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Introduction

Updates to the Beers Criteria play an important role in quality measures.


How do you assess high-risk medications before dispensing to elderly
patients?
Over the past 25 years, the Beers Criteria have become one of the most influential clinicaldecision making tools for medication use in the elderly.1 The Beers Criteria are the
American Geriatrics Society's listing of potentially inappropriate medications to be avoided
in older adults. Now in its fifth release, the 2015 update continues to be an important
resource for geriatric clinical care and the development of quality measures.
Patients 65 years and older frequently seek medical care. Close to 40% of geriatric patients
take five or more prescription medications compared to 15% in the general population.2
Polypharmacy has tripled in the geriatric population over the past 25 years. And it is
associated with poorer outcomes including falls, memory problems, and decreased
functioning in activities of daily life.3
Aging patients are more likely to use more medications as they accumulate more chronic
disease states. This puts them at increased risk for drug-drug interactions and adverse
effects.3 The elderly population may also be more vulnerable to adverse drug effects due to
age-associated changes such as decreased metabolism and renal clearance.
Thanks to prescribing education efforts like the Beers Criteria, potentially inappropriate
medication fills are decreasing.3 But use is still high. The Agency for Healthcare Research
and Quality (AHRQ) estimates 42% of older adults who fill a prescription have at least one
medication that appears on the Beers Criteria.4
But the Beers Criteria are not a blacklist of medications. Think of them more like a caution
flag on a patient's medication list. Careful consideration should be given when using these
agents in patients who are over the age of 65.5
Beers Criteria 2015 Update
Which medications do you most commonly see your elderly patients use for
insomnia? For pain? Which of these may need to be reviewed for appropriate
use?
Much like the previous update of the Beers Criteria in 2012, the 2015 update includes lists
of potentially inappropriate medications to be avoided in older adults age 65 years and
older.
The American Geriatrics Society's Beers Criteria panel consists of 13 experts in geriatric
medicine, nursing, pharmacy practice, research, and quality measures who develop a
consensus based upon systematic reviews of information. The panel grades the strength and

quality of each statement using the American College of Physicians' Guideline Grading
System.6 The quality of evidence is identified as high, moderate, or low and the strength of
the recommendation is graded as strong, weak, or insufficient based upon the agent's riskto-benefit ratio.
The Criteria includes new evidence for previously listed medications as well as new
medications and conditions that have growing evidence for concern in geriatric patients.
The update also includes two new sections: select drug-drug interactions and select
medications requiring dose adjustments for renal function.
Drug-Drug Interactions1
The American Geriatrics Society added a drug-drug interaction section to their criteria.
Keep in mind this is not a comprehensive list. Think of the section as a spotlight for drugdrug interactions that may cause serious harm if ignored, missed, or overlooked in the aging
population.
The drug-drug interaction list does not include an anti-infectives section. The panel
intentionally excluded these agents to focus on chronic medications. However, antiinfectives, even when used acutely, can cause interactions. Review a patient's medication
list carefully and use drug interaction checkers to avoid drug-drug interactions when
initiating therapy.
The Beers Criteria's drug-drug interaction section emphasizes the importance of minimizing
the number of central nervous system (CNS) active drugs such as tricyclic antidepressants,
selective serotonin reuptake inhibitors, antipsychotics, opioids, benzodiazepines, and nonbenzodiazepine hypnotics ("Z drugs"zolpidem, zaleplon, eszopiclone). When possible,
avoid using three or more CNS-active medications due to increased risk of falls.
Also avoid using peripheral alpha-1 blockers such as doxazosin in combination with loop
diuretics in elderly women. The combination can increase the risk of urinary incontinence.
The Eighth Joint National Committee no longer recommends alpha-1 blockers for
hypertension, so this combination should be rare for female patients.7
Reserve angiotensin converting enzyme (ACE) inhibitors paired with potassium-sparing
diuretics (amiloride, triamterene) for patients with documented hypokalemia when taking an
ACE-inhibitor alone.
The Beers Criteria also emphasizes classic drug-drug interactions such as those of lithium or
warfarin. The drug-drug interaction section lists lithium toxicity as a concern when used in
combination with ACE-inhibitors or loop diuretics. Avoid the combination or make sure
lithium levels are carefully monitored. For warfarin, increased bleeding risk can occur when
combined with amiodarone or nonsteroidal anti-inflammatory drugs (NSAIDs). Use of both
NSAIDs and corticosteroids may increase risk of peptic ulcer disease or gastrointestinal
bleeding.

