A Prospective Analytical Study on Medication Assessment in Geriatrics Using Beer Criteria -At A Tertiary Care Hospital

Natasha Agarwal, Syeda Bushra Hashim, Bijji Shravya Shree, Sampath Priya Baandhavi, Dr. PDSS Prakash,

doi:10.5281/zenodo.14390122

Research Paper | Open Access
Volume 02 | Issue 12 | Article Id IJPS/240211574

A Prospective Analytical Study on Medication Assessment in Geriatrics Using Beer Criteria -At A Tertiary Care Hospital
Natasha Agarwal* Syeda Bushra Hashim Bijji Shravya Shree Sampath Priya Baandhavi Dr. PDSS Prakash
Malla Reddy College Of Pharmacy, Maisammaguda, Hyderabad, Telangana, India- 500100

Abstract

Geriatric patients are especially vulnerable to adverse drug reactions (ADRs) and inappropriate medication use due to age-related physiological changes and the presence of multiple comorbidities. These age-related changes have significant implications for the clinical management of older adults, as alterations in metabolism and variations in drug response often require adjustments in medication dosages. To mitigate these risks, healthcare professionals rely on various guidelines and criteria, among which the Beers Criteria is widely recognised. Objective- This study was intended to assess the medications utilised by the geriatric demographic with the aim of discerning potentially inappropriate medications, as outlined by the Beer’s criteria.Materials and method- We conducted a prospective observational study for a period of 6 months, reviewing a total of 287 patient prescriptions of age above 65 years to asses the use medications based on 2023 updated Beers criteria.Result- The study population was predominantly male, with a significant majority (62.4%) falling within the age group of 65-75 years. The most common comorbidities among patients were hypertension, diabetes mellitus, and thyroid disorders.A total of 2156 were prescribed from which 606 drugs were present in category 1, 162 drugs in category 2, 118 drugs in category 3 and 121 drugs in category 5.The most frequently prescribed drugs were Pantoprazole, Acetaminophen, Ondansetron, Telmisartan, and Glimepiride. Pantoprazole was the most prevalent potentially inappropriate medication (PIM) in category 1, followed by Glimepiride, Aspirin, Diclofenac, and Nifedipine. In category 2, Zolpidem, Acetaminophen, Aspirin, Tramadol, and Ibuprofen were the most prescribed drugs. Tramadol was the most prevalent PIM in category 3, followed by Antipsychotics, SSRIs, Diuretics, and Antidepressants. . In category 5, NSAIDs, Levetiracetam, and Tramadol were the most frequently prescribed drugs.Conclusion- this study concludes that the geriatrics are at significant risk of receiving potentially inappropriate medication, with the majority of potentially inappropriate medication identified were from category 1 of Beers criteria.The findings of this study highlight the need for increased awareness and careful monitoring of medication use in elderly patients to minimise the risk of adverse drug events and improve patient outcomes.

Keywords

Beers Criteria, American geriatrics society (AGS), Potentially Inappropriate Medications (PIMs), targeted interventions, prescribed drug therapy.

Introduction

The Beers Criteria, officially called the "Beers Criteria for Potentially Inappropriate Medication Use in Older Adults," is a widely recognized set of guidelines aimed at enhancing the safety and quality of prescribing practices for older adults. First developed in 1991 by Dr. Mark H. Beers and a team of experts, the criteria identify medications that may present higher risks of adverse effects in older adults, taking into account the age-related changes in pharmacokinetics and pharmacodynamics. It identifies potentially inappropriate medications for individuals over 65 years of age due to the risk outweighing benefits .The Beers Criteria is meant to serve as a guide for clinicians and health care providers. It does not prohibit the use of drugs, but restricts them on occasion, depending on the possible interactions between the drugs and the disease or syndrome presented by the individual 1 . The American Geriatrics Society reviews and amends this list every three years.The Society creates the Beers Criteria list by reviewing new medical evidence published since the last revision. A group of selected experts looks at clinical trials and research studies to revise the last published list. During the review process, the AGS panel may add, remove, or modify medications on the Beers Criteria list based on the latest published evidence regarding the safety of each drug. The Beers Criteria plays a vital role in optimizing medication choices and improving patient outcomes. The American Geriatrics Society (AGS) organizes the criteria into five sections, which outline potentially inappropriate medications for adults aged 65 and older 2 . The are as follows (a)Medications to avoid if you’re over 65 years old and not in a palliative care setting-This category includes drugs that should generally be avoided because they pose a high risk of serious side effects, such as benzodiazepines, which can increase the risk of cognitive impairment, delirium, falls, and fractures.

