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Guideline Summary
Guideline Title
American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.
Bibliographic Source(s)
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. [35 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • May 15, 2014 – Eszopiclone (Lunesta) External Web Site Policy: The U.S. Food and Drug Administration (FDA) has notified health professionals and their medical care organizations of a new warning that the insomnia drug Lunesta (eszopiclone) can cause next-day impairment of driving and other activities that require alertness. FDA recommends a decreased starting dose of Lunesta to 1 mg at bedtime. Women and men are equally susceptible to impairment from Lunesta, so the recommended starting dose of 1 mg is the same for both. FDA approved changes to the Lunesta prescribing information and the patient Medication Guide to include these new recommendations. The drug labels for generic eszopiclone products will also be updated to include these changes.

Scope

Disease/Condition(s)
  • Any disease or condition in older adults
  • Adverse drug events
    • Drug-drug interactions
    • Drug-disease interactions
    • Inappropriate prescribing
Guideline Category
Management
Prevention
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Pharmacology
Intended Users
Advanced Practice Nurses
Health Plans
Hospitals
Managed Care Organizations
Pharmacists
Physician Assistants
Physicians
Public Health Departments
Utilization Management
Guideline Objective(s)
  • To improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs)
  • To update the previous Beers Criteria using a comprehensive, systematic review and grading of the evidence on drug-related problems and adverse drug events (ADEs) in older adults
Target Population

Populations aged 65 and older in all ambulatory and institutional settings of care in the United States

Interventions and Practices Considered
  1. Avoidance of potentially inappropriate medications (PIMs)
  2. Use of alternative medications
Major Outcomes Considered
  • Prevalence of potentially inappropriate medication use in older adults
  • Incidence of medication related problems and adverse drug events in geriatric population
  • Mortality related to medication use

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search

The literature from December 1, 2001 (the end of the previous panel's search) to March 30, 2011, was searched to identify published systematic reviews and meta-analyses that were relevant to the project. Search terms included adverse drug reactions, adverse drug events, medication problems, polypharmacy, inappropriate drug use, suboptimal drug therapy, drug monitoring, pharmacokinetics, drug interactions, and medication errors. Terms were searched alone and in combination. Search limits included human subjects, English language, and aged 65 and older. Data sources for the initial search included Medline, the Cochrane Library (Cochrane Database of Systematic Reviews), International Pharmaceutical abstracts, and reference lists of selected articles that the panel co-chairs identified.

The initial search identified 25,549 citations, of which 6,505 were selected for preliminary review. The panel co-chairs reviewed 2,267 citations, of which 844 were excluded for not meeting the study purpose or not containing primary data. An additional search was conducted with the additional terms drug–drug and drug–disease interactions, pharmacoepidemiology, drug safety, geriatrics, and elderly prescribing. An additional search for randomized clinical trials and postmarketing and observational studies published between 2009 and 2011 was conducted using terms related to major drug classes and conditions, delimited by more general topics (e.g., adverse drug reactions, Beers Criteria, suboptimal prescribing, and interventions). Previous searches were used to develop additional terms to be included in subsequent searches, such as a list of authors whose work was relevant to the goals of the project. When evidence was sparse on older medications, searches were conducted on drug class and individual medication names and included older search dates for these drugs. The co-chairs continually reviewed the updated search results for articles that might be relevant to the project. Panelists were also asked to forward pertinent citations that might be useful for revising the previous Beers Criteria or supporting additions to them.

At the time of the panel's face-to-face meeting, the co-chairs had selected 2,169 unduplicated citations for the full panel review. This total included 446 systematic reviews or meta-analyses, 629 randomized controlled trials, and 1,094 observational studies. Additional articles were found in a manual search of the reference lists of identified articles and the panelists' files, book chapter, and recent review articles, with 258 citations selected for the final evidence tables to support the list of drugs to avoid.