Select Beers Criteria Drug Interactions1


Drug or drug class

Interacting drug or drug


class

ACEI

Amiloride, triamterene

Avoid;
increased risk
of
hyperkalemia.
Use only in
patients with
hypokalemia
while taking
ACEI alone

Loop diuretics

Avoid when
possible in
women;
increased risk
of urinary
incontinence

Anticholinergic

Avoid;
minimize
number of
anticholinergic
drugs

Alpha-1 blockers

Anticholinergic

CNS Active Drugs

Antidepressants
(TCAs, SSRIs)
Antipsychotics
Benzodiazepines,
nonbenzodiazepine
hypnotics
Opioids

CNS Active Drugs

Antidepressants
(TCAs, SSRIs)
Antipsychotics
Benzodiazepines,
nonbenzodiazepine
hypnotics
Opioids

Corticosteroids

NSAIDs

Lithium

Risk and
rationale

ACEIs, loop diuretics

Avoid use of 3
or more CNSactive drugs.
Minimize use
and
recommend
lowest
effective dose
when possible
Avoid when
possible;
increased PUD
risk. Provide
GI protection
with PPI
during use.
Avoid;
increased

lithium
toxicity risk
Warfarin
Amiodarone, NSAIDs

Avoid when
possible;
increased
bleed risk

Abbreviations: ACEI = angiotensin converting enzyme inhibitors, CNS =


central nervous system, GI = gastrointestinal, NSAIDs = nonsteroidal antiinflammatory drug, PPI = proton pump inhibitor, PUD = peptic ulcer disease,
SSRIs = selective serotonin reuptake inhibitors, TCAs = tricyclic
antidepressants
Renal Function1
Another addition to the 2015 Beers Criteria is a section on agents requiring specialized renal
dosing for patients with declining kidney function. Much of this evidence comes from
consensus guidelines developed by Beers Criteria panel members.8 Added to the Criteria are
spironolactone, triamterene, and several new oral anticoagulants (apixaban, dabigatran,
edoxaban, rivaroxaban). Be aware the panel's recommendations may differ from the agent's
current FDA labeling.
Like the drug-drug interaction section, the section on agents requiring renal dosing
adjustment is not comprehensive and does not include anti-infectives. However,
nitrofurantoin was mentioned in the list of potentially inappropriate medications.
The Beers Criteria updated their recommendation for use of nitrofurantoin in elderly
patients with decreased renal function. The Criteria currently suggests nitrofurantoin can be
used safely in patients with creatinine clearance of > 30 mL/min (previously > 60 mL/min).
Continue to avoid long-term use of nitrofurantoin in elderly patients due to irreversible
pulmonary fibrosis, liver toxicity, and peripheral neuropathy.
Dose reductions may be necessary when using the following agents in
elderly patients with the stated reduced renal function:1
Cardiovascular

Edoxaban or rivaroxaban if CrCl 30 to 50 mL/min


Enoxaparin if CrCl < 30 mL/min

CNS

Gabapentin or pregabalin if CrCl < 60 mL/min

Levetiracetam if CrCl < 80 mL/min


Tramadol (immediate release) if CrCl < 30 mL/min

Cimetidine, famotidine, nizatidine, ranitidine if CrCl < 50 mL/min

GI

Gout

Colchicine if CrCl < 30 mL/min

Abbreviations: CrCl = creatinine clearance


Avoid use of the following agents in elderly patients with the stated reduced
renal function:1
Cardiovascular

CrCl greater than 95 mL/min do not use: edoxaban


CrCl < 30 mL/min do not use: amiloride, dabigatran, edoxaban,
fondaparinux, rivaroxaban, spironolactone, triamterene
CrCl < 25 mL/min do not use: apixaban

CNS

CrCl < 30 mL/min do not use: duloxetine, tramadol (extended


release)

Gout

CrCl < 30 mL/min do not use: probenecid

Abbreviations: CrCl = creatinine clearance


Changes to the List of Potentially Inappropriate Medications1
New potentially inappropriate medications include proton pump inhibitors, desmopressin,
and meclizine. When possible, avoid proton pump inhibitor use beyond 8 weeks as exposure
leads to increase risk of C. difficile infection, bone loss, and fractures. There are still
patients who will benefit from long-term proton-pump inhibitors use such as those with
chronic NSAID use or Barrett's esophagus.
Avoid desmopressin for the treatment of nocturia or nocturnal polyuria due to risk of
hyponatremia. Avoid meclizine due to its anticholinergic effects and reduced clearance in
aging adults.
Physicians prescribe desmopressin most frequently for treatment of diabetes insipidus, bedwetting, or nocturia.

