Recently, the American Geriatrics Society (AGS) Beers criteria were unveiled as a measure of potentially inappropriate medication use in older adults.1 We thought it would be timely and relevant to comment on this updated quality measure for medication use. Of note, a recent systematic review summarized the current literature on the more than a dozen measures of potentially inappropriate prescribing in older adults and reported that the Beers criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria were some of the most common measures used.2 With that in mind, in this commentary we discuss some of the history of the Beers criteria as well as briefly describe the process of updating the criteria, highlighting some of the key changes made. Then, we compare and contrast the new criteria with the STOPP criteria from Europe.3 Finally, we briefly comment on some future directions for the Beers criteria as an explicit measure of potentially inappropriate medication use in older adults.
History of the Beers Criteria
One of the first set of explicit criteria for inappropriate drug use was developed by Mark H. Beers, MD, while a junior faculty at the University of California, Los Angeles and was published in 1991.4 He defined inappropriate prescribing as the use of medication where the potential risks outweigh the potential benefits.4 For the first set of Beers criteria, a 13 member expert panel was part of a two-stage Delphi survey in which consensus was reached regarding 30 therapeutic classes/medications whose use should be avoided in the elderly residing in nursing homes. These criteria were used as a process measure in Dr. Beers' John A. Hartford Foundation-funded cluster randomized trial of a computer feedback intervention aimed at improving prescribing for older nursing home patients. The results of this successful trial were presented by Dr. Beers at the 1993 American Geriatric Society (AGS) Annual Meeting, but to the best of our knowledge were never published as a peer-reviewed manuscript. Moving ahead to 1997, Dr. Beers was then employed by Merck & Co., Inc. and published an updated set of criteria.5 This time, a 6 member expert panel was utilized. Overall, they agreed upon 28 therapeutic classes/medications to avoid in the elderly residing in nursing homes or in the community. In addition, these updated criteria included severity ratings for the “do-not-use” list of medications. Moreover, new explicit criteria were agreed upon for 35 drug-disease interactions to be avoided in older adults. In 1999, a partial list (i.e., 22 “drugs-to-avoid” and 12 drug-disease interaction criteria) was adopted by the Center for Medicare and Medicaid Services (CMS) as quality indicator measures for long-term care facilities (LTCF).6
In 2003, Dr. Beers participated in a panel led by Dr. Donna Fick with other health professionals from Georgia to update the 1997 criteria.7 An expert panel of 12 members was used to establish consensus on 48 medications/classes of “drugs-to-avoid” and 20 drug-disease interactions. In 2006, CMS updated its quality indicator criteria for LTCFs using some of the new criteria.8 In addition in 2006, the National Committee for Quality Assurance (NCQA) chose some of these “do-not-use” and drug-disease interaction criteria for new ambulatory care quality indicators as one of their HEDIS measures.9 In 2009, sadly, Dr. Beers passed away.
Updating the Beers Criteria and Highlighting Some Key Changes
In 2011, NCQA asked AGS to revise the 2003 Beers criteria. The co-chair persons (Drs. Fick and Semla) for the 2012 update were also involved in the development of the 2003 criteria. These two individuals and nine others, including one of the authors of this commentary (JTH), served as the members of a multidisciplinary expert panel (two nurses, four physicians, five pharmacists) who completed a two-stage Delphi survey and participated in live and teleconferenced meetings in order to reach consensus. Importantly, a period of time was made available for the public and any key stakeholders to provide comments and feedback on these updated criteria prior to publication. Of note, various professional and public education materials are currently available on the AGS website, including all of the criteria and supportive evidence tables.10
In looking at the updated “drugs-to-avoid” list, it is important to note some of the key therapeutic class/medication additions and deletions compare to the 2003 criteria (Table 1). Of those therapeutic classes/medications removed from the previous criteria, seven were due to drugs being withdrawn from the market since the last time the criteria were published in 2003 (e.g., propoxyphene) and one removal was due to the lack of evidence that long-term stimulant laxatives lose effectiveness or result in unacceptable adverse effects (the original reason this drug/class was included in the list of “drugs-to-avoid”).11 Fluoxetine and cimetidine were also dropped from the “drugs-to-avoid” list since the potential drug interaction problems with these medications are not unique to the elderly.12 Specifically, these are not drugs of choice within their therapeutic classes due to the greater potential for drug-drug interactions as a result of inhibition of CYP-450 hepatic isoenzymes. Similarly, the recommendation NOT to use > 325 mg per day of ferrous sulfate to treat iron deficiency anemia applies to adults of all ages and thus was dropped.13 Finally, ethacrynic acid was dropped due to its extremely low use and lack of information on ototoxicity risk derived from rigorously designed studies in humans.14 Among the new therapeutic classes/medications added to the 2003 criteria, some noteworthy additions of “drugs-to-avoid” include all short-acting benzodiazepines (regardless of dose), glyburide, megesterol, metoclopramide, and sliding scale insulin.1
Table 1.