(b)Medications to avoid among people with certain health conditions-Some drugs may worsen particular health conditions common in older adults. For example, non-steroidal anti-inflammatory drugs (NSAIDs) are discouraged in individuals with chronic kidney disease or heart failure due to the risk of worsening these conditions.

(c) Medications to Use with Caution: These drugs may be acceptable in certain circumstances, but they require close monitoring and should be used with caution. For example, anticoagulants such as warfarin are necessary for preventing blood clots but require careful dose management to avoid bleeding complications in the elderly.

(d)Potentially inappropriate drug-drug interaction-The Beers Criteria highlights medications that, when used together, may increase the risk of adverse reactions. For instance, using two or more central nervous system depressants, such as opioids and benzodiazepines, can significantly heighten the risk of falls and respiratory depression.

(e)Medications whose doses should be adjusted based on renal function-Because kidney function typically declines with age, certain medications require dosage adjustments to avoid toxicity. The Beers Criteria flags these medications, such as certain antibiotics or diabetes medications like metformin, which should be dosed according to the patient’s renal function.

MATERIALS AND METHODS:

A prospective observational study was conducted at Malla Reddy Hospital, Suraram, Hyderabad for a period of 6 months from December to May 2024. After receiving approval from the institutional ethics committee, informed consent was obtained from each participant individually.The study was conducted on inpatients with a inclusion criteria of 1) AGE : 65 years and above. 2)Number of drugs prescribed more than one. The exclusion criteria was patients of age less than 65 and Hospice and end-of-life care setting patients.

Information was obtained regarding the patient’s socio-demographic characteristics, medical history, diagnosis and prescribed drug therapy.The prescribed medications were reviewed and compared to the list of medicines present in 2023 updated Beer’s list to optimise medication regimens.

RESULTS-

The study included the total of 287 patients, with varying demographic and clinical characteristics. We examined the medical records of 287 elderly patients, of whom 153 are males and females constituting 134. The study involved patients from the age group 65 years to 90 years the population was dominated by the males of age group 65-70 years with percentage of 33.1% this was closely followed by females of age group 65-70 years representing 29.3%. Additionally, males and females of age group 71-75 years constituted 9.8% and 6.3% respectively. Furthermore, the males and females of age group 76-80 years exhibits 2.8% and 5.2% respectively. The males and females of age group 80-85 years make up 7.3% and 4.2% respectively. The lowest count accounted from 86-90 years with males and females representing 0.3% and 1.7% respectively.(Table-1)

Table 1: DISTRIBUTION ACCORDING TO AGE AND GENDER

AGE (in years)	GENDER	COUNT	PERCENTAGE OF TOTAL	CUMULATIVE %
65-70	FEMALE	84	29.3	29.3%
	MALE	95	33.1	62.4%
71-75	FEMALE	18	6.3	68.6%
	MALE	28	9.8	78.4%
76-80	FEMALE	15	5.2	83.6%
	MALE	8	2.8	86.4%
80-85	FEMALE	12	4.2	90.6%
	MALE	21	7.3	97.9%
86-90	FEMALE	5	1.7	99.7%
	MALE	1	0.3	100.0%

Participant of study were from various departments ,The department of General Medicine received the highest number of admissions , with 98 samples, accounting for 34.1% .Followed closely by Gastrointestinal department, with 55 samples (19.2%), Central nervous system 35 samples (12.2%),Psychiatry with count 23 (8%), Nephrology and Pulmonary each were with count of 21 (7.3%), CVS count 13 (4.5%), Orthopaedic with count 10 (3.5%). The least count accounted were for Haematology and endocrine department each constituting count of 6 (2.1%) and 5 (1.7%) respectively.(Table 2)

