Objectives. What are the Beers Criteria? Mark H Beers, MD Beers Criteria: History and Utilization 5/24/2016

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1 @agilis Objectives Understand what the AGS Beer s list is and the methods used for the AGS Beer s Update HOW TO USE THE BEERS CRITERIA IN PERSONS WITH DEMENTIA & IN YOUR HEALTHCARE SYSTEM DONNA FICK, RN, PHD, FAAN DISTINGUISHED PROFESSOR NURSING PENN STATE HARTFORD CENTER OF GERIATRIC NURSING EXCELLENCE DMF21@PSU.EDU Describe commonly used medications that should be avoided in the elderly Understand how to use the 2015 Beer s list in clinical decision making and in persons with dementia How Much Do You Like the Beers Criteria? What are the Beers Criteria? Completely and totally fabulous Pretty good Good, but I have some issues with them Don t like them An explicit list of drugs to avoid (potentially inappropriate or PIMS) in older adults in general and in those with certain diseases or syndromes, prescribed at reduced dosages or used with great caution and carefully monitored. Have been found to be associated with poor outcomes such as confusion, falls, increased healthcare costs and higher mortality Mark H Beers, MD Beers Criteria: History and Utilization A ballet dancing opera critic who hiked the Alps and took up rowing after diabetes cost him his legs MD, Univ of Vermont First med student to do a geriatrics elective at Harvard s new Division on Aging Geriatric Fellowship, Harvard Faculty, UCLA/RAND Co editor, Merck Manual of Geriatrics Editor in Chief, Merck Manuals Original 1991 Nursing home pts Updates 1997 All elderly; adopted by CMS in 1999 for nursing home regulation 2003 Era of generalization to Med D, then NCQA, HEDIS 2012 First AGS Updated Beers Criteria Released, Further adoption into quality measures 1

2 2015 AGS Beers Criteria Update Method Specific aim: Update the Beers Criteria using a comprehensive, systematic review and grading of evidence Strategy same as 2012: 1. Incorporate new evidence 2. Grade the evidence 3. Use an interdisciplinary panel 4. Incorporate exceptions Framework Expert panel 13 members Followed IOM 2011 recommendations on guideline development Includes a period for public comment Literature search tables prepared, rated quality of evidence and strength of recommendation Panel Members Assembling the Co chairs Donna Fick, PhD, RN, FAAN Todd Semla, MS, PharmD Panelists (voting) Judith Beizer, PharmD Nicole Brandt, PharmD Catherine DuBeau, MD Jerome Epplin, MD Nina Flanagan, CRNP,CS BC Joseph Hanlon, PharmD, MS Peter Hollmann, MD Rosemary Laird, MD, MHSA Sunny Linnebur, PharmD Satinderpal Sandhu, MD Michael Steinman, MD Nonvoting Panelists Robert Dombrowski, PharmD (CMS) Woody Eisenberg, MD (PQA) Erin Giovannetti (NCQA) AGS Staff Elvy Ickowicz, MPH Mary Jordan Samuel Others Sue Radcliff (research) Susan Aiello, DVM (editing) Gina Rocco (research) Jirong Yue (research) SEARCH TERMS: ADE, inappropriate drug use, med errors, polypharmacy x age/human/english Initial Search (8/1/2001 7/1 2014) n=20,748 citations Records reviewed by co chairs n=6,719 Records Screened by Full Panel (n=1,188 citations) Studies Used to create Tables (n=342) Designations of Quality and : ACP Guideline Grading System, GRADE Designations of Quality and : ACP Guideline Grading System, GRADE QUALITY OF EVIDENCE GRADING USING GRADE High Low STRENGTH OF RECOMMENDATION HOW DID WE DO THIS? Benefits clearly outweigh harms, adverse events, and risks or harms, adverse events, and risks clearly outweigh benefits. Weak Benefits finely balanced with harms, adverse events, and risks. Insufficient inadequate to determine net harms, adverse events, and risks. 2

3 2015 AGS Beers Criteria Update Not included in Beer s List What s New Two New Tables 1. Drug Drug Interactions Table 2. Renal Dosage Table Two New Companion Pieces 1. How to Use Paper 2. Beers Alternatives Drugs with risks not unique to elderly Purpose is for PIMs specific to elderly Drugs used with patients in the hospice and palliative care setting Tables Table 2 PIM list (with some selective caveats) Table 3 PIMs due to Drug Disease/Syndrome Interaction Table 4 Medications to be used with caution Table 5 Non Anti infective Drug Drug Interactions Table 6 Non Anti Infective Medications that should be avoided or have dosage reduced with varying levels of kidney function Table 7 Drugs with strong anticholinergic properties Table 8 Medications Moved or Modified Table 9 Medications Removed Table 10 Medications Added Table 2. Drugs to Avoid (except if ) Organ System or TC or Drug Nitrofurantoin Antipsychotics (conventional or atypical) Insulin, sliding scale Chlorpropamide Glyburide Rationale Recommend. Quality of Pulmonary and hepatic toxicity, peripheral neuropathy; Lack of efficacy <30 ml/min Increase CVA risk; increased cognitive decline and mortality in dementia Hypoglycemia risk Hypoglycemia risk Avoid long term suppression; avoid if CrCl <30 ml/min Avoid unless danger to self/others and non pharm has failed Low Recommend. Avoid Avoid High Table 3. Drug disease/syndrome Interactions Table 4. Use with Caution Disease or Syndrome Drug Rationale Recomm. Quality of Recomm. Drug Rationale Recommend Quality of Recommend Syncope Insomnia AChEIs Peripheral α blockers Tert. TCAs Chlorpromazine Thioridazine Olanzapine Oral decongestants Stimulants Theobromines Orthostatic hypotension or bradycardia CNS stimulant effects Avoid α blockers: High TCAs, AChEIs, antipsych: AChEIs, TCAs: α blockers, antipsych.: Weak Avoid Dabigatran Drugs linked to SIADH/ Hyponatremia (eg SSRI, TCA, CBZ, antipsychotics) Risk of bleeding; lack of evidence of efficacy if CrCl < 30mL/min May exacerbate or cause SIADH/ hyponatremia; monitor sodium level Use with caution if >75 years old or if CrCl <30mL/min Use with caution 3

