GC079 (supp-3)ags Beers Criteria For Potentially Inappropriate Med Use: 2023
The 2023 AGS Beers Criteria is an evidence-based guideline identifying medications that are potentially inappropriate for older adults (≥65 years) due to unfavorable risk-benefit profiles, aimed at optimizing prescribing safety in geriatric care.
AGS Beers Criteria® 2023 — Potentially Inappropriate Medication Use in Older Adults
The AGS Beers Criteria® is one of the two most important explicit prescribing tools for older adults (the other being STOPP/START). This supplementary reading accompanies GC 079: Prescribing in Older People and provides the detailed, drug-by-drug framework that examiners love to test.
Why this matters clinically: Older adults (≥65 years) are disproportionately affected by adverse drug events (ADEs) because of age-related pharmacokinetic changes (reduced renal clearance, hepatic metabolism, increased body fat, decreased lean mass, altered receptor sensitivity), multimorbidity, and polypharmacy. The Beers Criteria is a systematic tool to flag medications where potential harm outweighs expected benefit in this population.
The criteria are intended to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. [1]
Learning Objectives:
- Understand the purpose, structure, and proper application of the AGS Beers Criteria®
- Identify the five categories of potentially inappropriate medications (PIMs)
- Know the highest-yield PIMs by organ system, their rationale, and recommended alternatives
- Recognize drug–disease/syndrome interactions that exacerbate geriatric syndromes
- Apply renal dosing adjustments for key medications in older adults
- Understand how to use the criteria in shared decision-making (not punitively)
A PIM is a medication where the potential for harm outweighs the expected clinical benefit, particularly in older adults. This does not mean the drug is absolutely contraindicated — rather, it should be avoided in most circumstances unless safer alternatives have failed and shared decision-making supports its use.
"Avoid" is not defined as an absolute contraindication unless specified in the medication's label. It is the expert panel's intent that when a PIM is chosen, it is done so through shared decision-making. [1]
First-principles reasoning for why older adults are vulnerable:
| Factor | Mechanism | Clinical Impact |
|---|---|---|
| ↓ Renal clearance (GFR declines ~1 mL/min/year after 40) | Drug accumulation | Toxicity from renally-cleared drugs (digoxin, DOACs, gabapentin) |
| ↓ Hepatic mass & blood flow | Slower Phase I metabolism | Prolonged half-life of lipophilic drugs |
| ↑ Body fat proportion | Increased volume of distribution for lipophilic drugs | Prolonged action of benzodiazepines |
| ↓ Lean body mass & total body water | Higher plasma concentration of hydrophilic drugs | Increased sensitivity to digoxin, lithium |
| ↓ Serum albumin | More free (active) drug | Toxicity at "normal" doses of highly protein-bound drugs |
| ↑ Blood-brain barrier permeability | Greater CNS drug penetration | Increased sensitivity to anticholinergics, sedatives |
| Altered receptor sensitivity | Increased pharmacodynamic sensitivity | Exaggerated response to sedatives, anticholinergics |
| Multimorbidity + Polypharmacy | Drug–drug and drug–disease interactions | Cascading prescribing, ADEs |
The expert panel organized the criteria into five general categories: [1]
| Category | Table | What It Covers |
|---|---|---|
| 1. PIMs regardless of diagnosis | Table 2 | Drugs that are generally inappropriate in most older adults |
| 2. PIMs due to drug–disease/syndrome interactions | Table 3 | Drugs that exacerbate specific conditions (HF, delirium, falls, etc.) |
| 3. Drugs to use with caution | Table 4 | Drugs with concerning but less clear-cut evidence of harm |
| 4. Drug–drug interactions to avoid | Table 5 | Clinically important interactions in older adults |
| 5. Renal dose adjustments | Table 6 | Drugs needing dose reduction or avoidance based on CrCl/eGFR |
Additional reference tables:
- Table 7: Drugs with strong anticholinergic properties (cross-referenced in Tables 2, 3, 5)
- Table 8: Drugs removed from main tables due to low/absent US usage (still considered PIMs)
Category 1: PIMs Regardless of Diagnosis or Condition (Table 2)
This is the highest-yield table for exams. Organized by organ system:
First-generation antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine, promethazine, meclizine, etc.): Highly anticholinergic; clearance reduced with advanced age; tolerance develops when used as hypnotic. Risk of confusion, dry mouth, constipation. Cumulative anticholinergic exposure is associated with increased risk of falls, delirium, and dementia. AVOID. (Moderate evidence, Strong recommendation) [1]
Why from first principles: First-generation antihistamines cross the blood-brain barrier freely (unlike second-generation agents like cetirizine, loratadine). In older adults with already-reduced cholinergic reserve (the "cholinergic hypothesis" of age-related cognitive decline), adding anticholinergic drugs pushes them over a threshold into delirium, cognitive impairment, and falls. The anticholinergic burden is cumulative — each additional drug adds to the total load.