Table 2: Distribution Of Patients Based On Department

Department	Count	Percentage Of Total	Cumulative %
CNS	35	12.2	12.2
CVS	13	4.5	16.7
Endocrine	5	1.7	18.5
General Medicine	98	34.1	52.6
GIT	55	19.2	71.8
Haematology	6	2.1	73.9
Nephrology	21	7.3	81.2
Orthopaedic	10	3.5	84.7
Psychiatric	23	8	92.7
Pulmonary	21	7.3	100

Of the 287 patients examined 50 (11.2%) of patients had no comorbidities and 237 patients had one or more comorbidities. Most frequent comorbidities were hypertension accounting for 163 patients (36.5%) followed closely by Diabetes mellitus with count 110 (24.6%), Thyroid disorders having count of 63 (14.1%), seizures with count of 36 (8.1%), Asthma with count of 17(3.8%). The least number of patients accounted for kidney disorder having the count of 8 (1.7%). A total of 2156 were prescribed from which 606 drugs were present in category 1, 162 drugs in category 2, 118 drugs in category 3 and 121 drugs in category 5

Table 3: Distribution Of Patients Based On Comorbidities

Comorbidities	Count	Percentage Of Total
Asthma	17	3.8%
Diabetes Mellitus	110	24.6%
Hypertension	163	36.5%
Nil	50	11.2%
Seizures	36	8.1%
Thyroid	63	14.1%
Kidney Disorder	8	1.7%

The most commonly prescribes drugs in our study were found to be Pantoprazole with count of 202 (9%). Followed closely by Acetaminophen with count of 130 (6%), Ondansetron with count of 86(3.9%), Telmisartan with count of 72(3.3%), Glimepiride with count of 69(3.1%), Levothyroxine with the count of 62 (2.9%), Aspirin and Atorvastatin each with the count of 54 (2.5%), and clinidipine with the count of 51(2.4%).(Table 4)

Table 4: Distribution Of Prescribed Drugs

Prevalent Drugs	Number Of Times Durgs Was Prescribed	% Of Total
Pantoprazole	189	8.8%
Paracetamol	130	6%
Ondansetron	86	3.9%
Telmisartan	72	3.3%
Glimipride	69	3.1%
Levothyroxine	62	2.9%
Aspirin	54	2.5%
Atorvastatin	54	2.5%
Clinidipine	51	2.4%
Thiamine	50	2.3%
Metformin	49	2.2%
Ceftriaxone	45	2.1%
Tramadol	42	2.0%
Diclofenac	33	1.5%
Levitiracetam	30	1.4%

In category 1 The most prescribed PIM was found to be Pantoprazole with the count of 202 (33.3%). Followed closely by Glimepiride with the count of 69(11.4%) , aspirin with count of 61(10.1%), diclofenac with count of 39 (6.4%), nifedipine with count of 25 (4.1%), lorazepam with count of 24 (4%).(TABLE 5)

Table 5: Distribution Of Medications To Be Avoided

Drugs	Count	Percentage Of Total	Cumulative %
Alprazolam	4	0.7%	0.7%
Amitryptalin	8	1.3%	2%
Aspirin	61	10.1%	12%
Bromphenaramine	3	0.5%	12.5%
Cholrphenaramine	4	0.7%	13.2%
Clonazepam	7	1.2	14.4
Clonidine	4	0.7	15
Diclofenac	39	6.4	21.5
Digoxin	2	0.3	21.8
Esmoprazole	5	0.8	22.6
Glimepride	69	11.4	34
Glipizide	18	3	37
Halopiridol	14	2.3	39.3
Hydroxizine	4	0.7	39.9
Iburofen	15	2.5	42.4
Lorazepam	24	4	46.4
Midazolam	1	0.2	46.5
Naproxen	15	2.5	49
Nifedipine	25	4.1	53.1
Nitrofurantoin	2	0.3	53.5
Olanzapine	6	1	54.5
Omeprazole	20	3.3	57.8
Oxazepam	2	0.3	58.1
Pantoprazole	202	33.3	91.4
Praxetine	3	0.5	91.9
Prazosin	5	0.8	92.7
Promethazine	3	0.5	93.2
Quatiapine	8	1.3	94.6
Rabeprazole	9	1.5	96
Resperidone	4	0.7	96.7
Scopilamine	5	0.8	97.5
Warfarin	5	0.8	98.3
Zolpidem	10	1.7	100

