The Beers CriteriaA Review of Rx Safety Issues in Geriatric Patients

Dane A. Higgins, M.B.A., Pharm.D.

Covington Healthcare Associates, LLC

Objectives

• Address clinical issues involving medication

use in older individuals.

• Provide a basic understanding of the Beers

Criteria and Potentially Inappropriate

Medications (PIMs).

• Identify commonly encountered PIMs and

address lifetime treatment plan issues

involving PIMs.

Aging & Medication Use

• Age-related differences in Rx effectiveness,

sensitivity and toxicity.

• Pharmacokinetic and pharmacodynamic

drug properties change with aging.

• Age-related declines in renal and hepatic

function.

• Increased sensitivity (e.g., anticholinergic

properties of Rxs).

• Rx regimen that is effective, safe and

appropriate in a 45 year old, may be highly

inappropriate in a 65 year old.

What is the Beers Criteria?

• Potentially Inappropriate Medications (PIMs)

• Identifies “High Risk” Drugs in ≥65 YO

• Includes 53 medications or medication

classes and 14 medical conditions/disease

states with caution about using specific

drugs.

• Goal of Criteria to Improve Quality of Care in

Older Individuals.

• Two Primary Purposes:

– Educational Tool

– Quality Measure

Beers Criteria as a Quality Measure

• National Committee for Quality Assurance

(NCQA)

• Healthcare Effectiveness Data and

Information Set (HEDIS)

• Pharmacy Quality Alliance (PQA)

• CMS and Medicare Part D

– Start ratings

– In 2012, “quality bonus payments” (QBPs) linked

to star ratings – 3 stars = 3%, 5 stars = 5%

History of Beers Criteria

• First published by Dr. Beers in 1991

• Updated in 1997, 2003 and 2012

• In 2012, the American Geriatrics Society

(AGS) was responsible for update.

• Interdisciplinary panel of experts in geriatric

care and pharmacotherapy.

Prevalence of PIM Use

• As many as 40% of seniors receive one or

more of the Beers Drugs, depending on care

setting.

– Medicare Part D Plans (2013) ~ 9% used PIMs.

• Adverse Health Effects of PIMs…

– 27% of adverse drug events in primary care are

preventable.

– 42% of adverse drug events in long-term care

are preventable.

– In a 2000/2001 Medical Expenditure Panel

Survey, total estimated healthcare expenditures

related to the use of PIMs was $7.2 billion.

Commonly Used PIMs

PIMs Comments

First-generation antihistamines

(e.g., hydroxyzine, promethazine,

diphenhydramine)

Highly anticholinergic. Avoid.

Antispasmodics (e.g., belladonna,

dicyclomine, hyoscyamine,

scopolamine)

Highly anticholinergic and

uncertain efficacy. Avoid.

Dipyridamole Orthostatic hypotension and more

effective alternatives. Avoid.

Nitrofurantoin Pulmonary toxicity. Not effective

with CrCl <60 mL/min. Avoid

chronic use and CrCl <60 mL/min.

Alpha Blockers (doxazosin,

prazosin, and terazosin)

Orthostatic hypotension. Avoid as

antihypertensive.

Alpha Blockers – Central

(clonidine, methyldopa, etc)

Avoid clonidine as 1st line

antihypertensive. Avoid others.

Commonly Used PIMs

PIMs Comments

Antiarrhythmic (e.g., amiodarone,

propafenone, sotalol)

Rate control better than rhythm

control in geriatrics. Not 1st line.

Digoxin over 0.125 mg/day Higher doses no more effective in

heart failure.

Nifedipine Immediate-release Hypotension. Avoid.

Spironolactone > 25 mg/day High risk of hyperkalemia. Avoid in

heart failure of CrCl < 30 mL/min.

Tertiary Tricyclic Antidepressants

(e.g., amitriptyline, doxepin > 6

mg/day, imipramine)

Highly anticholinergic, sedating,

and can cause orthostatic

hypotension. Secondary TCAs

(nortripytline) are preferred.

Antipsychotics (e.g., quetiapine,

risperidone, olanzapine,

ziprasidone)

Increased risk of stroke and

mortality in people with dementia.

Avoid in dementia.

Commonly Used PIMs

PIMs Comments

Barbiturates (e.g., butalbital,

phenobarbital)

High rate of physical dependence,

tolerance and risk of overdose at

low doses. Avoid.

Benzodiazepines (e.g., alprazolam,

lorazepam, temazepam, diazepam)

Increased sensitivity and slower

metabolism to long-acting agents.

Avoid for insomnia, agitation or

delirium. May be used in seizure

disorder, severe anxiety, etc.

Non-benzodiazepine Hypnotics

(Lunesta®, Ambien®, Sonata®)

Adverse events similar to

benzodiazepines (delirium, falls,

fractures). Minimal improvement in

sleep latency or duration.

Androgens (testosterone) Potential for cardiac problems.

Estrogens +/- Progestin Carcinogenic potential (e.g.,

endometrium, breast) and other

risks.

Commonly Used PIMs

PIMs Comments

Sliding Scale Insulin Higher risk of hypoglycemia.

Avoid.

Megestrol Minimal effect on weight, increases

risk of thrombotic events and

death.

Sulfonylureas – Long-duration Rxs

(glyburide)

Greater risk of severe prolonged

hypoglycemia.

Metoclopramide EPS effects (e.g., tardive

dyskinesia).

Meperidine Not effective. Can cause

neurotoxicity. Avoid.

NSAIDs (e.g., aspirin, diclofenac,

ibuprofen, meloxicam, naproxen)

Increase risk of GI bleeding in >75

or other high-risk (e.g., anticoag,

antiplatelet). Avoid unless patient

can take a gastroprotective agent

(PPI/omeprazole).