Continue avoiding sliding scale insulin in geriatric patients due to high risk of
hypoglycemia in any care setting. The Beers Criteria update now better defines a slidingscale regimen: short- or rapid-acting insulins to manage or avoid hyperglycemia in absence
of basal or long-acting insulin.
The update no longer recommends the avoidance of antiarrhythmics classes Ia
(disopyramide, procainamide), Ic (flecainide, propafenone), and III (dofetilide, sotalol) as
first-line therapy for atrial fibrillation. Evidence and guidelines suggest that rhythm control
have outcomes as good as or better than rate control.9,10,11
Amiodarone is still included on the Beers Criteria and should be avoided except in cases of
heart failure or severe left ventricular hypertrophy. Digoxin should also be avoided as a
first-line agent for atrial fibrillation, heart failure, or at doses exceeding 125 mcg daily.
Changes to the List of Drug-Disease Precautions1
Nonbenzodiazepine hypnotics (Z-drugs) have been added to the list of medications to avoid
in dementia or cognitive impairment. Avoid these agents regardless of duration due to safety
concerns matched with limited efficacy supporting their treatment of insomnia. Previously,
the Beers Criteria supported use for a duration of less than 90 days.
Opioids have been added to the list of CNS medications to avoid in patients with fall or
fracture history. If patients need to use opioids, make sure to avoid other CNS active
medications such as antipsychotics and benzodiazepines.
Antipsychotics should be avoided as first-line treatment of delirium due to conflicting
evidence of efficacy and potential for adverse drug effects. Avoid antipsychotics in patients
with behavioral problems until nonpharmacological options have failed or are not possible
AND the aging patient is "threatening substantial harm" to self or others.1
Anticholinergic Agents
Use of anticholinergic medications remains a concern in elderly patients due to increased
constipation, urinary retention, and dryness. They are also associated with impaired physical
functioning and cognition including dementia. Special attention to use of antipsychotics,
antiemetics, and muscle relaxants should be given in geriatric patients.
The most significant change to the anticholinergic list is the addition of the first-generation
antihistamine, meclizine, and removal of the second-generation antihistamine, loratadine.
2015 Beers Criteria Update Summary: Select Medications Added/Removed/Modified1
Added:

Proton-pump inhibitors use beyond 8 weeks as exposure leads to increase risk of C.

difficile infection, bone loss, and fractures


Desmopressin (hyponatremia)
Meclizine (anticholinergic)

Removed:

Antiarrhythmic classes Ia (disopyramide, procainamide), Ic (flecainide,


propafenone), and III (except amiodarone)
Trimethobenzamide (appropriate antiemetic in Parkinson's disease when used with
apomorphine)
Chloral hydrate and mesoridazine (no longer available in U.S.)

Modified:

Avoid opioids in patients with falls or fracture history


Avoid armodafinil and modafinil in insomnia
Avoid eszopiclone and zaleplon in patients with dementia or cognitive impairment
(zolpidem was previously listed)
Avoid antipsychotics in patients with delirium
Nitrofurantoin use appropriate until creatinine clearance < 30 mL/min (avoid longterm use)
Avoid using digoxin first-line and doses exceeding 125 mcg daily
Avoid dronedarone in permanent atrial fibrillation, severe or recent heart failure
Avoid meperidine especially in chronic kidney disease due to lack of efficacy as
analgesic and CNS toxicity
Avoid estrogens (except intravaginal) due to carcinogenic potential (breast,
endometrial, and ovarian), lack of cardioprotection, and may increase incontinence
Sliding scale insulin better defined. Continue to avoid due to risk of hypoglycemia

Intended Use of the Beers Criteria


Does the Beers Criteria help you make clinical decisions? Have you had
geriatric patients who needed to use a potentially inappropriate medication?
The primary audience for the Beers Criteria is health care workers in both inpatient and
outpatient settings who impact geriatric care. However, the list is widely distributed and
reaches consumers, pharmacy benefit managers, health systems, and policymakers.
One of the American Geriatrics Society's key goals for the Beers Criteria is to improve
patient care for older adults by reducing potentially inappropriate drug use. Proper use of
the Criteria should lead to close monitoring of medications in aging adults. Medications
appearing on Beers Criteria have been associated with poor health outcomes, including
confusion, falls, and mortality. By reducing potentially inappropriate medication use, the
Beers Criteria hopes to decrease risk of adverse events in the elderly.1
The Beers Criteria is a very useful clinical tool. But remember it does have limitations.