Number of Source Documents

A total of 258 citations was selected for the final evidence tables.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence

Designation Description
High Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (≥2 consistent, higher-quality randomized controlled trials or multiple, consistent observational studies with no significant methodological flaws showing large effects)
Moderate Evidence is sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (≥1 higher-quality trial with >100 participants; ≥2 higher-quality trials with some inconsistency; ≥2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence
Low Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The panel split into four groups, with each assigned a specific set of criteria for evaluation. Groups were assigned as closely as possible according to specific area of clinical expertise (e.g., cardiovascular, central nervous system). Groups reviewed the literature search, selected citations relevant to their assigned criteria, and determined which citations should be included in an evidence table. During this process, panelists were provided copies of abstracts and full-text articles. The groups then presented their findings to the full panel for comment and consensus. After the meeting, each group met in a conference call to resolve any questions or to include additional supporting literature.

An independent researcher prepared evidence tables, which were distributed to the four criteria-specific groups.

Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Description of Methods Used to Formulate the Recommendations

For this new update, the American Geriatric Society (AGS) employed a well-tested framework that has long been used for development of clinical practice guidelines. Specifically, the framework involved the appointment of an 11-member interdisciplinary expert panel with relevant clinical expertise and experience and an understanding of how the criteria have been previously used.

Panel Selection

After consultation with the AGS, the co-chairs identified prospective panel members with recognized expertise in geriatric medicine, nursing, pharmacy practice, research, and quality measures. Other factors that influenced selection were the desire to have interdisciplinary representation, a range of medical specialties, and representation from different practice settings (e.g., long-term care, ambulatory care, geriatric mental health, palliative care and hospice). In addition to the 11-member panel, representatives from Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Pharmacy Quality Alliance (PQA) were invited to serve as ex-officio members.

Development Process

The co-chairs and AGS staff edited the survey used in the previous Beers Criteria development process, excluding products no longer marketed. The resulting survey had three parts: medications currently listed as potentially inappropriate for older adults independent of diseases or conditions, medications currently listed as potentially inappropriate when used in older adults with certain diseases or conditions, and new submissions from the panel. Each panelist was asked to complete the survey using a 5-point Likert scale ranging from strongly agree to strongly disagree (or no opinion). Ratings were tallied and returned to the panel along with each panelist's original ratings. Two conference calls allowed for review of survey ratings, discussion, and consensus building.

The panel convened for a 2-day in-person meeting on August 2 and 3, 2011, to review the second draft of the survey and the results of the literature search. Panel discussions were used to define terms and to address questions of consistency, the inclusion of infrequently used drugs, the best strategies for evaluating the evidence, and the consolidation or expansion of individual criterion. The panel then split into four groups, with each assigned a specific set of criteria for evaluation (see the "Description of the Methods Used to Analyze the Evidence" field).

Each panelist independently rated the quality of evidence and strength of recommendation for each criterion using the American College of Physicians' Guideline Grading System (see the "Rating Scheme for the Strength of the Evidence" and "Rating Scheme for the Strength of the Recommendations" fields), which is based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) scheme developed previously. AGS staff compiled the panelist ratings for each group and returned them to that group, which then reached consensus in conference call. Additional literature was obtained and included as needed. When group consensus could not be reached, the full panel reviewed the ratings and worked through any differences until they reached consensus. For some criteria, the panel provided a "strong" recommendation even though the quality of evidence was low or moderate. In such cases, the strength of recommendation was based on potential severity of harm and the availability of treatment alternatives.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendation

Designation Description
Strong Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits
Weak Benefits finely balanced with risks and burden
Insufficient Insufficient evidence to determine net benefits or risks
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

Definitions of quality of evidence (high, moderate, low) and strength of recommendation (strong, weak, insufficient) are provided at the end of the "Major Recommendations" field.