Comparison of the Most Common Explicit Measures for Drugs to Avoid in Older Adults
| Therapeutic Class/Medication | Beers 2003 | Beers 2012 | STOPP 2006 |
|---|---|---|---|
| Central Nervous System and Psychotropic Drugs | |||
| Amphetamines and anorexic agents | X | -- | -- |
| Anticholinergics to treat extrapyramidal side effects of neuroleptic medications (e.g., benztropine, trihexyphenidyl) | -- | X | X |
| Antihistamines, 1st generation (select agents in Beers 2003; all agents in Beers 2012; select agents in STOPP 2006) | X | X | X |
| Antipsychotics, first (conventional) and second (atypical) generation (for behavioral problems of dementia) | -- | X | -- |
| Barbiturates (all agents except phenobarbital for seizure control in Beers 2003; all agents in Beers 2012) | X | X | -- |
| Benzodiazepines, short- and intermediate-acting (dose limits in Beers 2003; all doses in Beers 2012) | X | X | -- |
| Chloral hydrate | -- | X | -- |
| Dementia treatments, older (i.e., ergot mesylates and isoxsuprine in Beers 2003 and Beers 2012; cyclandelate in Beers 2003) | X | X | -- |
| Fluoxetine, daily | X | -- | -- |
| Long-acting benzodiazepines (e.g., clonazepam, diazepam, flurazepam) | X | X | X |
| Long-term neuroleptics for insomnia | -- | -- | X |
| Meprobamate | X | X | -- |
| Mesoridazine | X | X | -- |
| Nonbenzodiazepine (“Z”) hypnotics (i.e., eszoplicone, zaleplon, zolpidem) | -- | X | -- |
| Tertiary TCAs, alone or in combination (amitriptyline and doxepin in Beers 2003; all in Beers 2012) | X | X | -- |
| Thioridazine | X | X | -- |
| Cardiovascular | |||
| α-acting and central-acting agents for treatment of hypertension (clonidine, doxazosin, guanethidine, guanadrel, methyldopa, and reserpine in Beers 2003; clonidine, doxazosin, guanabenz, guanfacine, methyldopa, prazosin, terazosin, and reserpine in Beers 2012) | X | X | -- |
| Antiarrhythmic drugs (amiodarone and disopyramide in Beers 2003; Class Ia, Class Ic, and Class III drugs in Beers 2012) for atrial fibrillation | X | X | -- |
| Aspirin for primary prevention (to be used with caution in adults ≥80 years old for primary prevention of cardiac events in Beers 2012; to be avoided in those with no history of coronary, cerebral or peripheral vascular symptoms or occlusive events in STOPP 2006) | -- | X | X |
| Aspirin to treat dizziness not clearly attributable to cerebrovascular disease | -- | -- | X |
| Digoxin > 0.125 mg/day | X | X | X |
| Dipyridamole IR as monotherapy | X | X | X |
| Ethacrynic acid | X | -- | -- |
| Loop diuretic for ankle edema (i.e., no clinical signs of heart failure) or as 1st line monotherapy for hypertension | -- | -- | X |
| Nifedipine IR | X | X | -- |
| Spironolactone > 25 mg/day | -- | X | -- |
| Ticlopidine | X | X | -- |
| Endocrine | |||
| Androgens (methyltestosterone in both Beers 2003 and Beers 2012; testosterone in Beers 2012) | X | X | -- |
| Chlorpropamide | X | X | X |
