Step 1: Review the 2015 AGS Beers Criteria for PIM. An example of the criteria is presented in Supplemental Table 1 (Supplemental Digital Content [SDC] 1, available at: http://links.lww.com/HHN/A36).
Step 2: Glen's medications that are on the 2015 AGS Beers Criteria List:
Step 3: Addressing each medication individually for Glen (Table 2)
Step 4: Using the 2015 AGS Beers Criteria as guide for monitoring of adverse effects and condition changes
The Beers Criteria also address drug–disease and drug–syndrome PIMs. The nonbenzodiazepines, benzodiazepine receptor agonist hypnotics (e.g., zolpidem) have been added to the “avoid” list in older adults. Opioids have been added to the list of CNS medications that should be avoided in individuals with a history of falls or fractures. Antipsychotics are to be avoided as first-line treatment for behavior disturbances associated with dementia because of conflicting evidence on their effectiveness and potential of adverse effects. The drug–disease and drug–syndrome table can be found in Supplemental Table 2 (SDC 2, available at: http://links.lww.com/HHN/A37).
Glen has a history of cognitive impairment and falls. The oxycodone/acetaminophen prescribed to him may not be appropriate, assuming acetaminophen is effective for his pain. He did report oxycodone/acetaminophen made him feel “loopy” in the hospital. An accurate pain assessment is imperative for evaluation and plan. He has a history of neuropathy for which he was taking gabapentin. Gabapentin is listed in Supplemental Table 2 (SDC 2: http://links.lww.com/HHN/A37) as a PIM for individuals with history of falls, and Glen does have a history of falls. This medication was discontinued in the hospital. The nurse should discuss with the provider the pain assessment, the omission, and rationale for discontinuation of the gabapentin and pain management plan. If the gabapentin is resumed, then close monitoring for adverse CNS effects is required. Explicit education about side effects should be provided to Glen and Michele. Sertraline is also listed in Supplemental Table 2 (SDC 2: http://links.lww.com/HHN/A37) due to its risk for inappropriate secretion of antidiuretic hormone syndrome. This medication was discontinued in the hospital and the omission and rationale should be discussed with provider. A discussion with Glen and Michele and assessment of depressive symptoms and the effectiveness of the medication is warranted. If the medication is resumed, monitoring for adverse effects and education as with gabapentin is crucial.
It is important to remember that medication reconciliation protocols vary by health system and adherence is also variable. Some health systems and home healthcare agencies have linking electronic health records that give real-time access to current medication lists. The process also varies by provider. Providers must update the list routinely for changes and this does not always occur. Patients and family members tend to not seek clarification about medication changes due to insufficient knowledge, lack of opportunities, forgetfulness, and lack of insight of possible repercussions. It is not until medication problems occur that they realize the ramifications associated with not seeking clarification (Manias et al., 2014). Home healthcare clinicians often have continuity with patients, and medication reconciliation is a routine portion of posthospital visits. Patient and caregiver education on the importance of medication reconciliation and communication with providers in the outpatient and inpatient setting is imperative in avoiding medication misadventures. Because Glen has multiple providers, his wife may be the only constant in his care so she needs to understand the significance of medication reconciliation.
New to the 2015 AGS Beers Criteria are drug–drug interactions (excluding anti-infective) that are highly associated with harmful outcomes in older adults (Hines & Murphy, 2011). The list is selective and not comprehensive, and should be considered a reminder to assess drug–drug interactions. In Glen's case, the use of spironolactone, lisinopril, and potassium has the potential for hyperkalemia and should be monitored closely by routine chemistries. The use of gabapentin and sertraline, if restarted, has the potential for a drug–drug interaction.
Also new to the 2015 criteria are drugs to be avoided or for which the dose should be adjusted in individuals with a specific degree of kidney impairment. This list was adapted from published consensus guidelines developed by an expert group including two AGS Beers Criteria panelists (Hanlon et al., 2009). The AGS Beers panel reviewed the evidence and selected medications from these earlier consensus guidelines for inclusion, added additional medications, including several anticoagulants, and included spironolactone and triamterene, which were in the 2012 Beers Criteria. Glen is on spironolactone and has stage III kidney disease, so close monitoring of chemistries is needed to watch for worsening kidney function and the high potential for adverse effects.
