BEERS CRITERIA FOR MEDICATION USE IN OLDER PATIENTS: DANGEROUS COMBINATIONS
Until I read the April 2024 issue of American Family Physician, I was unaware the American Geriatrics Society (AGS) had established a set of guidelines for the use of “Potentially Inappropriate Medications (PIM).” These guidelines, called the Beers Criteria, suggest that certain combinations of medications should be avoided by older adults because of the possibility of severe adverse interactions. These criteria were first introduced in 1991, but have been updated several times with 2023 being the most recent.
The list of drugs the AGS has evaluated is very exhaustive, and many drugs have a single interaction listed to be avoided. Overall, guidelines have been narrowed down to two broad general categories which are:
1. Avoid combining 3 or more drugs that act on the central nervous system.
2. Avoid 2 or more drugs that have strong anticholinergic properties (interfere with the
parasympathetic nervous system)
Avoiding combining central nervous system drugs means
Anticonvulsants (anti-seizure drugs)
Antidepressants
Antipsychotics
Tranquilizers
Opioids
It is obvious that combining these drugs can cause sedation, agitation, hallucinations, abnormal muscle movements, among other disturbing symptoms.
Avoiding combining drugs with strong anticholinergic properties means
Antidepressants
Antiemetics (for nausea, vomiting)
Antihistamines (first generation-meclizine, Dimetapp, Benadryl, Chlortrimeton, etc)
Antimuscarinics (bladder control drugs-Ditropan, Detrol, etc.)
Antiparkinsonians
Antipsychotics
Antispasmodics (Atropine, Scopolamine, Librax, Bentyl, etc.)
Muscle Relaxants
Combining these can cause hallucinations, glaucoma, dry mouth, constipation, sedation, and
urinary retention.
Single recommendations are:
Antithrombotic (anti-blood clot) drugs: The Beers Criteria prefer non-warfarin anticoagulants over warfarin (Coumadin), initially and long term, for patients with non-valvular atrial fibrillation or venous blood clots. This is in spite of my experience with much more common bleeding problems with newer drugs like Eliquis, Pradaxa, and Xarelto.
Estrogen in all delivery forms should be avoided.
Diabetes should not be treated with sulfonylureas (Amaryl, Diabinese, Glucotrol) because of a higher risk of low blood sugar and more cardiovascular events.
For high blood pressure angiotensin converting enzyme inhibitors (ACEI like lisinopril, ramipril, captopril, enalopril, etc) should not be combined with angiotensin receptor blockers (ARB-Losartan, irbesartan, valsartan, etc.) and with potassium-sparing diuretics (spironolactone, triamterene). They can cause severe hyperkalemia (elevated blood potassium) with fatal arrhythmias.
The journal article that published the updated 2023 Beers Criteria was 30 pages long so you can surmise from that that what I have related here only scratches the surface. The real message in these criteria is the potential harm that can result from older patients taking multiple prescription drugs that interact unfavorably with one another plus the confusion added to the mix by taking certain OTC drugs. The waters get very muddy and patients are at risk of serious adverse interactions unless someone, primarily the family physician, doesn’t oversee the med list and stop, or change, combinations with potential problems. Pharmacists and electronic medical record programs detect adverse interactions as well. I think that today most doctors keep a med list in the patient’s record and look for problems. They also are aware of drug interactions and avoid dug combinations that conflict. Still, the FMD is the person who should be the most attentive to this problem.
References: Practice Guidelines: Beers Criteria for Inappropriate Medication Use in Older Adults: Update from the American Geriatrics Society. Am Fam Phys 2024 April;109(4):374-375.
American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc 2023;71(7):2052-2081.