The Criteria does not apply to all aging patients. It excludes palliative care and hospice
patients. The harm-to-benefit ratio shifts in these populations, and there is little evidence for
avoiding certain drugs during end-of-life decision making.
The Criteria is not meant to be an all-encompassing list of medications to avoid. But it is
often mislabeled as a "do not use" list. Individualization of care is key. The American
Geriatrics Society intends the Beers Criteria to act as a warning light to caution clinicians
before using potentially inappropriate medications in elderly patients. Be conscious of the
risks associated with these agents.
Appreciate that medications appearing on the Beers Criteria should be avoided in most
geriatric patients. After all, these agents were placed on the list by geriatric specialists
because of an unfavorable risk-to-benefit ratio in elderly patents. But that doesn't mean
access to these medications should be restricted. There are still many good reasons for using
medications appearing on the list. While making patient-centered decisions are not always
clear cut, using the Beers Criteria as an ultimatum for prescribing or dispensing practices is
not appropriate.
Keys for optimal use of the Beers Criteria:5
Beers Criteria medications are potentially inappropriate in geriatric patients.
Use the Criteria to start process of determining a medication's
appropriateness and safety.
Care for patients should be individualized after weighing risk and benefit.
Offer alternatives, both nonpharmacological and pharmacological, where
appropriate.
Avoid restricting access to medications after appropriate use has been
established.
Criteria are not equally applicable to all practice settings including different
countries.
The AGS Beers Criteria is just one tool for analyzing medication use in older adults.
Other tools such as the Screening Tool of Older Persons' potentially inappropriate
Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START)
criteria are also important.12 After being first published in 2008, STOPP/START criteria
were also updated in 2015 and include drugs affecting or being affected by renal function.13
Canadian criteria is another available resource to consider in geriatric care.14
These tools, including the Beers Criteria, are cutting down on inappropriate prescribing
habits. However, it is still unclear whether these changes can be directly tied to improved
clinical outcomes.15
Use and Limitations for Quality Measures
The intended use of the Criteria is to improve medication selection, reduce adverse drug

effects, and serve as a tool for evaluating quality of care, cost, and patterns of drug use in
patients 65 years and older.5 This means the Beers Criteria serves as both an educational
tool and the foundation for quality measures. This dual nature of the Criteria creates
problems.
Sometimes pharmacists may think of the Beers Criteria more in terms of quality measures
rather than a clinical tool. Agents appearing on the Beers list often have warnings in
computerized decision support systems used during a drug's verification process. Potentially
inappropriate drugs are also often tied to prior authorization requests from insurers.
In general, quality measures are good for the U.S. health care system. They are a sign of
moving toward a value-oriented health care model. The United States spends more money
on health care than any other nation in the world but has some of the poorest outcomes.
Health care spending is nearing $10,000 per person/year in the United States.16 Despite the
high spending, the U.S. has some of the lowest life expectancies and highest infant mortality
rates when compared to nations with similar access to health care.17
Traditionally health care in the United States has been based upon providing services.
Billing focused on how many health-related products a patient used including office visits,
diagnostic tests, procedures and medications.
Now consumers and payers want to maximize their health care dollar, which leads us to our
current model of pay-for-performance.18 Patients and payers are more willing to pay for
value, in terms of better health outcomes, than general services.19 Quality measures are one
way to gauge improvement as health care delivery shifts from a pay-for-service to pay-forperformance model.
Centers for Medicare and Medicaid Services (CMS) identifies quality measures as one of
the most important tools in providing high standards of healthcare.20 Quality measures allow
for monitoring of health care usage. And they are able to be connected to a specific and
measurable outcome. Establishing quality measures is a necessary component of continual
improvement of patient care.
Quality measures allow for assessment of important goals including whether a therapy is
safe, effective, patient-centered, and equitable.20,21 Everyone from consumers to
practitioners to payers should be aware of the current standard of care. Comparing one's
performance to recognized quality standards can validate payment and improve care on a
local or population-specific level. Quantifying specific processes within the health care
system is essential to ensure outcomes and patient perceptions remain positive.
Quality measures improve health care by:16,22