Table. 2012 American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Organ System or Therapeutic Category or Drug Rationale Recommendation Quality of Evidence Strength of Recommendation
Anticholinergics (excludes TCAs)
First-Generation Antihistamines (as single agent or as part of combination products)
  • Brompheniramine
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine
  • Cyproheptadine
  • Dexbrompheniramine
  • Dexchlorpheniramine
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine
  • Promethazine
  • Triprolidine
Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity

Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate.
Avoid Hydroxyzine and promethazine: High

All others: Moderate
Strong
Antiparkinson Agents
  • Benztropine (oral)
  • Trihexyphenidyl
Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson's disease Avoid Moderate Strong
Antispasmodics
  • Belladonna alkaloids
  • Clidinium-chlordiazepoxide
  • Dicyclomine
  • Hyoscyamine
  • Propantheline
  • Scopolamine
Highly anticholinergic, uncertain effectiveness Avoid except in short-term palliative care to decrease oral secretions Moderate Strong
Antithrombotics
Dipyridamole, oral short-acting* (does not apply to the extended-release combination with aspirin) May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing Avoid Moderate Strong
Ticlopidine* Safer effective alternatives available Avoid Moderate Strong
Anti-infective
Nitrofurantoin Potential for pulmonary toxicity; safer alternatives available; lack of efficacy in patients with CrCl <60 mL/min due to inadequate drug concentration in the urine Avoid for long-term suppression; avoid in patients with CrCl <60 mL/min Moderate Strong
Cardiovascular
Alpha1 blockers
  • Doxazosin
  • Prazosin
  • Terazosin
High risk of orthostatic hypotension; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile. Avoid use as an antihypertensive Moderate Strong
Alpha agonists, central
  • Clonidine
  • Guanabenz*
  • Guanfacine*
  • Methyldopa*
  • Reserpine (>0.1 mg/day)*
High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension Avoid clonidine as a first-line antihypertensive. Avoid others as listed. Low Strong
Antiarrhythmic drugs (Class Ia, Ic, III)
  • Amiodarone
  • Dofetilide
  • Dronedarone
  • Flecainide
  • Ibutilide
  • Procainamide
  • Propafenone
  • Quinidine
  • Sotalol
Data suggest that rate control yields better balance of benefits and harms than rhythm control for most older adults.

Amiodarone is associated with multiple toxicities, including thyroid disease, pulmonary disorders, and QT interval prolongation.
Avoid antiarrhythmic drugs as first-line treatment of atrial fibrillation. High Strong
Disopyramide* Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred. Avoid Low Strong
Dronedarone Worse outcomes have been reported in patients taking dronedarone who have permanent atrial fibrillation or heart failure. In general, rate control is preferred over rhythm control for atrial fibrillation. Avoid in patients with permanent atrial fibrillation or heart failure Moderate Strong
Digoxin >0.125 mg/day In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may lead to increased risk of toxic effects. Avoid Moderate Strong
Nifedipine, immediate release* Potential for hypotension; risk of precipitating myocardial ischemia Avoid High Strong
Spironolactone >25 mg/day In heart failure, the risk of hyperkalemia is higher in older adults if taking >25 mg/day or taking concomitant NSAID, angiotensin converting-enzyme inhibitor, angiotensin receptor blocker, or potassium supplement. Avoid in patients with heart failure or with a CrCl <30 mL/min Moderate Strong
Central Nervous System
Tertiary TCAs, alone or in combination
  • Amitriptyline
  • Chlordiazepoxide-amitriptyline
  • Clomipramine
  • Doxepin >6 mg/day
  • Imipramine
  • Perphenazine-amitriptyline
  • Trimipramine
Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo. Avoid High Strong
Antipsychotics, First- (conventional) and Second- (atypical) Generation (see Table 8 in the original guideline document for full list) Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others Moderate Strong
Thioridazine
Mesoridazine
Highly anticholinergic and greater risk of QT-interval prolongation Avoid Moderate Strong
Barbiturates
  • Amobarbital*
  • Butabarbital*
  • Butalbital
  • Mephobarbital*
  • Pentobarbital*
  • Phenobarbital
  • Secobarbital*
High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages Avoid High Strong
Benzodiazepines
Short- and intermediate-acting:
  • Alprazolam
  • Estazolam
  • Lorazepam
  • Oxazepam
  • Temazepam
  • Triazolam
Long-acting:
  • Chlordiazepoxide
  • Chlordiazepoxide-amitriptyline
  • Clidinium-chlordiazepoxide
  • Clonazepam
  • Clorazepate
  • Diazepam
  • Flurazepam
  • Quazepam
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults.