Fig 1: Distribution Of Drugs Prescribed In Category 1

In category 2 the highest prescribed drugs were found to be Zolpidem with the count of 24 (14.8%). This is closely followed by Acetaminophen 23 (14.2%), Aspirin with the count of 20 (12.3%), tramadol with the count of 13 (8%), ibuprofen with the count of 12(7.4%) , diclofenac with the count of 10 (6.2%).(FIG:2)

FIG 2: Distribution Of Drugs Prescribed In Category 2

Table 6: Distribution Of Medications To Be Used With Caution

Drug	Count	Percentage Of Total	Cumulative %
Antidepressants	10	8.5	8.5%
Antipsychotic	28	23.7	32.2%
Carbazapime	4	3.4	35.6%
Cetuximab	1	0.8	36.4%
Corticosteroids	1	0.8	37.3%
Diuretics	12	10.2	47.5%
Ibuprofen	2	1.6	49.2%
Methylprednisolone	1	0.8	50%
Snri	3	2.5	52.5%
Ssri	15	12.7	65.3%
Tca	4	3.4	68.6%
Tramadol	36	30.5	99.2%
Warfarin	1	0.8	100%

In category 3 the most prescribed drugs were tramadol with the count of 36 (30.5%). This was closely followed by Antipsychotics with the count of 28 (23.7%), SSRI’s with the count of 15 (12.7%), diuretics with the count of 12 (10.2%), antidepressants with the count of 10 (8.5%).(Table-6)

Table7: Distribution Of Medications Needng Dosage Adjustment

Drug	Count	Percentage Of Total	Cummilative%
Enoxaparin	8	6.6	6.6%
Famotidine	1	0.8	7.4%
Gabapentin	6	4.9	12.3%
Levitiracetam	26	21.3	33.6%
Methylprednisolone	1	0.8	34.4%
Nsaid	46	37.7	72.1%
Ranitidine	3	2.5	74.6%
Spiranolactone	8	6.6	81.1%
Tramadol	23	18.9	100%

In category 5 the most prescribed drugs were NSAIDs with the count of 46 (37.7%), this is closely followed by levetiracetam with the count of 26 (21.3%), tramadol with the count of 23 (18..9%). (Table 7)

DISCUSSION:

The 2023 update to the Beers Criteria represents the latest effort by the American Geriatrics Society to provide healthcare professionals with evidence-based guidance on potentially inappropriate medications for older adults. This update incorporates new research and clinical insights, refining recommendations to enhance medication safety and reduce the risk of adverse drug events in the elderly population. This study analysed the medication patterns of elderly patients, aged 65 to 90 years, admitted to different departments within a hospital. The study population was predominantly male, with a significant majority (62.4%) falling within the age group of 65-75 years. The most prevalent comorbidities among patients were hypertension, diabetes mellitus, and thyroid disorders. A total of 2156 prescribed drugs were analysed, encompassing 606 drugs from category 1, (n=162) from category 2, (n=118) from category 3, and (n=121) from category 5. The most frequently prescribed drugs were Pantoprazole, Acetaminophen, Ondansetron, Telmisartan, and Glimepiride.

Category 1

This category mainly contains drugs which are considered potentially inappropriate. Pantoprazole, Glimepiride, Aspirin, Diclofenac, Nifedipine were found to be the prevalent medications used from category 1 in our study.A study conducted by Sarah khamis et al (Northern Cyprus) had similar results with Pantoprazole with the most prevalent PIM followed by furosemide, omeprazole, enoxaparin

Pantoprazole

is a proton-pump inhibitor, in our study Pantoprazole was found to be the most widely used drug from category-1. The percentage of Pantoprazole was found to be 33.3% with the count of 202. Based on the beers criteria 2023 recommendations, this drug should not be used for more than eight weeks unless high risk patients (example - Erosive esophagitis, barrette’s esophagitis, hypersecretory conditions. Adverse effects associated with long-term use of PPI include community-acquired pneumonia, vitamin B12 deficiency, dementia, kidney diseases, fracture, osteoporosis and accidental falls. A few observational studies have been carried out that demonstrates an association between use of PPIs and risk of fracture. Alternative therapeutic options may involve histamine-2 receptor antagonists, which have been linked to a reduced risk of Clostridioides difficile-associated diarrhea (CDAD) and fractures.

