What are the BEER (Beers) criteria for identifying potentially inappropriate medications in older adults?

What is the Beers Criteria?

The Beers Criteria is an evidence-based list of potentially inappropriate medications (PIMs) that should typically be avoided in adults 65 years and older because they pose unnecessarily high risks or have an unfavorable balance of benefits versus harms compared to safer alternatives. 1

Purpose and Application

The American Geriatrics Society (AGS) Beers Criteria® serves multiple critical functions in geriatric care 1:

• Educational tool for clinicians and patients to reduce adverse drug events
• Quality measure for evaluating patterns of drug use in older adults
• Clinical decision support across all ambulatory, acute, and institutionalized settings (excluding hospice and end-of-life care)

The criteria are updated on a regular 3-year cycle using systematic evidence reviews and an interdisciplinary expert panel applying modified Delphi methodology 1, 2.

Five Categories of Criteria

The Beers Criteria organizes PIMs into five distinct categories 1:

1. Medications to Avoid in Most Older Adults

These medications have unfavorable risk-benefit profiles regardless of specific conditions. Examples include:

• NSAIDs (ibuprofen, naproxen, indomethacin) - increased risk of GI bleeding, kidney injury, cardiovascular events 1
• Muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol) - sedation, falls, anticholinergic effects 1
• Meperidine - neurotoxicity risk 1

2. Medications to Avoid with Specific Diseases/Conditions

Drug-disease interactions where medications can exacerbate existing conditions 1:

• Nondihydropyridine CCBs (diltiazem, verapamil) - avoid in heart failure (bradycardia, syncope risk)
• Thiazolidinediones - avoid in heart failure (worsening fluid retention)
• NSAIDs - avoid in heart failure or high cerebrovascular accident risk
• TCAs, alpha-1 inhibitors - condition-specific avoidance

All these carry strong recommendations with varying evidence quality 1.

3. Medications to Use with Caution

Drugs requiring careful monitoring 1:

• Dabigatran and rivaroxaban in adults ≥75 years (bleeding risk)
• Tramadol (hyponatremia/SIADH risk)
• Dextromethorphan/quinidine (falls, drug interactions)
• TMP-SMX with ACEIs/ARBs in reduced kidney function (hyperkalemia)

4. Drug-Drug Interactions to Avoid

Clinically important interactions 1:

• Opioids + benzodiazepines (avoid concurrent use)
• Opioids + gabapentinoids (avoid except when transitioning)
• Interactions involving TMP-SMX, macrolide antibiotics, ciprofloxacin

5. Dose Adjustments Based on Kidney Function

Medications requiring renal dose adjustment to prevent toxicity 1.

Key Updates in Recent Versions

The 2019 update 1 made several important changes:

• Lowered aspirin primary prevention age threshold from 80 to 70 years or older
• Added tramadol to hyponatremia-causing drugs
• Expanded caution for rivaroxaban in adults ≥75 years
• Added dextromethorphan/quinidine to use-with-caution list

The 2023 update 2 represents the most current version with additional modifications and new criteria.

Critical Implementation Points

What the Criteria Are NOT:

• Not punitive - prescribing decisions require clinical judgment 1
• Not absolute - exceptions exist for specific clinical circumstances 1
• Not a replacement for shared decision-making 2

Common Pitfalls to Avoid:

1. Rigid application without context - some patients may appropriately use listed medications when benefits clearly outweigh risks
2. Ignoring discontinuation opportunities - medications no longer indicated should be stopped 1
3. Overlooking safer alternatives - the goal is substitution with better options, not therapeutic nihilism 3

Strength of Evidence

Each criterion includes 1:

• Strength of recommendation (strong vs. weak)
• Quality of evidence (high, moderate, low)
• Rationale explaining the harm-benefit assessment

The 2019 criteria reviewed 17,627 references, ultimately abstracting 377 articles including 67 systematic reviews/meta-analyses, 29 controlled trials, and 281 observational studies 1.

Clinical Bottom Line

Use the Beers Criteria as a systematic screening tool during medication reconciliation for all patients ≥65 years, but apply clinical judgment to determine when exceptions are appropriate based on individual patient circumstances, goals of care, and availability of safer alternatives. The criteria prioritize reducing morbidity and mortality from preventable adverse drug events while maintaining quality of life 1.