2 Beers Criteria Created by Dr. Mark Beers in 1991 Identified medications that could be considered inappropriate in long-term care facility patients 65 years and olderUpdated in 1997, 2003, and 2012Current list geared toward providers caring for the elderly inpatient or outpatientUpgrade panel used expertise in geriatric medicine, nursing, pharmacy practice, research, and quality measures along with reps from CMS, NCQA, and PQANCQA = national committee for quality assurancePQA = pharmacy quality alliance
3 Beers Criteria, contMain objective is for the provider to review this list when considering initiating medications and consider alternatives if availableCenters for Medicare and Medicaid Services are using these recommendations in assessing the quality of care rendered to elderly patientsPharmacists participate in Medication Therapy Management Services
4 Beers Criteria 2012 Update Includes 53 medications/medication classes Inappropriate medications and medications to avoid in elderlyPotentially inappropriate medications/classes to avoid in elderly with certain diseases and/or syndromes that could be exacerbated by the medicationMedications to be used with caution in elderly patients
5 Beers Criteria 2012 Update, cont Update for medications to avoidAddition of the following medications:Megestrol (Megace)Glyburide (DiaBeta, Glynase)Sliding-scale InsulinUpdate for medications to use with cautionDabigatran (Pradaxa) and Prasugrel (Effient) due to increased risk of bleeding if 75yo or older
6 Beers Criteria 2012 Update, Cont Update for PIM and classes to avoid in elderly with certain diseases/syndromes that the medication could exacerbateAddition of the followings medications/classesPioglitazone (Actos) and Rosiglitazone (Avandia) in HF patientsAcetylcholinesterase inhibitors with history of syncopeSSRIs with falls/fracturesAvandia is now part of a REMS program for md and pt enrollmentNew medication: Alogliptin and Pioglitazone (Oseni)AI: aricept, exelon, razadyne
7 How could a medication be inappropriate for an elderly patient? Adverse reactions that worsen current disease statesAdverse reactions that require treatment or hospitalization/office visitCurrent trials have not proven efficacy in elderly patientsCurrent trials have proven increased mortality riskIncreased healthcare costMedications that cause orthostatic hypotension/falls/syncope which causes a fall that causes a hematoma or causes a fracture that requires surgeryAll antipsychotics may increase risk of stroke and death when used to treat behavioral symptoms in demented elderly ptsAnticholinergic medications may cause unpleasant side effects and worsen dementiaSome medications may lower seizure threshold (tramadol, bupropion, thiothixene)Some medications are not effective at higher doses in the elderly and higher doses increase the risk of adverse reactions
8 Drawbacks of Beers Criteria Primary purpose is to be an educational tool and quality measurePIM affected by aging were not includedMedications requiring renal dosingDrug-Drug interactionsTherapeutic duplicationPalliative Care/Hospice patients are not includedNon-English literature was not included in reviewNot for disciplinary actionsPalliative care/hospice need symptom control
9 Possible Inappropriate Medication Classes AnalgesicsAntidepressantsAntihistaminesAntihypertensivesAntiplatelet Agents/AnticoagulantsAntipsychoticsAnxiolyticsCardiac DrugsCentral Nervous System AgentsChemotherapyDiabetes DrugsGastrointestinal DrugsHormonesHypnoticsMusculoskeletal AgentsNSAIDsRespiratory DrugsStimulant DrugsUrinary Drugs
11 Is the patient allergic to any medications? AnalgesicsSafer AlternativesAcetaminophen (Tylenol)Short-term NSAIDSalicylatesTopical CapsaicinCodeineHydrocodone/APAP (Norco/Vicodin)Oxycodone/APAP (Percocet/Roxicet)Is the patient allergic to any medications?
16 Antiplatelet Agents & Anticoagulants AspirinCaution in patients >= 80yoDabigatron (Pradaxa)Increased bleeding risk in patients >= 75yoDecreased efficacy in renal impairmentPrasugrel (Effient)Increased bleeding riskTiclopidine (Ticlid)Dipyridamole short-acting (Persantine)Orthostatic Hypotension
17 AntipsychoticsAll antipsychotics increase the risk of stroke, death, and SIADH in demented elderly patients requiring behavioral treatmentChlorpromazine, Clozapine, Fluphenazine, Olanzapine (Zyprexa), Perphenazine, Thioridazine, Thiothixene (Navane), TrifluoperazineMay cause/worsen delirium, worsen constipation, worsen cognitive impairment, worsen urinary retentionClozapine requires close monitoring of WBC and ANC due to agranulocytosis
18 AntipsychoticsQuetiapine (Seroquel) or Clozapine (Clozaril) are better options for Parkinson’s diseaseLess Anticholinergic Options:Aripiprazole (Abilify)Asenapine (Saphris)HaloperidolIloperidoneLurasidone (Latuda)Paliperidone (Invega)Quetiapine (Seroquel)Risperidone (Risperdal)Ziprasidone (Geodon)Atypical antipsychotics carry unwanted side effects (weight gain, diabetes, etc)
19 AnxiolyticsBenzodiazepines should be used with caution when used for agitation/delirium or in patients with dementia/cognitive impairmentMeprobamate may cause dependence or sedationBenzos are okay for severe anxiety, seizures, REM sleep d/o, benzo/ETOH withdrawal, EOL or perioperative anesthesiaAlternative: SSRI, SNRI, Buspirone
20 Cardiac Medications Amiodarone Antiarrhythmics Dronedarone (Multaq) QT prolongation, Pulmonary toxicity, hypo- or hyperthyroidismAntiarrhythmicsDofetilide, Flecainide, Ibutilide, Procainamide, Propafenone, Quinidine, SotalolPrefer rate control over rhythm control for AfibDronedarone (Multaq)Shown to produce worse outcome in AFib/HFDisopyramide (Norpace)Anticholinergic SEDiltiazem & VerapamilCould worsen systolic HF or constipationDigoxinDoses >0.125 mg/day have shown to provide no additional efficacyCilostazol (Pletal)Could worsen HFSpironolactoneHyperkalemia, caution if CrCl <30 ml/minDig-monitor for renal impairmentHF-recommend using ACEI, ARB, Diuretic, BB (titrated)
27 NSAIDs Cause GI bleeding or peptic ulcer Cause renal injury in advanced renal diseaseCaution in CHF due to edema SEIndomethacinCauses more SE than other NSAIDsAspirinMax daily dose of 325 mgRecommend—hydrocodone/APAP, oxycodone/APAP, codeine, celecoxib (except in HF), duloxetine, venlafaxine, pregabalin, gabapentin, topical analgesics, lidocaine patchesAvoid ketorolac and indomethacinIf NSAIDs are used then recommend to use a GI protectant (misoprostol/PPI)
31 START and STOPP STOPP START Screening Tool of Older Persons’ potentially inappropriate PrescriptionsSTARTScreening Tool to Alert doctors to Right Treatment
32 START and STOPP Organized by organ system Provides the “START” options initiallyExample: START ACEI or ARB for HF, post-MI, or in diabetic nephropathyThen provides the “STOPP” treatmentsExample: STOPP beta-blockers in COPD or diabetic patientsBB in COPD: bronchospasmBB in DM: masks hypoglycemia
33 ReferencesAmerican Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc Apr;60(4):PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012.PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.
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