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TABLE 1. 2019 American Geriatrics Society Beers Criteria for Potentially InappropriateMedication Use in Older AdultsFrom THE AMERICAN GERIATRICS SOCIETYA POCKET GUIDE TO THEOrgan System, TherapeuticCategory, Drug(s)Anticholinergics *First-generationantihistamines: Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dexchlorpheniramine Dimenhydrinate Diphenhydramine (oral) Doxylamine Hydroxyzine Meclizine Promethazine Pyrilamine TriprolidineAntiparkinsonian agents Benztropine (oral) Trihexyphenidyl2019 AGS BEERS CRITERIA This guide has been developed as a tool to assist healthcare providers in improvingmedication safety in older adults. The role of this guide is to inform clinical decisionmaking, research, training, quality measures and regulations concerning the prescribing ofmedications for older adults to improve safety and quality of care. It is based on The 2019AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the BeersCriteria catalogues medications that cause side effects in older adults due to thephysiologic changes of aging. In 2011, the AGS sponsored its first update of the criteria,assembling a team of experts and using an enhanced, evidence-based methodology.Since 2011, the AGS has been the steward of the criteria and has produced updatesusing an evidence-based methodology and rating each Criterion (quality of evidenceand strength of evidence) using the American College of Physicians’ Guideline GradingSystem, which is based on the GRADE scheme developed by Guyatt et al.The full document, along with accompanying resources, can be found in its entirety onlineat geriatricscareonline.org.INTENDED USEThe goal of this guide is to improve care of older adults by reducing their exposure toPotentially Inappropriate Medications (PIMs).Antispasmodics: Atropine (excludesophthalmic) Belladonna alkaloids ClidiniumChlordiazepoxide Dicyclomine Homatropine (excludesophthalmic) Hyoscyamine Methscopolamine Propantheline ScopolamineAntithrombotics Dipyridamole, oralshort-acting (does notapply to the extendedrelease combinationwith aspirin) This should be viewed as a guideline for identifying medications for which the risksof their use in older adults outweigh the benefits. These criteria are not meant to be applied in a punitive manner. This list is not meant to supersede clinical judgment or an individual patient’s valuesand needs. Prescribing and managing disease conditions should be individualizedand involve shared decision-making. These criteria also underscore the importance of using a team approach toprescribing and the use of non-pharmacological approaches and of havingeconomic and organizational incentives for this type of model. A companion piece that addresses the best way for patients, providers, and healthsystems to use (and not use) the AGS Beers Criteria was also developed. Thedocument can be found on geriatricscareonline.org.The criteria are not applicable in all circumstances (i.e. patients receiving palliative andhospice care). If a provider is not able to find an alternative and chooses to continue touse a drug on this list in an individual patient, designation of the medication as potentiallyinappropriate can serve as a reminder for close monitoring so that adverse drug effectscan be incorporated into the electronic health record and prevented or detected early.Recommendation, Rationale, Quality of Evidence(QE), Strength of Recommendation (SR)AvoidHighly anticholinergic; clearance reduced with advanced age,and tolerance develops when used as hypnotic; risk of confusion,dry mouth, constipation, and other anticholinergic effects ortoxicityUse of diphenhydramine in situations such as acute treatment ofsevere allergic reaction may be appropriateQE Moderate; SR StrongAvoidNot recommended for prevention of extrapyramidal symptomswith antipsychotics; more effective agents available fortreatment of Parkinson diseaseQE Moderate; SR StrongAvoidHighly anticholinergic, uncertain effectivenessQE Moderate; SR StrongAvoidRationale: May cause orthostatic hypotension; more effectivealternatives available; IV form acceptable for use in cardiacstress testingQE Moderate; SR Strong*See also criterion on highly anticholinergic antidepressants AGSCNS central nervous system; NSAIDs nonsteroidal anti-inflammatory drugs; SIADH, syndrome ofinappropriate antidiuretic hormone.THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.PAGE 1PAGE 2Table 1 (continued on page 3)
