The American Geriatrics Society (AGS) has recently updated the Beers Criteria for potentially inappropriate medication (PIM) use in older adults. The Beers Criteria is an evidenced-based approach to identify medications that are typically best avoided in people over 65 years of age. Medications included in this criteria are associated with poor health outcomes, including confusion, falls, and mortality. Therefore, avoiding PIMs in older adults could be expected to improve care by reducing exposure to medications with an unfavourable risk to benefit ratio.
The 2019 update is the result of an extensive systematic review and grading of evidence pertaining to drug-related problems and adverse events in older adults. Several medications have been removed from the criteria for the following reasons:
- The risks associated with the drug in question were not unique to older people (e.g. the use of stimulants in people with insomnia);
- The weak nature of evidence used to support the inclusion of the drug (e.g. H2-receptor antagonists in dementia);
- The highly specialised nature of the drug made its use fall outside the scope of the criteria (e.g. chemotherapeutic agents such as carboplatin and vincristine); and
- The drug is no longer available.
A selection of medications included in the 2019 Beers Criteria of PIMs to avoid in older adults is shown in Table 1. The complete list can be found here.
Table 1. Potentially inappropriate medications to avoid in older adults.
||Risk of anticholinergic adverse effects or toxicity.
Clearance reduced with advanced age, tolerance develops to use as hypnotic.
Diphenhydramine may be appropriate in some situations (e.g. acute allergy).
||More effective agents available for the treatment of Parkinson’s disease (e.g. levodopa).
Not recommended for treatment or prevention of extrapyramidal symptoms.
Poor evidence to support efficacy.
|Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy.
Safer alternatives available.
|Avoid if CrCl <30mL/min.
Avoid long-term use.
|Prazosin (for hypertension)
|High risk of orthostatic hypotension.
Alternative agents have better risk/benefit profile.
|Avoid use as an antihypertensive.|
||High risk of CNS effects.
May cause bradycardia and orthostatic hypotension.
|Avoid as first-line therapy for hypertension.|
Potent negative inotrope (may induce heart failure).
May cause orthostatic hypotension.
|Increased risk of stroke, cognitive decline, and mortality in people with dementia.
Avoid in dementia unless other options have failed and the patient is a significant threat to self or others.
|Avoid (except in schizophrenia, bipolar disorder, or for short-term antiemetic use during chemotherapy).|
|Benzodiazepines||Increased risk of cognitive impairment, delirium, and falls.
Older adults have greater sensitivity to these agents and reduced metabolism of long-acting agents (e.g. diazepam).
|Avoid (may be appropriate for some indications such as seizure disorders and peri-procedural anaesthesia).|
|Proton-pump inhibitors||Risk of Clostridium difficile infection and bone loss.
|Avoid prolonged use (unless the patient is high risk, has oesophageal disease, a hypersecretory condition, or a demonstrated need for maintenance therapy).|
|Non-selective NSAIDs||Increased risk of GI bleeding or peptic ulcer disease.
May increase blood pressure and induce kidney injury.
|Avoid chronic use|
||Higher risk of severe prolonged hypoglycaemia in older adults.||Avoid|
Abbreviations: NSAIDs, non-steroidal anti-inflammatory drugs; CNS, central nervous system; GI, gastrointestinal; CrCl, creatinine clearance.
A number of other medications have been identified as being potentially inappropriate in older adults with specific medical conditions. For example, anticholinesterases should be avoided in older adults with a history of syncope that may be due to bradycardia. Anticholinesterases such as donepezil, galantamine, and rivastigmine can produce vagotonic effects on the heart rate and worsen any pre-existing bradycardia. Other key conditions that warrant particular consideration of PIMs include heart failure, delirium, dementia or cognitive impairment, history of falls or fractures, Parkinson’s disease, history of gastric or duodenal ulcers, chronic kidney disease with a CrCl <30mL/min, urinary incontinence in women, lower urinary tract symptoms, and benign prostatic hyperplasia.
