Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
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Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Results of a US Consensus Panel of Experts Donna M. Fick, PhD, RN; James W. Cooper, PhD, RPh; William E. Wade, PharmD, FASHP, FCCP; Jennifer L. Waller, PhD; J. Ross Maclean, MD; Mark H. Beers, MD Background: Medication toxic effects and drug- related problems can have profound medical and safety con seq uences for old er adu ltsandeconomica lly aff ect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inap- propriate medication use in adults 65 years and older in the United States. Methods: This study used a modified Delphi method, a setof proced ure s an d me thods fo r formulating a group judg- ment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of state- ments: (1) medications or medication classes that should generally be avoided in persons 65 years or older because the y are eit her ine ffe cti ve or they po se unn ece ssa ril y high ris k fo r older pe rsonsanda sa feralte rna tiv e is av ai la ble and (2) medications that should not be used in older persons known to have specific medical conditions. Results: This study identified 48 individual medica- tions or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and med ica tions to be avo ide d in ol der adu lts wit h the se conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. Conclusions: This st udy is an import ant upda te of pr e- viously established criteria that have been widely used and cited.The app lication of the Bee rs cri teria and oth er tools for identifying potentially inappropriate medica- tion use will continue to enable providers to plan inter- vent ion s for dec reas ing bot h drug -re late d cos ts and over- all costs and thus minimize drug-related problems. Arch Intern Med. 2003;163:2716-2724 T OXIC EFFECTS of medica- tions and dru g-re lat ed pro b- lems can have profound medical and safety conse- quen ces for old er adul ts and economically effect the health care sys- tem. Thi rty per cent of hos pit al admissio ns in elderly patients may be linked to drug- rela ted prob lems or drug toxi c effe cts. 1 Ad- ve rse dru g events (AD Es)have be en lin ked to preventable problems in elderly pa- tients such as depr ession, cons tipat ion, fall s, immobility, confusion, and hip frac- tures. 1,2 A 1997 study of ADEs found that 35% of ambulatory older adults experi- enc ed an ADEand 29% req uir ed hea lth car e services (physician, emergency depart- men t, or hosp ita liz atio n) for the ADE. 1 Some two thir ds of nurs ing fac ilit y resi den ts hav e ADEs ov er a 4- ye arperio d. 3 Of the se ADEs, 1 in 7 results in hospitalization. 4 Recent estimates of the overall hu- man and economic con seq uences of med i- cation-related prob lems vast ly exceed the fin din gs of the Institute of Med ici ne (IO M) on deaths from medical errors, estimated to cost the nation $8 billion annually. 5 In 2000, it is estimated that medication- relate d probl ems caused 106000 death s annually at a cost of $85 billion. 6 Others have calculated the cost of medication- rel ate d pro ble ms to be $76.6 bi llion to am- bul ato ry care, $20 bil lio n to hos pit als , and $4 billio n to nur sing hom e fac ilities. 2,7,8 If medic ation-related proble ms were ranked asa di se as e bycauseof de at h, itwo ul d be the fifth leading cause of death in the United States. 9 The prevention and rec- ognition of drug-related problems in el- derl y pati ents and other vulnerable popu- lations is one of the principal health care quality and safety issues for this decade. The aforementioned IOM report has focused increased attention on finding so- lution s for unsafe medicatio n practices, pol ypha rmacy , and drug -rela ted prob lems in the care of ol de r ad ul ts. Th ere are ma ny ways to define medication-related prob- CME course available at www.archinternmed.com ORIGINAL INVESTIGATION From the Department of Medicine, Center for Health Care Improvement (Drs Fick and Maclean); and Office of Biostatistics (Dr Waller), Medical College of Georgia, Augusta; Department of Veterans Affairs Medical Center, Augusta (Dr Fick); Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, (Drs Cooper and Wade); and Merck & Co Inc, West Point, Pa (Dr Beers). The authors have no relevant financial interest in this article. ARCH INTER N MED/VOL 163, DEC 8/22, 2003 WWW.ARCHINTER NMED.COM 2716 ©2003 American Medical Association. All rights reserved. (REPRINTED WITH CORRECTIONS) at Bahagian Bahan-Bahan Bersiri dan Dokumen, on October 11, 2011 www.archinternmed.com Downloaded from
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Updating the Beers Criteria for PotentiallyInappropriate Medication Use in Older Adults
Results of a US Consensus Panel of Experts
Donna M. Fick, PhD, RN; James W. Cooper, PhD, RPh; William E. Wade, PharmD, FASHP, FCCP; Jennifer L. Waller, PhD; J. Ross Maclean, MD; Mark H. Beers, MD
Background: Medication toxic effects and drug-related problems can have profound medical and safetyconsequencesfor older adults and economically affect thehealth care system. The purpose of this initiative was torevise and update the Beers criteria for potentially inap-propriate medication use in adults 65 years and older inthe United States.