| Dessicated thyroid | X | X | -- |
| Estrogen (estrogens only in Beers 2003; estrogen with or without progestins in Beers 2012; estrogen without progestin in patients with intact uterus in STOPP 2006) | X | X | X |
| Glyburide/glibenclamide (European generic name) | -- | X | X |
| Growth hormone | -- | X | -- |
| Megesterol | -- | X | -- |
| Sliding scale insulin | -- | X | -- |
| Gastrointestinal | |||
| GI antispasmodics (e.g., dicyclomine, hyoscyamine) | X | X | -- |
| Cimetidine | X | -- | -- |
| Diphenoxylate, loperamide or codeine for treatment of diarrhea of unknown cause or severe infective gastroenteritis | -- | -- | X |
| Long-term use of stimulant laxatives (i.e., bisacodyl, cascara sagrada, and neoloid except in the presence of opioid use) | X | -- | -- |
| Metoclopramide | -- | X | -- |
| Mineral oil (given orally) | X | X | -- |
| Trimethobenzamide | X | X | -- |
| Miscellaneous | |||
| Ferrous sulfate > 325 mg/d | X | -- | -- |
| Nitrofurantoin | X | X | -- |
| Skeletal muscle relaxants (e.g., carisoprodol, cyclobenzaprine, orphenadrine) | X | X | -- |
| Musculoskeletal | |||
| Chronic non-COX-selective NSAIDs (naproxen, oxaprozin, and piroxicam in Beers 2003; all agents in Beers 2012 and STOPP 2006) | X | X | X |
| Indomethacin | X | X | -- |
| Ketorolac | X | X | -- |
| Long-term corticosteroids as monotherapy for RA or OA | -- | -- | X |
| Long-term colchicine for chronic treatment of gout where there is no contraindication to allopurinol | -- | -- | X |
| Powerful opiates (e.g., morphine or fentanyl) as first-line therapy for for mild/moderate pain | -- | -- | X |
| Meperidine | X | X | -- |
| Pentazocine (Talwin) | X | X | -- |
| Propoxyphene (Darvon) and combination products | X | -- | -- |
| Respiratory | |||
| Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-to-severe COPD | -- | -- | X |
| Theophylline monotherapy for COPD | -- | -- | X |
Abbreviations: COPD, chronic obstructive pulmonary disease; COX, cyclooxygenase; GI, gastrointestinal; IR, immediate release; NSAID, non-steroidal anti-inflammatory drugs; OA, osteoarthritis; TCA, tricyclic antidepressants; RA, rheumatoid arthritis; SR, sustained release
Several drug-disease interactions were added to the previous criteria whereas some were removed (Table 2).1 For the drug-disease interactions dropped from the 2003 criteria, the main reason was due to the medications no longer being on the market (e.g., phenylpropanolamine and hypertension), or the publication of data that shows insufficient evidence that a therapeutic class/medication can exacerbate a specific disease/syndrome in a clinically important way (e.g., pseudoephedrine and hypertension).15 Among the new drug-disease interactions added to the 2003 criteria, some noteworthy additions are acetylcholinesterase inhibitors/syncope, selective serotonin reuptake inhibitors/falls or fractures, and pioglitazone/rosiglitazone/heart failure.1
Table 2.