May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end-of-life care
Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium. High Strong
Chloral hydrate* Tolerance occurs within 10 days and risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose. Avoid Low Strong
Meprobamate High rate of physical dependence; very sedating Avoid Moderate Strong
Nonbenzodiazepine Hypnotics
  • Eszopiclone
  • Zolpidem
  • Zaleplon
Benzodiazepine-receptor agonists that have adverse events similar to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration. Avoid chronic use (>90 days) Moderate Strong
Ergot mesylates*
Isoxsuprine*
Lack of efficacy Avoid High Strong
Endocrine
Androgens
  • Methyltestosterone*
  • Testosterone
Potential for cardiac problems and contraindicated in men with prostate cancer. Avoid unless indicated for moderate to severe hypogonadism Moderate Weak
Desiccated thyroid Concerns about cardiac effects; safer alternatives available Avoid Low Strong
Estrogens with or without progestins Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women

Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 µg twice weekly
Avoid oral and topical patch

Topical vaginal cream: Acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infections, and other vaginal symptoms
Oral and patch: High

Topical: Moderate
Oral and patch: Strong

Topical: Weak
Growth hormone Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose. Avoid, except as hormone replacement following pituitary gland removal High Strong
Insulin, sliding scale Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting Avoid Moderate Strong
Megestrol Minimal effect on weight; increases risk of thrombotic events and possibly death in older adults Avoid Moderate Strong
Sulfonylureas, long-duration
  • Chlorpropamide
  • Glyburide
Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADH
Glyburide: higher risk of severe prolonged hypoglycemia in older adults
Avoid High Strong
Gastrointestinal
Metoclopramide Can cause extrapyramidal effects including tardive dyskinesia; risk may be further increased in frail older adults. Avoid, unless for gastroparesis Moderate Strong
Mineral oil, oral Potential for aspiration and adverse effects; safer alternatives available Avoid Moderate Strong
Trimethobenzamide One of the least effective antiemetic drugs; can cause extrapyramidal adverse effects Avoid Moderate Strong
Pain
Meperidine Not an effective oral analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available Avoid High Strong
Non–COX-selective NSAIDs, oral
  • Aspirin >325 mg/day
  • Diclofenac
  • Diflunisal
  • Etodolac
  • Fenoprofen
  • Ibuprofen
  • Ketoprofen
  • Meclofenamate
  • Mefenamic acid
  • Meloxicam
  • Nabumetone
  • Naproxen
  • Oxaprozin
  • Piroxicam
  • Sulindac
  • Tolmetin
Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months, and in about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use. Avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol) Moderate Strong
Indomethacin
Ketorolac, includes parenteral
Increases risk of GI bleeding/peptic ulcer disease in high-risk groups. (See above Non-COX-selective NSAIDs.) Of all the NSAIDs, indomethacin has most adverse effects. Avoid Indomethacin: Moderate

Ketorolac: High
Strong
Pentazocine* Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available. Avoid Low Strong
Skeletal muscle relaxants
  • Carisoprodol
  • Chlorzoxazone
  • Cyclobenzaprine
  • Metaxalone
  • Methocarbamol
  • Orphenadrine
Most muscle relaxants are poorly tolerated by older adults because of anticholinergic adverse effects, sedation, risk of fracture; effectiveness at dosages tolerated by older adults is questionable. Avoid Moderate Strong
AGS, American Geriatric Society; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; TCAs, tricyclic antidepressants

The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality of care, cost, and utilization data.