Methods: This study used a modified Delphi method, asetof procedures and methodsfor formulating a groupjudg-ment for a subject matter in which precise information islacking. The criteria reviewed covered 2 types of state-ments: (1) medications or medication classes that shouldgenerally be avoided in persons 65 years or older becausethey are either ineffective or they pose unnecessarily highrisk for older persons anda saferalternative is available and(2) medications that should not be used in older personsknown to have specific medical conditions.
Results: This study identified 48 individual medica-tions or classes of medications to avoid in older adultsand their potential concerns and 20 diseases/conditionsand medications to be avoided in older adults with theseconditions. Of these potentially inappropriate drugs, 66were considered by the panel to have adverse outcomesof high severity.
Conclusions:This study is an important update of pre-viously established criteria that have been widely usedand cited. The application of the Beers criteria and othertools for identifying potentially inappropriate medica-tion use will continue to enable providers to plan inter-ventions for decreasing both drug-related costs and over-all costs and thus minimize drug-related problems.
Arch Intern Med. 2003;163:2716-2724
TOXIC EFFECTS of medica-tions anddrug-related prob-lems can have profoundmedical and safety conse-quencesfor older adults and
economically effect the health care sys-tem. Thirty percent of hospital admissionsin elderly patients may be linked to drug-related problemsor drug toxic effects.1 Ad-versedrug events(ADEs)have been linkedto preventable problems in elderly pa-tients suchas depression,constipation,falls,immobility, confusion, and hip frac-tures.1,2 A 1997 study of ADEs found that35% of ambulatory older adults experi-
enced an ADEand 29% required healthcareservices (physician, emergency depart-ment, or hospitalization)fortheADE.1 Sometwo thirds of nursing facility residents haveADEs over a 4-year period.3 Of these ADEs,1 in 7 results in hospitalization.4
Recent estimates of the overall hu-manand economic consequences of medi-cation-related problems vastly exceed thefindings of theInstituteof Medicine (IOM)on deaths from medical errors, estimated
to cost the nation $8 billion annually.5 In2000, it is estimated that medication-related problems caused 106000 deathsannually at a cost of $85 billion.6 Othershave calculated the cost of medication-related problems to be $76.6 billion to am-bulatory care, $20 billion to hospitals, and$4 billion to nursing home facilities.2,7,8 If medication-relatedproblems were rankedasa disease bycauseof death, it would bethe fifth leading cause of death in theUnited States.9 The prevention and rec-ognition of drug-related problems in el-derly patients and other vulnerable popu-lations is one of the principal health care
quality and safety issues for this decade.
The aforementioned IOM report hasfocused increased attention on finding so-lutions for unsafe medication practices,polypharmacy, and drug-related problemsin the care of older adults. There are manyways to define medication-related prob-
CME course available atwww.archinternmed.com
ORIGINAL INVESTIGATION
From the Department of Medicine, Center for HealthCare Improvement (Drs Fickand Maclean); and Office of Biostatistics (Dr Waller),Medical College of Georgia,
Augusta; Department of Veterans Affairs MedicalCenter, Augusta (Dr Fick);Department of Clinical and Administrative Pharmacy,College of Pharmacy,University of Georgia, Athens,(Drs Cooper and Wade); andMerck & Co Inc, West Point,Pa (Dr Beers). The authorshave no relevant financialinterest in this article.
ARCH INTERN MED/VOL 163, DEC 8/22, 2003 WWW.ARCHINTERNMED.COM2716
©2003 American Medical Association. All rights reserved.(REPRINTED WITH CORRECTIONS)
at Bahagian Bahan-Bahan Bersiri dan Dokumen, on October 11, 2011www.archinternmed.comDownloaded from
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