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AGS UPDATED 2015 BEERS CRITERIA
FOR POTENTIALLY INAPPROPRIATE
MEDICATION USE IN OLDER ADULTS
Disclosures
Conflict of Interest

Dr. Beizer is an author and editor for LexiComp, Inc. Dr. Brandt is a consultant for Omnicare, Centers for
Medicare and Medicaid Services, and University of Pittsburgh and a Section Editor for the Journal of
Gerontological Nursing and received a grant from Econometrica. Dr. Fick is a paid consultant for SLACK Inc.,
is an editor for the Journal of Gerontological Nursing, and has current R01 funding from the National
Institutes of Health and the National Institute of Nursing Research. Dr. Linnebur is a consultant for
Colorado Access and Kindred Healthcare. Dr. Semla serves on the AARP Caregiver Advisory Panel, is an
editor for Lexi-Comp, and is a consultant for Omnicare. Dr. Semla’s wife holds commercial interest in
AbbVie (at which she is also an employee), Abbott, and Hospira. 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 and is a past president and chair of the AGS Board of Directors.
Dr. Steinman is a consult for Iodine.com, a web start-up company.
Author Contributions
All panel members contributed to the concept, design, and preparation of the manuscript.
Sponsor’s Role
AGS staff participated in the final technical preparation and submission of the manuscript.
Objectives
 Understand commonly used medications that should
be avoided in the elderly.
 Understand how to use the 2015 Beer’s list in clinical
decision making.
Mark H Beers, MD 1954-2009
“A ballet-dancing opera
critic who hiked the Alps
and took up rowing after
diabetes cost him his legs”
 MD, Univ of Vermont
 First med student to do a geriatrics
elective at Harvard‘s new Division on
Aging
 Geriatric Fellowship, Harvard
 Faculty, UCLA/RAND
 Co-editor, Merck Manual of
Geriatrics
 Editor in Chief, Merck Manuals
Original Purpose
1991 Original Beers Criteria
 Evaluate inappropriate Rx used in NH residents in
“common” situations, but under “certain
circumstances” might be appropriate (e.g., using
amitriptyline to treat pt with both Parkinson’s disease
and depression)
 Clinical research on use of Potentially Inappropriate
medications (PIMs)
 QA/QI
 Education of students, residents
Beers Criteria: History and Utilization
 Original 1991 – Nursing home pts
 Updates
1997
2003
2012
All elderly; adopted by CMS in 1999
for nursing home regulation
Era of generalization to Med D, then
NCQA, HEDIS
First AGS Updated Beers Criteria
Released, Further adoption into
quality measures
2015 AGS Beers Criteria Update
Specific aim: Update 2012 Beers Criteria using a
comprehensive, systematic review and
grading of evidence
Strategy – same as 2012:
1. Incorporate new evidence
2. Grade the evidence
3. Use an interdisciplinary panel
4. Incorporate exceptions
2015 AGS Beers Criteria Update
What’s New
Two New Tables
1. Drug-Drug Interactions Table
2. Renal Dosage Table
Two New Companion Pieces
1. How to Use Paper
2. Beers Alternatives
2015 AGS Beers Criteria Update
What’s New
1. New Drugs – Table 2
1. PPI’s > 8 weeks without justification
2. Desmopressin for treatment of nocturia or
nocturnal polyuria
2. New Drugs – Table 3
1. Eszopiclone and zaleplon added to list of drugs to
avoid in dementia or cognitive impairment
2. Opioids added to list of drugs to avoid in patients
with history of falls
Intent of the AGS 2015 Beers Criteria
Goals:
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Improve care by ↓ exposure to PIMS
Educational tool
Quality measure
Research tool
Method
Framework
 Expert panel
• 13 members
 Followed IOM 2011 recommendations on guideline
development