*Infrequently used drugs

Table. 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome

Disease or Syndrome Drug(s) Rationale Recommendation Quality of Evidence Strength of Recommendation
Cardiovascular
Heart failure NSAIDs and COX-2 inhibitors
Nondihydropyridine CCBs (avoid only for systolic heart failure)
  • Diltiazem
  • Verapamil
Pioglitazone, rosiglitazone
Cilostazol
Dronedarone
Potential to promote fluid retention and/or exacerbate heart failure. Avoid NSAIDs: Moderate;
CCBs: Moderate;
Thiazolidinediones (glitazones): High;
Cilostazol: Low;
Dronedarone: Moderate
Strong
Syncope AChEIs
Peripheral alpha blockers
  • Doxazosin
  • Prazosin
  • Terazosin
Tertiary TCAs
Chlorpromazine, thioridazine, and olanzapine
Increases risk of orthostatic hypotension or bradycardia Avoid Alpha blockers: High

AChEIs, TCAs and antipsychotics: Moderate
AChEIs and TCAs: Strong

Alpha blockers and antipsychotics: Weak
Central Nervous System
Chronic seizures or epilepsy Bupropion
Chlorpromazine
Clozapine
Maprotiline
Olanzapine
Thioridazine
Thiothixene
Tramadol
Lowers seizure threshold; may be acceptable in patients with well-controlled seizures in whom alternative agents have not been effective Avoid Moderate Strong
Delirium All TCAs
Anticholinergics (see Table 9 in the original guideline document for full list)
Benzodiazepines
Chlorpromazine
Corticosteroids
H2-receptor antagonist
Meperidine
Sedative hypnotics
Thioridazine
Avoid in older adults with or at high risk of delirium because of inducing or worsening delirium in older adults; if discontinuing drugs used chronically, taper to avoid withdrawal symptoms. Avoid Moderate Strong
Dementia and cognitive impairment Anticholinergics (see Table 9 in the original guideline document for full list)
Benzodiazepines
H2-receptor antagonists
Zolpidem
Antipsychotics, chronic and as-needed use
Avoid due to adverse CNS effects

Avoid antipsychotics for behavioral problems of dementia unless nonpharmacological options have failed and patient is a threat to themselves or others. Antipsychotics are associated with increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.
Avoid High Strong
History of falls or fractures Anticonvulsants
Antipsychotics
Benzodiazepines
Nonbenzodiazepine hypnotics
  • Eszopiclone
  • Zaleplon
  • Zolpidem
TCAs/SSRIs
Ability to produce ataxia, impaired psychomotor function, syncope, and additional falls; shorter-acting benzodiazepines are not safer than long-acting ones. Avoid unless safer alternatives are not available; avoid anticonvulsants except for seizure. High Strong
Insomnia Oral decongestants
  • Pseudoephedrine
  • Phenylephrine
Stimulants
  • Amphetamine
  • Methylphenidate
  • Pemoline
Theobromines
  • Theophylline
  • Caffeine
CNS stimulant effects Avoid Moderate Strong
Parkinson's disease All antipsychotics (see Table 8 in the original guideline document for full list, except for quetiapine and clozapine)
Antiemetics
  • Metoclopramide
  • Prochlorperazine
  • Promethazine
Dopamine receptor antagonists with potential to worsen parkinsonian symptoms.

Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson's disease.
Avoid Moderate Strong
Gastrointestinal
Chronic constipation Oral antimuscarinics for urinary incontinence
  • Darifenacin
  • Fesoterodine
  • Oxybutynin (oral)
  • Solifenacin
  • Tolterodine
  • Trospium
Nondihydropyridine CCB
  • Diltiazem
  • Verapamil
First-generation antihistamines as single agent or part of combination products
  • Brompheniramine (various)
  • Carbinoxamine
  • Chlorpheniramine
  • Clemastine (various)
  • Cyproheptadine
  • Dexbrompheniramine
  • Dexchlorpheniramine (various)
  • Diphenhydramine
  • Doxylamine
  • Hydroxyzine
  • Promethazine
  • Triprolidine
Anticholinergics/antispasmodics (see Table 9 in the original guideline document for full list of drugs with strong anticholinergic properties)
  • Antipsychotics
  • Belladonna alkaloids
  • Clidinium-chlordiazepoxide
  • Dicyclomine
  • Hyoscyamine
  • Propantheline
  • Scopolamine
  • Tertiary TCAs (amitriptyline, clomipramine, doxepin, imipramine, and trimipramine)
Can worsen constipation; agents for urinary incontinence: antimuscarinics overall differ in incidence of constipation; response variable; consider alternative agent if constipation develops. Avoid unless no other alternatives For urinary incontinence: High

All others: Moderate to Low
Weak
History of gastric or duodenal ulcers Aspirin (>325 mg/day)
Non–COX-2 selective NSAIDs
May exacerbate existing ulcers or cause new/additional ulcers Avoid unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol) Moderate Strong
Kidney/Urinary Tract
Chronic kidney disease stages IV and V NSAIDs
Triamterene (alone or in combination)
May increase risk of kidney injury. Avoid NSAIDs: Moderate

Triamterene: Low
NSAIDs: Strong

Triamterene: Weak
Urinary incontinence (all types) in women Estrogen oral and transdermal (excludes intravaginal estrogen) Aggravation of incontinence. Avoid in women High Strong
Lower urinary tract symptoms, benign prostatic hyperplasia Inhaled anticholinergic agents
Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence (see Table 9 in the original guideline document for complete list)
May decrease urinary flow and cause urinary retention. Avoid in men Moderate Inhaled agents: Strong

All others: Weak
Stress or mixed urinary incontinence Alpha-blockers
  • Doxazosin
  • Prazosin
  • Terazosin
Aggravation of incontinence. Avoid in women Moderate Strong
CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central nervous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants

The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality of care, cost, and utilization data.

Table. 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults

Drug(s) Rationale Recommendation Quality of Evidence Strength of Recommendation
Aspirin for primary prevention of cardiac events Lack of evidence of benefit versus risk in individuals ≥80 years old Use with caution in adults ≥80 years old Low Weak
Dabigatran Greater risk of bleeding than with warfarin in adults ≥75 years old; lack of evidence for efficacy and safety in patients with CrCl <30 mL/min Use with caution in adults ≥75 years old or if CrCl <30 mL/min. Moderate Weak
Prasugrel Greater risk of bleeding in older adults; risk may be offset by benefit in highest-risk older adults (e.g., those with prior myocardial infarction or diabetes mellitus). Use with caution in adults ≥75 years old Moderate Weak
Antipsychotics
Carbamazepine
Carboplatin
Cisplatin
Mirtazapine
SNRIs
SSRIs
TCAs
Vincristine
May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk Use with caution Moderate Strong
Vasodilators May exacerbate episodes of syncope in individuals with history of syncope Use with caution Moderate Weak
CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants

The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality of care, cost, and utilization data.

Definitions:

Quality of Evidence

Designation Description
High Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (≥2 consistent, higher-quality randomized controlled trials or multiple, consistent observational studies with no significant methodological flaws showing large effects)
Moderate Evidence is sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (≥1 higher-quality trial with >100 participants; ≥2 higher-quality trials with some inconsistency; ≥2 consistent, lower-quality trials; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects) limits the strength of the evidence
Low Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes

Strength of Recommendation

Designation Description
Strong Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits
Weak Benefits finely balanced with risks and burden
Insufficient Insufficient evidence to determine net benefits or risks
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Thoughtful application of the updated Beers Criteria will allow for closer monitoring of drug use, application of real-time e-prescribing and interventions to decrease adverse drug events (ADEs) in older adults, and better patient outcomes.

