The materials were compiled by an advisory group of leaders and practitioners in long-term care and are intended for:

• Pharmacists
• Physicians
• Nurses
• Nurse Practitioners
• Other Healthcare Practitioners

As a result of potential adverse effects due to pharmacokinetic and pharmacodynamic changes in older people, certain medications should be avoided, or used cautiously with monitoring. This site provides information about the "Beers List"¹ and other drugs which are potentially harmful when used inappropriately. If used, documentation should note the reason for use and show that monitoring is in place.

The information provided is intended for practitioners caring for the older person in all settings i.e. home, long term care, and acute care.

• What is the "Beers List"?
• What drugs are included?
• How widespread is the problem?
• What are the alternatives to using these medications?

• High Alert Medications
• Drugs with Anticholinergic Properties
• General Information about Drug Use in Older Persons

What is the "Beers List"?

The Beers List is a consensus list of potentially inappropriate medications for older persons developed by Dr Mark Beers and an American panel of experts. It was first published in 1991, with the goal of reducing preventable adverse drug effects among older persons in nursing homes. The Beers List was updated in 1997 and 2003 and is now targeted to all older persons, including those living in the community. Building on Dr Beers' work, a Canadian review of inappropriate prescription practices in older persons was conducted in 1997. This review, carried out by McLeod and colleagues and based on a survey of a 32 member national panel of experts, also considered reasons for prescribing the medications, comorbidities, and duration of therapy.

The Beers criteria was updated and released in 2012. See AGS releases updated Beers criteria.

Back to Top

What drugs are included on the "Beers List"?

The Beers List¹ was published in the Archives of Internal Medicine journal.

There have been are various adaptations to the original list, for example a specific jurisdiction may create a list that aligns with a provincial formulary. The Canadian Institute for Health Information has developed a list², as has Saskatchewan³, which readers can review if interested.

The list below is taken from Health Quality Ontario (formerly Ontario Health Quality Council)⁴, ⁵ and Canadian brand names are used where available (medications not available in Canada are not included in the list).

The footnotes of references below link to the article (just click on the reference).

Websites are available offering more detailed information about each drug (generally US FDA approved drug information). For example, a couple of sites are:

• www.nlm.nih.gov/medlineplus/
• www.drugs.com/ppa/#
• dir.pharmacy.dal.ca/

Drugs approved for use in Canada, along with some Canadian monographs, can be found through Health Canada's Drug Product Database search engine at http://webprod.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp.

Safety information/warnings from Health Canada can be viewed at Recent Advisories Warnings and Recalls; as well as Canadian Adverse Reaction newsletters

Not all of the medications listed below are funded through the Ontario Public Drug Programs. Availability of a particular medication in the Ontario Drug Benefit Formulary/Comparative Drug Index can be found at: https://www.healthinfo.moh.gov.on.ca/formulary/index.jsp

• ¹ Fick Donna M. et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults:Results of a US Consensus Panel of Experts. Archives of Internal Medicine. 2003;163:2716-2724
• ² Drug Claims by Seniors: An Analysis Focusing on Potentially Inappropriate Medication Use, 2000 to 2006 CIHI Analysis in Brief September 2007 Appendix A
• ³ Potentially risky drugs and their safer alternatives: Beers drugs commonly used in SK and recommended substitutes by HQC SK
• ⁴ List of Drugs Not to be Used in the Elderly as adopted by OHQC (July 2009)
• ⁵ What is the Beers list?
• ⁶ Potentially Harmful Drugs in the Elderly: Beers List and More. Pharmacist's Letter/ Prescriber's Letter September 2007 ∼ Volume 23 ~ Number 230907

Back to Top

How widespread is the problem?

Because the Beers List has been updated several times and also varies across jurisdictions, comparable data related to the use of these drugs and their effects are difficult to obtain. A 2001 study found that 21% of community-dwelling elderly US patients were on at least one of 33 potentially inappropriate medications. A more recent study found that 34% to 47% of elderly outpatients and nursing home Medicare and Medicaid Service residents in the United States were taking at least one Beers List medication.