Exception: Diphenhydramine may be appropriate for acute severe allergic reactions
Exam Trap: Diphenhydramine as a Sleep Aid
A very common error is accepting diphenhydramine (Benadryl) as a benign OTC sleep aid for elderly patients. It is explicitly listed as a PIM — tolerance develops quickly, and the anticholinergic side effects persist. Always flag this in prescribing review questions.
Nitrofurantoin: Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, especially with long-term use. Avoid in individuals with CrCl < 30 mL/min or for long-term suppression. (Low evidence, Strong recommendation) [1]
Why: Nitrofurantoin relies on urinary concentration for efficacy. When CrCl < 30, it doesn't concentrate adequately in urine (→ ineffective) and systemic accumulation causes pulmonary fibrosis and neuropathy. Short courses for acute uncomplicated UTI are still acceptable if CrCl > 30.
Cardiovascular and Antithrombotics
This is the most heavily updated section in the 2023 criteria and extremely high yield.
Risk of major bleeding from aspirin increases markedly in older age. Studies suggest a lack of net benefit and potential for net harm when initiated for primary prevention in older adults. Avoid initiating aspirin for primary prevention of CVD. Consider deprescribing in those already taking it for primary prevention. (High evidence, Strong recommendation) [1]
Key nuance: Aspirin remains generally indicated for secondary prevention (i.e., established CVD — prior MI, stroke, PVD). This was moved from "use with caution" (2019) to "avoid" (2023), aligning with the USPSTF recommendation. The ASPREE trial (2018) specifically showed no benefit and increased bleeding in healthy older adults ≥70 years.
High Yield
Aspirin for primary prevention = AVOID in older adults (2023 Beers). For secondary prevention = still indicated. This distinction is a classic exam discriminator.
Warfarin: Avoid starting as initial therapy for nonvalvular AF or VTE unless DOACs are contraindicated or there are substantial barriers to their use. For long-term users with well-controlled INRs ( > 70% time in therapeutic range), it may be reasonable to continue. (High evidence, Strong recommendation) [1]
Rivaroxaban: Avoid for long-term treatment of nonvalvular AF or VTE in favor of safer alternatives. At standard doses, rivaroxaban has a higher risk of major bleeding and GI bleeding than other DOACs, particularly apixaban. (Moderate evidence, Strong recommendation) [1]
Dabigatran: Use with caution — increased risk of GI bleeding compared with warfarin (head-to-head RCTs) and compared with apixaban (observational data). (Moderate evidence, Strong recommendation) [1]
The practical hierarchy for older adults:
BEST → Apixaban (safest DOAC profile in elderly)
↓
CAUTION → Dabigatran (GI bleeding concern)
↓
AVOID → Rivaroxaban (highest major/GI bleeding risk among DOACs)
↓
AVOID initiating → Warfarin (higher intracranial hemorrhage risk than all DOACs)Why apixaban wins: In network meta-analyses and the ARISTOTLE trial, apixaban had the lowest rates of major bleeding among DOACs while maintaining non-inferior efficacy. It also has the most favorable renal safety data — the 2023 criteria removed the previous CrCl < 25 avoidance threshold for apixaban because of emerging evidence supporting safe use even in ESRD.