Comparison of the Most Common Explicit Measures for Drug-Disease Interactions in Older Adults
| Disease – Therapeutic Class/Medication | Beers 2003 | Beers 2012 | STOPP 2006 |
|---|---|---|---|
| Anorexia and Malnutrition | |||
| CNS stimulants (e.g., dextroamphetamine, methylphenidate, methamphetamine, pemolin) | X | -- | -- |
| Bleeding Disorder * | |||
| Antithrombotics/anticoagulants (aspirin, dipyridamole, and clopidogrel in both Beers 2003 and STOPP 2006; NSAIDs and ticlopidine in Beers 2003) | X | -- | X |
| Cardiac Conduction Abnormalities | |||
| Tricyclic antidepressants | X | -- | X |
| Chronic Constipation | |||
| Anticholinergics, not listed below | -- | X | -- |
| Anticholinergic GI antispasmodic drugs (e.g., dicyclomine) | X | X | X |
| Antihistamines, 1st generation (e.g., diphenhydramine) | X | X | -- |
| Antipsychotics | -- | X | -- |
| Calcium channel blockers, nondihydropyridine (i.e., diltiazem, verapamil) | X | X | X |
| Bladder antimuscarinic drugs (e.g., oxybutynin) | -- | X | X |
| Opioids, regular (>2 weeks) and without concurrent use of laxatives | -- | -- | X |
| Tricyclic antidepressants (amitriptyline, doxepin, and imipramine in Beers 2003; all in Beers 2012 and STOPP 2006) | X | X | X |
| Chronic Kidney Disease (Stages IV and V) | |||
| NSAID, all | -- | X | X |
| Triamterene | -- | X | -- |
| COPD | |||
| β blockers, non-cardioselective (propanolol in Beers 2003; all in STOPP 2006) | X | -- | X |
| Long-acting benzodiazepines | X | -- | -- |
| Diabetes Mellitus and frequent hypoglycemic episodes (i.e., ≥ 1 episode per month) | |||
| β blockers | -- | -- | X |
| Delirium | |||
| Anticholinergics | -- | X | -- |
| Benzodiazepines | -- | X | -- |
| Chlorpromazine | -- | X | -- |
| Corticosteroids | -- | X | -- |
| H2-receptor antagonist | -- | X | -- |
| Meperidine | -- | X | -- |
| Sedative hypnotics (e.g., zolpidem) | -- | X | -- |
| Thioridazine | -- | X | -- |
| Tricyclic antidepressants, all | -- | X | -- |
| Dementia and Cognitive Impairment | |||
| Anticholinergics, not listed below | X | X | -- |
| Antipsychotics, chronic and as-needed use | -- | X | -- |
| Barbiturates | X | -- | -- |
| Benzodiazepines | -- | X | -- |
| Bladder antimuscarinic drugs | X | X | X |
| CNS stimulants (dextroamphetamine, methylphenidate, methamphetamine, pemolin) | X | -- | -- |
| GI antispasmodics (e.g., dicyclomine, hyoscyamine) | X | X | -- |
| H2-receptor antagonists | -- | X | -- |
| Muscle relaxants | X | X | -- |
| Opioids, long-term (unless indicated for palliative care or management of moderate-severe chronic pain | -- | -- | X |
| Tricyclic antidepressants, all | -- | X | X |
| Zolpidem | -- | X | -- |
| Depression | |||
| Long-term benzodiazepine use | X | -- | -- |
| Sympatholytic agents (methyldopa, reserpine, guanethidine) | X | -- | -- |
| Glaucoma | |||
| Bladder antimuscarinic drugs | -- | -- | X |
| Ipratropium, nebulized | -- | -- | X |
| Tricyclic antidepressants | -- | -- | X |
| Gout | |||
| Diuretic, thiazide | -- | -- | X |
| Heart Failure (systolic specified in Beers 2012) | |||
| Calcium channel blockers, nondihydropyridine (i.e., diltiazem, verapamil) | -- | X | X |
| Cilostazol | -- | X | -- |
| Disopyramide | X | -- | -- |
| Dronaderone | -- | X | -- |
| High sodium content drugs (sodium and sodium salts) | X | -- | -- |
| NSAID, all | -- | X | X |
| Thiazolidinediones (i.e., pioglitazone, rosiglitazone) | -- | X | -- |
| History of Breast Cancer or VTE | |||
| Estrogen | -- | -- | X |
| History of Falls/Fractures | |||
| Anticonvulsants | -- | X | -- |
| Antihistamines, 1st generation | -- | -- | X |