Glimepiride

Sulphonyl urea drug Glimepiride was found to be the second most prevalent PIM with the percentage of 11.4% and count of 69. According to the 2023 Beers Criteria recommendations, long-term use of glimepiride can increase the risk of hypoglycaemia. It should generally be avoided as first- or second-line monotherapy or add-on therapy, unless there are significant barriers to using safer and more effective alternatives. If a sulfonylurea is necessary, shorter-acting agents like glipizide are preferred over longer-acting options like glimepiride (AGS, 2023).

Category 2

Category-2 mainly contains medications that are potentially inappropriate medications in certain diseases, or they can cause drug-disease interaction that can worsen the condition. In our study, Zolpidem, acetaminophen, aspirin, ibuprofen, Diclofenac were found to be the most prevalent drugs from category-2.

Zolpidem

Zolpidem is a drug in category-2 used in the elderly with delirium, dementia, cognitive impairment, history of falls and fractures. The percentage of zolpidem was found to be 14.8% with the count of 24. Based on 2023 beers criteria zolpidem should be avoided for behavioural problems in case of delirium and dementia and it may also cause ataxia, impaired psychomotor function, syncope, or additional falls in patients with history of fall or fracture. The use of this drug is avoided unless nonpharmacologic options (e.g., behavioural interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If glimepiride is used, periodic attempts at deprescribing should be considered to evaluate the ongoing need for the medication and determine the lowest effective dose (AGS, 2023).

Category 3

This category mainly contains drugs potentially inappropriate medications to be used with caution. Tramadol, antipsychotics, SSRI and diuretics were found to be the most prevalent drugs from category 3 used in our study.A study conducted by Fathima Nashiyae et al had similar results with tramadol, furosemide and aspirin are the most prescribed drugs in category 3.

Tramadol use in this category reached a count of 36 with (30.5%), This was closely followed by Antipsychotics with the count of 28 (23.7%), SSRI’s with the count of 15 (12.7%), diuretics with the count of 12 (10.2%), antidepressants with the count of 10 (8.5%). Based on the 2023 Beers criteria this class of drugs can May exacerbate or cause SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) or hyponatremia. They should be administered with caution, and sodium levels should be closely monitored when initiating or adjusting dosages in older adults.

Category 4

This category has a list of medications to avoid due to their potential to cause drug interactions when combined with other medications. Our adherence to these guidelines was thorough, and the findings revealed no drug interactions within the elderly patient population studies

Category 5

This category includes medications that should be avoided or have their dosages adjusted based on the level of kidney function in older adults. In our study NSIADs, levetiracetam and tramadol were found to be the most prevalent drugs from category-5. NSAIDs.In a study conducted by Kittipak Jenghua et al Colchicine, tramadol, and spironolactone were the most prescribed drugs,

NSAIDs use in category 5 reached a count of 46 and percentage of 37.7%. NSAIDs block prostaglandin synthesis can lead to renal vasoconstriction and reduction of kidney function. Based on the 2023 Beers criteria this class of drugs may increase the risk of acute kidney injury and a further decline in kidney function. The use of NSAIDs is avoided in elderly patients with kidney disorders.

CONCLUSIONS

This study concludes that the geriatrics are at significant risk of receiving potentially inappropriate medication, with the majority of potentially inappropriate medication identified were from category 1 of Beers criteria.These results underscore the importance of regular medication review and adherence to the Beers criteria to optimise pharmacotherapy in the elderly.Implementing the Beers Criteria in daily pharmacy practice involves integrating it into medication therapy management (MTM) reviews and using it as a checklist during medication dispensing. Pharmacists can use software that flags PIMs based on the Beers Criteria during prescription processing, allowing for real-time interventions. Additionally, organising educational workshops for healthcare professionals on the Beers Criteria and conducting regular audits of prescriptions can ensure that its recommendations are consistently applied.The findings of this study highlight the need for increased awareness and careful monitoring of medication use in elderly patients to minimise the risk of adverse drug events and improve patient outcomes..

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