• Includes a period for public comment
 Literature search
 Evidence tables prepared, rated quality of evidence
and strength of recommendation
Panel Members
 Co-chairs
• Donna Fick, PhD, RN, FAAN
• Todd Semla, MS, PharmD
 Panelists (voting)
•
•
•
•
•
•
•
•
•
•
•
Judith Beizer, PharmD
Nicole Brandt, PharmD
Catherine DuBeau, MD
Jerome Epplin, MD
Nina Flanagan, CRNP,CS-BC
Joseph Hanlon, PharmD, MS
Peter Hollmann, MD
Rosemary Laird, MD, MHSA
Sunny Linnebur, PharmD
Satinderpal Sandhu, MD
Michael Steinman, MD
 Nonvoting Panelists
• Robert Dombrowski, PharmD (CMS)
• Woody Eisenberg, MD (PQA)
• Erin Giovannetti (NCQA)
 AGS Staff
• Elvy Ickowicz, MPH
• Mary Jordan Samuel
 Others
•
•
•
•
Sue Radcliff (research)
Susan Aiello, DVM (editing)
Gina Rocco (research)
Jirong Yue (research)
Assembling the Evidence
SEARCH TERMS: ADE, inappropriate drug use, med errors,
polypharmacy x age/human/English
Initial Search (8/1/2001-7/1-2014)
n=27,467 citations
Records reviewed by co-chairs
n=3,387
Records Screened by Full Panel
(n=1,188 citations)
Studies Used to create Evidence Tables
(n=342)
Designations of Quality and Strength of Evidence:
ACP Guideline Grading System, GRADE
QUALITY OF EVIDENCE GRADING—USING GRADE

High Evidence

Moderate Evidence

Low Evidence
Designations of Quality and Strength of Evidence:
ACP Guideline Grading System, GRADE
STRENGTH OF RECOMMENDATION—HOW DID WE DO THIS?
Strong
Benefits clearly outweigh harms, adverse events, and risks – or –
harms, adverse events, and risks clearly outweigh benefits.
Weak
Benefits finely balanced with harms, adverse events, and risks.
Insufficient
Evidence inadequate to determine net harms, adverse events, and
risks.
Not included in Beer’s List
 Drugs with risks not unique to elderly
• Purpose is for PIMs specific to elderly
 Drugs used with patients in the hospice and
palliative care setting
Tables
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Table 2 – PIM list (with some selective caveats)
Table 3 – PIMs due to Drug – Disease/Syndrome Interaction
Table 4 – Medications to be used with caution
Table 5 – Non-Anti-infective Drug-Drug Interactions
Table 6 – Non-Anti-Infective Medications that should be
avoided or have dosage reduced with varying levels of kidney
function
Table 7 – Drugs with strong anticholinergic properties
Table 8 – Medications Moved or Modified
Table 9 – Medications Removed
Table 10 – Medications Added
Table 2. Drugs to Avoid (except if…)
Organ System or
TC or Drug
Rationale
Recommend.
Quality of
Evidence
Strength of
Recommend.
Nitrofurantoin
Pulmonary and
hepatic toxicity,
peripheral
neuropathy;
Lack of efficacy
<30 mL/min
Avoid long
term
suppression;
avoid if CrCl
<30 mL/min
Low
Strong
Antipsychotics
(conventional or
atypical)
Increase CVA
risk; increased
cognitive decline
and mortality in
dementia
Avoid unless
danger to
self/others
and non
pharm has
failed
Moderate
Strong
Insulin, sliding
scale
Hypoglycemia
risk
Avoid
Moderate
Strong
Chlorpropamide
Glyburide
Hypoglycemia
risk
Avoid
High
Strong
Table 2. Drugs to Avoid (except if…)
Organ System or
TC or Drug
Rationale
Benzodiazepines
Short and long
acting
Recommend.
Quality of
Evidence
Strength of
Recommend.
Risk cognitive
Avoid
effects and injury
(fall/MVA); may
be appropriate, eg
EtOH withdrawal
Moderate
Strong
Megestrol
Minimal effect on Avoid
weight; risk of
thrombotic events
and death
Moderate
Strong
Proton –pump
inhibitors
Risk of C. diff
infection, bone
loss and fractures
High
Strong
Moderate
Strong
Avoid use for
>8 weeks
unless high-risk
Non-COX NSAIDs, GI bleeding;
Avoid chronic
oral
Protection w/ PPIs use
or misoprostol
Table 2. Drugs to Avoid (except if…)
Organ System or
TC or Drug
Rationale
Recommend.