| Antipsychotics | -- | X | X |
| Benzodiazepines (short- to intermediate-acting in Beers 2003; all in Beers 2012 and in STOPP 2006) | X | X | X |
| Nonbenzodiazepine (“Z”) hypnotics (i.e., eszopiclone, zaleplon, zolpidem) | -- | X | -- |
| Opioids, long-term | -- | -- | X |
| SSRIs | -- | X | -- |
| Tricyclic antidepressants (amitriptyline, doxepin, and imipramine Beers 2003; all in Beers 2012) | X | X | -- |
| History of Peptic Ulcer Disease | |||
| NSAID, non-COX-2-selective, without gastroprotection (non-COX-2 NSAIDs in Beers 2003 and Beers 2012; all NSAIDs in STOPP 2006) | X | X | X |
| Hypertension | |||
| Amphetamines | X | -- | -- |
| Diet pills | X | -- | -- |
| NSAIDs (moderate to severe hypertension) | -- | -- | X |
| Phenylpropanolamine hydrochloride | X | -- | -- |
| Pseudoephedrine | X | -- | -- |
| Insomnia | |||
| Decongestants, oral (i.e., pseudoephedrine, phenylephrine) | X | X | -- |
| MAOIs | X | -- | -- |
| Stimulants (e.g., amphetamine, methylphenidate, pemoline) | X | X | -- |
| Theobromines (i.e., theophylline, caffeine) | X | X | -- |
| Lower Urinary Tract Symptoms | |||
| Anticholinergics (oral in Beers 2003; oral and inhaled in Beers 2012; bladder antispasmodic agents only in STOPP 2006) | X | X | X |
| Decongestants, oral | X | -- | -- |
| Obesity | |||
| Olanzapine | X | -- | -- |
| Parkinson's Disease | |||
| Antipsychotics (conventional antipsychotics in Beers 2003; all except for quetiapine and clozapine for Beers 2012; all for STOPP 2006) | X | X | X |
| Metoclopramide | X | X | X |
| Prochlorperazine | -- | X | X |
| Promethazine | -- | X | -- |
| Tacrine | X | -- | -- |
| Persistent Postural Hypotension | |||
| Vasodilators | -- | -- | X |
| Seizures | |||
| Antipsychotics, atypical (clozapine in Beers 2003; clozapine, olanzapine in Beers 2012) | X | X | -- |
| Antipyschotics, conventional (e.g., chlorpromazine, thioridazine, thiothixene) | X | X | X |
| Bupropion | X | X | -- |
| Maprotiline | -- | X | -- |
| Tramadol | -- | X | -- |
| SIADH/Hyponatremia † | |||
| SSRIs | X | -- | X |
| Syncope ‡ | |||
| Acetylcholinesterase inhibitors | -- | X | -- |
| α blockers, peripheral (i.e., doxazosin, prazosin, terazosin) | -- | X | -- |
| Chlorpromazine | -- | X | -- |
| Olanzapine | -- | X | -- |
| Thioridazine | -- | X | -- |
| Tricyclic antidepressants (amitriptyline, doxepin, and imipramine Beers 2003; all in Beers 2012) | X | X | -- |
| Urinary Incontinence | |||
| α blockers (stress incontinence in Beers 2003; stress or mixed urinary incontinence, avoid in women in Beers 2012; avoid in men with frequent incontinence in STOPP 2006) | X | X | X |
| Long-acting benzodiazepines (stress) | X | -- | -- |
| Estrogen oral and transdermal dosage forms only (applies to women) | X | ||
| Tricyclic antidepressants (amitriptyline, doxepin, and imipramine with stress incontinence in Beers 2003; all in both Beers 2012 and STOPP 2006) | X | X | X |
Beers 2012 includes aspirin for primary prevention, dabigatran, and prasugrel in the category of potentially inappropriate medications to be used with caution in older adults due to the increased risk of bleeding.
Beers 2012 includes antipyschotics, carbamazepine, carboplatin, cisplatin, mirtazapine, SNRIs, SSRIs, TCAs, and vincristine in the category of potentially inappropriate medications to be used with caution in older adults due to increased risk of SIADH/hyponatremia.
Beers 2012 includes vasodilators in the category of potentially inappropriate medications to be used with caution in older adults due to increased risk of syncope in individuals with a history of syncope.
