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A Summary of the 2023 American Geriatrics Society Updated Beers Criteria® for Potentially Inappropriate Medication Use in the Elderly

The American Geriatrics Society (AGS) Beer’s Criteria are a set of guidelines and recommendations aimed at improving the appropriate use of medications in older adults, defined as those aged 65 years or older.  Elderly patients have unique physiological changes and increased susceptibility to adverse drug reactions, which necessitate specialized considerations when prescribing medications. Age-related changes in body composition as well as organ function can influence the pharmacodynamics and pharmacokinetics of many drugs.1,2 Polypharmacy is of particular concern for older adults as well, as it increases the risk for drug-drug or drug-disease interactions, which can lead to adverse effects.3  By raising awareness about potentially inappropriate medications (PIMs) and promoting safer alternatives, the Beers Criteria® plays a pivotal role in enhancing the quality of care and the overall well-being of older adults.  Optimizing medication regimens is a fundamental step towards minimizing exposure to adverse effects and improving health outcomes in the elderly population.

The Beers Criteria® were first introduced in 1991 and are updated periodically, with the most recent update occurring in 2023, replacing the version previously updated in 2019.4,5,6  The criteria are organized into 5 categories and developed by an interprofessional expert panel:  medications considered potentially inappropriate, medications potentially inappropriate in patients with certain diseases or syndromes, medications to be used with caution, potentially inappropriate drug-drug interactions, and medication with dosage adjustments based on renal function.  This overall framework was kept for the 2023 edition, but several noteworthy changes to the content and organization were made.  This article will summarize the major changes since the last release of the criteria.

Updates were based on a structured assessment of evidence and trends that were noteworthy since the previous update. The criteria were modified to include additions, deletions, and revisions that facilitate clinical application and shared decision making. PIMs with low utilization or no longer available in the United States were removed to introduce a user-friendly format with enhanced accessibility. In addition, several organizational changes were made, including re-organizing the order and grouping of some of the drugs in the tables, addition of a separate box that summarizes anticoagulant use criteria, and addition of a table listing the PIMs that were removed.

Potentially Inappropriate Medications

Within the Beers Criteria®, Table 2 is the largest table and is organized by organ system and therapeutic category.  This table, which focuses on PIMS in older adults, had the most revisions since the 2019 update. In particular, changes were made to the following medications and/or drug classes:  warfarin, aspirin, rivaroxaban, dronedarone, digoxin, antidepressants, antipsychotics, benzodiazepines, androgens, systemic estrogens, sulfonylurea, proton pump inhibitors, oral NSAIDs and skeletal muscle relaxants. A summary of major changes is included in the Table below.

Table:  Major Changes to Table 2 of the AGS Beers Criteria in 2023.    
Drug or class (disease)
Updates
Ratings (Quality of Evidence/Strength of Recommendation)
Warfarin
 
DOACs should be initiated for anticoagulation instead of warfarin, unless they are contraindicated or substantial barriers exist
 
Patients who are long-term users can continue warfarin based on clinical judgment and consideration of INR
High/Strong
Aspirin
For primary prevention, recommendation updated from “use with caution” to “avoid initiating” to agree with U.S. Preventive Services Task Force’s recommendation7
 
Consider deprescribing
High/Strong
Rivaroxaban for long-term treatment of NVAF of VTE
Recommendation updated from “use with caution” to “avoid” due to higher risk of major and GI bleeding compared to other DOACs
 
Consider alternative anticoagulants   
 
Consider rivaroxaban if once-daily dosing is necessary
Moderate/Strong
 
Dronedarone
Updated recommendation to use with caution in patients with HFrEF with less severe symptoms (NYHA class I or II). 
High/Strong
 
Digoxin for 1st line treatment of AF or HF
Added language to use caution when discontinuing in patients with HFrEF
 
Low/Strong
 
 
Systemic estrogen
 
Added language that risks are greater than benefits for women starting HRT after age 60.
 