Quality of
Evidence
Strength of
Recommend.
Non
Benzodiazepines
Hypnotic s
(“z” drugs)
Risk cognitive
effects and injury
(fall/MVA); same
ADE as benzo’s
Avoid
Moderate
Strong
Estrogens with or Carcinogenic
w/o progestin
potential, lack of
efficacy in
dementia/CV
disease
prevention
Avoid oral and
topical patch.
Vaginal cream
and tablets safe
and effective
for vaginal
symptoms
Oral and
Oral and
patch: high patch: strong
Vaginal
crm/tab:
moderate
Vaginal
crm/tab: weak
Muscle Relaxants Ineffective at
tolerated doses,
antichol, falls
Avoid
Moderate
Strong
Table 3. Drug-disease/syndrome
Interactions
Disease or
Syndrome
Drug
Rationale
Recomm.
Quality of
Evidence
Strength of
Recomm.
Syncope
AChEIs
Peripheral αblockers
Tert. TCAs
Orthostatic
hypotension
or
bradycardia
Avoid
α- blockers:
High
TCAs,
AChEIs,
antipsych:
Moderate
AChEIs,
TCAs: Strong
CNS
stimulant
effects
Avoid
Moderate
Strong
Chlorpromazine
Thioridazine
Olanzapine
Insomnia
Oral
decongestants
Stimulants
Theobromines
α- blockers,
antipsych.:
Weak
Table 4. Use with Caution
Drug
Rationale
Recommend
Quality of
Evidence
Strength of
Recommend
Dabigatran
Risk of bleeding;
lack of evidence of
efficacy if CrCl <
30mL/min
Use with
caution if >75
years old or if
CrCl
<30mL/min
Moderate
Strong
Drugs linked to
SIADH/
Hyponatremia (eg
SSRI, TCA, CBZ,
antipsychotics)
May exacerbate or
cause SIADH/
hyponatremia;
monitor sodium
level
Use with
caution
Moderate
Strong
Previous Drugs to Avoid Dropped from
2015 AGS Beers Criteria
DRUGS
Antiarrhythmic drugs
(Class 1a, 1c, III except
amiodarone)
Trimethobenzamide
Rationale
• New evidence suggests that rhythm
control is just as good as rate control.
• For treatment of apomorphine-induced
nausea; evidence did not support its
inclusion
Mesoridazine
• Off market in US
Chloral hydrate
• Off market in US
Previous Disease and Syndrome Interactions
Dropped from 2015 AGS Beers Criteria
DRUGS
Rationale
Chronic Constipation
• Syndrome is not applicable primarily
to older adults.