Abbreviations: COPD, chronic obstructive pulmonary disease; COX, cyclooxygenase; GI, gastrointestinal; H, histamine; MAOI: monoamine oxidase inhibitor; NSAID, non-steroidal anti- inflammatory drugs; SIADH, syndrome of inappropriate diuretic hormone secretion; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressants VTE, venous thromboembolism
One noted difference in the updated criteria compared to previous versions is the creation of a new category of potentially inappropriate medications to be used with caution in older adults, with three out of the five warnings being related to an increased risk of bleeding (i.e., aspirin for primary prevention of cardiac events, dabigatran, and prasugrel).1 Additional updates to the new Beers criteria are detailed in the main publication.1
Comparison of 2012 AGS Beers Criteria with 2006 STOPP Criteria
To establish in part the face validity of the new AGS Beers criteria it is important to compare them with the STOPP criteria since it is one of the most common explicit measures of potentially inappropriate prescribing in older adults.3 Briefly, the STOPP criteria include a list of risky medication situations, involving specific “drugs-to-avoid”, drug-disease interactions, drug-drug interactions, and duration of therapy concerns. For the purposes of this commentary in comparing the Beers and STOPP criteria, we will only be comparing the “drugs-to-avoid” and drug-disease interactions included in these two measures (Tables 1 and 2). There is quite a bit of concordance the between the Beers 2012 and STOPP 2006 criteria. One of the most consistent findings is that the use of NSAIDs in older adults is high-risk, showing up on both “drugs-to-avoid” lists as well as drug-disease interactions with heart failure, chronic renal failure, and peptic ulcer disease.16 In addition, both the Beers and STOPP criteria include tricyclic antidepressants as a class of drugs that can exacerbate a number of conditions including falls/fractures, and dementia/cognitive impairment.
It is also interesting to note the discordances between the Beers 2012 and STOPP 2006 criteria. This may be due to the different patterns of prescribing quality in the United States compared to Europe where certain medication classes may be more problematic than others. One notable difference with NSAID use is that the STOPP 2006 criteria list a drug-disease interaction with hypertension while the Beers 2012 criteria do not. Although this drug-disease interaction does not appear on the Beers criteria, it is a clinically significant interaction in older adults that deserves attention.17 Another difference between the Beers 2012 and STOPP 2006 criteria involves benzodiazepine use. While the two instruments both include long-acting benzodiazepines as “drugs-to-avoid”, only the Beers criteria include short- and intermediate-acting benzodiazepines as well. This comprehensive inclusion of all benzodiazepines is supported by literature showing that all benzodiazepines can lead to adverse events (e.g., falls, fractures, cognitive impairment) in older adults and not only the long-acting agents.18, 19 Furthermore, the STOPP criteria list the use of first generation antihistamines and falls as a drug-disease interaction while the Beers criteria do not. The rationale for the Beers criteria not including this drug-disease interaction is due to the fact that the evidence for these agents being associated with falls is limited to two studies and the findings are mixed.20,21
Looking Ahead
Because of the partnership developed with the AGS, the Beers criteria will be regularly updated every three years (AGS press release, March 1, 2012). Similarly, with the support of the European Union Geriatric Medicine Society (EUGMS) an updated version of the STOPP criteria in addition to the START [Screening Tool to Alert doctors to Right Treatment] criteria will be validated and published later this year (personal communication with Dr. Denis O'Mahony, February 20112). Future research will be needed to assess the psychometric/clinimetric properties of both the new AGS Beers criteria and the EUGMS STOPP criteria. This should include studies of inter- and intra-rater reliability of these measures along with their predictive validity with adverse drug events. Also, it will be important to demonstrate their responsiveness to change in randomized controlled trials designed to improve prescribing. Finally, it would be useful to conduct studies to better understand their concordance with implicit measures of potential inappropriate prescribing (e.g., Medication Appropriateness Index) that consider a greater number of prescribing factors.22
Conclusion
The new AGS Beers criteria were carefully and thoughtfully developed based on the current best evidence. It would seem they are a definite step in the right direction toward improving the care of older adults. At the same time, it is important to recognize the areas for future work.
ACKNOWLEDGEMENTS
This work was supported by National Institute on Aging grants and contracts (P30AG024827, T32 AG021885, K07AG033174, R56AG027017, R01AG034056), a National Institute of Nursing Research grant (R01 NR010135), and Agency for Healthcare Research and Quality grants (R01 HS017695, R01 HS018721). We would like to thank the attendees at the February 3, 2012 Geriatric Medicine Conference at the University of Pittsburgh for their thoughtful comments after a presentation about the new AGS Beers criteria. Finally, we would like to thank our colleague Walid Gellad, MD, MPH for his helpful comments regarding an earlier draft of this manuscript.
