In This Episode:
Dr. K talks with geriatrician Dr. Michael Steinman, Professor of Medicine at UCSF and an expert on medication safety in older adults. He recently served on the expert panel that authored the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults, which lists medications that older adults should avoid or use with caution. They discuss:
- What is “inappropriate prescribing” and why it affects an estimated 50% of older adults
- How ageism can affect medication prescribing
- How inertia, hospitalizations, and other factors lead to medications “accumulating”
- Why it’s not safe to assume that all your medications are being prescribed for a good reason
- How to be proactive about asking your health providers to review whether all medications are still necessary and appropriate
- What is the Beer’s Criteria list and how does the Expert Panel decide what should be on it
- Why older adults become more vulnerable to medications as they age
- Some key Beers Criteria medications older adults should know about
- What you can do if you’re taking a medication on the Beer’s Criteria list
- How pharmacists can help, and other tips on ensuring safer medication use in aging
046 – Interview: Deprescribing & Reducing Risky Medications in Aging
073 – Anticholinergic Medications & Protecting Brain Health
034 – Preventing Falls: 10 Types of Medication to Reconsider
(Note: To date, HealthinAging.org and the American Geriatrics Society have not made the full 2019 Beers Criteria available for free to the public. For a full list, an option is to purchase the pocketcard, which we link to below.)
- From HealthinAging.org:
- About the 2019 Beers Criteria Update:
- Other Related Articles by Michael Steinman:
- How to Taper Benzodiazepines (Helpful consumer handout with sample tapering schedule)
- Related Better Health While Aging Articles:
- Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria (2019 Update)
- Deprescribing: How to Be on Less Medication for Healthier Aging
- 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution
- 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory
- How to Review Medications for Safety & Appropriateness
Dave deBronkart says
It continues to amaze me how many clinicians I bump into are not familiar with the Beers list (which I first learned about here, of course), and it continues to alarm me a little to see how many SAY they are, but with the kind of “um, yeah, I heard about that somewhere” uncertainty in their voice that makes me worry.
So when I talk to people over 50, or family caregivers, I’m thrilled that this is a really easy first step for them to start being “engaged and empowered” e-patients. So thanks again for this.
Re the actual list not being available, there are nonetheless some useful specifics in this Medscape article https://www.medscape.org/viewarticle/909799, e.g. –
“Two [things] were added in response to the worsening opioid crisis: not prescribing opioids with benzodiazepines or gabapentinoids. … [The 2019 list] dropped 8 seizure medications, 8 drugs for insomnia, and vasodilators for syncope. Some of these drugs were dropped because the problems associated with their use are not unique to older patients…”
That last line raised my eyebrows, because I suspect a lot of people out there (in ANY age group) would benefit from knowing what those issues are that aren’t specific to geriatrics. But if we tried to list every such issue it would be like boiling the ocean, and this site’s focus is elders.
Question: what does one do if a clinician shrugs off these concerns, with a remark like “I’ve never encountered any problems with this”? I don’t think I’ve seen an episode of BHWA on that touchy issue.
It’s one thing if you live near freaking Harvard or Stanford or something and alternate doctors are everywhere, but a lot of my friends and family don’t.
Leslie Kernisan, MD MPH says
That’s a good question, re what to do when one’s health provider shrugs this off. Honestly, I think in many cases it behooves people to learn to diplomatically help their doctor brush up on the necessary knowledge. You want to avoid embarassing them or getting into arguments, but still be clear about your concerns and that you value paying attention to relevant expert guidelines.
So I guess you could say something like “Hm, that’s great that you haven’t encountered problems with these medications. Still, I’ve decided I want to be well-informed and proactive about my aging health, so I’ve been learning more about what geriatricians and other aging health experts recommend. Since they say these medications should be used with caution, I would like to avoid them or only use them if there’s no suitable alternative and it really seems necessary.”