In Canada, concerns related to the use of drugs on the Beers List have been flagged by several organizations including the Canadian Institute for Health Information⁸, Ontario Joint Task Force on Medication Management in Long-term Care,⁹ the Saskatchewan Health Quality Council¹⁰ and the Ontario Health Quality Council.¹¹ Reported rates of inappropriate prescribing vary depending on the source of information, the drugs studied and prescription practices. Older persons living in the community or coming from hospital to a long term care home are more likely to be on a Beers List medication than those in long term care¹². The likelihood of being prescribed a drug inappropriately increases with the number of prescription medications and prescribing physicians.¹³

• ⁸ Drug Claims by Seniors: An Analysis Focusing on Potentially Inappropriate Use of Medications, 2000-2006
• ⁹ Joint Task Force on Medication Management in Long-Term Care Report November 4th, 2009 p.22
• ¹⁰ Improving the Quality of Saskatchewan Seniors in Long-Term Care Drug Management Portfolio HQC December 2004
• ¹¹ Quality Monitor Ontario Health Quality Council 2010 Report on Ontario's Health System. Drug Safety 4.4 p.52
• ¹² More than half of hospitalized elderly patients in the Intensive Care Unit (ICU) prescribed with inappropriate medications
• ¹³ Cormier, R, Beers Criteria-Based Review of Medication Inappropriateness in British Columbia Seniors Living in Care Facilities, 2006

Back to Top

What are the alternatives to using these medications?

In some cases there may be a non-pharmacological alternative or another, possibly safer, medication available. Suggestions are noted in the following references (Pharmacist's Letter / Prescriber's Letter and Saskatchewan Health Quality Council). Evidence-based guidelines as well as a person's clinical status, co-morbidities, other treatments and organ function should be considered. Regular monitoring assists in identifying possible adverse effects and allows for management of such effects in a timely manner.

• Pharmacist's Letter / Prescriber's Letter Potentially Harmful Drugs in the Elderly: Beers List and More
• Potentially risky drugs and their safer alternatives: Beers drugs commonly used in SK and recommended substitutes, Saskatchewan Health Quality Council

Back to Top

There are other medications that could lead to serious adverse events in older persons depending on the pharmacology of the drug, patient characteristics, and monitoring requirements.

High Alert Medications

High alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) have been defined for acute care¹⁶ and community care¹⁷.

• Warfarin
• Insulin
• Opioids, and
• Digoxin.¹⁸, ¹⁹

• ¹⁶ ISMP's List of High-Alert Medications
• ¹⁷ ISMP List of High-Alert Medications in Community/Ambulatory Healthcare
• ¹⁸ Budnitz DS et al. Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults Ann Intern Med 2007; 147(11): 755-765. Abstract available at http://www.annals.org/content/147/11/755.abstract
• ¹⁹ Analysis of Medication Incidents in LTC ISMP Canada Safety Bulletin 2010; 10(Dec 10):1-3.

Drugs with Anticholinergic Properties

Older persons are often sensitive to the anticholinergic effects of drugs and combinations of drugs with these properties can lead to cumulative effects. For information about "Anticholinergic Burden" see:

• Nishtala PS. et al. Anticholinergic Activity of Commonly Prescribed Medications and Neuropsychiatric Adverse Events in Older People. J Clin Pharmacol 2009; 49(10): 1176-1184
• Chew ML. et al Anticholinergic activity of 107 medications commonly used by older adults. J Am Geriatr Soc 2008: 56:1333-1341

General Information about Drug Use in Older Persons

• Information about Aging and Drugs

This section will continue to evolve over time as information is brought to our attention or new information is published. If you would like to suggest additions please contact Kris Wichman.