High Yield: Anticoagulant Selection in Elderly
If the exam asks about starting anticoagulation in a 78-year-old with new AF: Apixaban is the preferred choice. Mention avoiding warfarin as initial therapy and avoiding rivaroxaban for long-term use. When selecting among DOACs, consider kidney function, indication, and body weight.
| Drug | Rationale | Recommendation | Evidence/Strength |
|---|---|---|---|
| Dipyridamole (oral short-acting) | Orthostatic hypotension; more effective alternatives | Avoid | Moderate/Strong |
| Non-selective alpha-1 blockers (doxazosin, prazosin, terazosin) for HTN | High risk of orthostatic hypotension | Avoid as antihypertensive | Moderate/Strong |
| Central alpha-agonists (clonidine, guanfacine) for HTN | Adverse CNS effects; bradycardia; orthostatic hypotension | Avoid clonidine as first-line for HTN; avoid others for HTN | Low/Strong |
| Nifedipine IR | Hypotension; precipitates myocardial ischemia | Avoid | High/Strong |
| Amiodarone | Greater toxicity than alternatives for AF | Avoid as first-line for AF unless HF or significant LVH | High/Strong |
| Dronedarone | Worse outcomes in permanent AF or severe/recently decompensated HF | Avoid in permanent AF or severe HF | High/Strong |
| Digoxin (first-line for AF or HF) | Not first-line; toxicity risk at higher doses; reduced renal clearance in elderly | Avoid as first-line; if used, dose ≤0.125 mg/day | Low-Moderate/Strong |
Why nifedipine IR is dangerous: Immediate-release nifedipine causes rapid, unpredictable drops in blood pressure → reflex tachycardia → coronary steal → myocardial ischemia. Sustained-release formulations are fine.
Why digoxin dose matters: The narrow therapeutic index (0.5–0.9 ng/mL for HF) combined with age-related decline in renal clearance makes toxicity common. Doses > 0.125 mg/day are associated with higher serum levels without additional benefit.
Central Nervous System
This is arguably the most important section for geriatric medicine exams.
TCAs with strong anticholinergic activity (amitriptyline, imipramine, doxepin > 6 mg/day, nortriptyline, paroxetine, clomipramine, desipramine, amoxapine): Highly anticholinergic, sedating, cause orthostatic hypotension. AVOID. (High evidence, Strong recommendation) [1]
Key point: Low-dose doxepin (≤6 mg/day) has a safety profile comparable to placebo and is NOT included in the "avoid" recommendation — it is specifically used for insomnia in elderly at this ultra-low dose.
Why paroxetine is here (not with other SSRIs): Paroxetine is the most anticholinergic SSRI. It appears in this anticholinergic antidepressant criterion rather than the general antidepressant sections.
Both first-generation (haloperidol) and second-generation (olanzapine, quetiapine, risperidone, aripiprazole): Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Evidence also suggests increased mortality independent of dementia. AVOID except for FDA-approved indications (schizophrenia, bipolar disorder, Parkinson disease psychosis, adjunctive treatment of MDD, or short-term antiemetic use). (Moderate evidence, Strong recommendation) [1]
Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options have failed and/or the patient threatens substantial harm to self or others. If used, periodic deprescribing attempts should be considered. [1]
The DICE approach (Describe, Investigate, Create, Evaluate) is the recommended non-pharmacologic framework for behavioral and psychological symptoms of dementia (BPSD). Always try behavioral interventions first.
FDA Black Box Warning
All antipsychotics carry an FDA black box warning for increased mortality in elderly patients with dementia-related psychosis. This applies to BOTH typical and atypical agents. This is a classic exam fact.