Consider deprescribing
High/Strong
Sulfonylurea
 
Expanded class to include all sulfonylureas; (previous version only included long-acting)
 
Added language clarifying risks beyond hypoglycemia including CV events, all-cause mortality, CV death and ischemic stroke
 
Avoid unless there are substantial barriers to using safer/more effective agents and then short-acting agents are preferred
CV events/all-cause mortality: 
Moderate/Strong
 
CV death and ischemic stroke:  Low/Strong
Proton Pump Inhibitors
 
Added “pneumonia” and “GI malignancies” to risks of therapy
 
Moderate/Strong
 
Abbreviations: AF=atrial fibrillation; CV=cardiovascular; DOAC=direct oral anticoagulants; GI=gastrointestinal; HF=heart failure; HFrEF=heart failure with reduced ejection fraction; HRT=hormone replacement therapy; INR=international normalized ratio; NVAF=non-valvular atrial fibrillation, NYHA=New York heart association; VTE=venous thromboembolism.

In addition to the changes noted in the Table above, the interprofessional panel clarified language as applicable for several other drug classes including antidepressants, antipsychotics, benzodiazepines, androgens, systemic estrogens, oral non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants. General information regarding the language that was clarified for these agents based on new data are included below:

  • Antidepressants: The language was modified to specifically state that the recommendations apply to highly anticholinergic antidepressants.
  • Antipsychotics: Based on recent data, new language was added to strengthen the warning of increased risks associated with use in patients with dementia or delirium and encourage attempts at non-pharmacological management and deprescribing.8-12
  • Benzodiazepines: This section was modified to provide more information regarding risks of coadministration with opioids.
  • Androgens: Updated language from “contraindicated” to “potential risks” in men with prostate cancer.
  • NSAIDs (oral): A recommendation to avoid short-term use in certain clinical scenarios where drug interactions are present was added to the existing recommendation to avoid chronic use unless other alternatives are ineffective and patient can use a gastroprotective agent.
  • Skeletal muscle relaxants: Added language to clarify that the recommendation to avoid skeletal muscle relaxants does not apply to agents used for spasticity (ie baclofen and tizanidine), although these drugs may still be poorly tolerated.

PIMs in Patients with Certain Disease States or Syndromes

Table 3 of the Beers Criteria® contains information regarding PIMs that can exacerbate certain diseases or syndromes. There were less changes to this section of the recommendations.  In addition to language changes, major additions include: adding dextromethorphan/quinidine to the list of drugs to be avoided in patients with heart failure, adding opioids to the list of medications that can exacerbate delirium, and adding anticholinergics to the list of medications to avoid in patients with a history of falls or fractures.

Medications to be Used with Caution

Table 4 in the Beers Criteria® outlines PIMS that should be used with caution.  In the most recent edition, aspirin and rivaroxaban were moved from table 4 to table 2 and ticagrelor and SGLT2 inhibitors were added to the table.  Consideration for using a lower dose for prasugrel (5 mg) in patients 75 years of age or older was also added, as was information on the risk of heart failure concerns with dextromethorphan-quinidine and increased risk of hyperkalemia when ARNIs are used concurrently with trimethoprim-sulfamethoxazole.  Additional changes focused on clarifying the language to allow for better readability.

Drug Interactions

Table 5 of the Beers Criteria® includes clinically important drug-drug interactions.  Notable changes to this section include adding clarifying language highlighting the risks associated with multiple concurrent anticholinergic agents, adding skeletal muscle relaxants to the list of CNS-active drugs that should be limited to less than 3, adding ARBs and ARNIs to the list of drugs to be avoided in patients taking lithium, and adding SSRIs to the list of drugs to be avoided with warfarin when possible.

