Geriatrics

American Geriatrics Society: Beers Criteria

SUMMARY:

The vast majority of older adults use at least one prescription medication regularly, while over half of all older adults depend on three or more prescriptions each month. The Beers Criteria, developed in 1991 by Dr. Mark Beers and his colleagues, has been regularly updated and maintained by the American Geriatrics Society (AGS) since 2011. The AGS has released their most recent update in 2023, outlining the medications that they recommend be avoided, used with caution, or have their dose adjusted in older patients. Below is a summary containing high yield and commonly used medications – for the full list please see “Primary Sources – Learn More”.

General Principles

The Beers Criteria is meant for use in all adults age ≥ 65 years old in all ambulatory, acute, and institutionalized settings
- The Beers Criteria is not applicable to patients enrolled in hospice or at the end of life
Medications in the Beers Criteria are “potentially” inappropriate, not “definitely” inappropriate, and the clinician should use their best medical judgement and review of the patient’s circumstances to determine whether a medication should be discontinued, or dose reduced
- Additionally, shared decision making is recommended, and patient preference as well as history of drug tolerance should be considered when making medication changes
Optimal use of the AGS Beers Criteria involves replacing higher risk medications with better tolerated medications or non-pharmacologic interventions when appropriate
Medications listed often include caveats and explanations that may influence care or apply only to patients with certain medical conditions or risk of drug-drug interactions
- Pay attention to caveats!
The Beers Criteria is not an exhaustive list of medications, and does not include certain generally considered high-risk drugs due to their benefits outweighing risks in most cases
Medications are subdivided into five broad categories
- Medications considered potentially inappropriate
- Medications considered potentially inappropriate in patients with certain disease or syndromes
- Medications to be used with caution
- Potentially inappropriate drug-drug interactions
- Medications whose dosages should be adjusted based on renal function

Potentially Inappropriate Medications

Muscle relaxants
- Examples include: Cyclobenzaprine (Flexeril) | Methocarbamol (Robaxin) | Carisoprodol (Soma)
- Associated with: Increased risk of falls | Confusion | Constipation | Urinary retention
Anxiety/Insomnia medications
- Benzodiazepines (e.g., Diazepam (Valium) | Alprazolam (Xanax), and Chlordiazepoxide (Librium))
- Sleeping pills (e.g, Zaleplon (Sonata) | Zolpidem (Ambien) | Eszopiclone (Lunesta))
- Associated with: Increased risk of falls | Confusion | Long duration of action
Anticholinergic drugs
- Certain highly anticholinergic drugs should be avoided
- Antidepressants: Amitriptyline (Elavil) | Imipramine (Tofranil) | Paroxetine (Paxil) | Nortriptyline (Pamelor)
- GI antispasmodics (e.g., Dicyclomine (Bentyl) | Hyoscyamine (Levsin))
- Atropine (Excludes ophthalmic)
- Benztropine (Cogentin)
- First generation antihistamines (e.g. Diphenhydramine (Benadryl) | Chlorpheniramine (AllerChlor)
- Associated with: Confusion | Constipation | Dry mouth | Urinary retention | Blurry vision
Estrogen pills/patches
- Generally prescribed for hot flashes and post-menopausal symptoms
- Can increase risk of blood clots and breast cancer
Sulfonylureas
- Glyburide (Glynase) | Glipizide (Glucotrol) | Glimepiride (Amaryl) | Gliclazide (Diamicron)
- Should be avoided as first – or second – line therapy for diabetes, as well as avoided as monotherapy, unless there are significant barriers to access of other diabetes medications
- Major adverse effect is hypoglycemia, which is more common in longer acting formulations (e.g., Glyburide (Glynase) | Glimepiride (Amaryl)); if used shorting acting formulation is preferred (e.g., Glipizide (Glucotrol))
Proton pump inhibitors
- Includes: Omeprazole (Prilosec) | Esomeprazole (Nexium) | Lansoprazole (Prevacid) | Pantoprazole (Protonix) | Rabeprazole (Aciphex) | Dexlansoprazole (Dexilant)
- Associated with: Increased risk of C. Diff infection | Osteoporosis/Bone loss | Pneumonia | GI malignancies
- Avoid scheduled use for > 8 weeks (exception is high risk patients; see “Related Topics” below)
Rivaroxaban (Xarelto) | Warfarin (Coumadin) | Dabigatran (Pradaxa)
- Avoid use for long term anticoagulation for atrial fibrillation or VTE
- Replace with safer DOAC options for long term anticoagulation when possible (e.g., Apixiban (Eliquis))
- Associated with increased risk of major (e.g. GI | Intracranial) bleeding

Medications to Use with Caution

Antipsychotics
- Includes: Haloperidol (Haldol) | Risperidone (Risperdal) | Quetiapine (Seroquel)
- Associated with: Increased risk of stroke and death in older adults with dementia | Tremors | Increased risk of falls
- This recommendation excludes patient who require these medications for psychiatric diseases/psychosis
NSAIDs
- Includes: Ibuprofen (Advil) | Indomethacin (Tivorbex) | Naproxen (Aleve) | Meloxicam (Mobic)
- Associated with: Increase risk of GI bleeding | Increased blood pressure | Kidney injury | Worsening heart failure
- Should be used with caution in patients with: Renal insufficiency | Heart disease | Steroid use | Blood thinner use
- Risk of GI bleeding can be augmented with addition of PPI
Aspirin (ASA)
- Should be avoided in older patients who are using it for primary prevention of heart disease and strokes (i.e., No history of CAD or CVA)
- Benefits outweigh risks for most patients using Aspirin for secondary prevention of heart disease and strokes
Digoxin (Lanoxin)
- Used in treatment of heart failure and arrhythmias, but other drugs are generally better tolerated
- Avoid doses higher than 0.125mg/day, higher doses increase toxicity without additional benefit
- Use caution in patients with renal disease

Medications that Require Dose Adjustment

Many commonly used medications should be dose reduced based on renal function, which typically declines with age, or discontinued altogether when renal function declines
Antimicrobials
- Ciprofloxacin | Nitrofurantoin (Macrobid) | Trimethoprim-Sulfamethoxazole (Bactrim)
Cardiovascular drugs | Antithrombotics
- Dabigatran (Pradaxa) | Edoxaban (Lixiana) | Enoxaparin (Lovenox) | Rivaroxaban (Xarelto) | Fondaparinux (Arixtra)
- Spironolactone (Aldactone) | Triamterene (Dyrenium) | Dofetilide (Tikosyn) | Amiloride (Midamor)
Gout/hyperuricemia
- Probenecid | Colchicine
GERD
- Famotidine (Pepcid) | Cimetidine (Tagamet)
CNS acting agents
- Duloxetine (Cymbalta)
Levetiracetam (Keppra)
Pregabalin (Lyrica) | Gabapentin (Neurontin)

KEY POINTS:

The Beers Criteria, first developed in 1991, is a list of medications that should be avoided, used with caution, or have their dosages reduced in older adults due to risks outweighing benefits in most cases
Even with medications that are potentially inappropriate, clinicians should use their own medical judgement and consider the patient’s preferences using shared decision making
When appropriate, clinicians should try to replace higher risk medications with better tolerated drugs or non-pharmacologic therapy