All benzodiazepines: Increased sensitivity in older adults; decreased metabolism of long-acting agents; risk of cognitive impairment, delirium, falls, fractures, motor vehicle crashes; physical dependence. AVOID. (Moderate evidence, Strong recommendation) [1]
Acceptable exceptions: seizure disorders, REM sleep behavior disorder, benzodiazepine/ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia.
Why shorter-acting is NOT safer: A common misconception. For falls risk, shorter-acting benzodiazepines are NOT safer than long-acting ones — the criterion explicitly states this.
Eszopiclone, zaleplon, zolpidem: Adverse events similar to benzodiazepines (delirium, falls, fractures); minimal improvement in sleep latency and duration. AVOID. (Moderate evidence, Strong recommendation) [1]
Why from first principles: Z-drugs act on the same GABA-A receptor complex as benzodiazepines (specifically the α1 subunit). Despite marketing claims of selectivity, they produce functionally similar CNS depression in older adults.
Butalbital, phenobarbital, primidone: High rate of physical dependence, tolerance, greater risk of overdose at low dosages. AVOID. (High evidence, Strong recommendation) [1]
| Drug | Rationale | Recommendation | Key Points |
|---|---|---|---|
| Androgens | Cardiac risk; prostate cancer risk | Avoid unless confirmed hypogonadism with symptoms | Weak recommendation |
| Systemic estrogens | Carcinogenic (breast, endometrium); no cardio/cognitive protection; ↑ stroke, VTE, dementia if started ≥60 y | Do not initiate; consider deprescribing if already using | Vaginal estrogen is SAFE for atrophic vaginitis and recurrent UTI |
| Sliding scale insulin (without basal) | Higher hypoglycemia risk without better glycemic control | Avoid SSI without concurrent basal/long-acting insulin | Applies to ALL settings |
| Sulfonylureas (ALL) | Higher CV events, all-cause mortality, hypoglycemia vs alternatives | Avoid as 1st/2nd-line; if must use, prefer short-acting (glipizide) over long-acting (glyburide/glimepiride) | NEW in 2023: expanded from just long-acting to ALL SUs |
| Desiccated thyroid | Cardiac effects; inconsistent hormone levels | Avoid | Use levothyroxine instead |
| Megestrol | Thrombotic events, possible death; minimal weight effect | Avoid | — |
| Growth hormone | Minimal body composition benefit; edema, carpal tunnel, glucose impairment | Avoid unless proven GH deficiency | — |
High Yield: Sulfonylureas 2023 Update
The 2023 criteria expanded the "avoid" recommendation to include ALL sulfonylureas as first- or second-line therapy (previously only long-acting agents were flagged). If a sulfonylurea must be used: glipizide (short-acting) > glyburide/glimepiride (long-acting) because long-acting agents cause prolonged hypoglycemia. This reflects newer data showing CV events and mortality risk across the class.
Proton-pump inhibitors: Risk of C. difficile, pneumonia, GI malignancies, bone loss, fractures. Avoid scheduled use for > 8 weeks unless high-risk (chronic NSAID/steroid use, erosive esophagitis, Barrett's, pathological hypersecretory condition, or demonstrated maintenance need). (High evidence for C. diff/bone loss; Moderate for pneumonia/GI malignancies; Strong recommendation) [1]
Why PPIs are problematic long-term: PPIs reduce gastric acid → altered gut microbiome → C. difficile colonization; acid suppression → ↓ calcium absorption → bone loss; chronic hypergastrinemia → theoretical GI malignancy risk.