Lower Urinary Tract –
Inhaled
anticholinergic drugs
• Evidence no longer compelling for
inclusion
Table 5. 2015 AGSBeers Criteria for Potentially Clinically Important Non-anti-infective Drug–
Drug Interactions That Should Be Avoided in Older Adults
Object Drug and
Class
Interacting Drug
and Class
Risk Rationale
Recommendation
Quality of Strength of
Evidence Recommendation
ACEIs
Amiloride or
triamterene
Increased risk of Avoid routine use;
hyperkalemia reserve for patients
with demonstrated
hypokalemia while
taking an ACEI
Moderate Strong
Anticholinergic
Anticholinergic
Increased risk of Avoid, minimize
cognitive
number of
decline
anticholinergic drugs
(Table 7)
Moderate Strong
Antidepressants (ie, ≥2 other CNSTCAs and SSRIs)
active drugsa
Increased risk of Avoid total of ≥3 CNS- Moderate Strong
falls
active drugsa; minimize
number of CNS-active
drugs
Antipsychotics
Increased risk of Avoid total of ≥3 CNS- Moderate Strong
falls
active drugsa; minimize
number of CNS active
drugs
≥2 other CNSactive drugsa
Table 5, continued
Object Drug and
Class
Interacting Drug
and Class
Benzodiazepines and ≥2 other CNS-active
nonbenzodiazepine, drugsa
benzodiazepine
receptor agonist
hypnotics
Corticosteroids, oral NSAIDs
or parenteral
Lithium
Lithium
Opioid receptor
agonist analgesics
Risk Rationale
Recommendation
Quality of
Evidence
Increased risk of Avoid total of ≥3 CNS- High
falls and
active drugsa;
fractures
minimize number of
CNS active drugs
Avoid; if not possible, Moderate
provide
gastrointestinal
protection
Strong
Avoid, monitor
Moderate
lithium
concentrations
Loop diuretics
Increased risk of Avoid, monitor
Moderate
lithium toxicity lithium
concentrations
≥2 other CNS-active Increased risk of Avoid total of ≥3 CNS- High
drugsa
falls
active drugsa;
minimize number of
CNS drugs
Strong
ACEIs
Increased risk of
peptic ulcer
disease or
gastrointestinal
bleeding
Increased risk of
lithium toxicity
Strength of
Recommendati
on
Strong
Strong
Strong
Table 5, continued
Object Drug and
Class
Interacting Drug
and Class
Peripheral, Alpha-1 Loop diuretics
blockers
Theophylline
Cimetidine
Warfarin
Amiodarone
Warfarin
NSAIDs
Risk Rationale
Recommendation
Quality of
Evidence
Strength of
Recommendation
Increased risk of
urinary
incontinence in
older women
Increased risk of
theophylline
toxicity
Increased risk of
bleeding
Increased risk of
bleeding
Avoid in older
women, unless
conditions warrant
both drugs
Avoid.
Moderate
Strong
Moderate
Strong
Avoid when possible; Moderate
monitor INR closely
Avoid when possible; High
if used together,
monitor for bleeding
closely
Strong
Strong
Table 6. 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective
Medications That Should Be Avoided or Have Their Dosage Reduced with Varying
Levels of Kidney Function in Older Adults
Medication
Class and
Medication
CrCL, mL/min, at
Which Action
Required
Cardiovascular or hemostasis
Amiloride
<30
Rationale
Recommendation
Quality of Strength of
Evidence Recommend
ation
Increased potassium Avoid
and decreased
sodium
Increased risk of
Avoid
bleeding
Moderate Strong
Apixaban
<25
Moderate Strong
Dabigatran
<30
Increased risk of
bleeding
Avoid
Moderate Strong
Edoxaban
30–50
<30 or >95
Increased risk of
bleeding
Reduce dose
Avoid
Moderate Strong
Enoxaparin
<30
Increased risk of
bleeding
Reduce dose
Moderate Strong
Fondaparinux
<30
Increased risk of
bleeding
Avoid
Moderate Strong
Table 6, continued
Medication Class CrCL, mL/min, at
and Medication Which Action
Required
Rivaroxaban
30–50
<30
Spironolactone
Triamterene
<30
<30
Rationale
Recommendation
Quality of
Evidence
Increased risk of
bleeding
Reduce dose
Avoid
Moderate
Strength of
Recommenda
tion
Strong
Increased potassium
Increased potassium
and decreased
sodium
Avoid
Avoid
Moderate
Moderate
Strong
Strong
Avoid
Moderate
Weak
Reduce dose
Moderate
Strong
Central nervous system and analgesics
Duloxetine
<30
Gabapentin
<60
Increased
gastrointestinal
adverse effects
(nausea, diarrhea)
CNS adverse effects
Levetiracetam
≤80
CNS adverse effects
Reduce dose
Moderate
Strong
Pregabalin
<60
CNS adverse effects
Reduce dose
Moderate
Strong
Tramadol
<30
CNS adverse effects
Immediate release:
reduce dose
Extended release:
avoid
Low
Weak
Table 6, continued
Medication
CrCL, mL/min, at
Class and
Which Action
Medication
Required
Gastrointestinal
Rationale
Recommendation
Quality Strength of
of
Recommendati
Evidence on
Cimetidine
<50
Mental status
changes
Reduce dose
Moderat Strong
e
Famotidine
<50
Mental status
changes
Reduce dose
Moderat Strong
e
Nizatidine
<50
Mental status
changes
Reduce dose
Moderat Strong
e
Ranitidine
<50
Mental status
changes
Reduce dose
Moderat Strong
e
Colchicine
<30
Gastrointestinal,
neuromuscular,
bone marrow
toxicity
Reduce dose; monitor for Moderat Strong
adverse effects
e
Probenecid
<30
Loss of
effectiveness
Avoid
Hyperuricemia
Moderat Strong
e
Key Principles on
How To Use the Beers Criteria

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Medications in the Beers Criteria are potentially
inappropriate, not definitely inappropriate.
