Updatirg the BeersCriteria for Potentially InappropriateMedication Use in Older Adults Resultsof a US ConsensusPanel of Experts DonnaM.Fich,PhD,RN;lamesW.Cooper,PhD,RPh;WilliamE.Wade,PhannD,FASHP,FCCP; JenniJerL. Waller, PhD;J, RossMaclean, MD; Marh H. Beers,MD Bcckground: Medication toxic effectsand drug- Reruhr: This study identified 48 individual medica- relatedproblems can have profound medical and safety tions or classeso[ medicationsto avoid in older adults consequencesfor older adults and economically affect the and their potential concernsand 20 diseases/conditions health caresystem. The purpose of this initiative was to and medicationsto be avoidedin older adultswith these reviseand update the Beerscriteria for potentially inap- conditions.Of thesepotentially inappropriate drugs, 66 propriate medicationuse in adults 65 yearsand older in wereconsidered by the panelto haveadverse outcomes the United States. of high severity. lYlcthcdr: This study used a modified Delphi method, a Concludonr: This study is an importantupdate of pre- setof proceduresand methodsfor formulating a groupjudg- viously establishedcriteria that have been widely used ment for a subject matter in which precise information is and cited. The application of the Beerscriteria and other Iacking. The criteria reviewed covered 2 types of state- tools for identifying potentially inapproprlate medica- ments: (l) medicationsor medicationclasses that should tion use will continue to enableproviders to plan inter- grnerally be avoidedin persons 65 years or older because ventionsfor decreasingboth drug-relatedcosts and over- they are either ineffective or they pose unnecessarilyhigh all costsand thus minimize drug-relatedproblems. risk for older personsand a saferalternative is availableand (2) medicationsthat should not be usedin older persons known to have specificmedical conditions. Arch InternM ed,2003 ;1 63 :27 1 6-27 24 oxlc EFFEcTSof medica- to costthe nation $8 biilion annually.5In tions and drug-relatedprob- 2000, it is estimatedthat medication- lems can have profound relatedproblems caused I06000 deaths medical and safety conse- annuallyat- a cost of $85 billion.6Others + quencesforolderadultsand have calculatedthe cost of medication- economically effect the health care sys- relatedproblems to be $76.6billion to am- tem. Thirty percentof hospitaladmissions bulatory care,$20 billion to hospitals,and in elderly patients may be linked to drug- $4 billion to nursinghome facilities.2'7'8If relatedproblems or drug toxic effects,rAd- medication-relatedproblems were ranked versedrug evens (ADEs)have been linked asa diseaseby causeof death,it would be From the Departmentof to preventableproblems in elderly pa- the fifth leading causeof death in the Medicine,Center Health Jor tientssuch asdepression, constipation, falls, United States.eThe preventionand rec- CareImprowment (Drs Ftch and hip frac- ognition of drug-relatedproblems in el- and Maclean);and OlJiceof immobility, confusion, derly patientsand other vulnerablepopu- Bio statistics (Dr Waller), rures.l'2A 1997 study of ADEs found that health care MedicalCollege of Georgia, 35o/oof ambulatory older adults experi- Iations is one of the principal Augusta;Department of encedan ADE and 29olorequired health care quality and safetyissues for this decade. Vet er ans AJJ air s M edi c al services(physician, emergency depart- Center,Augustd (Dr Fich); ment,or hospitalization)lor theADE.] Some CME courseavailable at DepartmentoJ Clinical and two thirds of nursing facility residens have ww w . dr chinternme d. c om Administrativ e Pharmacy, ADEs overa 4-yearperiod.s Of theseADEs, Pharmacy, Collegeof I in 7 resultsin hospitalization.a The aforementionedIOM report has Untuersityof Georgia,Athens, Recent estimatesof the overall hu- focusedincreased attention on finding so- (Drs CooperandWade); and medication practices, Merch6 Co Inc,West Point. man and economicconsequences of medi- lutions for unsafe Pa (Dr Beers).The authors cation-relatedproblems vastly exceedthe polypharmacy,and drug-relatedproblems (IOM) There are many haveno relevantJinancial findings of the Institute of Medicine in the care of older adults. interestin this article. on deathsfrom medical errors,estimated ways to define medication-relatedprob- ARCHINTERN MED/VOL 163. DEC 8/22.2003 WWW.ARCHINTERNMED.COM 2716 Downloader@ill0lAmerichirft[ndicdlcAcsotldtiomsft!ofglttridq€flvddly 24,2008 (REPRINTED WITH CORRECTIONS) lems in elderly patients, including the use of lists contain- Beloware the Beers criteria published in 1997. In parts 1 and2, we are firsl ing specificdrugs to avoid in the elderly and appropriate- askingyou t0 rateyour level 0f agreement onthese 1997 criteria. nessindexes applied by pharmacistsor clinicians.l'10'11 Pl€aseanswer the f0llowing questions regarding the use of medicationslnadults Systematicreview of the evidence-basedliterature on medi- 65yearc ot oldBr. cation use in eiderly patients is another approach to de- Pleasegive one of the following answers: fining the problem,but the number of controlledstudies 1=StronglyAgre€2=Agree 3=Unsure 4=Disagree s=StronglyDisagree on medicationuse in elderlypatients is limited. 