Metoclopramide: Extrapyramidal effects including tardive dyskinesia; risk greater in frail elderly and with prolonged exposure. Avoid unless for gastroparesis, duration not to exceed 12 weeks. (Moderate/Strong) [1]
GI antispasmodics (atropine, dicyclomine, hyoscyamine, scopolamine): Highly anticholinergic, uncertain effectiveness. AVOID. (Moderate/Strong) [1]
Desmopressin: High risk of hyponatremia. Avoid for nocturia/nocturnal polyuria. (Moderate/Strong) [1]
Pain Medications
Non-COX-2-selective NSAIDs: ↑ GI bleeding/peptic ulcer in those > 75, or on corticosteroids/anticoagulants/antiplatelets. Upper GI ulcers/bleeding occur in ~1% at 3–6 months, 2–4% at 1 year. Also ↑ BP and renal injury. AVOID chronic use unless no alternative + gastroprotective agent. (Moderate/Strong) [1]
Indomethacin and ketorolac: Of ALL NSAIDs, indomethacin has the most adverse effects including CNS effects. Both have highest risk of GI bleeding and AKI. AVOID. (Moderate/Strong) [1]
Why indomethacin is singled out: It has the highest CNS penetration of any NSAID → causes confusion, headache, dizziness in elderly. It is also among the most potent COX-1 inhibitors → highest GI toxicity.
Meperidine (pethidine): Oral form not effective at usual doses; neurotoxic metabolite (normeperidine) causes delirium, seizures. AVOID. (Moderate/Strong) [1]
Carisoprodol, cyclobenzaprine, methocarbamol, orphenadrine, etc.: Poorly tolerated due to anticholinergic effects, sedation, fracture risk. AVOID. (Moderate/Strong) [1]
Note: This does NOT apply to baclofen/tizanidine (used for spasticity), though these also have adverse effects.
Category 2: Drug–Disease/Syndrome Interactions (Table 3)
These are PIMs that specifically exacerbate geriatric syndromes. Extremely high yield for clinical scenarios.
| Drugs to Avoid | Rationale |
|---|---|
| Cilostazol, dextromethorphan-quinidine | ↑ mortality, QT prolongation |
| Non-DHP CCBs (diltiazem, verapamil) | Negative inotropes → worsen HFrEF |
| Dronedarone | Avoid in symptomatic HF |
| NSAIDs/COX-2 inhibitors | Fluid retention, worsen HF |
| Thiazolidinediones (pioglitazone) | Fluid retention, worsen HF |
Why non-DHP CCBs are harmful in HFrEF: Diltiazem and verapamil have negative inotropic effects → further reduce cardiac output. DHP CCBs (amlodipine) are generally safe in HF.
| Drugs to Avoid | Mechanism |
|---|---|
| Selected antipsychotics (chlorpromazine, olanzapine) | Orthostatic hypotension |
| Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) | Bradycardia → vasovagal syncope |
| Non-selective alpha-1 blockers | Orthostatic hypotension |
| Tertiary TCAs (amitriptyline, imipramine, doxepin) | Orthostatic hypotension |
Avoid anticholinergics, antipsychotics, benzodiazepines, corticosteroids (oral/parenteral), H2-receptor antagonists, Z-drugs, and opioids in older adults with or at HIGH RISK of delirium. [1]
2023 addition: Opioids now explicitly included as deliriogenic agents. A balanced approach using multimodal analgesia and validated pain tools is recommended.
Antipsychotic exception for delirium: May be used when nonpharmacologic interventions have failed AND patient threatens substantial harm to self/others → lowest effective dose → periodic deprescribing attempts.
Avoid anticholinergics, chronic antipsychotic use, benzodiazepines, Z-drugs. (Moderate/Strong) [1]
Avoid: anticholinergics, selected antidepressants (SNRIs, SSRIs, TCAs), antiepileptics, antipsychotics, benzodiazepines, Z-drugs, opioids — unless safer alternatives unavailable. [1]
Critical nuance: Shorter-acting benzodiazepines are NOT safer than long-acting ones for falls risk.
If a CNS-active drug must be used: Reduce the number of OTHER CNS-active drugs and implement fall-risk reduction strategies.
