CRITERIA FOR MEDICATION USE IN GERIATRIC PATIENTS

To support comprehensive medication management, including assessment of physiologic and pharmacokinetic factors, as a central component of providing safe and effective medication therapy to geriatric patients; further,

To oppose use of the Beers criteria or similar criteria by the Centers for Medicare & Medicaid Services, other accreditation and quality improvement entities, and payers as the sole indicator to assess the appropriateness of prescribing for geriatric patients based on known limitations in the evidence evaluating the association between use of medications listed in such criteria and subsequent adverse drug events; further,

To advocate for the development, refinement, and validation of new criteria that consider drug-, disease-, and patient-specific factors, and criteria and quality measures that demonstrate the ability to decrease the occurrence of adverse drug events in geriatric patients; further,

To support research to assess the clinical application of existing and proposed criteria, including assessment of their correlation to patient outcomes and strategies for implementation; further,

To encourage inclusion of validated criteria in clinical decision support systems and other information technologies to facilitate prescribing and deprescribing for geriatric patients; further,

To acknowledge that such criteria are intended as a guide and should not replace the clinical judgment of pharmacists and other clinicians.

Rationale

Criteria have been developed to identify high-risk drugs that should be avoided in geriatric patients (i.e., those 65 years of age or older) based on the potential for these therapies to cause adverse drug events that can result in falls, hospitalizations, and other incidents that lead to significant morbidity and mortality in this patient population. Those criteria include the 2019 iteration of the Beers criteria and the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions, or STOPP (version 2 of the STOPP/START criteria was published in 2015). Although ASHP supports the intent of these criteria to prevent patient harm, safe and effective use of medications in geriatric patients requires the more thorough assessment associated with pharmacist-provided comprehensive medication management. ASHP opposes adoption of the Beers criteria by the Centers for Medicare & Medicaid Services (CMS) and other accreditation and quality improvement organizations as a tool to assess prescribing in long-term care and other settings, noting concerns about the development and validation of that tool. More importantly, studies evaluating the clinical application of the 2003 iteration of the Beers criteria have not demonstrated a reduction in adverse events when that tool is used. The American Geriatric Society publishes an update every three years, with the most recent update occurring in 2019. Although the update addressed some concerns (e.g., removal of drugs no longer available, drug-drug interactions), some of the criteria’s shortcomings (e.g., lack of validation) remain unresolved. In that regard, STOPP, which is based on organ systems and accounts for patients’ concomitant disease, is considered more useful. Studies evaluating STOPP, though small in number and consisting of heterogeneous study populations and implementation plans, project a favorable impact on patient outcomes. ASHP encourages additional work to develop, refine, and validate this and similar evidence-based criteria.

Quality indicators for appropriate medication use in older adults were identified as part of the Assessing Care of Vulnerable Elders (ACOVE) project. The indicators provide suggestions for improving prescribing practices and identify medications that require monitoring or should be avoided in vulnerable elders. Practical indicators that can be reviewed from patient encounters and transitions of care include maintenance of a medication list, periodic drug therapy review, assessing response to therapy, drug monitoring, and patient education. Review of these indicators may facilitate benchmarking and consideration of discontinuing unnecessary medications, dose reduction, and consideration of nonpharmacologic alternative strategies.

Further, there is a need for practice-based research to evaluate the application of such criteria and inclusion of validated criteria in clinical decision support systems and other information technologies is necessary to facilitate the use of these criteria in clinical practice. Finally, these tools are intended to serve as a guide or screening tool and should not replace the clinical judgment of pharmacists and other clinicians.