Beer’s List- Medications You Shouldn’t Give to Old People

Do you ever get stumped when it comes to prescribing medications for the elderly? Or, maybe you just don’t know what you don’t know concerning drugs and old people. It seems like some of the most common feedback my colleagues and I working in the emergency department receive from primary care providers relates to prescribing in the elderly population. 

Some docs really don’t like to see older people take Macrobid given it’s propensity to cause renal issues. Other providers hesitate to prescribe any sort of pain meds regardless of the extent of injury. So, how do you determine which meds are OK to prescribe elderly patients and those you should shy away from?

Prescribing practices when it comes to older patients vary from physician to physician, and nurse practitioner to nurse practitioner. These practices seem to center around an informal mix of pet peeves and personal opinion. While as nurse practitioners we all realize that medications affects older adults differently than younger, and caution should be taken when prescribing, the extent to which this is done is a toss up. Fortunately, there is a set of more formal criteria to follow as a guide in prescribing medications for elderly patients- the Beer’s List. 

What is the Beer’s List?

The Beer’s List, also known as the Beer’s Criteria for Potentially Inappropriate Medication Use in Older Adults, is a set of guidelines to help improve the safety of prescribing medications to the elderly. The criteria was originally developed in 1991 by Dr. Mark Beers, a geriatrician, along with a panel of experts. Beer’s List has been updated several times since it’s inception, most recently in 2012.

Is Beer’s List the end-all-be-all of medication use in the elderly?

Beer’s List is meant to be used as a helpful guide rather than a strict criteria. Authors of the list advise that it should not be used in a punitive manner, or supersede clinical judgement. They recognize that sometimes, the benefit of prescribing medications with potentially negative side effects outweighs the risk. 

Creators of the Beer’s Criteria recommend using the list in conjunction with other sets of criteria, namely the STOPP and START criteria, to develop the safest prescribing practices possible. The STOPP guidelines, Screening Tool of Older Person’s Prescriptions, also lists medications which may be inappropriate for use in older adults. The START guidelines, Screening Tool to Alert to Right Treatment, gives prescribing indicators for diseases commonly found in older adults. 

Why is Beer’s List so important?

Older adults can be particularly sensitive to medications, not to mention they are often a land mine of chronic medical diseases and a pitfall when it comes to polysubstance use. They are at increased risk of experiencing negative side effects of medications, for example gastrointestinal bleeding with NSAID use. Chronic diseases like renal disease and hepatic failure mean that medications are metabolized differently in the body making prescribing tricky. 

Thirty percent of hospital admissions among the elderly may be linked to drug-related problems or toxic medication effects. Complications like falls, hip fractures, constipation, and confusion are commonly linked to medications among older patients. Medication-related problems cause an estimated 106,000 deaths annually and cost the economy an estimated $85 billion each year. By prescribing medications more appropriately in old age, healthcare providers can save lives, improve functionality among the elderly, and use healthcare resources more prudently.

How is Beer’s Criteria structured?

Medications included in the Beer’s Criteria are categorized according to organ system, drug class, and risk for poor outcomes. The tables include information on when to avoid a given medication in all elderly patients in general, when to avoid the medication in conjunction with certain comorbid medical conditions, and precautions to take when prescribing a given medication. 

Where can I find a copy of Beer’s List?

Beer’s list is a practical guide for use in nurse practitioner practice. It isn’t too long and gives a quick synopsis of prescribing guidelines you can quickly reference during the workday. The American Geriatrics Society offers a printable list of the guidelines, complete with scored edges so you can cut out the list keeping it handy at your desk for easy reference. 

Is there a set of guidelines you follow in prescribing to the elderly?

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