4 How Much Do You Agree with this? Mr. A Don t like other people telling me how to practice Don t agree with criteria Criteria generally reasonable but implementation in real world of practice causes problems Mr. A 82 year old man, visiting new PCP for the first time. He has mild dementia and has been taking zolpidem for sleep for several years and prn diphenhydramine for allergies and sleep and has reported no problems with it during visits with his previous providers. Zolpidem and diphenhydramine are included in the 2015 Beers Criteria in the table for drug disease and drug syndrome interactions I read somewhere that older people with memory problems should never take sleeping pills. These doctors / nurses / pharmacists must not know what they are doing! Why did some idiot doctor prescribe a Beers drug? We need to stop it now! I know the Beers criteria say never to prescribe this drug, but it s really useful for some people and sleep is so important. Those criteria are out of touch with clinical reality. Now that it s included in the Beers Criteria, we re going to require prior authorization for all uses of zolpidem in persons with dementia. I know clinicians complain they have to spend forever on the phone to get approval, but... 4

5 Seven Key Principles Key Principle #1 Use clinical judgment and common sense Medications in the Beers Criteria are potentially inappropriate, not definitely inappropriate. Key Principle #2 Read the rationale and recommendations statements for each criterion. The caveats and guidance listed there are important. Disease or Syndrome Dementia or cognitive impairment Drug (s) Anticholinergics Benzodiazepines H2 Receptor agonists Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics Escopiclone Zolpidem Zalepon Antipsychotics Recommendation & Rationale Avoid Avoid because of adverse CNS effects Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (behavioral, environmental) have failed or are not possible AND the older adult is threatening substantial harm to self or others. Antipsychotics are associated with > risk of stroke and mortality in PWD. Quality of Rec. Disease or Syndrome Drug (s) Recommendation & Rationale Quality of Rec. Key Principle #3 Dementia or cognitive impairment Anticholinergics Avoid Benzodiazepines H2 Receptor agonists Avoid because of Nonbenzodiazepine, adverse CNS benzodiazepine effects receptor agonist hypnotics Escopiclone Zolpidem Zalepon Antipsychotics Avoid antipsychotics for behavioral problems of dementia ZOLPIDEM = BAD Understand why medications are included in the Beers Criteria, and adjust your approach to those medications accordingly 5

6 Key Principle #4 Key Principle #5 Optimal application of the Beers Criteria involves offering safer nonpharmacologic and pharmacologic therapies The Beers Criteria should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety Patient centered approach Key Principle #6 Access to meds in the Beers Criteria should not be excessively restricted by prior authorization and/or health plan coverage policies Key Principle #7 The Beers Criteria are not equally applicable to all countries Application to Clinicians Think of Beers Criteria as a warning light Why is patient taking the drug; is it truly needed? Safer and/or more effective alternatives? Does patient have particular characteristics that increase or mitigate risk of this medication? At time of initial Rx and at follow up Actively assess for symptoms, and assess whether these could be related to meds Don t automatically defer to colleagues 6

7 Mr. A Mr. A Doctor (or Nurse Practitioner NP) remembers that zolpidem is on the Beers Criteria because of its multiple toxicities. Warning light Doctor asks Mr. A about common and serious adverse effects of zolpidem and the timing with his memory and attention problems. Mr. A s and his wife report that he did seem to have more problems with thinking and memory after starting the drug and he has had two minor falls in the past month. He has attributed these symptoms to old age. Elicit potential harms Mr. A Doctor or NP s Mr. A s cardiologist who had prescribed the drug for sleep to inform her of the patient s symptoms and discuss options for using another medication. The cardiologist concurs that it would be reasonable to try another medication. The NP elicits the patient and caregiver understanding of sleep hygiene, their preferences & expectations regarding sleep and discusses alternatives. They agree to taper the drug & try non drug approaches for 3 months. Explore alternatives Discuss with colleagues Mr. A Be careful when you stop or start Doctor or NP reviews Mr. A s other medications, including evaluating their indication, patient s understanding, adherence, effectiveness, and potential adverse events. Beers Criteria as a starting point for comprehensive medication review 7

8 Emerging Literature Dementia Conclusions Beers Criteria should be used with clinical judgment and common sense Keep in mind key principles to help you best use Beers Criteria in practice Warning light Use resources (and direct your patients to them too) Thank you for your time! Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american geriatrics society AGS Beers Criteria Resources Criteria AGS Updated Beers Criteria How-to-Use Article Alternative Medications List Coming Soon! Updated Beers Criteria Pocket Card Updated Beers Criteria App Public Education Resources for Patients & Caregivers AGS Beers Criteria Summary 10 Medications Older Adults Should Avoid Avoiding Overmedication and Harmful Drug Reactions What to Do and What to Ask Your Healthcare Provider if a Medication You Take is Listed in the Beers Criteria My Medication Diary - Printable Download Eldercare at Home: Using Medicines Safely - Illustrated PowerPoint Presentation Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american geriatrics society 8