Beers Criteria Updates with a Focus on Psychiatric Medications

Approximately 44% of men and 57% of women older than 65 years take five or more nonprescription and/or prescription medications per week.¹ Older adults, especially those with psychiatric conditions, are at heightened risk of polypharmacy, drug interactions, and drug-related adverse effects.

Optimizing drug therapy is an essential part of caring for an older person, however, clinicians face unique challenges when prescribing for older patients. Many medications need to be used with special caution because of age-related changes in pharmacokinetics, avoidable adverse drug events (ADEs), comorbid conditions, and more.

Various criteria have been developed by experts to assess the quality of prescribing practices and medication use in older patients. One of the most widely recognized and frequently cited reference tools for assessing inappropriate drug prescribing is the Beers criteria. This article focuses on the recent updates to the Beers criteria that are especially relevant for treating older adults with psychiatric conditions.

Beers Criteria History

First developed by Mark Beers, MD, and colleagues in 1991, the Beers criteria are a list of medications that are considered potentially inappropriate for use in older patients, mostly due to high risk for ADEs. The original version was focused on nursing home residents and subsequent revisions included expanded considerations for all clinical settings. These lists have been staples of care for nearly three decades and were transitioned to the American Geriatrics Society (AGS) in 2011.

Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle. The latest update was unveiled in 2019 as the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. For the update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation.

What are the Beers Criteria?

The AGS Beers Criteria® is a list of potentially inappropriate medications (PIMs) that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. The criteria are intended to be used for all adults aged 65 years and older in institutionalized, acute, and ambulatory care settings, with the exception of patients in hospice and palliative care settings.

“The primary target audience for the AGS Beers Criteria® is practicing clinicians. The criteria are intended for use in adults 65 years and older in all ambulatory, acute, and institutionalized settings of care, except for the hospice and palliative care settings. Consumers, researchers, pharmacy benefits managers, regulators, and policymakers also widely use the AGS Beers Criteria®. The intention of the AGS Beers Criteria® is to improve medication selection; educate clinicians and patients; reduce adverse drug events; and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults.”

Potentially Inappropriate Medications (PIMs)

The AGS Beers Criteria® consists of 5 lists of potentially inappropriate medications (PIMs) under the following subcategories:

1. Medications that are potentially inappropriate in most older adults
2. Medications that should typically be avoided in older adults with certain conditions
3. Drugs to use with caution
4. Drug-drug interactions
5. Drug dose adjustment based on kidney function.

Beers Criteria Updates: Changes Impacting Psychiatric Medications: Noteworthy Changes to PIMs

The following changes were emphasized by the authors of the AGS Beers Criteria® as “noteworthy changes to PIMs for older adults” and are especially relevant for psychiatry.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

The serotonin-norepinephrine reuptake inhibitors (SNRIs) have been added to the list of drugs to avoid in patients with a history of falls or fractures. However, following a principle that applies to all criteria, the panel recognizes there may be situations when SNRIs, other antidepressants, and other medications listed in this criterion may be appropriate for people with a history of falls or fractures, based on potential benefits and the lack of availability of safer alternatives.

A careful risk-benefit assessment should be performed in those cases. If using these medications is necessary, precautions should be taken to reduce the risk of falls, such as limiting the use of other CNS-active medications and employing non-pharmacologic interventions (e.g., removing hazards, wearing appropriate footwear, use of assistive devices).

Antipsychotics

Aripriprazole was removed as the preferred agent to treat psychosis in patients with Parkinson disease while pimavanserin was added. The criteria recognizes quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson’s disease. However, none of these three drugs are close to ideal in terms of safety or efficacy, each having its own limitations and concerns.

Beers Criteria Updates: Changes Impacting Psychiatric Medications

Drugs to Be Used with Caution

• Tramadol was added to the list of drugs associated with syndrome of inappropriate antidiuretic hormone secretion.
• The combination drug dextromethorphan/quinidine was added to this list due its limited efficacy in treating behavioral symptoms of dementia without pseudobulbar affect while potentially increasing the risk of drug interactions and falls.

Drug-Drug Interactions

• Avoid use of opioids concurrently with benzodiazepines
• Avoid use of opioids concurrently with gabapentinoids (except when transitioning from the former to the latter).
• The concurrent use of a combination of three or more central nervous system (CNS) agents (antidepressants, antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, antiepileptics, and opioids) and increased fall risk have been collapsed into one recommendation instead of separate recommendations for each drug class.