Avoid dopamine-receptor antagonists: metoclopramide, prochlorperazine, promethazine, and all antipsychotics EXCEPT clozapine, pimavanserin, and quetiapine. [1]
Why these three antipsychotics are excepted: They have the lowest D2-receptor binding affinity → least likely to worsen parkinsonian motor symptoms. Pimavanserin is a 5-HT2A inverse agonist with no D2 activity (FDA-approved for Parkinson disease psychosis).
| Disease/Syndrome | Avoid | Rationale |
|---|---|---|
| Gastric/duodenal ulcers | Aspirin, non-COX-2 NSAIDs | Exacerbate ulcers |
| Urinary incontinence (women) | Alpha-1 blockers, oral/transdermal estrogen | Aggravate incontinence; oral estrogen lacks efficacy |
| BPH / Lower urinary tract symptoms | Strongly anticholinergic drugs | ↓ urinary flow, urinary retention |
These drugs are concerning but not at the "avoid" level — evidence is weaker, harm is less clear-cut, or clinical exceptions are common.
| Drug | Rationale | Recommendation |
|---|---|---|
| Dabigatran | ↑ GI bleeding vs warfarin and apixaban | Use caution; prefer apixaban |
| Prasugrel, ticagrelor | ↑ major bleeding vs clopidogrel, especially ≥75 years | Use with caution; consider prasugrel 5 mg for ≥75 |
| Antidepressants (SSRIs, SNRIs, TCAs, mirtazapine), antiepileptics (carbamazepine, oxcarbazepine), antipsychotics, diuretics, tramadol | May cause SIADH/hyponatremia | Use with caution; monitor Na+ closely |
| Dextromethorphan-quinidine | Limited efficacy for dementia BPSD; fall risk; drug interactions | Use with caution |
| TMP-SMX | Hyperkalemia with ACEi/ARB/ARNI + ↓ CrCl | Use with caution in that setting |
| SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) | ↑ urogenital infections (especially women, first month); euglycemic DKA | Use with caution; monitor |
SGLT2 Inhibitors — New 2023 Criterion
SGLT2 inhibitors are NOT "avoid" — they are "use with caution." The panel explicitly recognizes their value (CV and renal benefits in HF and CKD) but flags urogenital infections and euglycemic DKA as risks requiring monitoring. This nuance is exam-relevant: do NOT mark SGLT2i as "contraindicated" in elderly.
| Object Drug | Interacting Drug | Risk | Recommendation |
|---|---|---|---|
| RAS inhibitors (ACEi/ARB/ARNI/aliskiren) or K+-sparing diuretics | Another RAS inhibitor or K+-sparing diuretic | Hyperkalemia | Avoid dual RAS + K+-sparing in CKD ≥3a |
| Opioids | Benzodiazepines | Overdose, respiratory depression, death | AVOID |
| Opioids | Gabapentin/pregabalin | Severe sedation, respiratory depression | Avoid (exception: transitioning off opioids) |
| Anticholinergic | Anticholinergic | ↑ cognitive decline, delirium, falls | Avoid; minimize total ACh burden |
| ≥3 CNS-active drugs | From categories: antiepileptics, antidepressants, antipsychotics, BZDs, Z-drugs, opioids, skeletal muscle relaxants | ↑ falls and fractures | AVOID ≥3 concurrent CNS-active drugs |
| Lithium | ACEi/ARB/ARNI or loop diuretics | Lithium toxicity | Avoid; monitor levels |
| Non-selective alpha-1 blockers | Loop diuretics | Urinary incontinence (older women) | Avoid in women |
| Phenytoin | TMP-SMX | Phenytoin toxicity | Avoid |
| Theophylline | Cimetidine or ciprofloxacin | Theophylline toxicity | Avoid |
| Warfarin | Amiodarone, ciprofloxacin, macrolides (not azithromycin), TMP-SMX, SSRIs (NEW 2023) | ↑ bleeding | Avoid if possible; monitor INR |
High Yield: ≥3 CNS-Active Drugs Rule
The concurrent use of ≥3 CNS-active drugs from specified categories (antiepileptics/gabapentinoids, antidepressants, antipsychotics, BZDs, Z-drugs, opioids, skeletal muscle relaxants) is explicitly flagged as inappropriate. Skeletal muscle relaxants were newly added to this list in 2023. Count the number of CNS-active drugs in any polypharmacy scenario.
