Optimizing Medication Use: Key Principles of AGS Beers Criteria for Prescribers

What is Beers criteria about?

Updated by the American Geriatric society (AGS), Beers criteria is a list of medications that are potentially inappropriate to use in older adults because their risks of adverse events is higher in this group age of patients. The tool was first developed by Mark Beers, MD in 1991, then the AGS ( American Geriatric Society) updated the list for the first time in 2011. The most recent version of the list was updated in 2023. This tool is made based on evidence and is intended to help patients and health care professionals to make safer decisions when taking or prescribing medications to patients 65 year and older.

Categories of Medications

Medications in the Beers criteria are divided into 5 categories:

1. Medications that are potentially inappropriate and must be avoided by most older adults (outside hospice and palliative care settings). Example:
   • Aspirin for primary prevention of cardiovascular disease:
     • Prescribers are advised to to avoid initiating Aspirin for primary prevention of cardiovascular disease, and to consider deprescribing it if the older adult is already taking it for primary prevention. Note that long-term aspirin users have little evidence supporting stopping Aspirin.
     • Cause: major risk for bleeding that it is high in older adults.
     • Note: aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease.
2. Medications that must be avoided by older adults with specific health conditions. Example:
   • Antiemetics (Metoclopramide, Prochlorperazine, Promethazine) should be avoided in patients who have Parkinson disease, because they have the potential to worsen PD symptoms.
3. Medications that should be Used with caution because of the potential for harmful side effects. Example:
   • Prasugrel, Ticagrelor: When compared to clopidogrel, both raise the risk of major bleeding, particularly in people 75 years of age and older. In other cases, though, the benefits of those medications to the cardiovascular system might outweigh this risk. Note that when prasugrel is used, consider lower dose (5 mg) for those 75 years and older
4. Medications that should be avoided in combination with other treatments because of the risk for harmful “drug-drug” interactions. Example:
   • Lithium and Loop diuretics: this combination must be avoided due to increased risk of lithium toxicity. Monitor lithium concentrations, when used together.
5. Medications that must be used differently or avoided among older adults with reduced kidney function (which impacts how the body processes medicine). Example:
   • Ciprofloxacin doses must be adjusted when creatinine clearance is <30mL/min, Due to Increased risk of CNS effects (eg, seizures, confusion) and tendon rupture.

How to best use the list?

AGS emphasizes the importance of the use of common sense and clinical judgment when consulting the Beers criteria list, therefore the application of all Beers criteria recommendation is not always possible.

Seven key principles should guide the prescribers to use the criteria:

1. Understand that potentially inappropriate medications don’t mean that medications are not “definitely inappropriate”. They still could be prescribed in some clinical settings according to each elderly case.
2. Read well the recommendations and warning of use for each criterion, because sometimes some medications are potentially inappropriate only in certain circumstances!
3. Understand the “rationale” behind each criterion. The reason why some medications are listed in the Beer’s criteria help prescribers to individualize treatment according to each patient’s risks.
4. Understand that non-pharmacological practice optimizes the use of the Beers criteria. Those practices involve patient counseling and lifestyle modifications.
5. Understand that the use of Beers criteria alone is not enough to provide the most safe and effective therapy, however it should be a “starting point” when dealing with a clinical case. Other medication and patient related problems should always be assessed.
6.  For health care coverage plan and prior authorization: Beers criteria shouldn’t limit access to listed medications by patients.
7. Understand that Beers criteria are developed based on the medications that are available in the United States.

Where to find the list

you can consult The American Geriatric Society website to know more about medications that are included..