Article, Emergency Medicine

Beers criteria and the ED: an adequate standard for inappropriate prescribing?

Editorial

Beers criteria and the ED: an adequate standard for Inappropriate prescribing?

Fredric M. Hustey MD?

Department of Emergency Medicine-E-19, The Cleveland Clinic, Cleveland, OH 44195, USA

Received 26 January 2008; accepted 27 January 2008

Drug-related morbidity and mortality are a major problem for older patients and the health care system. It is estimated to cost nearly 80 billion dollars annually in the United States [1] and accounts for between 7% and 11% of all ED visits by older patients [2,3]. It is also likely to contribute to 12% of hospital admissions by older adults [4].

In this issue of The American Journal of Emergency Medicine, Nixdorff et al describes the scope of this problem in the ED of a large tertiary care center. Using the 2003 update of Beers Explicit criteria, they found that nearly one third of elderly ED patients were taking a potentially inappropriate medication (PIM) at the time of the ED visit. An additional 7% were prescribed a potentially inappropriate medication upon discharge from the ED. The authors also go on to describe the frequency and nature of potential adverse Drug interactions, complementary and Alternative medication use, and significant discrepancies between Medication lists obtained by ED health care providers and medications patients were actually taking.

Nearly all other studies attempting to address prescribing problems in older ED patients have used Beers explicit criteria as a standard for ED care. Hustey et al [5] reported that 32% of older ED patients presented with at least one PIM in routine medications, and 13% were prescribed a PIM at ED discharge. Caterino et al [6], in a review of the National Hospital Ambulatory Medical Care Survey database, found that 13% of all older patients received a PIM as part of the ED visit. Chin et al [7], in a prospective cohort study of elderly ED patients, found a prevalence of PIM use of 15%.

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Widespread adaptation of the Beers criteria in ED studies has likely resulted from the absence of ED-specific prescrib- ing standards for older patients in general. The Beers list was originally developed based on a consensus of nationally recognized experts in geriatrics, clinical pharmacology, and psychopharmacology using a modified Delphi technique. These criteria were originally published in 1991 [8] in an attempt to define a set of potentially inappropriate medica- tions for nursing home patients. They were subsequently updated in 1997 [9] and again in 2003 [10] to include older outpatients. This most recent list includes 48 medications or Medication classes to avoid regardless of comorbidities and 20 medication and comorbidity combinations to avoid. Risk is stratified into low or high severity for each medication or medication class. Beers criteria were adapted as a standard by Centers for Medicare and Medicaid Services in 1999 for nursing home care and were included in the 2005 National Health care quality Report as a measure of use of inappropriate medications in the elderly. Medications on this list that are commonly encountered in older ED patients include skeletal Muscle relaxants, propoxyphene with acetaminophen (Darvocet), and indomethacin.

Although studies such as these bring to light important issues related to prescribing practices for our older patients, they are also limited by the applicability of Beers criteria to the ED. As these guidelines were not originally intended for ED care, neither the original publication nor subsequent updates included input from emergency medicine. In addition, although there is some evidence to support the association between use of Beers list medications and morbidity in other health care settings [11-14], the develop- ment of the list itself was not evidence based. The list also does not take into account clinical circumstances

0735-6757/$ – see front matter (C) 2008 doi:10.1016/j.ajem.2008.01.008

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surrounding medication use. Medications are often adminis- tered in the ED on a one-time basis. Home going medications are typically for short-term use, as opposed to many of those prescribed in the Primary care setting. Does a single dose of prochlorperazine in the ED for nausea carry the same risk as long-term use in a nursing home patient? Is administration of diphenhydramine for a severe allergic reaction comparable to long-term use for insomnia?

In addition, Beers medications may only be responsible for a small proportion of ED visits for adverse drug events in older adults. Budnitz et al [15], in a nationally representative probability sample of older patients, found that only 3.6% of all ED visits by older patients for adverse drug events involved medications considered to always be potentially inappropriate based on Beers criteria. Alternatively, 33% of ED visits related to adverse drug events by older patients involved warfarin, digoxin, or insulin. Beers Criteria medications caused lower numbers of and few risks for ED visits for adverse events than other drugs. Drug-drug interactions are likely to play a big role in medication related morbidity and mortality. Focusing on Beers criteria as a single standard by which to measure the potential for adverse drug events in older ED patients results in a failure to address most of the problem.

In spite of these limitations, in the absence of ED- specific criteria the Beers list can provide some helpful guidelines for ED care. Some of the more common medications on the list that are prescribed during ED visits should be avoided regardless of clinical circumstances or duration of use. skeletal muscle relaxants are unlikely to produce therapeutic benefit in doses tolerated by older patients. They also can precipitate dizziness, delirium, and falls. Propoxyphene with acetaminophen (Darvocet) offers little analgesic benefit over acetaminophen alone but carries side effects typical of narcotic analgesics. Indomethacin crosses the blood brain barrier and is the most likely of all nonsteroidal antiinflammatory drugs to precipitate delirium. In most cases, better alternatives are available for the treatment of acute gouty arthritis. The American Medical Directors Association and American Society of Consultant Pharmacists joint position statement [16] perhaps best sums up the use of the Beers list in the clinical setting: The Beers list is a helpful guide; it must be used in conjunction with a patient-centered care process, and checklist approaches should not be used as a substitute for clinically based prescribing decisions. Nonetheless, given the limitations of applying Beers criteria in the ED setting, the development of ED-specific guidelines would help us to better define at least one aspect of inappropriate prescribing in our older ED population.

References

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