The Significant Role of the Pharmacist
In all care settings, pharmacists have an important role in educating other healthcare professionals about the Beers Criteria and how to use them in clinical practice. In the hospital setting, computerized physician order entry systems with clinical decision support can be configured to flag the Beers medications. If a prescriber enters an order for a Beers medication for a patient >65 years old, the system will alert the prescriber with information about why this medication may not be recommended for this patient and possible alternatives. Beers medications can also be imbedded into dispensing, so the pharmacist is alerted to high-risk medications. The pharmacist would then contact the prescriber and offer alternative medications on formulary. If a Beers medication is truly indicated for the patient, the pharmacist can inform the prescriber about appropriate dosing guidelines and monitoring parameters.
Community pharmacy computer systems can also imbed Beers medications to alert pharmacists of potentially inappropriate medications for patients >65 years old. To complete the entry of the prescription, the pharmacist would have to document that he or she either contacted the prescriber or reviewed the patient profile to override the alert. Because community pharmacists generally do not have access to laboratory values or past medical history, it is easier for them to monitor the “medications to avoid” list rather than the medications that should be avoided in specific disease states.
Community pharmacists, because of their accessibility, can also be a resource to their patients about the implications of medications on the Beers list. It is important to stress to patients that they should not abruptly discontinue their medications just because it is on the Beers list. Rather, they should discuss it with their provider. The pharmacist can also offer to call the patient's provider to alert him or her about the Beers medication in question. AGS has developed patient education material to assist healthcare professionals when discussing Beers medications with their patients available at: http://geriatricscareonline.org/toc/ags-patient-handouts/H001/
Another role for the pharmacist in the community is working with Medicare Part D prescription plans. It has come to the attention of AGS that many Part D plans have placed some Beers medications on prior authorization lists or they do not cover them at all (Berger, 2014; McCormick, 2014). The pharmacist can either call the prescriber for an alternative medication or can facilitate getting prior approval when the medication is appropriate for the patient. This seems to be common with some of the CNS depressants such as the benzodiazepines, the nonbenzodiazepine hypnotics, and skeletal muscle relaxants.
Shared Decision Making
The Beers Criteria can be a starting point to not only discuss medication risks/benefits, but also to open a discussion about quality of life and care preferences for patients. Medication education requires active engagement of patients and caregivers for shared decision making. Glen has multiple medical comorbidities as well as multiple hospitalizations and frequent falls over the last several months. Both he and Michele have voiced their concerns regarding the number of medications that have been prescribed. Patient-centered care revolves around the wishes and needs of the patient. Frequently, adverse medication effects occur in patients, and caregivers aren't always able to make the connection until prompted by healthcare professionals. Jane has a rapport with Glen and Michele. She can ask what they understand about Glen's current condition and what their goals are for treatment.
Remember the criteria deal with only a small portion of the many types of prescribing issues that older adults face—that is, medications that are providing them limited benefit or causing bothersome adverse effects, problems with medication adherence, medication costs that make it difficult to afford medications, and management of complex regimens. So, although the Beers Criteria is a useful tool, we need to stay attentive to these other types of problems as well.
Home healthcare clinicians act as liaisons between patients and providers during transitions of care. The broad base of knowledge they possess, and their expertise and experience in all matters of direct patient care is what makes them so well suited to ensure safety during transitions of care and ongoing home healthcare. This expertise and experience combined with the longitudinal nature of their interactions with a home healthcare patient are why it is important to be knowledgeable about the Beers Criteria. A clear understanding of the 2015 AGS Beers Criteria and its application can play a vital role in the care and medication management of older adults in the home setting.
Instructions for Taking the CE Test Online Medication Reconciliation and Education for Older Adults: Using the 2015 AGS Beers Criteria as a Guide
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Registration Deadline: December 31, 2018
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Supplemental Digital Content
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