Back to Top

• Why was the Campaign on Safer Medication Use in Older Persons launched?
• What are the goals of the Campaign?
• Who are the partners?
• What are the expectations of the campaign partners?
• What are the key messages of the Campaign?
• How can I get involved?

Why was the Campaign launched?

The Campaign on Safer Medication Use in Older Persons began as a collaborative effort to reduce the use of Beers List Drugs in long-term care homes across Ontario. Beers List medication use was flagged for potential improvement in recent reports of the Ontario Health Quality Council¹⁶ and the Ministry of Health and Long-Term Care¹⁷. Discussion with front line practitioners working in long term care also indicated a lack of awareness of these drugs.

During the campaign planning process, it became clear that the scope of the campaign was too narrow. The partners therefore decided to expand the focus of the campaign to all older persons, since those living in the community and coming from hospital to long-term care are more likely to be on a Beers List drug. The partners also decided to expand beyond the Beers List to include a short list of other high risk drugs that have serious side effects and should be carefully monitored when used in older persons.

• ¹⁶ Quality Monitor Ontario Health Quality Council 2010 Report on Ontario's Health System. Drug Safety 4.4 p.52
• ¹⁷Joint Task Force Report on Medication Management, Nov 2009 Ontario Ministry of Health and Long-Term Care

Back to Top

What are the goals of the Campaign?

The Campaign for Safer Medication Use in Older Persons is a three year social marketing campaign designed to:

• develop consensus among key stakeholders on common messages to promote safer medication use in older persons.
• increase awareness of Beers List and other high risk medications used in the elderly
• reduce use of a short list of potentially inappropriate medications in long term care homes.

Back to Top

Who are the Partners?

The founding partners in this campaign are:

• Classic Care Pharmacy
• Geriatrx Pharmacy
• Institute for Clinical and Evaluative Sciences (ICES)
• Institute for Safe Medication Practices (ISMP) Canada
• Jeffers' Pharmacy Limited
• Medical Pharmacies Group Limited
• MediSystem Pharmacy
• Nurse Practitioners Association of Ontario
• Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS)
• Health Quality Ontario
• Ontario Long Term Care Physicians (OLTCP)
• Ontario Long Term Care Association (OLTCA)
• Ontario Pharmacists Association (OPA)
• Registered Nurses' Association of Ontario (RNAO)
• Summit Pharmacy Inc.
• Westmount Pharmacy
• Ministry of Health and Long-Term Care

What are the expectations of Campaign partners?

Campaign partners contribute to the campaign by endorsing its goals, educating their staff, membership and community stakeholders about potentially inappropriate medications for use in the elderly, implementing safer medication practices and monitoring their performance with respect to adverse drug events and other safety and quality indicators.

Back to Top

What are the key messages of the Campaign?

1. Some medications such those on the Beers List, have serious adverse effects in older persons.
2. Safer medications may be available and should be considered by health care professionals and their patients.
3. If a safer medication is not available, the reason for continued use of the listed drug should be documented and its effect monitored on a regular basis.

All medications should be regularly reviewed for safety and effectiveness. In healthcare settings, regular review may take place on admission and discharge, following a change in health status, or on a quarterly basis. For more information on how to conduct a best possible medication history and other resources, visit ISMP Canada's website.

Some provinces have programs in place to ensure patients are getting the most benefit from their drug therapy. These programs enable pharmacists to conduct comprehensive medication reviews and identify potentially harmful drug interactions or side effects. Ontario's Medscheck Program covers medication reviews in community and long-term care settings. For more information click here.

Back to Top

How can I get involved?

If you are interested in joining the campaign, please contact Kris Wichman, Project Leader, Institute for Safe Medication Practices (ISMP) Canada or Paula Neves, Director of Health Planning and Research, Ontario Long Term Care Association (OLTCA).

