2012 AGS Beers List Update

As seen in the Consultant Connection December 2012 Issue
By: Michael A Witherow, Geriatrics APPE

The Beers Criterion is an evidenced based resource used by healthcare personnel to prevent the use of potentially inappropriate medications (PIMs) in elderly patients as well as what to monitor for in those patients taking these PIMs.  The most recent update of the Beers Criterion was developed in 2012 and is comprised of fifty-three medications or medication classes divided into three specific categories that are organized by therapeutic class and organ system.  In most practices settings, elderly patients are on medications that are either currently on the Beers List or are older medications in which safer alternatives are available.  The next few paragraphs will discuss some of the additions to the updated Beers List.

Some of the most notable updates to the Beers List medications regardless of diagnosis include stopping the use of sliding scale insulin in patients who have not received sufficient glycemic control due to its increased chance of causing hypoglycemia.  Patients should not be using selective serotonin reuptake inhibitors due to the increased chance of a fall or fracture.  Megestrol should not be used due to its increased risk of thrombotic events and possibly death in elderly patients.  It is also recommended to avoid the use of benzodiazepines for the treatment of insomnia, agitation or delirium. 

The Criterion also included a section for medications that are not recommended for patients that have been diagnosed with specific conditions.  Patients who have a history of falls or fractures should avoid the use of nortriptyline and Desipramine due to their increased chance of mental confusion leading to avoidable falls.  Heart failure patients should avoid using COX-2 inhibitors, non-DHP calcium channel blockers or TZD’s as they can cause increased fluid retention and worsen heart failure.  Finally, and perhaps most importantly, the use of antipsychotics, anticholinergics and benzodiazepines should be avoided in patients who have dementia or cognitive impairment.  Antipsychotics in dementia patients have an increased chance of causing a stroke while the other two classes may increase mental confusion and lead to the patient harming themselves or others.  These medications should only be used if there is no other alternative and non-pharmacologic alternatives have not worked and they pose a threat to themselves and others.

Lastly, the Beers Criterion lists potentially inappropriate medications that can be used but only with caution in elderly patients.  The most notable being antipsychotics, mirtazapine and SNRI/SSRI’s as the long term use of these medications can cause hyponatremia or even syndrome of inappropriate antidiuretic hormone.  When starting or changing the dose for these medications, sodium levels need to be monitored.  Lastly, the use of Aspirin as the primary means of prevention of cardiac events is discouraged due to the lack of evidence of benefits in elderly patients aged 80 or older.

It is currently recommended that all settings who care for patients aged 65 years or older follow the guidelines established in this evidence based criterion.  However, this criterion is not meant to replace clinical judgment as patient care must be based off of the patient and should be individualized to meet their needs.  With continued and regular updates to the criterion, the Beers List will be more regularly used when making medication decisions in the elderly population.  The AGS 2012 update can be found in the April American Geriatrics Society Journal (vol. 60, no. 4).

Back to Articles