This table is critical for clinical scenarios involving CKD patients.
| Drug | CrCl Threshold | Action | Rationale |
|---|---|---|---|
| Ciprofloxacin | < 30 | Reduce dose | CNS effects (seizures, confusion), tendon rupture |
| Nitrofurantoin | < 30 | Avoid | Pulmonary/hepatic/neural toxicity; ineffective |
| TMP-SMX | < 30 (< 15 avoid) | Reduce dose 15–29; avoid < 15 | Worsening renal function, hyperkalemia |
| Amiloride, triamterene, spironolactone | < 30 | Avoid | Hyperkalemia (± hyponatremia) |
| Dabigatran | < 30 | Avoid | No safety/efficacy data |
| Dofetilide | < 60 | Dose reduce; avoid < 20 | QTc prolongation, torsades |
| Edoxaban | 15–50 (avoid < 15 or > 95) | Dose reduce | No efficacy data at extremes |
| Enoxaparin | < 30 | Reduce dose | Bleeding risk |
| Fondaparinux | < 30 | Avoid | Bleeding risk |
| Rivaroxaban | < 50 | Dose reduce; avoid < 15 | Indication-specific dosing |
| Baclofen | eGFR < 60 | Avoid (NEW 2023) | Encephalopathy requiring hospitalization |
| Duloxetine | < 30 | Avoid | GI side effects (nausea, diarrhea) |
| Gabapentin, pregabalin | < 60 | Reduce dose | CNS adverse effects |
| Levetiracetam | ≤ 80 | Reduce dose | CNS adverse effects |
| NSAIDs (all) | < 30 | Avoid | AKI and further renal decline |
| Tramadol | < 30 | IR: reduce dose; ER: avoid | CNS effects |
| H2 blockers (cimetidine, famotidine, nizatidine) | < 50 | Reduce dose | Mental status changes |
| Colchicine | < 30 | Reduce dose; monitor | GI, neuromuscular, bone marrow toxicity |
| Probenecid | < 30 | Avoid | Loss of effectiveness (needs adequate renal excretion of uric acid) |
2023 Update: Apixaban Removed from Renal Table
The criterion for apixaban avoidance at CrCl < 25 has been REMOVED based on emerging evidence supporting safe use in end-stage renal disease. This makes apixaban the most renally-forgiving DOAC and reinforces its position as the preferred DOAC in elderly patients with CKD.
This is a reference list cross-referenced throughout the criteria. Know these drug categories:
| Category | Key Drugs |
|---|---|
| Antidepressants | Amitriptyline, imipramine, nortriptyline, doxepin ( > 6 mg), paroxetine, clomipramine, desipramine, amoxapine |
| Antiemetics | Prochlorperazine, promethazine |
| Antihistamines (1st gen) | Diphenhydramine, chlorpheniramine, hydroxyzine, meclizine, promethazine |
| Antimuscarinics (bladder) | Oxybutynin (worst evidence for cognitive effects), tolterodine, solifenacin, darifenacin, fesoterodine, trospium |
| Antiparkinsonian | Benztropine, trihexyphenidyl |
| Antipsychotics | Chlorpromazine, clozapine, olanzapine, perphenazine |
| Antispasmodics | Atropine, dicyclomine, hyoscyamine, scopolamine |
| Skeletal muscle relaxants | Cyclobenzaprine, orphenadrine |
The concept of cumulative anticholinergic burden:
Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia, even in younger adults. Consider total anticholinergic burden during regular medication reviews. [1]
| Rating | Meaning |
|---|---|
| High quality evidence | Well-designed RCTs with consistent, directly applicable results |
| Moderate quality evidence | RCTs with important limitations OR well-designed observational studies |
| Low quality evidence | Observational studies with risk of bias |
| Strong recommendation | Harms clearly outweigh benefits |
| Weak recommendation | Harms may not outweigh benefits |
The criteria should be applied thoughtfully and in a manner that supports, rather than replaces, shared clinical decision-making. [1]
Key principles (from Table 11 guidance):
- Not punitive — The criteria are a screening tool, not an absolute prohibition
- Individualized — Consider the older person's preferences, goals of care, functional status, life expectancy
- Deprescribing focus — Use as a trigger for medication review and shared decision-making about stopping unnecessary medications
