Goldilocks was hungry. She tasted the porridge from the first bowl. “This porridge is too hot!” she exclaimed. So, she tasted the porridge from the second bowl. “This porridge is too cold,” she said. So, she tasted the last bowl of porridge. “Ahhh, this porridge is just right,” she said happily, and she ate it all up.
Consensus criteria (as well as clinical practice guidelines) have potential to improve quality of care and outcomes that are important to patients. They also may have substantial downsides. Even when applied correctly, unintended consequences can occur. Yet, perhaps a bigger problem is their misuse, misapplication, and a lack of understanding of how to ideally use clinical recommendations and guidelines. The American Geriatrics Society (AGS; 2012) guiding principles for patients with multiple chronic conditions summarize some of the pitfalls of following disease-specific guidelines when treating complex frail older adults. Recommendations intended to be applied with attention to individual patient circumstances can be treated as “black or white,” with little room for clinical nuance and individualized, person-centered care. And, attempts to improve care quality by translating consensus recommendations into quality measures and point-of-care reminders can sometimes incentivize care in harmful ways. The solution is not to give up on developing recommendations to guide clinicians in clinical practice or on the quality measures entirely, but to find an appropriate middle path that delineates the measures' optimal use and balances the imperatives of quality improvement with clinical nuance—supporting clinicians and the health care system to take the right action for the right patient at the right time.
The 2019 AGS Beers Criteria® (in press) is a list of criteria that provides recommendations for medications that should often be avoided in older adults. The AGS Beers Criteria®, developed through a modified Delphi consensus process, is no exception to the potential for promises and pitfalls. To promote optimal use of the Criteria, in 2015, a subgroup of the update expert panel published a companion paper entitled “How to Use the American Geriatrics Society 2015 Beers Criteria: A Guide for Patients, Clinicians, Health Systems, and Payors” (Steinman et al., 2015). Coincident with the release of the current update, we wish to remind readers of the seven key principles articulated in that companion paper (Table 1). These principles are intended to guide use of the AGS Beers Criteria® in a way that maximizes their benefits while minimizing unintended harms and reflects the spirit in which they were developed. The just-right porridge is waiting. We encourage you to eat.
Key Principles to Guide Optimal use of the American Geriatrics Society (AGS) Beers Criteria®
Key Principle 1
Medications in the AGS Beers Criteria® are potentially inappropriate, not definitely inappropriate. Medications are included in the Criteria on the basis of having an unfavorable balance of benefits and harms for many older adults compared to alternative treatments. However, there are some circumstances in which medications included in the AGS Beers Criteria® can be appropriate for older adults. For example, appropriate use can occur when alternative treatments are contraindicated or infeasible, or when an older adult has a well-established history of the medication being highly effective and, after careful examination, has little evidence of current harms and low potential for future harms.
Patient preferences also play an important role, particularly in the context of shared decision making whereby choice of an AGS Beers Criteria® medication over alternative treatment options aligns with patient values and goals. Although these considerations are important, they should be approached carefully. For example, a patient and clinician may attribute resolution of symptoms to an AGS Beers Criteria® medication, and thus wish to maintain it without realizing that the symptoms would have improved by themselves. In addition, subtle harms, such as cognitive slowing, mild balance impairment, or occasional falls, may result from use of certain AGS Beers Criteria® medications, but these symptoms are often not reported by patients, and when reported, may not be recognized by clinicians as potentially related to medication use.
Key Principle 2
Read the rationale and recommendations statements for each criterion. The caveats and guidance listed are important. Many medications listed in the criteria are considered potentially inappropriate only in certain circumstances. Understanding these circumstances and the rationale behind the recommendations is essential for tailoring treatment appropriately. In addition, the AGS Beers Criteria® in general are not intended for use among patients at the end of life, as unique prescribing considerations often come into play in this clinical setting.
Key Principle 3
Understand why medications are included in the AGS Beers Criteria® and adjust your approach to those medications accordingly. Understanding the rationale behind each criterion can guide appropriate care, including assessing the patient's baseline risk of the potential harms associated with a medication. For example, medications included in the Criteria because they increase risk of falls are especially important to avoid in older adults who have a high likelihood of falling. Although older adults with low fall risk should not be prescribed these medications wantonly, the concern for causing harms may be lower, thus potentially changing the risk/benefit calculation.
Key Principle 4
Optimal application of the AGS Beers Criteria® involves identifying potentially inappropriate medications and, where appropriate, offering safer nonpharmacological and pharmacological therapies. It is not enough to simply say “do not use this medication.” Patients and clinicians who have relied on medications for years need guidance and reassurance about substitute treatments and an understanding of what comes next. The next step for helping older adults discontinue inappropriate medications may involve alternative pharmacological and nonpharmacological treatment strategies or sometimes something as simple as education about normal aging changes, good sleep habits, or why the potentially inappropriate medication is no longer needed. To address this issue, in 2015, the AGS published a list of treatment alternatives for medications present on the 2015 update of the Criteria (Hanlon, Semla, & Schmader, 2015). This list is not comprehensive, and requires expansion and updating, but is a good starting place for identifying alternative treatment strategies.
