Understanding the American Geriatrics Society (AGS) Beers Criteria
For older adults, managing medication is a complex process due to age-related changes that affect how the body processes and responds to drugs. In this context, the American Geriatrics Society (AGS) Beers Criteria plays a vital role. This guideline, regularly updated by experts, identifies potentially inappropriate medications (PIMs) for older people. A drug can be on the list for several reasons: it may be less effective in older adults, pose a higher risk of adverse side effects, or interact dangerously with other medications or chronic health conditions common in this population.
Identifying which drug classification is on the list of potentially inappropriate medications (PIM) for older adults is the first step toward promoting safer prescribing practices. The goal is to maximize the therapeutic benefits of medications while minimizing the associated risks, thereby reducing the incidence of adverse drug events (ADEs), emergency room visits, and hospitalizations.
The Problem with Anticholinergic Drugs
Many of the medications flagged as potentially inappropriate for older adults exhibit anticholinergic properties. These drugs work by blocking the action of acetylcholine, a neurotransmitter involved in several bodily functions, including memory, muscle contractions, and heart rate regulation. While effective for treating various conditions, the side effects can be particularly pronounced and problematic in older individuals, who are more sensitive to their effects due to age-related physiological changes.
Adverse Effects of Anticholinergics
- Cognitive impairment: Can lead to confusion, delirium, and memory problems, especially in those with pre-existing cognitive issues.
- Central nervous system effects: Increased risk of dizziness, drowsiness, and sedation, which elevates the risk of falls and hip fractures.
- Peripheral effects: Include dry mouth, blurred vision, constipation, and difficulty urinating due to the medication's impact on various organ systems.
Examples of High-Risk Anticholinergics
- First-generation antihistamines: Common over-the-counter allergy and sleep aids like diphenhydramine (Benadryl).
- Tricyclic antidepressants: Such as amitriptyline (Elavil) and imipramine (Tofranil), which have strong anticholinergic effects.
- Gastrointestinal antispasmodics: For example, dicyclomine (Bentyl) used to treat cramps and irritable bowel syndrome.
The Dangers of Benzodiazepines for Older Adults
Another major classification of drugs on the PIM list is benzodiazepines, often prescribed for anxiety, insomnia, and seizures. While helpful in certain short-term situations, their use in older adults is strongly discouraged by organizations like the American Geriatrics Society due to a heightened risk of adverse effects.
Risks Associated with Benzodiazepines
- Increased fall risk: Their sedative and muscle-relaxing properties can impair balance and coordination, making falls more likely.
- Cognitive decline: Benzodiazepines can contribute to memory problems and cognitive impairment, potentially worsening existing dementia or impacting day-to-day mental function.
- Dependence and withdrawal: Prolonged use can lead to dependence, and sudden discontinuation can cause severe withdrawal symptoms, including seizures.
Other High-Risk Drug Classifications
Beyond anticholinergics and benzodiazepines, several other drug categories are identified as potentially inappropriate for older adults, each posing unique risks.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
For chronic use, many NSAIDs are considered inappropriate due to elevated risks of gastrointestinal bleeding, kidney injury, and increased blood pressure, especially in older adults with pre-existing conditions like kidney disease or heart failure. The risk of adverse effects outweighs potential benefits for long-term pain management.
Specific Cardiovascular Medications
Certain older cardiovascular drugs, such as digoxin at higher doses ($>0.125$ mg/day), are on the list. In older adults, a reduced volume of distribution and declining renal function can lead to drug accumulation and toxicity. Toxicity symptoms can include gastrointestinal issues and altered mental status.
Antipsychotics
Many antipsychotics, particularly first-generation (typical) antipsychotics, carry a heightened risk of stroke and death in older adults with dementia. They can also increase the risk of falls and other extrapyramidal side effects. While newer (atypical) antipsychotics are sometimes used, their risks must be carefully weighed against the benefits.
Comparison of High-Risk Drug Categories
| Drug Classification | Primary Reason for Inappropriateness | Common Adverse Effects in Older Adults | Alternatives to Consider |
|---|---|---|---|
| Anticholinergics | Increased sensitivity to adverse effects, especially cognitive impairment. | Confusion, sedation, dry mouth, constipation, blurry vision. | Second-generation antihistamines, non-medication strategies for sleep/allergies. |
| Benzodiazepines | Increased risk of sedation, falls, cognitive impairment, and dependence. | Dizziness, drowsiness, memory problems, withdrawal symptoms. | Cognitive behavioral therapy, safer sleep aids (e.g., zolpidem at lowest dose), gabapentinoids for anxiety. |
| NSAIDs (Chronic use) | High risk of gastrointestinal bleeding, kidney injury, and blood pressure issues. | Gastric ulcers, renal failure, worsening heart failure, elevated blood pressure. | Acetaminophen (within recommended dose), topical NSAIDs, physical therapy. |
| Digoxin (High dose >0.125mg/day) | Increased risk of toxicity due to age-related changes in body composition and kidney function. | Gastrointestinal issues, confusion, visual disturbances, irregular heart rhythms. | Safer and more effective heart failure medications. |
| Antipsychotics (Typical) | Higher risk of stroke and death in those with dementia; increased fall risk. | Sedation, extrapyramidal symptoms, confusion, falls. | Non-pharmacological interventions, limited and cautious use of certain atypicals. |
Navigating Medication Safety for Older Adults
Medication management for older adults requires careful consideration and a collaborative approach involving patients, caregivers, and healthcare professionals. Relying on tools like the AGS Beers Criteria is essential for ensuring patient safety and quality of care.
What can patients and caregivers do?
- Maintain a current medication list: Keep an updated list of all medications, including over-the-counter drugs, supplements, and vitamins, to share with every healthcare provider.
- Ask about alternatives: If a medication on the Beers Criteria list is prescribed, discuss whether safer or equally effective alternatives are available.
- Understand potential side effects: Be aware of common adverse effects associated with your medications and report any issues promptly to a healthcare provider.
- Never stop a medication abruptly: Discontinuation of certain drugs, like benzodiazepines, requires a gradual tapering process under medical supervision to avoid severe withdrawal symptoms.
The Role of Healthcare Providers
Healthcare providers have a responsibility to regularly review patients' medication regimens, a practice known as 'deprescribing', to assess if any PIMs can be reduced or eliminated safely. This includes being vigilant about drug-drug and drug-disease interactions, as well as adjusting dosages based on renal function.
Conclusion: Prioritizing Safety in Medication Management
Navigating the complex landscape of medication safety for older adults is a continuous process of evaluation and adjustment. By being aware of which classification of drugs is on the list of potentially inappropriate medications (PIM) for older adults, patients, caregivers, and healthcare providers can work together to mitigate risks and improve health outcomes. The Beers Criteria serves as a crucial resource for guiding safer prescribing and promoting healthier, more secure aging. Always consult with a healthcare professional to determine the most appropriate medication strategy for your individual needs. For a comprehensive overview of the updated criteria, visit the American Geriatrics Society's official resources available on their website.
Visit the American Geriatrics Society for Official Beers Criteria Resources