- Not a formulary restriction — Should not be used to deny access to medications without clinical assessment
- Does NOT apply to hospice/end-of-life care — Comfort measures may require medications otherwise on the Beers list
- Complement, not replace — Use alongside clinical judgment, STOPP/START criteria, and comprehensive geriatric assessment
| Feature | Beers Criteria 2023 | STOPP/START v3 2023 |
|---|---|---|
| Origin | US-based (AGS) | European (Ireland-based) |
| Format | Drug-focused list | Drug–disease pairing + START criteria (drugs to START) |
| Unique strength | Comprehensive drug list with evidence grading | Includes medications that SHOULD be prescribed (prevents errors of omission) |
| Overlap | Significant overlap in anticholinergics, BZDs, NSAIDs, antipsychotics | Covers same areas + adds positive prescribing recommendations |
| HKU exam relevance | Both are examinable; GC 079 covers both | — |
Exam Tip
When asked to review an elderly patient's medication list, use BOTH frameworks: Beers to identify PIMs to STOP, and START criteria to identify beneficial medications that are MISSING (e.g., bone protection in steroid users, statin in established CVD).
High Yield Summary
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The AGS Beers Criteria 2023 — Top 10 Points for Exams
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Summary
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- Applies to ≥65 years in ALL settings EXCEPT hospice/end-of-life 2. "Avoid" ≠ absolute contraindication — it means typically best avoided unless no safer alternative after shared decision-making 3. Aspirin for primary prevention: AVOID (moved from caution → avoid in 2023); secondary prevention still indicated 4. Anticoagulant hierarchy: Apixaban preferred > Dabigatran (caution) > Rivaroxaban (avoid for long-term AF/VTE) > Warfarin (avoid initiating) 5. ALL sulfonylureas now "avoid" as 1st/2nd-line (expanded from just long-acting in 2019); if needed, glipizide > glyburide 6. First-generation antihistamines, benzodiazepines, Z-drugs, and anticholinergic TCAs → AVOID (falls, delirium, cognitive decline) 7. Antipsychotics in dementia: AVOID unless nonpharmacologic measures failed + patient threatening harm; ↑ stroke + mortality (black box warning) 8. ≥3 concurrent CNS-active drugs = AVOID (now includes skeletal muscle relaxants) 9. PPIs: avoid scheduled use > 8 weeks unless high-risk indication (Barrett's, erosive esophagitis, chronic NSAID/steroid) 10. Cumulative anticholinergic burden — review total load, not just individual drugs; even "young-old" are at risk
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Active Recall - AGS Beers Criteria 2023
[1] GC 079 (supp-3)AGS Beers Criteria for potentially inappropriate med use_2023.pdf (Tables 1–8, Box 1, Results section, Discussion section) [2] GC 079 (supp-4)AGS Beers Criteria for potentially inappropriate med use_Pocket Guide_2023.pdf [3] GC 079. Prescribing in older people.pdf [4] GC 079 (supp-1)STOPP-START criteria for potentially inappropriate prescribing in older 2023.pdf [5] AOS - Geriatrics.pdf
GC079 (supp-2)stopp-start-v3
STOPP/START version 3 (GC079 supplement 2) is an updated evidence-based set of explicit criteria for potentially inappropriate prescribing (STOPP) and potential prescribing omissions (START) in older adults, designed to optimize medication appropriateness in people aged 65 and over.
GC079 (supp-4)ags Beers Criteria For Potentially Inappropriate Med Use: Pocket Guide: 2023
The 2023 AGS Beers Criteria is an evidence-based guideline listing medications that are potentially inappropriate for older adults (≥65 years) due to unfavorable risk–benefit profiles, intended to improve prescribing safety in geriatric care.