Monitoring use
Increasing patient safety
Targeting specific outcomes
Providing accountability

Identifying and measuring disparities


Educating consumers

Ideal quality measures should be clearly defined.23 Their focus should be gathering data on
what is already going on in practice. Measures should also be easily applied over a variety
of settings. Tracing outcomes through transitions of care is essential. Quality measures may
help incentivize change to optimize care by creating a more team-driven approach to health
care.
At their best, quality measures are a way to improve patient care by quantifying evidencebased practices, outcomes, and patient satisfaction. For more on quality measures, see our
Pharmacist's Letter Detail-Document Clinical Quality Measures.
High-Risk Medications in the Elderly Quality Measure
What improvements have you seen since your pharmacy started utilizing
quality measures? How can pharmacists promote a non-punitive environment
when recommending medications?
The American Geriatrics Society Beers Criteria has a key role in creating quality measures
for geriatric patients. The most widely used quality measure based on the Beers Criteria is
Use of High-Risk Medications in the Elderly (HRM). The HRM measure was developed by
the National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance
(PQA). The Beers Criteria also helped create NCQA's quality measure Potentially Harmful
Drug-Disease Interactions in the Elderly.24
The HRM measure is used by CMS and other payers to monitor and evaluate the quality of
care for elderly beneficiaries. CMS uses HRMs for its clinical quality measure CMS156v1.
This measure examines the percentage of geriatric patients (65 years and older) who
received two or more prescription fills for a high-risk medication during the measurement
period. These medications may be harmful when used in this population, so using them
extensively should negatively impact a health care plan's quality ratings.25
It is well known that CMS uses quality measures for quality improvement and public
reporting. But health care practitioners will also find pay-for-reporting and pay-forperformance programs becoming increasingly tied to their reimbursement levels and other
benefits such as accessibility to programs.
CMS also publishes annual Star Ratings to help consumers identify high performing plans.
These are the types of quality measures pharmacists see most. Star Rating has used HRM as
a key safety measure in assessing Medicare Advantage plans with prescription coverage as
well as standalone Part D plans for the past several years. For more information about Star
Ratings, see our PL CE, Quality Measures: What Pharmacy Teams Need to Know.

Considerations when creating HRM quality measure:26

Only includes medications that should be avoided independent of


diagnosis or condition. This means the measures could be utilized
with drug claim data alone.
Uses prescription drug claims data not over-the-counter drugs.
Over-the-counter drugs are an important part of therapy, but they are
difficult to capture with drug claims alone.
Focuses on products where Beers Criteria recommends avoiding the
agents not medications with clinical stipulations such as duration.
However, if a certain clinical stipulation can be efficiently measured
it should be included (e.g. estrogen and route of administration).

HRM and other quality measures are still based upon the 2012 update of the Beer's Criteria.
Expect updates to the quality measures based on the 2015 update.
Quality measures based upon the Beers Criteria also effect clinical decision support systems
and health systems benchmarking tools. The Criteria are a valuable tool for clinical care and
quality improvement for payers, clinicians, and patients.
However, the Beers Criteria have become such an important clinical and quality
improvement tool that it can be used in dangerous ways. Misuse of the Beers Criteria is
common and may lead to unintended patient harm.27
The Beers Criteria is the foundation for important quality measures surrounding use of
medications in the elderly. Its role can be misinterpreted as any use of these medications is
indicative of low quality of care. This isn't the criteria's intended use. HRM quality measure
works best on a population level for a health plan. Continue treating individual patients
based upon their unique risk versus benefit profile.
Restricting access to potentially inappropriate medications is becoming common. Insurance
companies are requiring prior authorizations before paying for these agents. They may also
send letters to beneficiaries stating that the drug may be harmful. This may cause confusion
for patients especially when the drug is appropriate.
Restrictions also occur at the place of prescribing.5 Clinical decision support systems often
flag Beers Criteria medications. These alerts are important in educating providers about
potential risks. Results from the alerts are recorded for quality improvement practices.
However, this data shouldn't be used to punish prescribers who still decide to prescribe the
agent. Prescribers should be documenting their rationale for use.
Restrictions may also delay proper care. There are instances where potentially inappropriate
medications appearing on the Beers Criteria or high-risk medications are the best choice.
Implementing quality measures needs to be flexible in health care systems and reassessed

