What are the Beers criteria for potentially inappropriate medication use in older adults?

What Are the Beers Criteria?

The Beers Criteria are an evidence-based list of potentially inappropriate medications (PIMs) that should typically be avoided in adults 65 years and older because their risks clearly outweigh benefits compared to safer alternatives. 1

Overview and Purpose

The American Geriatrics Society (AGS) Beers Criteria serve as both an educational tool and quality measure to reduce adverse drug events, falls, cognitive impairment, and mortality in older adults. 1 The criteria have been updated on a 3-year cycle since 2011, with the most recent major update published in 2019. 1, 2

The criteria function as a "warning light" to identify medications with unfavorable benefit-harm ratios, not as absolute prohibitions. 3 Clinical judgment remains essential, and exceptions exist for specific clinical situations. 1

Five Core Categories of the Beers Criteria

The 2019 AGS Beers Criteria organize potentially inappropriate medications into five distinct tables: 1

1. Medications to Avoid in Most Older Adults

• Over 30 individual medications or medication classes should be avoided regardless of diagnosis or condition. 4
• Examples include benzodiazepines (increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents), first-generation antihistamines, tricyclic antidepressants, and most antipsychotics. 1, 4
• NSAIDs carry increased risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation. 2, 4

2. Medications to Avoid in Specific Diseases or Conditions

• More than 40 medications require avoidance in older adults with particular conditions. 4
• For patients with history of falls or fractures: avoid benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics, opioids, and SNRIs (but not SSRIs). 4, 5
• For patients with dementia or cognitive impairment: avoid anticholinergics like oxybutynin, benzodiazepines, and antipsychotics. 4, 5
• For patients with heart failure: avoid NSAIDs, thiazolidinediones, and certain calcium channel blockers. 4

3. Medications to Use With Caution

• Aspirin for primary prevention in adults ≥70 years (bleeding risk exceeds cardiovascular benefit). 4
• Rivaroxaban in adults ≥75 years (higher bleeding risk). 4
• Dextromethorphan/quinidine (limited efficacy, significant drug interactions, increased fall risk). 4

4. Critical Drug-Drug Interactions

• Opioids combined with benzodiazepines cause severe respiratory depression and death. 4, 5
• Opioids combined with gabapentinoids increase adverse effects and overdose risk. 4, 5
• Trimethoprim-sulfamethoxazole with warfarin increases bleeding risk. 4

5. Medications Requiring Dose Adjustment Based on Kidney Function

• Ciprofloxacin, trimethoprim-sulfamethoxazole, dofetilide, edoxaban, and gabapentin require dose reduction or avoidance in reduced kidney function. 4, 5

Strength of Evidence Grading

The criteria use a two-tier strength rating: 1

• Strong recommendation: Harms, adverse events, and risks clearly outweigh benefits
• Weak recommendation: Harms, adverse events, and risks may not outweigh benefits

Each criterion includes quality of evidence ratings based on systematic literature review and expert consensus using a modified Delphi method. 1

Clinical Application Strategy

Apply the Beers Criteria systematically at every care transition—hospital admission, ICU transfer, discharge, and outpatient visits. 2, 4 Prioritize deprescribing medications with highest morbidity and mortality risks first: benzodiazepines, opioids, antipsychotics, and NSAIDs. 4

Use validated screening tools like Beers Criteria alongside STOPP/START criteria during comprehensive medication reviews that include all prescription drugs, over-the-counter medications, herbal products, and supplements. 2, 4

Common Pitfalls to Avoid

Do not apply the criteria punitively or as rigid rules—they support clinical judgment, not replace it. 1, 3 The criteria identify medications requiring extra scrutiny, not absolute contraindications. 3

Avoid disease-specific guideline adherence without considering multimorbidity burden, functional status, cognitive status, and patient-centered goals including life expectancy and quality of life. 2

Do not ignore that some medications listed have appropriate exceptions—for example, quetiapine, clozapine, and pimavanserin are acceptable antipsychotic options for Parkinson disease psychosis despite the general recommendation to avoid antipsychotics. 1

The criteria exclude patients in palliative and hospice care, where different risk-benefit considerations apply. 6