BEERS CRITERIA: ORIGIN, CLASSIFICATION, CONTROVERSIES - MEDICINE - 2025

The Beers criteria are a group of tools designed to detect medications that can be dangerous for the elderly. Older adults, from the medical point of view, represent a group of patients whose management is complex. Their physical, metabolic and mental characteristics make them really unique.

Because of this, the medical and pharmaceutical industry does not usually develop drugs specifically intended for this age group. However, they too require many treatments and the effects and consequences of their use must be known to determine which are safe and which are not.

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The pharmacokinetic and pharmacodynamic behavior of many drugs is modified depending on the age of the patient who will consume them. It is known that in the elderly there is a certain tendency to accumulate drugs or active forms of these in the body, both due to slow metabolism and the handling of inappropriate doses.

In today's world, thanks to the same medical advances, life expectancy has been exponentially prolonged. Many people over 65 are part of the world's population and are more likely to get sick. Taking care of them is important in developed nations and for them there are the Beers criteria.

Origin

The work of studying the effects of certain medications on the body of older adults was initially carried out by the American geriatrician Mark Howard Beers.

Hence the name "Beers criteria". This was done through the opinion of a group of experts using the Delphi method and other similar techniques.

The first consensus was produced in 1991. At that time, more than 150 drugs commonly used in older adults were evaluated, concluding that 41 of the drugs studied were unsuitable for use in the elderly. Another 7 also showed significant adverse effects in older adults but at certain doses.

Since then, numerous changes have been made. The last major update was in 2012, in which 199 drugs were evaluated, of which 53 were marked as inappropriate. Three years later, in 2015, the American Geriatrics Society carried out a new review with slight final changes.

Classification

The latest update of the Beers criteria, respecting the modifications carried out in 2012, classifies drugs into three different categories, namely:

Potentially inappropriate medications to avoid in any patient over 65 years of age.

In this group there are up to 34 different drugs that should be avoided in older adults under almost any circumstance. They are only authorized when they are essential to save the life of the patient and cannot be replaced by another.

Representatives of this group with the highest degree of evidence and strength of recommendation include: chlorpheniramine, hydroxyzine, nitrofurantoin, doxazosin, most NSAIDs and benzodiazepines. The new members of this group are megestrol (hormone - progesterone), glibenclamide (hypoglycemic) and insulin in a mobile scheme.

Potentially inappropriate medications to avoid in patients over 65 with certain particular diseases or syndromes.

This list is the most numerous. The reason for this is that there are many drugs that interact with others that have been indicated to treat a specific pathology and this relationship is more evident in older adults. It should not be forgotten that the elderly get sick more frequently and are usually polymedicated.

The most important new inclusions include glitazones - blood sugar normalizers - contraindicated in heart failure. Acetylcholinesterase inhibitors (donepezil) that should not be used in elderly patients with syncope and selective serotonin reuptake inhibitors that should be avoided in older patients with fractures.

Medications that should be indicated with caution in older adults.

These drugs are not formally contraindicated in the elderly but have shown certain unwanted side effects. The cost / benefit risk is acceptable as well as the tolerance of the patients. This list includes 40 drugs or drug families that share similar characteristics.

Two newer antithrombotics, prasugrel and dabigatran, are included in this category, which increase the risk of bleeding above what is acceptable in patients 75 years of age or older. The same is true of aspirin, whose benefits in the elderly over 80 years of age have been questioned.

The 2015 revision also includes some tables of information regarding the drugs that were changed category, those that were excluded from the Beers list and those that were added since 2003.

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There are also exclusive lists of drug families with many representatives in the Beers criteria. Among the most important groups of drugs are antipsychotics, with 12 representatives of the first generation and 10 of the second, as well as the almost 50 drugs with anticholinergic effects that should not be used in the elderly.

Controversies

Despite the original altruistic intentions of its creator, the Beers criteria are not without controversy. Controversies have arisen for three basic reasons since the first days of the publication of these protocols, including:

Scientific reasons

Although the Beers criteria arose thanks to the action of a group of experts and the use of the Delphi method, many have questioned the scientific bases of the same.

The main argument is that a real prospective study of each drug was not carried out but rather anecdotal reports on side effects were used.

For this reason, new evaluation systems for drugs indicated in older adults appear, such as the STOPP / START study, the TRIM protocol, the CIM-TRIAD study or the NORGEP-NH criteria. Most of them were carried out in countries in Europe and Asia, although there is some data from Africa and America.

The latest updates to the Beers criteria attempted to resolve this issue. They used recent prospective studies carried out by third parties, whose data is auditable and verified.

Business reasons

Some pharmaceutical companies have complained when seeing their products included in this list. This has caused a significant decrease in the sales of some drugs.

However, they have never manufactured drugs for the elderly, so lately they have dedicated a certain budget to investigate its effects in older adults.

Clinical reasons

Full respect for these criteria would leave many older patients without treatment. For this reason, many doctors have no choice but to indicate them but with certain restrictions.

The fact that there are almost no drugs for the elderly means that they often do not have therapeutic options for their diseases.

References

1. Vrdoljak D, Borovac JA. Medication in the elderly - considerations and therapy prescription guidelines. Academic Medical Act. 2015; 44 (2): 159-168. Available at ama.ba
2. Steinman (Chair) MA, Beizer JL, DuBeau CE, Laird RD, Lundebjerg NE, Mulhausen P. How to Use the AGS 2015 Beers Criteria - A Guide for Patients, Clinicians, Health Systems, and Payors. Journal of the American Geriatrics Society. 2015; 63 (12): e1-e7. Available at onlinelibrary.wiley.com/
3. Pastor-Cano J, Aranda-Garcia A, Gascón-Cánovas JJ, Rausell-Rausell VJ, Tobaruela-Soto M. Spanish adaptation of Beers criteria. Annals of the Navarra Health System. 2015; 38 (3): 375-385. Available at recyt.fecyt.es/
4. Campanelli CM. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society. 2012; 60 (4): 616-631. Available at onlinelibrary.wiley.com/
5. Sánchez-Muñoz LA. Inappropriate medication use in the elderly. Beers or STOPP-START criteria? Hospital pharmacy. 2012; 36 (6): 562-563. Available at grupoaulamedica.com/
6. Niehoff KM, Rajeevan N, Charpentier PA, Miller PL, Goldstein MK, Fried TR. Development of the Tool to Reduce Inappropriate Medications (TRIM): A Clinical Decision Support System to Improve Medication Prescribing for Older Adults. Pharmacotherapy. 2016; 36 (6): 694-701. Available at ncbi.nlm.nih.gov/
7. Heser K, Pohontsch NJ, Scherer M, et al. Perspective of elderly patients on chronic use of potentially inappropriate medication - Results of the qualitative CIM-TRIAD study. Marengoni A, ed. PLoS ONE. 2018; 13 (9). Available at journals.plos.org/
8. Wikipedia, the free encyclopaedia. Beers Criteria. Last update 2017. Available at en.wikipedia.org/