Potential Harms

See the tables in the "Major Recommendations" field for descriptions of adverse drug events.

Contraindications

Contraindications

Androgens (methyltestosterone and testosterone) are contraindicated in men with prostate cancer.

See also the tables in the "Major Recommendations" field.

Qualifying Statements

Qualifying Statements
  • The goal of the 2012 American Geriatric Society (AGS) Beers Criteria is to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs). This is accomplished by their use as an educational tool and a quality measure—two uses that are not always in agreement. These criteria are not meant to be applied in a punitive manner. Prescribing decisions are not always clear cut, and clinicians must consider multiple factors. Quality measures must be clearly defined, easily applied, and measured with limited information. The panel considered both roles during deliberations. The panel's review of evidence at times identified subgroups of individuals who should be exempt from the criteria or for whom only a specific criterion applies. Such a criterion may not be easily applied as a quality measure. These applications were balanced with the needs and complexities of the individual. The panel felt that a criterion could not be expanded to include all adults aged 65 and older when only individuals with specific characteristics may benefit or be at greater risk of harm.
  • The updated criteria should be viewed as a guideline for identifying medications for which the risks of their use in older adults outweigh the benefits. This list is not meant to supersede clinical judgment or an individual patient's values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision-making.
  • These criteria have some limitations. First, even though older adults are the largest consumers of medication, they are often underrepresented in drug trials. Thus, using an evidence-based approach may underestimate some drug-related problems or lead to a weaker evidence grading. Second, it does not address other types of potential PIMs that are not unique to aging (e.g., dosing of primarily renally cleared medications, drug–drug interactions, therapeutic duplication). Third, it does not comprehensively address the needs of individuals receiving palliative and hospice care, in whom symptom control is often more important than avoiding the use of PIMs. Finally, the search strategies used might have missed some studies published in languages other than English and studies available in unpublished technical reports, white papers, or other "gray literature" sources.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
Mobile Device Resources
Patient Resources
Pocket Guide/Reference Cards
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012 Apr;60(4):616-31. [35 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2012 Apr
Guideline Developer(s)
American Geriatrics Society - Medical Specialty Society
Source(s) of Funding

American Geriatrics Society

Guideline Committee

American Geriatrics Society 2012 Beers Criteria Update Expert Panel

Composition of Group That Authored the Guideline

Panel Members: Donna Fick, PhD, RN, FGSA, FAAN, School of Nursing and College of Medicine, Department of Psychiatry, Pennsylvania State University, University Park, PA (Co-chair); Todd Semla, PharmD, MS, BCPS, FCCP, AGSF, U.S. Department of Veterans Affairs National Pharmacy Benefits Management Services and Northwestern University, Chicago, IL (Co-chair); Judith Beizer, PharmD, CGP, FASCP, St. Johns University, New York, NY; Nicole Brandt, PharmD, BCPP, CGP, University of Maryland, Baltimore, MD; Robert Dombrowski, PharmD, Centers for Medicare and Medicaid Services, Baltimore, MD (nonvoting member); Catherine E. DuBeau, MD, University of Massachusetts Medical School, Worcester, MA; Nina Flanagan, CRNP, CS-BC, Binghamton University, Dunmore, PA; Joseph Hanlon, PharmD, MS, BCPS, FASHP, FASCP, FGSA, AGSF, Department of Medicine (Geriatric Medicine) School of Medicine, University of Pittsburgh and Geriatric Education and Research and Clinical Center, Veterans Administration Health System, Pittsburgh, PA; Peter Hollmann, MD, AGSF, Blue Cross Blue Shield of Rhode Island, Cranston, RI; Sunny Linnebur, PharmD, FCCP, BCPS, CGP, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO; David Nau, PhD, RPh, CPHQ, Pharmacy Quality Alliance, Inc., Baltimore, MD (nonvoting member); Bob Rehm, National Committee for Quality Assurance, Washington, DC (nonvoting member); Satinderpal Sandhu, MD, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH; Michael Steinman, MD, University of California at San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA

Financial Disclosures/Conflicts of Interest

To ensure that potential conflicts of interest are disclosed and addressed appropriately, panelists disclosed potential conflicts of interest with the panel. Each expert panel member completed a disclosure form that was shared with the entire panel before the process began. Potential conflicts of interest were resolved by the panel co-chairs and were available during the open comment period. Panel members who disclosed affiliations or financial interests with commercial entities are listed below.

