Why Geriatric-Specific Medication Criteria Are Necessary
As individuals age, numerous physiological changes occur that alter how the body absorbs, distributes, metabolizes, and eliminates drugs. Factors such as decreased renal and hepatic function, changes in body composition, and increased sensitivity to certain medications can increase the risk of adverse drug events (ADEs), drug-drug interactions, and drug-disease interactions. Furthermore, older adults often have multiple chronic conditions, leading to polypharmacy—the use of multiple medications simultaneously. These complexities necessitate specialized tools to ensure appropriate and safe prescribing.
The AGS Beers Criteria: A Standard for PIMs
The American Geriatrics Society (AGS) Beers Criteria is a widely recognized and frequently updated list of potentially inappropriate medications (PIMs) for older adults. First published in 1991, the criteria were developed to help clinicians weigh the risks and benefits of specific medications in this population. The latest version was updated in 2023, reflecting new research and clinical evidence.
Core Categories of the Beers Criteria
The criteria are structured into five main categories to guide prescribers:
- Medications to avoid in most older adults: These drugs carry a high risk of adverse effects and often have safer alternatives available. Examples include certain benzodiazepines and first-generation antihistamines.
- Medications to use with caution: These drugs may be potentially inappropriate for some older adults, and their use requires careful consideration of the risk-benefit balance.
- Potentially inappropriate medications for older adults with certain diseases or conditions: Some drugs can exacerbate specific medical conditions, such as heart failure, and should be avoided in those contexts.
- Drug-drug interactions: The criteria list combinations of medications that can cause harmful interactions, highlighting the need for careful medication review.
- Medications to be avoided or have their dosage adjusted based on kidney function: Kidney function often declines with age, requiring dose modifications for many drugs to prevent toxicity.
STOPP/START Criteria: A Complementary Approach
Developed in Europe, the STOPP/START (Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert doctors to Right Treatment) criteria provide a more comprehensive, physiological systems-based framework for medication review. While Beers primarily focuses on what to avoid, STOPP/START addresses both potentially inappropriate prescriptions (STOPP) and prescribing omissions (START).
How STOPP/START Works
- STOPP (Screening Tool of Older Persons' Prescriptions): This part of the criteria lists medications that are commonly and inappropriately prescribed for older adults, often leading to avoidable adverse effects. The third version, updated in 2023, includes 133 specific criteria.
- START (Screening Tool to Alert doctors to Right Treatment): This unique component addresses the problem of undertreatment in older adults by highlighting medications that are potentially omitted for specific conditions. The latest version includes 57 START criteria.
The Importance of Addressing Prescribing Omissions
Undertreatment can be just as harmful as overtreatment. For example, an older adult with coronary artery disease might not be prescribed a statin or antiplatelet agent, increasing their risk of a cardiovascular event. The START criteria help healthcare providers proactively identify and correct these omissions.
A Comparative Look: Beers vs. STOPP/START
While both sets of criteria aim to improve medication safety in older adults, they have different focuses and origins. Understanding their differences helps clinicians determine which tool is best suited for a particular clinical scenario or population.
| Feature | AGS Beers Criteria | STOPP/START Criteria |
|---|---|---|
| Origin | American Geriatrics Society (AGS) | European expert panel |
| Primary Focus | Explicitly identifying potentially inappropriate medications (PIMs) to avoid. | Comprehensive review for both PIMs (STOPP) and potential prescribing omissions (START). |
| Structure | Organized into five main categories, including drug-disease interactions and kidney function. | Organized by physiological system (e.g., cardiovascular, central nervous system). |
| Target Audience | Primarily US clinicians, widely known in the US healthcare system. | Primarily European clinicians, though used internationally. |
| Advantages | Easy to use for quick screening of high-risk drugs; highly recognized and regularly updated. | More comprehensive in scope by including prescribing omissions; based on a physiological systems approach. |
| Limitations | Primarily an avoidance list; may not be suitable for all patient care scenarios, such as end-of-life care. | More extensive, which can be time-consuming for busy clinicians; implementation can be complex. |
Practical Application and Future Direction
Using these consensus criteria effectively requires more than just checking a list. It involves integrating them into a holistic, patient-centered approach. Healthcare professionals must use their clinical judgment, considering individual patient preferences, goals of care, and overall health status.
Key Steps for Implementing Appropriate Medication Management
- Medication Reconciliation: Perform a comprehensive review of all medications, including prescription, over-the-counter drugs, and supplements. The 'brown bag' method, where patients bring all their medications, can be highly effective.
- Deprescribing: Purposefully and systematically stopping or reducing the dose of one or more medications when the potential for harm outweighs the benefits.
- Use Technology: Leverage electronic health records (EHRs) and computer decision support systems that integrate Beers or STOPP/START criteria to flag potential issues at the point of care.
- Team-Based Approach: Involve pharmacists, nurses, and other care team members in medication reviews to ensure a thorough and collaborative process.
- Patient Education and Shared Decision-Making: Educate older adults and their caregivers about medication risks and benefits, and involve them in decisions about their treatment plans.
For more information on the official guidelines and resources for safe prescribing, visit the American Geriatrics Society (AGS).
Conclusion
The AGS Beers Criteria and STOPP/START criteria are invaluable tools for guiding appropriate medication use in older adults. By providing evidence-based lists of potentially inappropriate medications and prescribing omissions, they help mitigate the risks associated with polypharmacy and age-related physiological changes. However, these criteria are best used as part of a larger strategy that includes careful clinical judgment, regular medication reviews, and active patient involvement. By combining these consensus criteria with a person-centered approach, healthcare providers can significantly enhance medication safety, reduce adverse drug events, and improve the overall quality of life for older adults.