Table 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)Anti-infective NitrofurantoinTable 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)Recommendation, Rationale, QE, SRDigoxin for first-linetreatment of atrialfibrillation or of heartfailureAvoid in individuals with creatinine clearance 30 mL/min orfor long-term suppressionPotential for pulmonary toxicity, hepatoxicity, and peripheralneuropathy, especially with long-term use; safer alternatives availableQE Low; SR StrongCardiovascularPeripheral alpha-1blockers for treatment ofhypertension Doxazosin Prazosin TerazosinAvoid use as an antihypertensiveHigh risk of orthostatic hypotension and associated harms,especially in older adults; not recommended as routinetreatment for hypertension; alternative agents have superiorrisk/benefit profileQE Moderate; SR StrongAvoid clonidine as first-line antihypertensive. Avoid other CNSCentral-alpha agonistsalpha-agonists as listedClonidine for first-linetreatment of hypertension High risk of adverse CNS effects; may cause bradycardia andOther CNS alpha-agonists orthostatic hypotension; not recommended as routine treatmentfor hypertension GuanabenzQE Low; SR Strong Guanfacine Methyldopa Reserpine ( 0.1 mg/d)AvoidDisopyramideMay induce heart failure in older adults because of potentnegative inotropic action; strongly anticholinergic; otherantiarrhythmic drugs preferredQE Low; SR StrongAmiodaroneAvoid in individuals with permanent atrial fibrillation or severeor recently decompensated heart failureWorse outcomes have been reported in patients takingdronedarone who have permanent atrial fibrillation or severe orrecently decompensated heart failureQE High; SR StrongCentral nervous systemAntidepressants, alone orin combination: Amitriptyline Amoxapine Clomipramine Desipramine Doxepin 6 mg/d Imipramine Nortriptyline Paroxetine Protriptyline TrimipramineAvoid as first-line therapy for atrial fibrillation unless the patienthas heart failure or substantial left ventricular hypertrophyEffective for maintaining sinus rhythm but has greater toxicitiesthan other antiarrhythmics used in atrial fibrillation; may bereasonable first-line therapy in patients with concomitant heartfailure or substantial left ventricular hypertrophy if rhythmcontrol is preferred over rate controlQE High; SR StrongAvoidHighly anticholinergic, sedating, and cause orthostatichypotension; safety profile of low-dose doxepin ( 6 mg/d)comparable to that of placeboQE High; SR Strong DronedaroneNifedipine, immediatereleaseRecommendation, Rationale, QE, SRAvoid this rate control agent as first-line therapy for atrialfibrillation. Avoid as first-line therapy for heart failure. If usedfor atrial fibrillation or heart failure, avoid dosages 0.125 mg/dUse in atrial fibrillation: should not be used as a first-line agentin atrial fibrillation, because there are safer and more effectivealternatives for rate control supported by high-quality evidence.Use in heart failure: evidence for benefits and harms of digoxin isconflicting and of lower quality; most but not all of the evidenceconcerns use in heart failure with reduced ejection fraction(HFrEF). There is strong evidence for other agents as first-linetherapy to reduce hospitalizations and mortality in adults wihtHFrEF. In heart failure, higher dosages are not associated withadditional benefit and may increase toxicity.Decreased renal clearance of digoxin may lead to increasedrisk of toxic effects; further dose reduction may be necessary inthose with Stage 4 or 5 chronic kidney disease.QE Atrial fibrillation: Low. Heart failure: Low.Dosage 0.125 mg/d: Moderate; SR Atrial fibrillation: Strong.Heart failure: Strong. Dosage 0.125 mg/d: StrongAvoidPotential for hypotension; risk of precipitating myocardialischemiaQE High; SR StrongPAGE 3Table 1 (continued on page 4)PAGE 4Table 1 (continued on page 5)
