Beers' List—Drugs NOT to Use
Tracking Prescriptions In the Elderly can be a Quality Measure
Older people have changes in how their bodies handle medications. Drugs that may be acceptable for young people may cause problems for seniors. And some drugs just shouldn’t be used at all anymore.
Those are the principles underlying the Beers’ list, meant to be a guide to the best prescription practices. Mark Beers led a group of experts to develop the list, first published in 1991. It has been updated since, and is also referred to as the “drugs to be avoided in the elderly” (DAE) list.
Now the list is being used as a measure of quality. A clinician, or a group of clinicians, who repeatedly prescribe for older people the undesirable medications would appear to be practicing a lesser quality of care. Equally important and compelling in today’s era, with health care reform high on the political agenda, is that it might be possible to actually get prescribers to improve their treatment of older people—to get them to prescribe fewer drugs on the DAE List.
This idea was tested recently in a population of older people covered by Medicare Part D Blue Cross and Blue Shield benefit plans. Records of over 325,000 people were reviewed. About 5% had been prescribed one or more DAE drugs. Over 7,000 letters were sent to the associated prescribers asking them to reconsider their use of “these higher risk medications.” After six months, DAE prescriptions were almost halved.
“Despite evidence to suggest certain medications can increase negative health outcomes in older adults, these agents are still commonly prescribed,” the researchers pointed out. Drugs on the Beers’ list have been associated with more hospitalizations, more falls, and higher health care costs.
Publicizing the list has had little effect. Authorities have required the Beers’ list to be incorporated in nursing home guidelines, without any notable effect on prescribing. This study suggests that interventions such as letters to prescribers may be of some value.
Some Of the Drugs On the List
A few trade names are listed after the generic name. The medication may also be prescribed under other names or be incorporated in another combination product.
Older people are very susceptible to adverse effects of drugs with anticholinergic effects.
cyproheptadine (Periactin)
- diphenhydramine (Benadryl)
- belladonna alkaloids (Bentyl, Donnatal, many others in combination products)
Many other drugs can contribute to confusion, delirium, and other brain dysfunction
- meperidine (Demerol)
- methocarbamol (Robaxin)
- propoxyphene (“Darvon,” Darvocet”)
- propanatheline (Pro-Banthine)
- barbituates
Other drugs are on the list for miscellaneous reasons.
- thyroid, desiccated (Armour Thyroid)
- estrogens
Problems With the List as a Quality Indicator
Sometimes there are legitimate reasons to use a drug on the DAE list. For example, nitrofurantoin (Macrobid, Macrodantin) is an antibiotic that can cause nerve damage, anemia, nausea, vertigo, and other adverse effects. Yet in communities in which resistance to other antibiotics is high, it may be the drug of choice for bladder infections (Pharmacist’s Letter, January, 2008). In those cases, prescribing it should not be a mark of lesser quality care.
Sources
Fick ED, et al. Beers criteria for potentially inappropriate medications use in older adults. Archives of Internal Medicine 2003; 163: 2716-2724
Starner CI, et al. Effect of a retrospective drug utilization review on potentially inappropriate prescribing in the elderly. American Journal of Geriatric Pharmacotherapy 2009; 7: 11-19
Medications To Avoid In the Elderly
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