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Beers Criteria for Medications to Avoid in the
Elderly Updated
Dec. 8, 2003 - Forty-eight medications or classes
of medications to avoid in adults age 65 or older have been identified
by a national expert panel charged with updating widely used criteria
for potentially harmful medications in older adults.
Estrogen in older women and the popular
over-the-counter antihistamine, Benadrylฎ, were among those on the list
to avoid in the update of the 1997 Beers Criteria, published in the Dec.
8 issue of the Archives of Internal Medicine.
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Links to Beers
Criteria Revised |
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> Beers Criteria Revised 2003 - Table 1
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>
Beers Criteria Revised 2003 - Table 2 -
Click |
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Nonsteroidal anti-inflammatory agents such as
Motrinฎ and Advilฎ, or ibuprofen, made a second list of medications to
avoid in older adults with certain medical conditions; nonsteroidals and
aspirin, known to increase the risk of bleeding, were listed as
potentially inappropriate for people with gastric or duodenal ulcers.
Researchers also added to this list of conditions that increase
patients' risk for adverse drug events; additions included cognitive
impairment, depression, Parkinson's disease, anorexia, malnutrition and
obesity.
"We realize that aging is an individualized process
and there are some 65-year-olds who are healthy and do fine on these
medications," said Dr. Donna M. Fick, a geriatric clinical nurse
specialist and associate professor of medicine at the Medical College of
Georgia in Augusta and principal author on the paper.
She and other geriatric practitioners also know
that older people are at increased risk for medication-related problems,
called adverse drug events, such as depression, confusion, falls and
even death.
"I don't know that there is enough evidence to tell
us exactly what the reasons are, but my theory would be because
generally older people are on more medicines, because they have more
chronic diseases, so it's an interaction of multiple diseases plus aging
changes plus the drugs they take for those diseases," said Dr. Fick, who
also directs MCG's Center for Health Care Improvement.
A 1997 study, also published in Archives of
Internal Medicine, found that 35 percent of ambulatory older adults
have had such an adverse event and most of them required medical care as
a result; the incidence was even higher in nursing homes where
two-thirds of residents experienced such events over a four-year period.
A more recent study published in March 2003 in the Journal of the
American Medical Association found that 27.6 percent of adverse drug
events in older people were preventable.
Another reason for these increased adverse events
is how drugs affect people may change as they age. "As we age, we have
more subcutaneous fat, less lean body mass, less total body water; all
those things conspire together to lead to increased drug toxicity and
overdose," Dr. Fick said.
"The issue that you worry about in older people is
changes in the pharmacokinetics of the drugs; how the body actually uses
the drug, what the body does to the drug," said Dr. William E. Wade,
University of Georgia pharmacist and associate department head for the
Department of Clinical and Administrative Pharmacy in the College of
Pharmacy. "Renal function changes, which can affect how drugs are
cleared from the body. The metabolism can slow down. Often the
half-life, or how long the drug stays in the body, changes because of
that," said Dr. Wade, a study co-author. That means drugs that were well
tolerated for years, may cause problems as people age.
"The single most common problem that I see in my
practice comes from the benzodiazepine group of tranquilizers (such as
the anti-anxiety medications, Valium and Xanax)," said Dr. Tom W.
Jackson, MCG geriatrician and a member of the expert panel that updated
the Beers Criteria. "These drugs tend to calm people down and relax them
but they also dis-inhibit them. The effects are much like alcohol," said
Dr. Jackson, who is on the American Geriatrics Society Board of
Directors. "Folks who are on these medications are also much more likely
to fall
they are actually four times more likely to fall and break
their hip than people who are not on these medications." Dr. Jackson
opted to participate in the panel because of the enormous problems he
sees in seniors with drugs and drug interactions.
Part of the reason the Beers Criteria was needed
was, despite the growing number of people reaching senior status, there
are not enough practitioners, such as Dr. Jackson, who specialize in
geriatrics and are knowledgeable about the problems, Dr. Fick said.
Also, many drug studies do not include older adults and only recently
did the body of published work exploring drug use and appropriateness in
those adults begin to grow. "There was not enough evidence out there
that we could pull and analyze," she said. So Dr. Fick used methodology
similar to that used by Dr. Mark H. Beers, editor-in-chief of the "Merck
Manual for Geriatrics" and a co-author on the update, to develop the
first set of criteria.
She put together a geographically diverse panel of
12 experts, including pharmacists, geriatricians and geriatric
psychiatrists, who were familiar with the latest medical literature on
the topic and brought their own experience with patients and drugs to
the review as well.
The criteria will require continual updating
because health care is changing daily, with new medicines, new findings
about old medicines and disease, old medicines being discontinued and
more, she said.
Some of those discontinued medicines made the list
of 15 medications or medication classes dropped in the criteria update;
new information about the benefits of beta blockers got them off the
list of potentially inappropriate drugs in patients with disease such as
diabetes and peripheral vascular disease.
"What we didn't do, and I hope someone does, is we
didn't say, 'Here is a list of the safest drugs,'" Dr. Fick said.
She knows that the new criteria will cause some
controversy but stressed that it's not intended as an absolute or to
tell physicians how to prescribe. Rather, they are guidelines that she
hopes will be useful to physicians and other practitioners as well as
others, such as health services researchers, who analyze different
approaches to health care in order to find the most effective approach
to drug-related problems.
She and Dr. Jackson also point out that patients
shouldn't stop or start taking medication because they are on this
list without first talking with their physician.
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