Table 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)Antipsychotics, first(conventional) andsecond- (atypical)generationBarbiturates Amobarbital Butabarbital Butalbital Mephobarbital Pentobarbital Phenobarbital SecobarbitalBenzodiazepinesShort- and intermediateacting: Alprazolam Estazolam Lorazepam Oxazepam Temazepam TriazolamLong-acting: Chlordiazepoxide (aloneor in combinationwith amitriptyline orclidinium) Clonazepam Clorazepate Diazepam Flurazepam QuazepamMeprobamateRecommendation, Rationale, QE, SRAvoid, except in schizophrenia, bipolar disorder, or for shortterm use as antiemetic during chemotherapyIncreased risk of cerebrovascular accident (stroke) and greaterrate of cognitive decline and mortality in persons with dementiaAvoid antipsychotics for behavioral problems of dementia ordelirium unless nonpharmacological options (e.g., behavioralinterventions) have failed or are not possible and the older adultis threatening substantial harm to self or othersQE Moderate; SR StrongAvoidHigh rate of physical dependence, tolerance to sleep benefits,greater risk of overdose at low dosagesQE High; SR StrongErgoloid mesylates(dehydrogenated ergotalkaloids)IsoxsuprineEndocrineAndrogens Methyltestosterone TestosteroneRecommendation, Rationale, QE, SRAvoidLack of efficacyQE High; SR StrongAvoid unless indicated for confirmed hypogonadism withclinical symptomsPotential for cardiac problems; contraindicated in men withprostate cancerQE Moderate; SR WeakAvoidDesiccated thyroidConcerns about cardiac effects; safer alternatives availableQE Low; SR StrongEstrogens with or without Avoid systemic estrogen (eg, oral and topical patch). Vaginalcream or vaginal tablets: acceptable to use low-doseprogestinsintravaginal estrogen for management of dyspareunia, recurrentlower urinary tract infections, and other vaginal symptomsEvidence of carcinogenic potential (breast and endometrium);lack of cardioprotective effect and cognitive protection in olderwomen.Evidence indicates that vaginal estrogens for the treatment ofvaginal dryness are safe and effective; women with a history ofbreast cancer who do not respond to nonhormonal therapiesare advised to discuss the risk and benefits of low-dose vaginalestrogen (dosages of estradiol 25 mcg twice weekly) with theirhealthcare providerQE Oral and patch: High. Vaginal cream or tablets: Moderate.;SR Oral and patch: Strong. Topical vaginal cream or tablets: WeakAvoid, except for patients rigorously diagnosed by evidence-basedGrowth hormonecriteria with growth hormone deficiency due to an establishedetiologyImpact on body composition is small and associated with edema,arthralgia, carpal tunnel syndrome, gynecomastia, impaired fastingglucoseQE High; SR StrongAvoidInsulin, sliding scale(insulin regimensHigher risk of hypoglycemia without improvement in hyperglycemiacontaining only short- or management regardless of care setting; Avoid insulin regimens thatrapid-acting insulin dosed include only short- or rapid-acting insulin dosed according to currentaccording to currentblood glucose levels without concurrent use of basal or long-actingblood gluclose levelsinsulin. This recommendation does not apply to regimens that containwithout concurrent usebasal insulin or long-acting insulin.of basal or long-actingQE Moderate; SR Stronginsulin)AvoidMegestrolMinimal effect on weight; increases risk of thrombotic eventsand possibly death in older adultsQE Moderate; SR StrongAvoidOlder adults have increased sensitivity to benzodiazepines anddecreased metabolism of long-acting agents; in