Back to Top

• Joint ISMP Canada / SHRTN Communities of Practice webinars on Medication Safety in LTC
• Peer-Reviewed Articles
• Evidence-Based Tools
• Reports & Policy Documents
• Other Useful Links

Joint ISMP Canada / SHRTN Communities of Practice webinars on Medication Safety in LTC

• Part 1: The Changing Culture in Healthcare, September 22, 2011 (slide presentation)
• Part 2: Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety, October 20, 2011 (slide presentation | view recording)
• Part 3: How MedsCheck for Long-Term Care Can Improve Medication Management in Long-Term Care Homes, November 17, 2011 (slide presentation | view recording)
• Part 4: An Update from Accreditation Canada on Medication Reconciliation in Long-Term Care, February 16, 2012 (slide presentation | view recording)
• Part 5: Contemporary Issues in the Use of Psychotropic Medications in Long-Term Care, March 21, 2012 (slide presentation | view recording)

Peer Reviewed Articles

• Beers MH, Ouslander JG, Rollingher J, Reuben DB, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825-1832.
  
  

  A two-round survey, based on Delphi methods, was used with 13 nationally recognized experts to reach consensus on explicit criteria for defining the inappropriate use of medications in the US nursing home population. The criteria were designed to use pharmacy data with minimal additional clinical data so that they could be applied to chart review or computerized data sets. The 30 factors agreed on by this method identify inappropriate use of such commonly used categories of medications as sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine 2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, gastrointestinal antispasmodics, and antiemetics.

• Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med. 1997;157:1531-1536.
  
  

  This study updates and expands explicit criteria defining potentially inappropriate medication use by the elderly. Additional goals were to address whether adverse outcomes were likely to be clinically severe and to incorporate clinical information on diagnoses when available. These criteria are meant to serve epidemiological studies, drug utilization review systems, health care providers, and educational efforts. Consensus from a panel of 6 nationally recognized experts on the appropriate use of medication in the elderly was sought. The expert panel agreed on the validity of 28 criteria describing the potentially inappropriate use of medication by general populations of the elderly as well as 35 criteria defining potentially inappropriate medication use in older persons known to have any of 15 common medical conditions. Updated, expanded, and more generally applicable criteria are now available to help identify inappropriate use of medications in elderly populations. These criteria define medications that should generally be avoided in the ambulatory elderly, doses or frequencies of administrations that should generally not be exceeded, and medications that should be avoided in older persons known to have any of several common conditions.

• Fick Donna M. et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: Results of a US Consensus Panel of Experts. Archives of Internal Medicine. 2003;163:2716-2724.
  
  

  This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

• McLeod PJ et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997; 156: 385 - 91.
  
  

  This Canadian article describes a list of inappropriate practices in prescribing for elderly people, to be used in a practice-based intervention study.

• Steven A. Blackwell, Gary M. Ciborowski, David K. Baugh, Melissa A. Montgomery, (2008) "Applying the 2003 Beers update to Medicaid/Medicare enrollees", International Journal of Pharmaceutical and Healthcare Marketing, Vol. 2 Iss: 4, pp.257 - 272.
  
  

  This paper examines rates of potentially inappropriate prescribing in a US population dually eligible for Medicare and Medicaid using the 2003 version of the Beers list.

• O'Mahony D., Gallageher PF. Inappropriate prescribing in the older population: need for new criteria Age and Ageing 2008; 37: 138-141
  
  

  Inappropriate prescribing (IP) is a common and serious global healthcare problem in elderly people, leading to increased risk of adverse drug reactions (ADRs), polypharmacy being the main risk factor for both IP and ADRs. IP in older people is highly prevalent but preventable; hence screening tools for IP have been devised, principally Beers' Criteria and the Inappropriate Prescribing in the Elderly Tool (IPET). Although Beers' Criteria have become the most widely cited IP criteria in the literature, nevertheless, they have serious deficiencies, including several drugs that are rarely prescribed nowadays, a lack of structure in the presentation of the criteria and omission of several important and common IP instances. New, more up-to-date, systems-based and easily applicable criteria are needed that can be applied in the routine clinical setting.