Drs. Dombrowski, Flanagan, Hanlon, Hollmann, Rehm, Sandhu, and Steinman indicated no conflicts of interest. Dr. Beizer is an author and editor for LexiComp, Inc. She is on the Pharmacy and Therapeutics Committee for Part D at Medco Health Solutions. Dr. Brandt is on the Pharmacy and Therapeutics Committees at Omnicare and receives grants from Talyst (research grant), Econometrics (research grant), Health Resources and Services Administration (educational grant), and the State of Maryland Office of Health Care Quality (educational grant). Dr. Dubeau serves as a consultant for Pfizer, Inc. (urinary incontinence) and the New England Research Institute (nocturia). Dr. Fick is partially supported by the National Institutes of Health (NIH) for National Institute of Nursing Research grants R01 NR011042 and R01NR012242. Dr. Hanlon is supported in part by National Institute on Aging grants and contracts (R01AG027017, P30AG024827, T32 AG021885, K07AG033174, R01AG034056), a National Institute of Nursing Research grant (R01 NR010135), and Agency for Healthcare Research and Quality grants (R01 HS017695, R01HS018721). Dr. Linnebur receives an honorarium for serving as a member of the Pharmacy and Therapeutics Committee for Colorado Access (a health plan serving indigent children and adults and Medicare members). Dr. Nau works for the Pharmacy Quality Alliance (PQA), which has received demonstration project grants from Pfizer, Inc., Merck & Co, Inc., sanofi-aventis, and GlaxoSmithKline. He also has held shares with Cardinal Health in the past 12 months. Dr. Semla receives honoraria from the AGS for his contribution as an author of Geriatrics at Your Fingertips and for serving as a Section Editor for the Journal of the American Geriatrics Society. He is a past President and Chair of the AGS Board of Directors. His spouse is an employee of Abbott Laboratories. He serves on the Omnicare Pharmacy and Therapeutics Committee. He is an author and editor for LexiComp, Inc.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Geriatrics Society (AGS) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • AGS Beers Criteria for potentially inappropriate medication use in older adults. Pocket card. New York: American Geriatrics Society; 2012. 4 p. Electronic copies: Available in Portable Document Format (PDF) from the American Geriatrics Society (AGS) Web site External Web Site Policy.
  • AGS updated Beers Criteria for potentially inappropriate medication use in older adults. Slide set. New York: American Geriatrics Society; 2012. 46 p. Electronic copies: Available from the AGS Web site External Web Site Policy.
  • Frick D, Resnick B. 2012 Beers Criteria update: how should practicing nurses use the criteria? J Gerontol Nurs. 2012 Jun;38(6):3-5. Electronic copies: Available from the Journal of Gerontological Nursing Web site External Web Site Policy.

In addition, the Beers Criteria are available through the mobile app for iPhone and Android, available from the AGS Web site External Web Site Policy.

Patient Resources

A variety of patient education resources, including lists of medications the elderly should avoid (in English and Spanish) and a slide presentation about using medications safely at home, are available from the American Geriatrics Society Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was updated by ECRI Institute on August 23, 2012. The information was verified by the guideline developer on October 5, 2012. This summary was updated by ECRI Institute on May 22, 2014 following the U.S. Food and Drug Administration advisory on Eszopiclone (Lunesta).

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information on the American Geriatrics Society (AGS) or AGS guidelines visit their Web site www.americangeriatrics.org External Web Site Policy, or call (212) 308-1414.

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