There are also a number of medications identified as being of concern in older adults, but for which the evidence is lacking to support a blanket recommendation to avoid. These agents are classified as drugs to be used with caution in older adults. A summary of these agents can be seen in Table 2.
Table 2. Drugs to be used with caution in older adults
|Drug||Rationale||Recommendation||Change from 2015 recommendations|
|Aspirin (for primary prevention of CV disease and colorectal cancer)||Increased risk of major bleeding from aspirin in older age.||Caution in adults ≥70 years.||Age lowered from 80 years.
Criterion expanded to include primary prevention of colorectal cancer.
|Increased risk of bleeding compared with warfarin and other DOACs when used for long-term treatment of VTE or AF in adults ≥75 years.||Caution for treatment of VTE or AF in adults ≥75 years.||Rivaroxaban added to the existing entry for dabigatran.|
|Prasugrel||Increased risk of bleeding in older adults.||Caution in adults ≥75 years.||–|
|May exacerbate or cause SIADH or hyponatraemia.||Use with caution, monitor sodium level closely upon initiation or dose changes.||Tramadol added to list Chemotherapeutic agents removed.|
|Trimethoprim + sulfamethoxazole||Increased risk of hyperkalaemia when used with an ACE-I or ARB in patients with reduced renal function.||Caution in patients taking an ACE-I or ARB with reduced CrCl.||New addition|
Abbreviations: CV, cardiovascular; SNRI, serotonin and noradrenaline reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; DOAC, direct-acting oral anticoagulant; VTE, venous thromboembolism; AF, atrial fibrillation; SIADH, syndrome of inappropriate antidiuretic hormone secretion; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor antagonist.
The Beers Criteria make additional considerations of drug interactions to avoid in older people and drugs to avoid or dose modify in older adults with reduced kidney function. Two significant additions to the drug interactions to avoid are the use of opioids with benzodiazepines and the use of opioids with gabapentinoids. Such combinations increase the risk of overdose or the risk of severe sedation-related adverse events such as respiratory depression and death. Recommendations for older adults with renal impairment include reducing the dose of enoxaparin and avoiding spironolactone, which echoes the advice contained in the respective Australian approved product information documents.
Although many of the medication issues described in the Beers Criteria are broadly applicable to patients of all ages, the elderly may be at greater risk of harms. The reasons for this are many and complex, but include physiological changes that affect drug absorption, distribution, metabolism, and excretion, and the greater incidence of polypharmacy in this patient group. The Australian Commission on Safety and Quality in Health Care reports that between 40% and 50% of residents in aged care facilities are prescribed at least one PIM.
Options to reduce the exposure to PIMs include:
- Reduce the number or dose of medications that may be causing harm. Evidence-based deprescribing guidelines can be consulted for further guidance;
- Consider safer alternatives to PIMs (e.g. a second-generation antihistamine may be preferred to a first-generation antihistamine); and
- Consideration of non-pharmacological therapies (e.g. massage, mouth care, animal-assisted therapy).
The Beers Criteria is a useful evidence-based aid that may be used to help assess the appropriateness of pharmacotherapy in older adults. However, it should be emphasised that medications identified in the criteria are potentially inappropriate rather than definitely inappropriate for all older persons. It is also important to note that the criteria was developed for the USA and is not intended to be used in hospice or palliative care settings where risk-benefit considerations may be different. In all cases, it is the clinical judgement of the prescriber in conjunction with the patient’s wishes that should guide decision making.
- Fick DM, Semla TP, Steinman M, Beizer J, Brandt N, Dombrowski R, et al. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019; 00: 1-21.
- Hanlon JT, Semla TP, Schmader KE. Alternative medications for medications included in the use of high-risk medications in the elderly and potentially harmful drug–disease interactions in the elderly quality measures. J Am Geriatr Soc. 2015; 63(12): e8-e18.
- Roughead L, Semple S, Rosenfeld E. Literature Review: Medication Safety in Australia. Sydney: Australian Commission on Safety and Quality in Health Care; 2013.