annually. If a quality measure is used as an all-or-nothing approach, this can lead to distrust
in the measure among the health care team. Instilling goodwill in the measure is important
in establishing its ability in providing quality of care.5
CMS is taking note of the limitations surrounding the HRM measure, and it may not even
be included in the new 2017 Star Ratings.30 However, there are plans to maintain it as a
display measure for Medicare Advantage plans with prescription coverage and standalone
Part D plans.
A variety of factors played a role in this decision. The dual nature of the Criteria as clinical
tool and a quality measure is complicated. It's difficult to use the Criteria as a tool without
having performance tied to it. Also drug plans don't have full access to the record of the
clinical decision making process especially when it comes to individualized care.
CMS hasn't ruled out the HRM measure indefinitely. It may be considered for Star Ratings
again possibly in the 2019 update.
Focus on using the Beers Criteria as a tool. It can't determine whether a medication is
appropriate or inappropriate for a specific patient. Only the health care team can do that. But
the Beers Criteria should be a component of the decision within the approach to medication
management and safety in elderly patients.
Why isn't there more standardized evidence available on medication use in the elderly? In
general, evidence for medication use in the elderly is limited. Aging patients are
underrepresented in clinical studies. When study populations are low, it is possible that
effects are underestimated and a lower grade of evidence is assigned.6
Emphasize individualized care when using the Beers Criteria. Clinical judgement plays the
biggest role in determining when high-risk medications are appropriate. Take into account
the specific patient's preferences, goals, and needs when determining therapy.
The Beers Criteria serves as a caution sign for certain medications.1 This warning helps
health care team members identify medications that often have unfavorable risk to benefit
ratios in geriatric patients, especially compared to alternatives.
While medications listed on the Beers Criteria are sometimes appropriate under certain
circumstances, remember the Criteria are an essential evidence-based tool to use in
decision-making for drugs to avoid in older adults. It consists of well-researched
recommendations from some of the most influential specialists in geriatric care. These
recommendations are really best for most geriatric patients.
Selecting Alternatives and Monitoring Potentially Inappropriate Medications in Patients
How does a patient's history impact medication selection? What medications
are you cautious of using in a patient with a history of falls? A history of
dementia?

Pharmacists play an important role in proper use of the Beers Criteria. Dispensing
medications allows pharmacists to be at the hub of the process. Pharmacists are an
important liaison for communication between prescribers, patients, and insurance
companies. They can also track long-term use of agents or whether multiple high-risk
medications are being prescribed by multiple providers.
The Beers Criteria are some of the best evidence available for potentially inappropriate
medication use in geriatric patients. Just remember the warnings don't equally apply to
every patient or setting.
Assess the patient's need for a potentially inappropriate medication before dispensing.
Pharmacists should ensure both the prescriber and the patient or caregiver are well aware of
rationale for why the agent is listed on the Beers Criteria.
Consider alternatives, both non-pharmacologic and pharmacologic, before dispensing a
potentially inappropriate medication in an elderly patient. This includes getting a thorough
medication history. What has the patient tried before? Can nonpharmacological agents be
considered? Did previous alternatives have a long enough trial before being ruled out as a
potential therapy?
There is increased emphasis on exhausting nonpharmacological measures in the 2015 Beers
update, especially for patients suffering from insomnia, delirium, or dementia. Researchers
from Pennsylvania State University developed a non-pharmacological toolkit for reducing
antipsychotic use. The kit includes strategies on behavior management and staff-training
models.31
In a separate article, the American Geriatrics Society published a list of medication
alternatives alongside their release of the 2015 Beers Criteria.24
Alternatives to Beers Criteria Agents Based on Patient Presentation1,24
Condition/Symptom Medication(s) to Avoid Potential Alternative
(examples)
Agents
(examples)
Allergies
First generation
antihistamines
(diphenhydramine,
doxylamine,
hydroxyzine) due to
anticholinergic effects
Anxiety

Intranasal saline flushes;


Second generation
antihistamines
(loratadine, cetirizine,
fexofenadine); Intranasal
corticosteroids
(fluticasone,
triamcinolone)

Benzodiazepines
Buspirone, SSRIs (except
(alprazolam, lorazepam)
paroxetine due to
due to delirium and fall
anticholinergic effects),

risk; meprobamate due


to high rate of physical
dependence and sedation

SNRIs (venlafaxine)