And then if the provider says it’s necessary, you need to be able to politely ask them to explain their reasoning and especially, spell out the likely magnitude of benefit and of the risks. Also, always ask again about non-drug alternatives and what happens if you just don’t take the medication.
It’s a challenge, to be sure, but people do usually want to maintain a decent relationship with their doctor, while ensuring they don’t get risky care that’s unwarranted.
Dave deBronkart says
> it behooves people to learn to diplomatically help their doctor brush up …
So, next time you’re looking for a quick easy blog post, I think you just wrote it. 🙂 Seriously, you could just paste that in, with a little opening and closing.
I think Mitzvah is your middle name…
Dave deBronkart says
I’m going to add more (copy/paste) from that Medscape article, because I know a lot of people don’t click links, and any caregiver (or 60+) interested in this subject at all should know how many things can warrant their attention!
“Two (ticlopidine and pentazocine) were dropped because they are no longer available in the United States.” <= well heck, I know this is the AMERICAN geriatrics society, but there are e-patients around the world …
A lot of this is medical terminology, which is why some docs don't want to let the general public see. But when a family member or 60+ is motivated (which not all are), we know they'll go googling and/or call the office to learn.
Removed From the Criteria
H2-receptor antagonists were removed from the criteria for dementia because the evidence that they harm people with dementia is weak. These drugs, which relieve gastric reflux, can continue to be used with caution in patients with high risk dementia but should be avoided in older adults with or at high risk of delirium because of potential of inducing or worsening delirium.
The chemo drugs carboplatin, cisplatin, vincristine, and cyclophosphamide were removed from the criteria because the panel considered them to be “highly specialized” and outside the scope of the criteria.
“Use With Caution”
Dextromethorphan/quinidine should be used with caution because it has limited efficacy in alleviating behavioral symptoms of dementia in patients without pseudobulbar affect and because it potentially increases the risk for falls and drug-drug interactions.
Rivaroxaban is to be used with caution for venous thromboembolism or atrial fibrillation in patients older than 75 years because of the risk for gastrointestinal bleeding.
Trimethoprim and sulfamethoxazole can elevate risk for hyperkalemia in patients with decreased kidney function who are receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
Carbamazepine, mirtazapine, oxcarbazepine, serotonin, norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants, and tramadol should be used with caution because they may exacerbate or cause what is known as syndrome of inappropriate antidiuretic hormone secretion. Sodium levels should be monitored closely when using these drugs.
Aspirin should be used with caution for primary protection against cardiovascular disease or colorectal cancer in patients older than >b>70 years, not 80 years, because new data show that the age at which the risk of bleeding is elevated has fallen.
Serotonin and norepinephrine reuptake inhibitors should be prescribed with caution for patients at risk of falling or sustaining fractures.
For Parkinson’s disease, the general advice to avoid all antipsychotics has been revised to except quetiapine, clozapine, and pimavanserin. [If I read the negative-negatives correctly, this change means it’s OKAY to use those drugs again.]
For heart failure, nondihydropyridine and calcium channel blockers should not be prescribed for patients with low ejection fractions, and nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, thiazolidinediones, and dronedarone should be prescribed with caution in patients who have no symptoms of heart failure.
Macrolides (except azithromycin) or ciprofloxacin should not be prescribed with warfarin because of bleeding risk.
Ciprofloxacin and theophylline should not be prescribed because of increased theophylline toxicity.
For patients with reduced kidney function, use of ciprofloxacin is associated with increased risk for tendon rupture and increased central nervous system effects. Use of trimethoprim-sulfamethoxazole is associated with worsening renal failure and hyperkalemia.
There’s more – I hope someone will make an app that looks at MY (or anyone’s) medical status and MY medications and draws attention to ones that need a clinician’s attention!
In any case, every caregiver should know they can help avoid preventable problems by getting as involved in this as they want and can.
So thank you again!
Leslie Kernisan, MD MPH says
Thank you Dave!