Understanding the Beers Criteria
What is the Beers Criteria?
First published in 1991, the AGS Beers Criteria® is a widely-used set of guidelines to help healthcare professionals identify medications that may cause more harm than benefit in older adults. It is not a rigid rule, but a clinical tool that encourages shared decision-making between patients and doctors to optimize medication use. The criteria address multiple drug classes and are regularly updated to reflect new research and clinical evidence. For older adults, age-related physiological changes—such as altered drug clearance and increased sensitivity—can make certain medications more dangerous than for younger individuals.
Why are sleep medications highlighted?
Sleep disturbances are common in older age, but many medications used to treat them carry disproportionately high risks. The Beers Criteria specifically flags several classes of sedative-hypnotics, including benzodiazepines and non-benzodiazepine receptor agonists (often called 'Z-drugs'), due to concerns about side effects that are particularly problematic for seniors. These risks, which include impaired cognition, increased fall risk, and dependence, often outweigh the modest benefits for improving sleep.
Specific sleep medications on the Beers Criteria list
Benzodiazepines
This class of drugs, which includes medications like diazepam (Valium) and lorazepam (Ativan), is often listed as potentially inappropriate for older adults. The Beers Criteria recommends avoiding them due to several risks:
- Increased sensitivity: Older adults are more sensitive to the central nervous system (CNS) depressant effects of benzodiazepines, leading to a higher risk of delirium, sedation, and cognitive impairment.
- Risk of falls and fractures: Sedation and reduced psychomotor function can increase the likelihood of falls, which can lead to serious injuries like hip fractures.
- Tolerance and dependence: The body can quickly develop tolerance to the hypnotic effects, and long-term use can lead to physical dependence.
- Prolonged half-life: Some benzodiazepines have a long half-life, meaning they stay in an older person’s system longer, leading to accumulation and increased risk of side effects.
Non-benzodiazepine receptor agonists ('Z-drugs')
Medications like zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) are also on the Beers list. While often perceived as safer than benzodiazepines, they pose similar risks for older adults:
- Adverse CNS effects: They are associated with a higher risk of delirium, confusion, and psychomotor impairment, especially at higher doses.
- Increased fall risk: Similar to benzodiazepines, these medications can cause unsteadiness and increase the risk of falls and fractures.
- Tolerance and dependence: There is a risk of developing tolerance and physical dependence, making discontinuation difficult.
- Limited evidence of efficacy: While approved for longer-term use in some cases, the evidence for their long-term effectiveness in older adults is weak and the risks are notable.
Comparison of potentially inappropriate sleep medications
| Feature | Benzodiazepines (e.g., Diazepam) | Non-benzodiazepine receptor agonists (e.g., Zolpidem) | Antihistamines (e.g., Diphenhydramine) |
|---|---|---|---|
| Risks in older adults | Delirium, sedation, cognitive impairment, falls, dependence | Delirium, falls, confusion, psychomotor impairment, dependence | Highly anticholinergic, confusion, sedation, constipation, urinary retention, dry mouth |
| Beers Criteria status | Avoid due to high risk of adverse CNS effects and dependence. | Avoid due to risks of delirium, falls, and other CNS effects. | Avoid due to anticholinergic effects and high risk of confusion. |
| Half-life | Often long-acting, leading to accumulation. | Generally shorter, but still carries significant risk. | Can be long-acting, causing daytime sedation. |
| Recommendation | Use for short-term, specific indications only if absolutely necessary, after non-pharmacologic options fail. | Use with caution for very short periods; risks often outweigh benefits. | Never use as a sedative in older adults. |
Alternatives to medication for better sleep
The Beers Criteria promotes exploring non-pharmacological interventions first, especially for older adults. Many strategies can effectively address sleep problems with far fewer risks:
- Cognitive Behavioral Therapy for Insomnia (CBT-I): This is considered the gold standard treatment for chronic insomnia and has excellent outcomes with long-lasting results. It addresses the thoughts and behaviors that contribute to sleep problems.
- Sleep hygiene education: Simple lifestyle adjustments can have a big impact. This includes establishing a consistent sleep schedule, creating a relaxing bedtime routine, avoiding caffeine and alcohol in the evening, and ensuring the bedroom is dark, quiet, and cool.
- Exercise: Regular physical activity, especially earlier in the day, can help improve sleep quality. Strenuous exercise too close to bedtime, however, can be counterproductive.
- Managing underlying conditions: Conditions such as restless legs syndrome, sleep apnea, or other health issues can disrupt sleep. Addressing these with a healthcare provider can resolve the sleep issue.
- Environmental modifications: Changing lighting, adjusting room temperature, and using white noise machines can help create a better sleep environment.
For a deeper dive into the specifics of the American Geriatrics Society's guidelines, you can review the latest official version of the AGS Beers Criteria®. This resource is invaluable for healthcare professionals and patients alike.
Making an informed decision
Navigating sleep challenges as an older adult requires careful consideration of the risks and benefits of all treatment options. The Beers Criteria serves as a vital reminder that what works for a younger person might not be appropriate or safe for a senior. By prioritizing non-medication strategies and using the Beers list as a guide, older adults and their healthcare providers can make safer, more informed decisions about sleep medication. This patient-centered approach ensures the focus remains on long-term well-being rather than short-term symptom management with potentially harmful side effects.