general, allbenzodiazepines increase risk of cognitive impairment, delirium,falls, fractures, and motor vehicle crashes in older adultsMay be appropriate for seizure disorders, rapid eye movementsleep behavior disorder, benzodiazepine withdrawal, ethanolwithdrawal, severe generalized anxiety disorder, andperiprocedural anesthesiaQE Moderate; SR StrongAvoidHigh rate of physical dependence; sedatingQE Moderate; SR StrongAvoidNonbenzodiazepine benzodiazepine-receptor agonist hypnotics(ie, “Z drugs”) have adverse events similar to those ofbenzodiazepines in older adults (e.g., delirium, falls, fractures);increased emergency room visits/hospitalizations; motor vehiclecrashes; minimal improvement in sleep latency and durationQE Moderate; SR Strong Nonbenzodiazepine,benzodiazepine receptoragonist hypnotics(ie, “Z-drugs”) Eszopiclone Zaleplon ZolpidemTable 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)PAGE 5Table 1 (continued on page 6)PAGE 6Table 1 (continued on page 7)
Table 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)Sulfonylureas, long-acting Chlorpropamide Glimeperide Glyburide (also knownas l oil, given orallyProton-pump inhibitorsPain medicationsMeperidineNon-cyclooxygenaseselective NSAIDs, oral: Aspirin 325 mg/d Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac TolmetinTable 1 ContinuedOrgan System, TherapeuticCategory, Drug(s)Recommendation, Rationale, QE, SRAvoidChlorpropamide: prolonged half-life in older adults; can causeprolonged hypoglycemia; causes SIADHGlimepiride and Glyburide: higher risk of severe prolongedhypoglycemia in older adultsQE High; SR StrongRecommendation, Rationale, QE, SR Indomethacin Ketorolac, includesAvoidIncreased risk of gastrointestinal bleeding/peptic ulcer disease,parenteraland acute kidney injury in older adultsIndomethacin is more likely than other NSAIDs to have adverseCNS effects. Of all the NSAIDs, indomethacin has the mostadverse effects.QE Moderate; SR StrongSkeletal muscle relaxants Avoid CarisoprodolMost muscle relaxants poorly tolerated by older adults because Chlorzoxazonesome have anticholinergic adverse effects, sedation, increased Cyclobenzaprinerisk of fractures; effectiveness at dosages tolerated by older Metaxaloneadults questionable MethocarbamolQE Moderate; SR Strong OrphenadrineGenitourinaryAvoid for treatment of nocturia or nocturnal polyuriaDesmopressinHigh risk of hyponatremia; safer alternative treatmentsQE Moderate; SR StrongAvoid, unless for gastroparesis with duration of use not toexceed 12 weeks except in rare casesCan cause extrapyramidal effects, including tardive dyskinesia;risk may be greater in frail older adults and with prolongedexposureQE Moderate; SR StrongAvoidPotential for aspiration and adverse effects; safer alternativesavailableQE Moderate; SR StrongAvoid scheduled use for 8 weeks unless for high-risk patients(e.g., oral corticosteroids or chronic NSAID use), erosiveesophagitis, Barrett’s esophagitis, pathological hypersecretorycondition, or demonstrated need for maintenance treatment(e.g., because of failure of drug discontinuation trial or H2receptor antagonistsRisk of C difficile infection and bone loss and fracturesQE High; SR StrongTABLE 2. 2019 American Geriatrics Society Beers Criteria for Potentially InappropriateMedication Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions ThatMay Exacerbate the Disease or SyndromeDisease orSyndromeDrug(s)CardiovascularHeart failure Avoid: CilostazolAvoid in heart failure withreduced ejection fraction: Nondihydropyridine CCBs (diltiazem,verapamil)Use with caution in patients withheart failure who are asymptomatic;avoid in patients with symptomaticheart failure:NSAIDs and COX-2 inhibitorsThiazolidinediones (pioglitazone,rosiglitazone)DronedaroneAvoidOral analgesic not effective in dosages commonly used; mayhave higher risk of neurotoxicity, including delirium, than otheropioids; safer alternatives availableQE Moderate; SR StrongAvoid chronic use, unless other