Key Principle 5
The AGS Beers Criteria® should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety. The Criteria represent only the tip of the iceberg for medication-related problems that older adults encounter. For example, serious adverse events commonly occur with anticoagulants, insulins, and other high-risk medications. For the most part, these medications are not included in the AGS Beers Criteria® because for many older adults the potential benefits of these medications substantially outweigh the risks. Nonetheless, it is imperative to ensure that these medications are used appropriately and safely. Moreover, other types of medication misadventures, including underuse of beneficial therapies, ongoing use of medications with no indication, burdensome medication costs and regimens, non-adherence, and discordance of medication regimens with patient preferences and care goals, are outside the scope of the AGS Beers Criteria®—but are no less critical to address.
Key Principle 6
Access to medications included in the AGS Beers Criteria® should not be excessively restricted by prior authorization and/or health plan coverage policies. There is a role for health systems to flag medications on the AGS Beers Criteria® for extra scrutiny. However, this scrutiny needs to be balanced with the recognition that many older adults' use of these medications is appropriate and harms may arise from overly restricting access. Excessive or highly burdensome restrictions can not only hinder access to appropriate medications but can engender an adversarial dynamic where the AGS Beers Criteria® seem more like a cudgel than a tool to educate clinicians and patients and improve care. This is not helpful.
Key Principle 7
The AGS Beers Criteria® are not equally applicable in all countries. The Criteria are developed by U.S.– based clinicians and for the most part focus on medications available in the U.S. market. The intent is not to be parochial but to comment on medications familiar to the Panel through its clinical, educational, programmatic, and research work. The need to adapt the AGS Beers Criteria® to other countries that have a different bundle of available medications is recognized. In doing so, the principles behind the criteria recommendations should still hold. For example, except in highly unusual circumstances, the criteria on benzodiazepine and strongly anticholinergic medications should apply to medications with these characteristics that are available in other countries but are not listed in the AGS Beers Criteria® by virtue of them not being available on the U.S. market.
Assuring the safe and effective use of medications by older adults is a cornerstone of high-quality health care and a superb arena for interprofessional practice. Nurse practitioners, RNs, and other clinicians play important roles in improving medication use in older adults, including careful prescribing, monitoring medication side effects, educating patients and families, and collaborating with other professionals to optimize medication use.
The Geropharmacology section in the Journal of Gerontological Nursing is an evidence-based section and an important complement for using tools such as the AGS Beers Criteria® to improve medication use in older adults.
Nurses should be familiar with the Criteria and can access bedside tools for using them at https://geriatricscareonline.org/ProductAbstract/beers-criteria-pocketcard-2018-pre-sale/PC007. Resources for educating family members can be accessed at http://www.healthinagingfoundation.org. When used correctly, the AGS Beers Criteria® can help achieve safe and effective medication use, serving as a teaching tool, quality guide, and vehicle for practice improvement. Use the AGS Beers Criteria® well and use them wisely.
Michael A. Steinman, MD
Division of Geriatrics, University of
California, San Francisco
San Francisco VA Medical Center
San Francisco, California
Donna M. Fick, PhD, RN, FGSA, FAAN
Elouise Ross Eberly Endowed Professor
College of Nursing and College of
Pennsylvania State University
Center of Geriatric Nursing Excellence
State College, Pennsylvania
Journal of Gerontological Nursing
- American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. Advance online publication. doi:10.1111/jgs.15767 [CrossRef]
- American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. (2012). Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. Journal of the American Geriatrics Society, 60, e1–e25. doi:10.1111/j.1532-5415.2012.04188.x [CrossRef]
- Hanlon, J.T., Semla, T.P. & Schmader, K.E. (2015). Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. Journal of the American Geriatrics Society, 63, e8–e18. doi:10.1111/jgs.13807 [CrossRef]
- Steinman, M.A., Beizer, J.L., DuBeau, C.E., Laird, R.D., Lundebjerg, N.E. & Mulhausen, P. (2015). How to use the American Geriatrics Society 2015 Beers Criteria: A guide for patients, clinicians, health systems, and payors. Journal of the American Geriatrics Society, 63, e1–e7. doi:10.1111/jgs.13701 [CrossRef]
- The story of Goldilocks and the three bears. (n.d.). Retrieved from https://www.dltk-teach.com/rhymes/goldilocks_story.htm
Key Principles to Guide Optimal use of the American Geriatrics Society (AGS) Beers Criteria®
|Principle 1||Medications in the 2019 AGS Beers Criteria® are potentially inappropriate, not definitely inappropriate.|
|Principle 2||Read the rationale and recommendations statements for each criterion. The caveats and guidance listed are important.|
|Principle 3||Understand why medications are included in the AGS Beers Criteria® and adjust your approach to those medications accordingly.|
|Principle 4||Optimal application of the AGS Beers Criteria® involves identifying potentially inappropriate medications and, where appropriate, offering safer nonpharmacological and pharmacological therapies.|
|Principle 5||The AGS Beers Criteria® should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety.|
|Principle 6||Access to medications included in the AGS Beers Criteria® should not be excessively restricted by prior authorization and/or health plan coverage policies.|
|Principle 7||The AGS Beers Criteria® are not equally applicable to all countries.|