What medications should be avoided or used with caution in adults aged 65 years and older according to the Beers Criteria?

Beers Criteria: Medications to Avoid in Older Adults

The American Geriatrics Society identifies 30 individual medications or medication classes to avoid in most older adults aged 65 years and older, plus over 40 additional medications requiring caution in specific diseases or conditions, with systematic application recommended at every care transition to reduce adverse drug events and mortality. 1, 2

High-Priority Medications to Target First

Prioritize removal of medications with the highest morbidity and mortality risks first, including benzodiazepines, opioids, antipsychotics, and NSAIDs, which increase the risk of cognitive impairment, delirium, falls, fractures, and respiratory depression. 1, 2

Central Nervous System Agents (Highest Risk Category)

• Benzodiazepines (e.g., temazepam, diazepam, lorazepam) increase risk of cognitive impairment, delirium, falls, fractures, motor vehicle accidents, and death in older adults. 2
• Nonbenzodiazepine hypnotics (e.g., zolpidem, eszopiclone) carry similar risks to benzodiazepines despite different chemical structure. 2
• Antipsychotics increase mortality risk, particularly in patients with dementia, and should be avoided for behavioral management. 1, 2
• Tricyclic antidepressants cause anticholinergic effects and orthostatic hypotension. 2

Anti-Inflammatory and Cardiovascular Medications

• NSAIDs increase risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation. 1, 2
• Thiazolidinediones worsen fluid retention in heart failure patients. 2

Disease-Specific Medications to Avoid

Patients with Fall or Fracture History

Avoid the following medications in patients with documented fall or fracture history:

• Benzodiazepines 2
• Nonbenzodiazepine hypnotics 2
• Antipsychotics 2
• Opioids 2
• SNRIs (but NOT SSRIs like sertraline) 2

Patients with Dementia or Cognitive Impairment

Avoid these medications in patients with dementia or cognitive impairment:

• Anticholinergics 2
• Benzodiazepines 2
• Antipsychotics 2

Patients with Heart Failure

Avoid these medications in heart failure patients:

• NSAIDs 2
• Thiazolidinediones 2
• Calcium channel blockers 2

Critical Drug-Drug Interactions to Avoid

These combinations pose severe risks and must be avoided:

• Opioids + Benzodiazepines: Causes severe respiratory depression and death. 2
• Opioids + Gabapentinoids: Increases risk of respiratory depression, overdose, and death (exception: when transitioning from opioids to gabapentinoids as alternative). 2
• TMP-SMX + Warfarin: Increases bleeding risk. 2
• Three or more CNS agents concurrently (including antidepressants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, antiepileptics like gabapentin, and opioids): Dramatically increases fall risk. 2

Medications Requiring Caution (Age ≥70-75 Years)

• Aspirin for primary prevention in adults ≥70 years: Bleeding risk exceeds cardiovascular benefit. 2
• Rivaroxaban in adults ≥75 years: Higher bleeding risk for venous thromboembolism or atrial fibrillation treatment. 2
• Dextromethorphan/quinidine: Limited efficacy, significant drug interactions, and increased fall risk. 2

Kidney Function-Based Dose Adjustments

Avoid or reduce doses of these medications in patients with reduced kidney function:

• Ciprofloxacin 2
• TMP-SMX 2
• Dofetilide 2
• Edoxaban 2
• Gabapentin (requires dose adjustment in renal impairment) 2

Implementation Algorithm

Apply this systematic approach at every care transition (hospital admission, ICU transfer, discharge, nursing home placement, outpatient visits): 1, 2

1. Review all medications including prescription drugs, over-the-counter medications, herbal products, and supplements. 3

2. Screen using validated tools such as Beers Criteria or STOPP/START criteria. 3, 2

3. Prioritize deprescribing medications with unfavorable benefit-risk ratios (NSAIDs, benzodiazepines) and those causing prescribing cascades. 3

4. Evaluate patient-specific factors including functional status, cognitive status, multimorbidity burden, life expectancy versus time-to-benefit, and individual goals of care. 3, 2

5. Target reduction of total medication burden rather than achieving multiple disease-specific targets, prioritizing patient-centered goals like quality of life and functional status. 1

6. Use team-based approach integrating pharmacist-led interventions within comprehensive geriatric assessment teams. 3

Strength of Evidence Grading

The American Geriatrics Society uses a two-tier strength rating: strong recommendations where harms clearly outweigh benefits, and weak recommendations where harms may not outweigh benefits. 1

Common Pitfalls to Avoid

• Do not apply chronological age alone when making decisions; incorporate functional and cognitive assessments. 3, 2
• Do not ignore drug-drug interactions; use interaction screening tools systematically. 3
• Do not pursue disease-specific guideline adherence without considering multimorbidity; prioritize patient-centered goals over achieving multiple disease-specific targets. 3
• Do not fail to reassess at care transitions; medication review must occur at every transition point. 3
• Do not apply criteria in a punitive manner; clinical judgment remains essential and individualization is required when considering patient-specific factors. 3

Scope and Limitations

The Beers Criteria apply to adults 65 years and older in all ambulatory, acute, and institutionalized settings, except hospice and end-of-life care. 4 The criteria are not exhaustive and do not address all possible inappropriate prescribing scenarios, but serve as an educational tool and quality measure to support clinical decision-making. 3