Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Because older adults often experience chronic health conditions that require treatment with multiple medications, there is a greater likelihood of experiencing unwanted drug side effects.

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A wide range of medications—some relatively new and others long available—can cause serious side effects and other adverse events in people 65 and older if not prescribed with care, according to the new American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

The criteria, last revised in 2003, appears today in the early online edition of the Journal of the American Geriatrics Society, and is available, with additional professional and public education materials, at www.americangeriatrics.org.

I think you will be very surprised if you take the time to review this information.

AGS Beers Criteria Summary - For Patients & Caregivers
Ten Medications Older Adults Should Avoid or Use with Caution
Criteria & Evidence Tables
Beers Criteria Pocket Card

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By identifying medications that are potentially harmful for older adults, the 2012 AGS Beers Criteria can help clinicians more safely prescribe for older patients.

More than 40% of people aged 65 and older take five or more medications according to a 2008 study published in the Journal of the American Medical Association (JAMA) and each year more than a third of them will suffer a drug side effect or other adverse drug event (ADE).

Estimates from studies published in JAMA (2003) and the American Journal of Medicine (2005) conclude that 27% of ADEs in primary care settings and 42% in long-term care facilities are preventable. A 2000-2001 Medical Expenditure Panel Survey estimates healthcare expenditures related to the use of potentially inappropriate medications at approximately $7.2 billion.

“Older adults run a particularly high risk of ADEs, in part because age-related physiological changes and multiple health problems can make them more vulnerable to such reactions,” says Jennie Chin Hansen, CEO of the American Geriatrics Society (AGS).


For example, a commonly used category of pain relievers known as non-steroidal anti-inflammatory drugs (NSAIDs) may worsen heart failure in those with this condition. Older adults are also at increased risk of ADEs because many take multiple medications, which can interact, causing potentially dangerous “drug-drug interactions.”

The late Mark H. Beers, MD, a geriatrician and editor of The Merck Manuals and The Merck Manual of Geriatrics, first published the Beers Criteria in 1991. In 2011, the AGS convened a panel of experts in geriatrics and pharmacotherapy to revise and expand the criteria, based on the latest research. The society plans to update the AGS Beers Criteria every three years.

Fifty-three medications and classes of medications are among those listed as potentially problematic in the 2012 AGS Beers Criteria, which group medications that may be harmful to older adults into three categories. The first category includes 34 medications that are potentially inappropriate because they either pose high risks of side effects or may have limited effectiveness in older adults, and because alternative treatments are available. New entries include “sliding scale insulin.”

The second category includes 14 medications that are potentially inappropriate for older people with certain diseases, risk factors, or disorders because they may exacerbate these conditions. Selective serotonin reuptake inhibitors, which may increase risks of falling in some older adults, are among the new entries in this category.

A third, new category added to the Beers Criteria includes 14 medications to be used with caution in older adults. These medications may be associated with more risks than benefits in older people in general, but nonetheless may be the best choice for a particular individual if administered with caution. Vasodilators are listed as they may increase episodes of syncope in older adults with a history of this condition, and contribute to greater risks of falling.

“These are drugs that studies suggest are potentially inappropriate for older people or should be used with caution in older adults with specific health problems. But responses to drugs vary significantly among older people. And, for some individuals, medications on these lists may be the best and only choice. The Beers Criteria alone should never dictate prescribing, nor should they be used punitively. They are intended to inform thoughtful prescribing decisions,” says Todd Semla, PharmD, MS, co-chair of the panel that the AGS convened to update and expand the criteria.

The Beers Criteria also influence research, the training of healthcare professionals, quality measures, and healthcare policy. The National Committee on Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) have used the Beers Criteria when developing key quality measures regarding pharmacotherapy and the Centers for Medicare and Medicaid Services (CMS) has incorporated the criteria into its evaluation of nursing home compliance with medication-related regulations.

The AGS has received funding from the John A. Hartford Foundation of New York and the Robert Wood Johnson Foundation to help support the development and dissemination of the criteria to the broadest possible audience of clinicians.


Original content Bob DeMarco, the Alzheimer's Reading Room

High Cholesterol Levels in Your 40s May Raise the Chance of Developing Alzheimer's disease

The study found people with total cholesterol levels between 249 and 500 milligrams were one-and-a-half times more likely to develop Alzheimer's disease than those people with cholesterol levels of less than 198 milligrams.

High cholesterol levels in your 40s may raise the chance of developing Alzheimer's disease decades later, according to a study underscoring the importance of health factors in middle age on risk for the brain ailment.

The study involving 9,752 people in northern California found that those with high cholesterol levels between ages 40 and 45 were about 50 percent more likely than those with low cholesterol levels to later develop Alzheimer's disease.

The findings were presented on Wednesday at a meeting of the American Academy of Neurology in Chicago.


"Alzheimer's disease does not happen overnight," Dr. Alina Solomon of the University of Kuopio in Finland, who helped lead the study, said in a telephone interview.

"Alzheimer's disease has a very long preclinical phase — a silent phase — when you don't see any signs of the disease, but the disease is there. The pathological changes in the brain can sometimes develop over decades."

The study found people with total cholesterol levels between 249 and 500 milligrams were one-and-a-half times more likely to develop Alzheimer's disease than those people with cholesterol levels of less than 198 milligrams. People with total cholesterol levels of 221 to 248 milligrams were more than one-and-a-quarter times more likely to develop Alzheimer's disease.

Alzheimer's disease is the most common form of dementia among older people, and researchers have been working to understand its causes and risk factors.

The findings come just weeks after another study showed that having a big belly in middle age may greatly increase one's risk of later developing Alzheimer's disease or another form of dementia.

Rachel Whitmer of the Kaiser Permanente Division of Research in Oakland, California who led that study also was involved in the new one on cholesterol levels.

"Cholesterol is just one piece of the puzzle. There are other risk factors like hypertension and obesity. The more risk factors you have, the higher the risk gets," Solomon said.

Solomon said previous research had looked at the issue of high cholesterol levels in middle age as a risk factor for later development of dementia, but did not focus specifically on Alzheimer's disease.

The people in the new study underwent detailed health evaluations between 1964 and 1973 when they were ages 40 to 45, including blood cholesterol measurements. The researchers then looked at the cholesterol measurements of the 504 people in the study who developed Alzheimer's disease decades later.

High levels of cholesterol — a waxy, fat-like substance that occurs naturally in the body — in the blood can raise one's risk of heart disease. Physical inactivity, obesity and a fatty diet can contribute to high cholesterol.

"The association between cholesterol and cardiovascular disease is well known. What we know now is that minding heart health may protect your brain as well," Solomon said.

Exercise and eating more fruits and vegetables can lower cholesterol, and there are cholesterol-lowering drugs as well.

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Bob DeMarco is the Founder of the Alzheimer's Reading Room and an Alzheimer's caregiver. The ARR knowledge base contains more than 5,000 articles with more than 399,100 links on the Internet. Bob lives in Delray Beach, FL.

Original content Bob DeMarco, the Alzheimer's Reading Room