Psychiatric Medications Included as PIMs in Most Older Adults

The following psychiatric medications are listed in Table 2: 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults

• First-generation antihistamines:
  • Hydroxyzine
• Alpha-agonists
  • Clonidine
  • Guanfacine
• Antidepressants, alone or in combination
  • Paroxetine
  • Tricyclic antidepressants (TCAs)
• Antipsychotics
• Benzodiazepines
• “Z-drugs”
• Pain Medications
  • Meperidine
  • Non-cyclooxygenase-selective NSAIDS
  • Indomethacin
  • Ketorolac
• Skeletal muscle relaxants

Psychiatric Medications Included as PIMs in Certain Conditions

The following psychiatric medications are listed in Table 3: 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the disease or Syndrome

• Heart Failure
  • NSAIDS and COX-2 inhibitors
• Syncope
  • Tertiary TCAs
  • Chlorpromazine, thioridazine, olanzapine
• Delirium
  • Anticholinergics
  • Antipsychotics
  • Benzodiazepines
  • Meperidine
  • “Z-drugs”
• Dementia or cognitive impairment
  • Anticholinergics
  • Antipsychotics, chronic and as-needed use
  • Benzodiazepines
  • “Z-drugs”
• History of falls or fractures
  • Antidepressants
    • TCAs
    • SSRIs
    • SNRIs
  • Antiepileptics
  • Antipsychotics
  • Benzodiazepines
  • Opioids
  • “Z-drugs”
• Parkinson disease
  • All antipsychotics except
    • Quetiapine
    • Clozapine
    • Pimavanserin
• History of gastric or duodenal ulcers
  • Non-COX-2-selective NSAIDS
• Chronic kidney disease stage 4 or higher
  • NSAIDS

Psychiatric Medications To Be Used With Caution in Older Adults

The following psychiatric medications are listed in Table 4: 2019 American Geriatrics Society Beers Criteria® for Potentially Inappropriate Medications: Drugs To Be Used With Caution in Older Adults.

• May exacerbate or cause SIADH or hyponatremia: monitor sodium level closely when starting or changing dosages in older adults
  • Antipsychotics
  • Carbamazepine
  • Mirtazapine
  • Oxcarbazepine
  • SNRIs
  • SSRIs
  • TCAs
  • Tramadol
• Dextromethorphan/quinidine may increase risk of falls and concerns with clinically significant drug interactions. Limited efficacy in patients with behavioral symptoms of dementia. Does not apply to treatment of pseudobulbar affect.

Psychiatric Drug-Drug Interactions To Avoid in Older Adults

The following psychiatric medications are listed in Table 5: 2019 American Geriatrics Society Beers Criteria® for Potentially Clinically Important Drug-Drug Interactions That Should Be Avoided in Older Adults

• Opioids – Benzodiazepines
• Opioids – Gabapentin, pregabalin
• Anticholinergic – Anticholinergic
• Any combination of three or more CNS-active drugs
  • Antidepressants (TCAs, SSRIs, and SNRIs)
  • Antipsychotics
  • Antiepileptics
  • Benzodiazepines
  • “Z-drugs”
  • Opioids
• Lithium – ACEIs
• Lithium – Loop diuretics
• NSAIDs – Corticosteroids
• NSAIDs – Warfarin

Psychiatric Medications With Dose Adjustment Based on Kidney Function

The following psychiatric medications are listed in Table 6: 2019 American Geriatrics Society Beers Criteria® for Medications That Should Be Avoided or Have Their Dosage Reduced With Varying Levels of Kidney Function in Older Adults

• Duloxetine
• Gabapentin
• Pregabalin
• Tramadol

In Conclusion

Older adults, especially those with psychiatric conditions, are at heightened risk of polypharmacy, drug interactions, and drug-related adverse effects. The AGS Beers Criteria® are a rigorously developed, evidence-based tool to guide clinicians’ decision-making when prescribing for geriatric populations. However, the criteria cannot account for the complexities of patient subpopulations in real-world practice. The Beers criteria should always be used alongside clinical judgement and a person-centered approach.

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References

1.  Saljoughian M. Polypharmacy and Drug Adherence in Elderly Patients. U.S Pharm. 2019 July;44(7): 33-36.
2. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694.
3. Marion, DW. Drug Prescribing for Older Adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2021.