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What Drugs Should You Avoid In the Elderly: An Update on the Beers Criteria

Dr. Mark Beers 
Should you always avoid the use of metaclopromide in the elderly (I still use it in some circumstances)?  What about scopolamine - avoid always or consider for some instances like motion sickness?   And what about Megace - yet another drug to always avoid?

According to the new draft guidelines for the new AGS Updated Beers Criteria the answer for these questions and for many other medications is a clear "avoid".  Now is your chance though to both read these draft guidelines and to give your opinion before they are finalized (click here for the AGS site).

Why spend your time doing this?

It’s been two decades since the original Beers Criteria was published by the late Dr. Mark Beers. The original list comprised of drugs that were potentially inappropriate for elderly patients residing in nursing homes but have been subsequently revised to include elderly patients in all settings.

The drugs listed in the Beers Criteria have side effects that were thought to be far more harmful in elderly patients than any potential therapeutic benefit.   They have been used by health care providers to help guide prescribing, and educators like myself to teach what drugs to avoid in the elderly.  Importantly though, other entities like CMS, the National Committee on Quality Assurance (NCQA), and Pharmaceutical Quality Alliance (PQA) are all interested in using the criteria as part of their quality measures.

In 2011, AGS convened an expert panel that reviewed available evidence as a part of its process for revising these guidelines.  These updated criteria address three primary areas:
  • Criteria for Potentially Inappropriate Medication Use in Older Persons: Independent of Diagnoses or Conditions 
  • Criteria for Potentially Inappropriate Medication Use in Older Persons Due To Drug – Disease/ Syndrome Interaction 
  • Criteria for Potentially Inappropriate Medication Use in Older Persons: Drugs to be used with caution

So now is the time to comment before these guidelines are potentially used as a quality measure for your own practice. The draft AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS Beers Criteria) will be available on the America Geriatrics Society (AGS) website for public comment until 5:00pm ET on November, 28, 2011.


 by: Eric Widera

Comments

Nancy Lundebjerg said…
Thanks Eric for getting the word out! We may call on you to help us collate the comments - just kidding.
Bruce Scott said…
The update of the list gives a chance for some self-reflection. I was very pleased to see Megace and sliding scale insulin on the list. I can't be too smug about it, however, as I also note some medications on the list that I currently use with fair frequency. They claim a "strong" recommendation based on "moderate" evidence against use of first and second generation antipsychotics. I still have yet to see what I consider to be good evidence that burdens clearly outweigh benefits for the types of patients that I use them in. (Seroquel and Clozaril are considered by the American Academy of Neurology to be the treatments of choice in Parkinsonian psychosis. Seroquel doesn't get a carve-out for REM sleep disturbances either--but clonazepam does.) Perhaps the panel would say that the caveat that I can use them if all other non-pharmacologic options have failed and the patient is a threat to self or others covers most of the cases where I'd be using them anyway.

There is a general blasting of NSAIDs for GI toxicity, without note that some (like nabumetone) seem to be considerably safer.

I've got some homework to do in a couple of cases. The SSRI caution in patients who fall is new to me. I've got to try to find the evidence against H2RAs in delirium. If someone could pass along a reference, that would be great. (And is the caution against using them only in current delirium, or does this mean that I should avoid them for some number of months out after an episode of delirium?) My recollection is that I was taught that cimetidine and IV routes were problematic, but oral ranitidine is OK. Perhaps one of those areas where medicine changes and I haven't kept up.

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