Commonly Used PIMs

PIMs Comments

Ketorolac Major increase in GI bleeding risk.

Avoid.

Pentazocine More CNS adverse events

(confusion and hallucinations) than

other opioids. Avoid.

Skeletal Muscle Relaxants (e.g.,

carisoprodol, chlorzoxazone,

cyclobenzaprine, metaxalone,

methocarbamol, orphenadrine)

Poorly tolerated and efficacy is

questionable (particularly with

chronic use). Avoid.

PIMs – Disease/Condition

Disease State PIMs Comments

Heart Failure NSAIDs, Diltiazem, Verapamil,

Pioglitazone, Rosiglitazone,

Cilostazol

Cause fluid retention

and exacerbate heart

failure.

Syncope Doxazosin, Prazosin,

Terazosin, Tertiary TCAs

(amitriptyline, etc), Olanzapine

Increase risk of

orthostatic

hypotension &

bradycardia.

Seizures Bupropion, clozapine,

olanzapine, tramadol, etc

Lower seizure

threshold.

Cognitive

Impairment

Anticholinergics, Zolpidem,

Benzodiazepines, etc

Worsen CNS

depressant effects.

History of Falls

and Fractures

TCAs, SSRIs, Hypnotics,

Benzos, Anticonvulsants,

Antipsychotics

Produce ataxia,

impaired psychomotor

function, syncope and

falls.

PIMs – Disease/Condition

Disease State PIMs Comments

Insomnia Pseudoephedrine,

Phenylephrine, Stimulants

Worsen insomnia.

Constipation Anticholinergics, Urinary

Incontinence Rxs, Diltiazem,

Verapamil, etc

Worsen constipation.

Avoid.

History of GI/

Duodenal

Ulcers

Aspirin (>325 mg/day) or

NSAIDs

May exacerbate or

cause ulcers.

Kidney

Disease

(Stage IV or V)

NSAIDs, Triamterene Kidney injury. Avoid.

Urinary

Incontinence

Estrogens May aggravate

incontinence.

Pocket List From AGS

Beyond Beers Criteria

• STOPP

– Screening Tool of Older Persons’ potentially

inappropriate Prescriptions

• START

– Screening Tool to Alert doctors to the Right

Treatment

– Beers Criteria focuses on prescribing drugs that

should be avoided, while START focuses on

under prescribing in the elderly (failure to use

statin in atherosclerotic disease, ACE inhibitor in

heart failure, etc)

– Study found one or more Rx omissions in 57.9%

of patients at time of hospital admission.

Beers Drugs and Life Care Plans

• Published reviews on the Beers Criteria by

nurses have suggested that practicing

nurses should use the AGS pocket list (see

previous slides) to help identify high-risk

drug use in their patients. (Fick DM. 2012 Beers Criteria Update –

How Should Practicing Nurses Use the Criteria? J Gerontological Nursing. 2012)

• Beers Criteria could be employed when

conducting a Life Care Plan….

• First Step is Identifying “PIMs”

• Modify Treatment Plan Due to PIMs

• Modification will vary based on PIM and

patient-specific medical considerations…

Beers Drugs and Life Care Plans

• Discontinue PIM/Not for Lifetime Use

– Muscle relaxants (carisoprodol, cyclobenz-

aprine, etc) – Not effective with chronic use and

major safety concerns.

– Benzos (alprazolam, diazepam, etc) – Efficacy

with chronic use is questionable. Numerous

safety concerns.

– Hypnotics (zolpidem, etc) – Chronic use

produced minimal improvement in sleep latency

and duration.

– NSAIDs: While NSAIDs are reasonable for pain

management in younger patients, risk is far

greater in older individuals.

Beers Drugs and Life Care Plans

• Convert PIM to Safer Alternative

– Amitriptyline Nortriptyline

– Long-Acting Benzo (diazepam, flurazepam)

Short-Acting Benzo (lorazepam, temazepam)

• Still risk with short-acting agents

– Meperidine Morphine, Oxycodone, etc

– Glyburide Glipizide or Glimepiride

Beers Drugs and Life Care Plans

• Dose Adjustments for PIMs

– Digoxin – If over 0.125 mg/day

– Spironolactone – If over 25 mg/day

– TCAs (e.g., amitriptyline) – If continued, a dose

reduction is often advisable on a trial basis.

– Virtually any CNS depressant from Beers could

be a target for weaning: benzos, antipsychotics

(except schizophrenia), hypnotics, muscle

relaxants, etc.

• In many cases (e.g., zolpidem, cyclobenz-

aprine), efficacy is not reduced at lower dose,

but risk of side effects are reduced.

Beers Drugs and Life Care Plans

• Add Medications

– In some instances medications may need to be

added to the treatment plan to address safety

concerns…

– NSAIDs: If chronic NSAIDs are employed in

older individuals, a proton-pump-inhibitor

(omeprazole, pantoprazole, etc) may need to be

added. Over-the-counter (OTC) PPIs can be

purchased for about $20/month.

Beers Drugs and Life Care Plans

• No Rx Change to PIM

– Beers Criteria is a Guideline, Not a Requirement

– Prescribing decisions must consider multiple

factors/issues in individual patients.

– Disagreement over some drugs. For example,

some clinicians feel that low-dose amitriptyline is

reasonable in neuropathic-related pain

management, alpha blockers are reasonable in

hypertension with co-morbid BPH, etc.

– In some cases (e.g., amitriptyline, doxazosin), if

the patient is tolerating the drug without side-

effects, a wait and see approach is reasonable (if

closely monitored and doses are low).

Dane A. Higgins, M.B.A., Pharm. D.

Covington Healthcare Associates, LLC

3800 Colonnade Pkwy, Suite 110

Birmingham, AL 35243

205-970-3939

dahiggin@charx.com