Atrial Fibrillation

Digoxin avoid first-line


especially doses > 125
mcg daily; Note: Beers
Rate control:
Criteria no longer
nondihydropyridine CCB
recommends to avoid
(diltiazem), beta-blockers
antiarrhythmic drugs
(metoprolol) Rhythm
(Classes 1a, 1c, III) as
control: dofetilide,
first-line treatment, but
flecainide, propafenone
these agents may still
appear on certain quality
measures

Delirium or
Dementia

If nonpharmacological
strategies have failed/not
Antipsychotics for
possible AND patient is a
behavioral problems due
danger to self/others,
to increased risk of
consider low dose nonstroke, cognitive decline,
anticholinergic agent
and mortality in persons
(risperidone, quetiapine)
with dementia
for shortest duration
possible

Diabetes

Long-acting
sulfonylureas
(glyburide) due to
increased risk of
hypoglycemia; TCAs
due to CNS effects

Glycemic control: Shortacting sulfonylureas


(glipizide) or metformin
Neuropathic pain: SNRIs
(duloxetine), gabapentin,
pregabalin, lidocaine
patch

TCAs (amitriptyline,
imipramine)

SSRIs (except paroxetine


due to anticholinergic
effects), SNRIs,
bupropion,
nonpharmacological
strategies; Avoid use of 3
or more CNS active
agents concurrently

Depression

Epilepsy

Barbiturates (butalbital,
Lamotrigine,
phenobarbital) and other levetiracetam; decrease
hepatic enzyme inducing
dose of other CNS
agents (phenytoin,
medication if possible,
carbamazepine) due to
consider discontinuation

increased risk of drugdrug interactions

Insomnia

Benzodiazepines
(alprazolam, lorazepam);
nonbenzodiazepine
hypnotics (eszopiclone,
zaleplon, zolpidem)

Menopause

Pain

of agent with proper taper


after a seizure-free period
of two years with normal
EEG
Emphasize
nonpharmacological
strategies32,33

Estrogens (oral, patch)


due to increased risk of
clots, kidney stones,
cancers (breast,
endometrial, ovarian)

Vaginal dryness: vaginal


lubricants and
moisturizers, intravaginal
estrogens Hot flashes:
SSRI (escitalopram),
SNRI (venlafaxine),
gabapentin

Avoid the opioids


meperidine and
pentazocine. Avoid
skeletal muscle relaxants
(carisoprodol,
cyclobenzaprine). Avoid
indomethacin, ketorolac.
Limit chronic of other
NSAIDs due to ulcer
risk; use PPI for NSAID
durations longer than 7
days to provide GI
protection.

Mild to moderate pain:


NSAIDs in patients
without heart failure and
CrCl > 30 mL/min,
acetaminophen Moderate
to severe pain: tramadol
and opioids (morphine,
oxycodone) Neuropathic
pain: SNRI, gabapentin,
pregabalin, topical
(capsaicin, lidocaine
patch)

Benztropine,
Trihexyphenidyl

Carbidopa-levodopa; first
line in older adults due to
decreased intensity of
tremors which shifts
risk/benefit ratio of
anticholinergic use

Parkinson's (tremor)

Abbreviations: CCB = calcium channel blocker, CNS = central nervous


system, COX-2 = cyclooxygenase-2, CrCl = creatinine clearance, EEG =
electroencephalogram, GI = gastrointestinal, HRM = high-risk medication,
NSAIDs = nonsteroidal anti-inflammatory drug, PPI = proton pump
inhibitor, SNRIs = serotonin norepinephrine reuptake inhibitors SSRIs =
selective serotonin reuptake inhibitors, TCAs = tricyclic antidepressants

Patients with a history of falls are especially at risk for drug adverse effects. Geriatric
patients who are at risk of falls should be taking calcium and vitamin D supplements,
potentially alongside a bisphosphonate.
Select medication classes to avoid in geriatric patients with a history of
falls:1,24

Anticonvulsants
Antipsychotics
Benzodiazepines
Nonbenzodiazepine hypnotics (Z-drugs)
Prolonged use of proton-pump inhibitors (greater than eight weeks)
Tricyclic antidepressants

