Managing Challenges of Insomnia in Elderly Patients - Episode 11
Peter L. Salgo, MD: Let’s talk about safety interactions. And I think we’re getting into the Beers Criteria. What are the Beers criteria and how does that affect all of this?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Right. I’ll come to the Beers Criteria after commenting on Gary’s remark. I think formularies are, in part, driven by lots of different factors. It’s evidence and access. What I find with prior authorizations, which leads into the safety, is that they sometimes use it as a way to look at chronic use over time, to some extent. So let’s bring up the Beers Criteria. The American Geriatrics Society, since 2012, has put updates to the Beers Criteria almost every 3 years.
Peter L. Salgo, MD: There was one in 2019.
Gary L. Johnson, MD, MS, MBA: Yes, this year.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Yes, this year. So there’s 2012, 2015. We were gunning for 2018 but we didn’t quite make it, so we made it in January of 2019. And that medication list, or I like to call it a tool, is really to help providers, to help insurers, to help researchers identify potentially inappropriate medications. It’s also used to look at some of the risk-benefit with diseases and potential other medications. It’s expanded this year to also include some additional drug-drug interactions, and we’ve continued the extension on some renal dosing, which are special considerations for older adults.
With relevance to this conversation focusing on sleep disorders and insomnia in our older adult, there are classes of medications that we’ve talked about that are on the potentially inappropriate medication list because of the implication on falls, or the implications on cognition, or maybe worsening delirium, such as benzodiazepines. There are anticholinergic agents, and they exclude the lower doses of doxepin because it doesn’t have the same anticholinergic properties.
This list is used by insurers to look at the safety implications for these medications, which brought up in more recent updates, the prolonged use of the nonbenzodiazepines, such as the Z-drugs. Because we saw some of the same safety signal that we saw with the benzodiazepines. Every 3 years there’s an in-depth review of the literature to look at older adults. If you look at the evidence tables that most people don’t pay attention to within the Beers Criteria that complement the table, we really are trying to focus on looking at even the age within the populations. Some of the studies are trying to look at those who are 75 and older, because I think, as we all get closer to 65, we’re like, that’s not really that old.
Peter L. Salgo, MD: The older I get, the younger they look.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Exactly, so however you want to define that. But in all seriousness, it’s a tool. What concerns me, as I’m sitting next to Gary here, is sometimes payers use this kind of as a punitive tool, what I will pay for, what I won’t pay for and may sometimes put a lot of roadblocks or barriers to prescribe it.
Peter L. Salgo, MD: Wait, again, poor Gary.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: I’m sorry, Gary.
Peter L. Salgo, MD: But if I were in Gary’s place, and I looked at the Beers Criteria and I saw drug A had a higher risk profile in the elderly than drug B, I might not put that on the formulary, Gary.
Gary L. Johnson, MD, MS, MBA: Well, that’s absolutely true. But let me say something about what I commented on earlier. It really depends on what the consumer wishes to purchase. Now that is true, but the Beers Criteria and high-risk medications in the elderly are a very real concern for insurers, for health plans for 3 reasons. One, from a purely altruistic standpoint, we want to see our subscribers do well and live happy. But the other one is purely economic. Some of the automobile accidents, the falls, the comorbidities that end up costing money are important. And then the third thing is again, I deal primarily with Medicare, CMS [Centers for Medicare and Medicaid Services] is very concerned about high-risk medications and rewards, if you will, health plans for making active steps to limit those drugs in the elderly.
Peter L. Salgo, MD: So all this rolls into your recommendations for your Medicare Advantage Part D formularies, is that right?
Gary L. Johnson, MD, MS, MBA: Yes.
Peter L. Salgo, MD: OK.