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

The Beers Criteria: Potentially Inappropriate Medications in Older Adults

The American Geriatrics Society Beers Criteria® is an explicit, evidence-based list of medications that should typically be avoided in adults 65 years and older because their potential harms outweigh benefits, updated every 3 years with the most recent versions published in 2019 and 2023. 1, 2

Core Purpose and Structure

The Beers Criteria serves as both an educational tool and quality measure to reduce adverse drug events, improve prescribing practices, and ultimately decrease morbidity and mortality in older adults. 1 The criteria apply to all older adults in ambulatory, acute, and institutionalized settings, with the exception of hospice and end-of-life care. 2

Five Categories of Potentially Inappropriate Medications

The Beers Criteria organizes recommendations into five distinct categories: 1

1. Medications to Avoid in Most Older Adults

The AGS identifies approximately 30 individual medications or medication classes that should generally be avoided regardless of diagnosis or condition: 3

Central Nervous System Agents (Highest Risk):

• Benzodiazepines (all types including temazepam) increase risk of cognitive impairment, delirium, falls, fractures, motor vehicle accidents, and death 4, 3
• Nonbenzodiazepine hypnotics (Z-drugs) carry similar risks to benzodiazepines 3
• First-generation antipsychotics and most second-generation antipsychotics increase mortality risk, particularly in patients with dementia 3
• Tricyclic antidepressants cause severe anticholinergic effects and orthostatic hypotension 3

Anticholinergic Medications:

• Oxybutynin should be avoided due to strong anticholinergic properties causing delirium and cognitive impairment 5
• Other anticholinergics pose similar risks across multiple organ systems 4

Anti-inflammatory and Cardiovascular Agents:

• NSAIDs (all types) increase risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation 4, 3
• Thiazolidinediones worsen fluid retention in heart failure patients 3

2. Medications to Avoid in Specific Diseases or Conditions

Over 40 medications require avoidance based on specific comorbidities: 3

History of Falls or Fractures:

• Avoid benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics, opioids, and SNRIs (notably, SSRIs like sertraline are NOT on this list) 3

Dementia or Cognitive Impairment:

• Avoid anticholinergics (including oxybutynin), benzodiazepines, and antipsychotics 3, 5

Heart Failure:

• Avoid NSAIDs, thiazolidinediones, and certain calcium channel blockers 3

3. Medications to Use With Caution

Several medications require heightened monitoring but are not absolutely contraindicated: 3

• Aspirin for primary prevention in adults ≥70 years (bleeding risk exceeds cardiovascular benefit) 3
• Rivaroxaban in adults ≥75 years (higher bleeding risk for VTE or atrial fibrillation) 3
• Dextromethorphan/quinidine (limited efficacy, significant drug interactions, increased fall risk) 3

4. Critical Drug-Drug Interactions

The most dangerous combinations that must be avoided: 3

• Opioids + Benzodiazepines: causes severe respiratory depression and death 3
• Opioids + Gabapentinoids (gabapentin, pregabalin): increases respiratory depression, overdose, and death risk 3
• Trimethoprim-sulfamethoxazole + Warfarin: significantly increases bleeding risk 3

A critical caveat: combining three or more CNS agents (antidepressants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, antiepileptics like gabapentin, and opioids) dramatically increases fall risk. 3

5. Medications Requiring Kidney Function-Based Dose Adjustment

Several medications require dose reduction or avoidance in reduced kidney function: 3

• Ciprofloxacin, trimethoprim-sulfamethoxazole, dofetilide, edoxaban, and gabapentin all require careful dose adjustment based on creatinine clearance 3

Clinical Application Strategy

Systematic implementation at every care transition is essential: 4, 3

1. Conduct comprehensive medication review including all prescription drugs, over-the-counter medications, herbal products, and supplements at hospital admission, ICU transfer, and discharge 4

2. Prioritize deprescribing by risk level: Remove medications with highest morbidity/mortality risks first—benzodiazepines, opioids, antipsychotics, and NSAIDs 3

3. Screen for drug-drug interactions systematically, particularly the lethal combinations of opioids with benzodiazepines or gabapentinoids 3

4. Evaluate life expectancy versus time-to-benefit for each medication, discontinuing preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit 4

5. Use team-based approach integrating pharmacist-led interventions within comprehensive geriatric assessment 4

Critical Limitations and Proper Use

The Beers Criteria are not meant to be applied punitively or as absolute prohibitions. 1 Clinical judgment remains essential, and prescribing decisions must consider multiple patient-specific factors including functional status, cognitive status, multimorbidity burden, and patient goals of care. 4

The criteria support rather than replace clinical decision-making and are not exhaustive—they do not address all possible inappropriate prescribing scenarios. 4 Quality measures derived from these criteria cannot perfectly distinguish appropriate from inappropriate care in every individual case. 1

Common pitfalls to avoid: 4

• Do not apply disease-specific guidelines without considering multimorbidity and overall patient goals
• Do not use chronological age alone when making prescribing decisions
• Do not fail to reassess medications at every care transition
• Do not ignore the cumulative burden of multiple CNS-active medications

Evidence Base and Updates

The criteria were first published in 1991 and have been systematically updated using modified Delphi methodology with interdisciplinary expert panels. 1, 4, 6 The AGS has maintained stewardship since 2011, producing updates on a 3-year cycle (2012,2015,2019,2023) using comprehensive systematic reviews and evidence grading. 1, 2

Each recommendation is graded based on strength of evidence and strength of recommendation, with the 2019 update reviewing literature from 2015-2017 and the 2023 update incorporating evidence through 2022. 1, 2