Pearson相关分析、Spearman相关分析等对数据进行统计分析。结果共入选患者264例,年龄(71.7±5.9)岁。标准1、标准2、标准3 PIM检出率逐渐增高,分别为28.4%、39.0%、50.8%。以标准3确定的PIM分组与男性(OR=1.941,95%CI 1.110~3.394,P=0.020)、CCI(OR=1.470,95%CI 1.115~1.939,P=0.006)、口服药种类(OR=1.241,95%CI 1.056~1.459,P=0.009)、认知功能障碍(OR=3.686,95%CI 1.448~9.382,P=0.006)等相关,而与年龄无相关性。结论乡镇门诊老年人PIM高发,联合使用中国和美国PIM标准可以提高PIM检出率,PIM与口服药种类、自身疾病严重程度和认知功能障碍相关。医师应联合使用中外PIM标准加强对存在共病、认知功能障碍老人的合理用药筛查,减少乡镇门诊老年人潜在不适当用药。     

Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.     

The use and abuse of diagnostic/classification criteria

In rheumatic diseases, classification criteria have been developed to identify well-defined homogenous cohorts for clinical research. Although they are commonly used in clinical practice, their use may not be appropriate for routine diagnostic clinical care. Classification criteria are being revised with improved methodology and further understanding of disease pathophysiology, but they still may not encompass all unique clinical situations to be applied for diagnosis of heterogenous, rare, evolving rheumatic diseases. Diagnostic criteria development is challenging primarily due to difficulty for universal application given significant differences in the prevalence of rheumatic diseases based on geographical area and clinic settings. Despite these shortcomings, the clinician can still use classification criteria for understanding the disease as well as a guide for diagnosis with a few caveats. We present the limits of current classification criteria, their use and abuse in clinical practice, and how they should be used with caution when applied in clinics.     

Polypharmacy and potentially inappropriate medications among elderly patients in the geriatric department at a single-center in China: A retrospective cross-sectional study

The aging of the population has become a worldwide concern, especially in China. Polypharmacy and potentially inappropriate medications (PIMs) are prominent issues in elderly patients. Therefore, the aim of this study was to investigate the prevalence of polypharmacy and PIMs in older inpatients and further to explore the factors associated with PIM use.A retrospective, single-center, cross-sectional study was conducted. A total of 1200 inpatients aged 65 years or older admitted from January 2015 to December 2015 were included. The prevalence of polypharmacy (5–9 medications) and hyperpolypharmacy (10 or more medications) was calculated. The 2019 American Geriatric Society Beers criteria were applied to assess PIMs use. Multivariate logistic regression was used to determine the independent factors of PIM use, while zero-inflated negative binomial regression was performed to evaluate the relationship between polypharmacy and PIM use.The median age of the study population was 76 years (interquartile range = 71–81). The median number of medications was 9 (interquartile range = 7–12). 91.58% of the patients took 5 or more medications simultaneously, and 30.08% of the patients were subjected to one or more PIMs. Spironolactone, furosemide, and zopiclone were the top 3 most frequently encountered PIMs. Hyperpolypharmacy and older age were identified as independent factors associated with PIM use. The risk of PIMs rises with the number of medications prescribed.Polypharmacy and PIM use were common in our study, and the risk of PIM use correlated with an increase in the number of medications already prescribed.     

Gastrointestinal Bleeding and Anticoagulant or Antiplatelet Drugs: Systematic Search for Clinical Practice Guidelines

Gastrointestinal (GI) bleeding is a frequently encountered and very serious problem in emergency room patients who are currently being treated with anticoagulant or antiplatelet medications. There is, however, a lack of clinical practice guidelines about how to respond to these situations. The goal of this study was to find published articles that contain specific information about how to safely adjust anticoagulant and antiplatelet therapy when GI bleeding occurs.The investigators initiated a global search on the PubMed and Google websites for published information about GI bleeding in the presence of anticoagulant or antiplatelet therapy. After eliminating duplicate entries, the medical articles that remained were screened to narrow the sets of articles to those that met specific criteria. Articles that most closely matched study criteria were analyzed in detail and compared to determine how many actual guidelines exist and are useful.We could provide only minimal information about appropriate therapeutic strategies because no articles provided sufficient specific advice about how to respond to situations involving acute GI bleeding and concurrent use of anticoagulant or antiplatelet drugs. Only 4 articles provided enough detail to be of any use in an emergency situation.Clinical practice guidelines and also clinical trials for GI hemorrhaging should be expanded to state in which situations the use of anticoagulant or antiplatelet drugs should be suspended and the medications should later be resumed, and they should state the level of risk for any particular action.