References
- 1.The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2012 Epub – ahead of print. [Google Scholar]
- 2.Dimitrow MS, Airaksinen MS, Kivela SL, et al. Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: a systematic review. J Am Geriatr Soc. 2011;59:1521–1530. doi: 10.1111/j.1532-5415.2011.03497.x. [DOI] [PubMed] [Google Scholar]
- 3.Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J Clin Pharm Ther. 2008;46:72–83. doi: 10.5414/cpp46072. [DOI] [PubMed] [Google Scholar]
- 4.Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991;151:1825–1832. [PubMed] [Google Scholar]
- 5.Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157:1531–1536. [PubMed] [Google Scholar]
- 6.Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics: drug-related problems in the elderly. Ann Pharmacother. 2000;34:360–365. doi: 10.1345/aph.19140. [DOI] [PubMed] [Google Scholar]
- 7.Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–2724. doi: 10.1001/archinte.163.22.2716. [DOI] [PubMed] [Google Scholar]
- 8.Centers for Medicare and Medicaid Services (CMS) [Accessed February 15, 2012];State Operations Manual: Surveyor Guidance for Unnecessary Medications (F329) Online. Available at www.cms.hhs.gov/transmittals/downloads/R22SOMA.pdf.
- 9.Pugh MJ, Hanlon JT, Zeber JE, Bierman A, Cornell J, Berlowitz DR. Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure. J Man Care Pharm. 2006;12:537–545. doi: 10.18553/jmcp.2006.12.7.537. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.The American Geriatrics Society [Accessed March 5, 2012];AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. 2012 Online. Available at http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guideline recommendations/2012.
- 11.Wald A. Is chronic use of stimulant laxatives harmful to the colon? J Clin Gastroenterol. 2003;36:386–389. doi: 10.1097/00004836-200305000-00004. [DOI] [PubMed] [Google Scholar]
- 12.Hansten PD, Horn JT, editors. Drug Interactions Analysis and Management. Wolters Kluwer Health, Inc.; St. Louis, MO: 2012. [Google Scholar]
- 13.Goddard AF, James MW, McIntyre AS, Scott BB. British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut. 2011;60:1309–1316. doi: 10.1136/gut.2010.228874. [DOI] [PubMed] [Google Scholar]
- 14.Rybak LP. Ototoxicity of loop diuretics. Otolaryngol Clin North Am. 1993;26:829–844. [PubMed] [Google Scholar]
- 15.Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med. 2005;165:1686–1694. doi: 10.1001/archinte.165.15.1686. [DOI] [PubMed] [Google Scholar]
- 16.Marcum ZA, Hanlon JT. Recognizing the risks of chronic non-steroidal anti-inflammatory drug use in older adults. Ann Longterm Care. 2010;18:24–27. [PMC free article] [PubMed] [Google Scholar]
- 17.Grossman E, Messerli FH. Drug-induced hypertension: an unappreciated cause of secondary hypertension. Am J Med. 2012;125:14–22. doi: 10.1016/j.amjmed.2011.05.024. [DOI] [PubMed] [Google Scholar]
- 18.Herings RM, Stricker BH, de Boer A, Baker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures: dosage more important than elimination half-life. Arch Intern Med. 1995;155:1801–1807. [PubMed] [Google Scholar]
- 19.Hanlon JT, Horner RD, Schmader KE, et al. Benzodiazepine use and cognitive function among community-dwelling elderly. Clin Pharmacol Ther. 1998;64:684–692. doi: 10.1016/S0009-9236(98)90059-5. [DOI] [PubMed] [Google Scholar]
- 20.Aizenberg D, Sigler M, Weizman A, Barak Y. Anticholinergic burden and the risk of falls among elderly psychiatric inpatients: a 4-year case-control study. Int Psychogeriatr. 2002;14:307–310. doi: 10.1017/s1041610202008505. [DOI] [PubMed] [Google Scholar]
- 21.Berdot S, Bertrand M, Dartigues JF, et al. Inappropriate medication use and risk of falls – a prospective study in a large community-dwelling elderly cohort. BMC Geriatr. 2009;9:30. doi: 10.1186/1471-2318-9-30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–1051. doi: 10.1016/0895-4356(92)90144-c. [DOI] [PubMed] [Google Scholar]