What is the Beers Criteria?
It’s nearly impossible to read a geriatrics-focused journal without seeing a reference to the Beers List, formally known as the American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medicine Use in Older Adults. It is well known that the Beers Criteria® are used extensively by practitioners, researchers, policymakers, and others as the gold standard for medication prescribing and use in older adults. However, not everyone knows its background, how it evolved, or much about its creator and namesake.
Mark Beers, MD, was a physician and geriatrician. In the 1980s, he led a Harvard University team in a study of 850 nursing home residents regarding their case histories and the medications they received. Using a Delphi survey method, they found that many of these patients exhibited mental confusion and tremors associated with the use of antidepressants, antipsychotics, and sedatives; and they developed 30 criteria sets to identify potentially inappropriate medications for nursing home residents. Their results were published in the Journal of the American Medical Association.
This research inspired Beers to develop a list called the Beers Criteria® in 1991. It listed specific groups of medications, including some antihistamines, antibiotics, antipsychotics, antihypertensives, cardiac medications, and muscle relaxants, that can possibly cause harm in older adults.
The American Geriatrics Society (AGS) assumed administration and oversight of the Beers Criteria® in 2011. It is updated every three years, the last time in 2023. Kishore Bose, PharmD, BCGP, senior manager of clinical services at PharMerica, said, “AGS has been an excellent steward of the criteria, not just publishing the list but also putting good material out to contextualize the contents. For instance, he referred to Table 11 in the document, which addresses the principles for how patients, clinicians, health systems, and payors should use the criteria. “AGS makes it very clear that medications on the list are potentially but not definitively inappropriate,” he said. Additionally, the organization’s commitment to maintaining and updating the criteria “speaks to its impact and how significant it is in the industry. By convening panels to review the body of evidence and updating the criteria every three years, AGS helps ensure it remains a good tool in our toolbelt as providers operating in senior and long-term care spaces,” Bose noted.
He added that he shares this table with his pharmacy students when he takes them on rotation. “We always do an inservice on the Beers Criteria® because it’s important to understand how not to use the list as well as how to use it.”
5 Sections of the Beers Criteria
- Medications to avoid if you’re over 65 years old and not in a hospice or palliative care setting.
- Medications to avoid among people with certain health conditions.
- Medications to avoid that cause drug interactions when combined with other medications.
- Medications to avoid due to harmful side effects that outweigh the benefits.
- Medications to use at limited doses or avoided due to their effects on kidney function (renal impairment).
LInitially, there were some mixed reactions to the Beers Criteria®. Charles Crecelius, MD, PhD, CMD, a semi-retired geriatrician and a past president of PALTmed, recalled, “Most of us realized that this was something that was needed.” Importantly, he noted, it referred to “potentially inappropriate medications,” with “potentially” being the key word. It was clear that prescribers could use the list as a guide and resource and make decisions, weighing the risks and benefits of medications for each individual patient. However, some practitioners were hesitant to embrace the criteria, seeing it as a deterrent to practicing the art of medicine. There also were some concerns about how state surveyors might use the list. At the same time, not everyone agreed that all the medications on the Beers Criteria® belong there. “There are always a few surprises when the list is updated,” Crecelius said.
Today, more than ever, suggested Crecelius, the Beers Criteria® are important as there is a shortage of geriatricians and a growing population of older adults being cared for by practitioners with limited experience or knowledge of geriatrics. “We know that adverse effects and drug interactions are a serious problem, so it’s good to have the Beers Criteria® as a resource,” David Smith, MD, president of Texas-based Geriatric Consultants, said. However, he added that many assisted living and long-term care residents are younger, with disabilities and illnesses that requires higher levels of care, for whom the criteria aren’t applicable.