0=Unableto offer an opinion The useof consensuscriteria for safemedication use 1) Propoxyphene(Darvon) and combination products (Darvon with ASA, in elderiypatients is one approachto developingreliable Darvon-N,and Darvocet-N) should be avoided. and explicit criteria when preciseclinical information is 123450 Iacking.The two most widely usedconsensus criteria for Samplesurvey question. medicationuse in older adults are the Beerscriteria and the Canadiancriteria.r2-ra The Beerscriteria are basedon expert consensusdeveloped through an extensivelitera- facility populations older than 65 years in the United ture reviewwith a bibliographyand questionnaireevalu- States.There were 3 main aims: (1) to reevaluatethe ated by nationally recognizedexperts in geriatric care, 1997 criteria to include new products and incorporate clinical pharmacology,and psychopharmacologyusing a new information available from the scientific literature, modified Delphi technique to reach consensus. The (2) to assign or reevaluatea relative rating of severity have been Beerscriteria used to survey clinical medica- for eachof the medications,and (3) to identify any new tion use, analyzecomputerized administrativedata sets, conditions or considerationsnot addressedin the 1997 and evaluateintervention studies to decreasemedication criteria. problemsin older adults.The Beerscriteria were also adoptedby the Centerslor Medicare& MedicaidSer- vices (CMS) in July 1999 for nursing home regulation. Previousstudies have shown these criteria to be useful There were 5 phasesin the data collection for this study: (1) in decreasingproblems in older adults.r5-1eThese crite- the review of the literature, (2) creation and mailing of the round I questionnaire,(3) ria, though controversialat times,have been widely used creation of the second-round question- naire based on round I and expert panel feedback,(4) con- over the past l0 yearsfor studying prescribingpatterns vening of the expert panel and panel responsesto the second- within populations,educating ciinicians,and evaluating round questionnaire,and (5) completionand analysisofa third health outcomes,cost, and utilization dau.20-21 and final mailed questionnairethat measuredthe severityrat- A recently published study of potentially inappro- ings of the PIMS to createthe final revisedlist. priatemedication (PIM) usewith the Beerscriteria in a The criteria reviewed covered 2 types of statements:(1) Medicare-managedcare population found a PIM preva- medicationsor medication classesthat shouldgenerally be lenceo[ 23%(541/2336). Those receiving a PIM hadsig- avoidedin persons 65 years or older becausethey are either nificantly higher total, provider, and facility costsand a ineffective or they pose unnecessarily high risk for older per- (2) highermean number oI inpatient,outpatient, and emer- sons and a safer alternative is availableand medications that should not be in persons gencydepartment visits than comparisonsafter control- used older known to have spe- cific medical conditions.The 2 statements each used a 5-point ling for sex,Charlson Comorbidity Index, and toralnum- Likert scaleand ask respondents to rate their agtee*ent oi dis- ber of prescripti.ons.20Other studieshave found that specific agreementwith the statement from strongly agree (1) to PIMs such as nonsteroidal anti-inflammatory drugs strongly disagree(5), with the midpoint (3) expressingequivo- (NSAIDs)and benzodiazepineshave been associated with cation. The second type of question asked the respondents to adverseoutcomes and increasedcosts.ls In contrast,a re- evaluate the medication appropriateness given certain condi- centstudy on the relationshipbetween inappropriate drug tions or diagnoses (Flgurc). All questions included an option use, functional statusdecline, and mortality in 3234 pa- to not answer if the respondent did not feel qualified to tients from the Duke cohort did not find an association answer. This methodology was similar to that used by Beerset with mortality and inappropriatedrug useas determined a|r in the creation o[ the first 2 iterations of the criteria.The methodology by the Beerscriteria after controlling for covariates.2a used in the third irerarion of the Beerscrireria only differed in the number of panelists(13 in I99t; in In summary,these criteria have been used exten- 6 1997; and 12 in 2002) and the use of a third-round