• Page R L, Linnebur SA, Bryant LL, Ruscin JM. Inappropriate prescribing in the hospitalized elderly patient: Defining the problem, evaluation tools, and possible solutions. Clinical Interventions in Aging 2010:5 75-87
  
  

  Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. In the acute care setting, PIM prescribing can be even more problematic due to multiple physicians and specialists who may be prescribing for a single patient as well as difficulty with medication reconciliation at transitions and limitations imposed by hospital formularies. This article highlights critical issues surrounding PIM prescribing in the acute care setting such as risk factors, screening tools, and potential strategies to minimize this significant public health problem.

Back to Top

Evidence-Based Tools

• Improving Prescribing in the Elderly Tool (IPET)
  Tool used to screen potentially inappropriate prescriptions in the elderly.
• START (Screening Tool to Alert doctors to the Right Treatment)-
  A validated screening tool to systematically identify appropriate omitted medicines in clinical practice.
• STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions)
  New, systems-defined medicine review tool.
• Try This - Beers Criteria for Potentially Inappropriate Medication Use in the Elderly
  Try This: Part I focuses on Table 1: 2002 Criteria Independent of Diagnoses and Conditions. It contains 48 individual medications or classes of medications to avoid in older adults and their potential concerns. The criteria will assist nurses to identify patients who may benefit from monitoring or medication review. The criteria do not identify all cases of potentially inappropriate prescribing or medication-associated adverse events, and do not address polypharmacy or underuse of helpful medications. The criteria are designed for population-based screening and are not intended to substitute for professional judgment regarding the individualized needs of particular older adults.
• Try This - Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Part II: 2002 Criteria Considering Diagnoses or Conditions
  Try This: Part II presents the criteria considering diagnosis or medical condition.
  http://consultgerirn.org/resources/media/?vid_id=4852321#player_container

Back to Top

Reports & Policy Documents

• Joint Task Force Report on Medication Management, Nov 2009
• Annual Report Of the Geriatric and Long Term Care Review Committee To the Chief Coroner For the Province of Ontario
• Canadian Institute for Health Information Reports...
• Ontario Health Quality Council Reports
• American Medical Directors...
• Policy Statement
  American Medical Directors Association and American Society of Consultant Pharmacists
  Joint Position Statement on the Beers List of Potentially Inappropriate Medications in Older Adults 200
• American Society of Consultant Pharmacists
  • - http://www.ascp.com/advocacy/briefing/upload/ASCPAMDABeers.pdf
  • - http://www.ascp.com/resources/clinical/beers.cfm
  • - Beers List / Criteria ASCP
• The Beers List
• http://www.ontca.ca/index.php?option=com_content&task=view&id=16&Itemid=30
• Canadian Institute for Health Information Reports...
• Ontario Health Quality Council Reports

Back to Top

Other Useful Links

• Search pubmed for beers list
• Quinine sulfate and serious adverse reactions
• Canadian Adverse Reaction Newsletter See Quinine sulfate and serious adverse reactions
• Health Canada's role in the Management and Prevention of Harmful Medication Incidents

Back to Top

For more information on the campaign or to suggest changes or additions to this website, please contact Kris Wichman, ISMP Canada, 416-733-3131.

To join the campaign or become a member of the advisory group, please contact Paula Neves, Ontario Long Term Care Association (OLTCA), 905-470-8995 ext 40.

For feedback on this information page, please complete the evaluation survey.

For information on the campaign partners, please click on the links below.

• OLTCA
• ISMP Canada
• Ontario Pharmacists' Association
• MediSystem
• Jeffers
• Classic Care Pharmacy
• OANHSS
• Ministry of Health and Long-Term Care
• npac
• Medical Pharmacies Group Limited
• School of Pharmacy, University of Waterloo
• OHQC
• Ontario Long-Term Care Physicians
• GeriatRx Pharmacy