In May 2011, the American Geriatrics Society (AGS) convened an interdisciplinary 11-member expert panel to update the Beers criteria for inappropriate medication use in older adults. The initial Beers criteria identified medications whose risks outweigh their benefits and those that should be avoided or used with caution in adults 65 and older. First published in 1991 by Mark Beers, MD, and colleagues, the criteria were subsequently updated in 1997 and 2003 and were recently revised and updated by AGS in 2012 (Beers, 1997; Beers et al., 1991; Fick et al., 2003). The revised criteria were published in the Journal of the American Geriatrics Society in March 2012 (AGS 2012 Beers Criteria Update Expert Panel, 2012) and can be accessed at http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012. This editorial, by the editors of the Journal of Gerontological Nursing and Geriatric Nursing—who also served as the panel co-chair (D.M.F.) and the current AGS chair (B.R.), respectively—provides our readers with insights into key changes and improvements in the criteria, offers guidance to practicing nurses on their use, and concludes with future directions for nurses.
The 2012 Beers criteria clearly strengthen the initial list developed by Beers as well as past updates based on both the Institute of Medicine (IOM, 2011) standards for clinical practice guidelines and the GRADE system (Guyatt et al., 2006) for grading evidence supporting the criteria. This latest update further benefits from the support and collective dissemination forces of the AGS. Consistent with IOM standards, the criteria were offered online and in print for a period of public comment and review by multiple stakeholders, including the American Academy of Nursing and the American Academy of Nurse Practitioners.
The 2012 criteria include 53 medications or medication classes that should be avoided in older adults and 14 that should be used with caution. Beers’ Table 3 lists medications that should be avoided under certain conditions, such as use of selective serotonin reuptake inhibitors in older adults at significant fall risk (e.g., those who may have already sustained multiple falls) and medications to avoid with older adults experiencing delirium and/or dementia (AGS 2012 Beers Criteria Update Expert Panel, 2012). Some of the significant changes in this year’s update are the inclusion of delirium as a condition and the addition of sliding-scale insulin and glyburide (Diabeta®, Glycron®, Glynase®, Micronase®) on the medications-to-avoid list.
Implications for Nursing Practice
Like many issues in gerontology, assuring the safe use of medications by older adults is the perfect arena for interprofessional practice, education, and research. Direct care nurses and advance practice nurses (APNs) can use the criteria in several different ways across all settings of care. The following individual example offers several instances.
Mrs. W. is an 82-year-old woman who has had six emergency department visits in the past 8 months due to falls. Her past medical history includes dementia, diabetes, hypertension, congestive heart failure (CHF), and osteoporosis.
Mrs. W. sees three different providers and is taking several medications, including acetaminophen (Tylenol® and others), duloxetine (Cymbalta®), docusate sodium (Colace® and others), glyburide, amlodipine (Norvasc®), and losartan and hydrochlorothiazide (Hyzaar®). Her physical function has been declining for some time, and there are questions about her safety because she lives alone and has been falling. Mrs. W. can perform all her activities of daily living (ADLs), but a daughter who lives nearby assists her with most of the instrumental ADLs. Her daughter handles all finances because she feels her mother cannot. She reports that her mother has burned several cooking pots; food in her refrigerator is frequently outdated; and the house is cluttered. Since her mother is financially secure, the daughter would like to hire someone to help her but Mrs. W. refuses to consider it.
Mrs. W. was recently hospitalized for an exacerbation of her CHF. While in the hospital her functioning declined; she became hypoalert with new-onset incontinence and was resisting care. She was given lorazepam (Ativan®) 1 mg in the emergency department, and once transferred to an inpatient unit was continued on lorazepam 0.5 mg as-needed every 6 hours. Mrs. W. is adamant that she wants to go home and that she can do so independently.
Mrs. W’s care can be optimized through the use of the Beers criteria, and nurses in acute care settings can use these criteria in several ways. For example, the nurse could review Mrs. W.’s scheduled and as-needed medications to assess whether they are on the 2012 Beers criteria list (in this case, glyburide and lorazepam are medications on the list). In addition, the nurse might use the table of “medications to avoid under certain circumstances” to provide guidance about how to best manage medication administration for Mrs. W. Since Mrs. W. has dementia and now has some positive features for delirium, based on the Beers criteria, use of benzodiazepines such as lorazepam should be avoided. In addition, while assessing Mrs. W. for possible causes of her delirium symptoms, the nurse should consider medications on the Beers list. The nurse should also work with the entire team and consult with the geriatric APN, social worker, or psychologist for non-drug alternatives for addressing Mrs. W.’s resistance to care and address the underlying cause of her delirium.
The APN’s role might focus on performing a comprehensive assessment to evaluate the cause of Mrs. W.’s falls, mental status changes, and delirium. This might start with an evaluation to rule out orthostatic hypotension since she is taking multiple cardiac medications. The APN may also consider a safer, shorter-acting alternative to glyburide for Mrs. W. The APN is likely to interface with the criteria in several other ways, including their use as a National Committee for Quality Assurance and Centers for Medicare & Medicaid Services measure and the integration of medications to avoid in the electronic health record in some health systems. The criteria are not meant to supersede the clinical judgment of the prescribing physician or nurse practitioner; rather, they are to be used to help providers best monitor older patients, reduce risk, and prevent harm that all to commonly occurs with medication use. The APN may also need to discuss medication preferences and lifestyle values with the patient and family when the patient is taking a medication that may be inappropriate for his or her age or condition.
It is critically important that nurses continue to lead in the development and implementation of guidelines and guidance for medication management among older adults. Several nurses engaged in leadership roles in clinical trials for non-drug alternatives may play active roles in future updates of the Beers criteria (for a truly holistic less-is-more approach). The Beers criteria are only one part of the equation in determining quality prescribing in older adults. Nurses, for example, have been extremely involved in research in many other areas of medication use, such as medication adherence and reconciliation and pain assessment in older adults. They are also integral to the criteria’s dissemination into practice. In a current study, Early Nurse Detection and Management of Delirium (END-DSD, see http://clini-caltrials.gov, trial NCT01505257), Beers criteria pocket cards (Figure) are handed out to physicians, nurses, pharmacists, and therapists during weekly rounds as a way to disseminate this information to direct care providers. Handing out the cards opens an opportunity to discuss how the criteria were developed and receive feedback from other clinician colleagues regarding their potential use. The pocket cards, which can be downloaded free from the AGS website, are an easy and effective way to disseminate information and move toward changing medication management behavior among providers.
Figure. Beers criteria pocket cards. Image used with permission from the American Geriatrics Society (AGS), “AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” (2012), http://www.americangeriatrics.org.
The continued development of explicit lists of medications to avoid in older adults, such as the Beers criteria, is a key initiative in geriatrics. The involvement of nurses in this endeavor is critical, and nursing research, education, and practice will help not only develop but also disseminate important pharmacological management information to the public and thereby decrease drug-related problems and improve the health of older adults.
Lastly, we wish to acknowledge Dr. Mark Beers’ tremendous leadership in conceptualizing the importance of medication management in older adults and in acknowledging the significance of the full-team approach in patient care. Mark, who passed away in 2009, was an incredible mentor and true champion of safe medication use in older adults.
Donna M. Fick, PhD, RN, FGSA, FAAN
Journal of Gerontological Nursing
Professor of Nursing
School of Nursing
Professor of Medicine
Department of Psychiatry
The Pennsylvania State University
University Park, Pennsylvania
Barbara Resnick, PhD, CRNP, FAAN,
Sonya Ziporkin Gershowitz Chair in
Professor of Nursing
University of Maryland School of Nursing
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