alternatives are not effectiveand patient can take gastroprotective agent (proton-pumpinhibitor or misoprostol)Increased risk of gastrointestinal bleeding or peptic ulcerdisease in high-risk groups, including those aged 75 or takingoral or parenteral corticosteroids, anticoagulants, or antiplateletagents; use of proton-pump inhibitor or misoprostol reducesbut does not eliminate risk. Upper gastrointestinal ulcers, grossbleeding, or perforation caused by NSAIDs occur in 1% ofpatients treated for 3–6 months and in 2–4% of patients treatedfor 1 year; these trends continue with longer duration of use.Also can increase blood pressure and induce kidney injury. Risksare dose-related.QE Moderate; SR StrongRecommendation, Rationale,Quality of Evidence (QE), Strengthof Recommendation (SR)As noted, avoid or use with cautionPotential to promote fluid retentionand/or exacerbate heart failure(NSAIDs and COX-2 inhibitors,non-dihydropyridine CCBs,thiazoildinediones); potential toincrease mortality in older adultswith heart failure (cilostazol anddronedarone)QE Cilostazol: Low Nondihydropyridine CCBs: ModerateNSAIDs: Moderate COX-2 inhibitors:Low. Thiazolidinediones: High.Dronedarone: High; SR Strong*See Table 7 in full criteria available on www.geriatricscareonline.org.aMay be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health conditions butshould be prescribed in the lowest effective dose and shortest possible duration.bExcludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such asexacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration. CCB calcium channel blocker; AChEI acetylcholinesterase inhibitor; CNS central nervous system;COX cyclooxygenase; NSAIDs nonsteroidal antiinflammatory drug; SNRI serotoninnorepinephrinereuptake inhibitor; SSRI selective serotonin reuptake inhibitor; TCAs tricyclic antidepressant.PAGE 7Table 1 (continued on page 8)PAGE 8Table 2 (continued on page 9)
Table 2 ContinuedDisease orSyndromeDrug(s)SyncopeAcetylcholinesterase inhibitors(AChEIs)Non-selective peripheral alpha-1blockers (ie, doxazosin, prazosin,terazosin)Tertiary TCAsAntipsychotics Chlorpromazine Thioridazine OlanzapineCentral nervous odiazepinesCorticosteroids (oral andparenteral)bH2-receptor antagonists Cimetidine Famotidine Nizatidine ne receptor agonisthypnotics: eszopiclone, onbenzodiazepine,benzodiazepine receptor agonisthypnotics Eszopiclone Zaleplon ZolpidemAntipsychotics, chronic and asneeded useaRecommendation, Rationale, QE, SRAvoidAChEIs cause bradycardia and shouldbe avoided in older adults whosesyncope may be due to bradycardia.Non-selective peripheral alpha-1blockers cause orthostatic bloodpressure changes and should beavoided in older adults whose syncopemay be due to orthostatic hypotension.Tertiary TCAs and the antipsychoticslisted increase the risk of orthostatichypotension or bradycardia.QE AChEIs, TCAs and antipsychotics:High. Non-selective peripheral alpha-1blockers: High; SR AChEIs, TCAs:Strong. Non-selective peripheralalpha-1 blockers, antipsychotics: WeakAvoidAvoid in older adults with or at highrisk of delirium because of potential ofinducing or worsening deliriumAvoid antipsychotics for behavioralproblems of dementia and/or deliriumunless nonpharmacological options(e.g
Prescribing and managing disease conditions should be individualized and involve shared decision-making. These criteria also underscore the importance of using a team approach to . TABLE 1. 2019 American Geriatrics Society Beers Criteria .
he American Geriatrics Society (AGS) Beers Criteria (AGS Beers Criteria ) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3-year cycle
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Oct 16, 2020 · Key principles to guide optimal use of the AGS Beers Criteria 1. Medication on the Beers list are considered potentially inappropriate but not definitely inappropriate 2. Read the rationale and recommendations statements for eac
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