See our chart Potentially Harmful Drugs in the Elderly: Beers List for more details
including potential alternative agents.
There are times when there is not a proper alternative for a specific patient. Help in the
decision making process by weighing patients' individualized risk-to-benefit ratio as they
age.
If a potentially inappropriate agent must be used, develop a clear plan for monitoring. A
specific parameter, goal, and frequency should be established. Clue in other health care
team members of your concerns to establish monitoring across settings. Encourage the
patient or caregiver to self-monitor at home.
It may be appropriate to increase the dose of potentially inappropriate medications or to add
additional agents to augment response to therapy. These changes also need to be carefully
monitored too. Patients doing fine on one potentially inappropriate medication may not be
able to handle more. For example, make sure CNS active agents (antidepressants,
benzodiazepines, opioids) are limited in use. Avoid using more than three agents at a time.
Discontinue an agent if the desired effect is not achieved. While medications appearing on
the Beers Criteria are often used as a last resort, they still need to demonstrate improvement.
Patient and provider buy-in is important to discontinuing medications. Setting clear goals
during the monitoring phase allows patients to appreciate what specific therapy can, and
can't, achieve.
Appropriate tapering is essential in many of these medications to prevent adverse effects.
Benzodiazepines or opioids should be slowly stopped to prevent withdrawal. Watch for falls
and dizziness when changing medication dosing or administration timing.
Use of potentially inappropriate medications should be reviewed regularly as part of a
comprehensive review of a patient's medication regimen. Pay attention to patient or

caregiver complaints such as dizziness, falls, or cognitive decline. Even chronic medications
that haven't been changed recently could be the source of the problem.
As patients age, their response to medications may change. Keep an eye on potentially
inappropriate medications appearing on a patient's drug list. They may no longer be a good
agent as the patient ages.
Educating Patients and Caregivers
When do you approach patients about non-pharmacological options? How
can you make sure they are accessing reliable information on the Internet?
Given the popularity of the Beers Criteria, pharmacists may get questions from patients
about potentially inappropriate medications appearing on their medication lists. Take time to
address their concerns. It is important for patients to be engaged with their healthcare team
members and empowered to ask questions about their medication therapy.
Patients wanting to know more about the Beers Criteria can visit HealthinAging.org. Health
in Aging is a foundation of the American Geriatrics Society that provides for helpful,
patient-friendly resources.
Health in Aging provides patients a variety of tip sheets. They advise patients to never stop
taking a medication without consulting their healthcare provider, keep a current medication
list, and review their medication list regularly with their prescribers and pharmacists. The
resources also alert patients of alternatives to medications listed on the Beers Criteria and to
discuss them with their prescriber.34
Health in Aging Resources for Older Adults & Caregivers
(http://www.healthinaging.org/resources)

Ten Medications for Older Adults to Avoid Tip Sheet


Avoiding Overmedication and Harmful Drug Reactions Tip Sheet
What to Do and What to Ask If a Medication You Take is on the
AGS Beers Criteria
Alternatives to Potentially Inappropriate Medications
My Medication Diary

Patients with insomnia or problems sleeping can get more information about how sleep
changes in geriatric patients as well as nonpharmacological strategies for improved sleep
from the National Institutes of Health's Senior Health website at
http://nihseniorhealth.gov.35 You can also share our PL Patient Education Handout,
Strategies for a Good Night's Sleep, with patients. This gives them nonpharmacological
options to help improve their sleep habits (also available in Spanish).
Hospital Elder Life Program (HELP) provides strategies for managing cognitive decline.

Patients and caregivers can access general information including nonpharmacological


interventions at www.hospitalelderlifeprogram.org.36
Remind patients not to panic if one of their current medications appears on the Beers
Criteria. Educate them that the list is more like a caution flag than a do not use list.
Patients and caregivers should also be educated on self-monitoring strategies. Advise
patients how long it will take before medications should take effect. Patients may need to
keep a dairy to keep track of subjective measures like pain or sleep quality.
Wrap Up
The 2015 Beers Criteria update is an influential tool in terms of both patient care and quality
improvement. As with any tool, it important to understand its limitations. The Criteria are
designed to aid prescribers, pharmacists, and patients select the best care. It isn't meant to
make decisions for them. An individualized, patient-centered approach to medication use in
the elderly is still the best method. Carefully consider the purpose for initiating or
discontinuing medications in aging patients. If a medication from the Beers Criteria needs to
be used, a monitoring plan should be in place and patients, as well as their caregivers,
should be educated on the potential risks and benefits. Continue to review patients'
medication lists as they age to assess the continued need for potentially inappropriate
agents.