Renal Dose Adjustment

Table 6 of the Beers Criteria® includes a list of agents needing dose adjustments based on renal function.  Baclofen and NSAIDs were added to this table for the 2023 edition.  Modifications were also made to the sections for trimethoprim-sulfamethoxazole and rivaroxaban to clarify language and rationale. The NSAID class (previously located in Table 2) was switched to Table 6 in the latest edition.

Additional Changes

Additional changes to the 2023 criteria include the removal of several medications from the main tables by the panel due to low or zero usage in the United States. A total of 28 medications fit these criteria with 15 (54%) removed due to low use (eg flurazepam, ketoprofen, mefenamic acid, and others) and 13 (46%) removed because they are not or no longer available in the U.S. “Low use” was defined by the panel as use by less than 0.01% of U.S. Medicare beneficiaries (over the age of 65) in 2020 based on Part D public use files.  Of note, certain medications that met these criteria were still retained on the list by group consensus due to their over-the-counter availability and the likelihood that they are still being used commonly in the elderly population. The updated guidelines noted that removal of these agents from the main tables should not be interpreted as a shift towards condoning the use of these agents.  Rather, the group felt that removing these agents might help to “declutter” the list and therefore not distract from the other important information in the guidelines.

Many changes to the content, format, organization, and language have been implemented with the most recent version of the AGS Beers Criteria®.  In addition to the published guidelines and pocket card, an app has been created to help clinicians implement these guidelines into everyday practice.

References

  1. Thürmann PA. Pharmacodynamics and pharmacokinetics in older adults. Curr Opin Anaesthesiol. 2020;33(1):109-113. doi:10.1097/ACO.0000000000000814.
  2. Delafuente JC. Pharmacokinetic and pharmacodynamic alterations in the geriatric patient. Consult Pharm. 2008 Apr;23(4):324-34. doi: 10.4140/tcp.n.2008.324. Erratum in: Consult Pharm. 2008 Aug;23(8):564.
  3. Proietti M, Raparelli V, Olshansky B, Lip GY. Polypharmacy and major adverse events in atrial fibrillation: observations from the AFFIRM trial. Clin Res Cardiol. 2016;105(5):412-420. doi:10.1007/s00392-015-0936-y.
  4. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991 Sep;151(9):1825-32.
  5. American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15767.
  6. 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052‐2081. doi:10.1111/jgs.18372.
  7. US Preventive Services Task Force; Davidson KW, Barry MJ, Mangione CM, Cabana M, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Krist AH, Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Stevermer J, Tseng CW, Wong JB. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. JAMA. 2022 Apr 26;327(16):1577-1584. doi: 10.1001/jama.2022.4983.
  8. Kales HC, Gitlin LN, Lyketsos CG. When less is more, but still not enough: why focusing on limiting antipsychotics in people with dementia is the wrong policy imperative. J Am Med Dir Assoc. 2019 Sep;20(9):1074-1079. doi: 10.1016/j.jamda.2019.05.022. Epub 2019 Aug 6.
  9. Marcantonio ER. Old habits die hard: antipsychotics for treatment of delirium. Ann Intern Med. 2019 Oct 1;171(7):516-517. doi: 10.7326/M19-2624. Epub 2019 Sep 3.
  10. Inouye SK. The importance of delirium and delirium prevention in older adults during lockdowns. JAMA. 2021 May 4;325(17):1779-1780. doi: 10.1001/jama.2021.2211.
  11. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behavioral symptoms in dementia. JAMA. 2012 Nov 21;308(19):2020-9. doi: 10.1001/jama.2012.36918.
  12. Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW. Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc. 2010 Aug;58(8):1465-74. doi: 10.1111/j.1532-5415.2010.02971.x. Epub 2010 Jul 19.

Prepared by:

Olamide Adebogun
PharmD Candidate Class of 2024
University of Illinois Chicago College of Pharmacy

Jennifer Phillips, PharmD, BCPS, FCCP, FASHP
Clinical Professor, Director of Drug Information Group
University of Illinois Chicago College of Pharmacy

September 2023

The information presented is current as of August 28, 2023. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.