Read the rationale and recommendations statements
for each criterion. The caveats and guidance listed
there are important.
Understand why medications are included in the Beers
Criteria, and adjust your approach to those medications
accordingly
Optimal application of the Beers Criteria involves
identifying potentially inappropriate medications, and
where appropriate offering safer non-pharmacologic
and pharmacologic therapies
Key Principle on How To Use the Beers
Criteria continued..

The Beers Criteria should be a starting point for a
comprehensive process of identifying and improving
medication appropriateness and safety

Access to meds in the Beers Criteria should not be
excessively restricted by prior authorization and/or
health plan coverage policies

The Beers Criteria are not equally applicable to all
countries
Uses of the Beers Criteria in Clinical Care
Quality Prescribing
 Patient-centered
 Patient-specific goals
 Tolerance for deviation
from EBM care guidelines
 Requires system-level
approaches
Quality Performance Measurement
 Population-centered
 Benchmark goals
 Less tolerance for deviation
from EBM care guidelines
 Requires system-level
approaches
Beers Criteria only Part of Quality Prescribing
 Quality prescribing includes
• Correct drug for correct diagnosis
• Appropriate dose (label; dose adjustments for
comorbidity, drug-drug interactions)
• Avoiding underuse of potentially important
medications (e.g., bisphosphonates for osteoporosis)
• Avoiding overuse (e.g., antibiotics)
• Avoiding potentially inappropriate drugs
• Avoiding withdrawal effects with discontinuation
• Consideration of cost
Perceived Barriers to Appropriate Prescribing
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Polypharmacy, can’t review such a long list
“Best” drugs may cost too much
Worrying about drug interactions if making drug changes
Time involved
Difficulty communicating with pt’s other prescribing
clinicians
Lack of knowledge re Beers
Lack of therapeutic alternatives
Patient unwillingness to change
Discomfort changing a med another clinician prescribed
Ramaswamy R et al, J Eval Clin Pract 2011
What are the challenges of using them in
clinical care?
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All of the above perceived barriers
RN/Family Request
Lack of Tested Non Drug Alternatives
Multiple prescribers
Risk of drug is less than risk of condition
Palliative Care and other special cases and
populations
Take homes
 Don’t let the perfect be the enemy of the good
 Beers PIMs are only part of appropriate prescribing
 Target initiatives to high prevalence/high severity
meds (based on local data, where possible)
 Stopping meds should be done with same
consideration as starting
 Beers Criteria = Patient-centered care
Limitations
 Evidence base available
 What’s not covered
• Therapeutic duplication
 Special populations within geriatrics
 Search strategy - missed information
Summary: AGS 2015 Beers Criteria
 Beers Criteria have come a long way since 1991
 Are explicit criteria supported by evidence-based
literature
 Guidelines for identifying medications whose
risks>benefits in older adults
 Not meant to supersede clinical judgment or
individual patient values or needs
AGS Beers Criteria Resources
Criteria
• AGS Updated Beers Criteria
• How-to-Use Article
• Alternative Medications List
Coming Soon!
• Updated Beers Criteria Pocket Card
• Updated Beers Criteria App
Public Education Resources for Patients & Caregivers
• AGS Beers Criteria Summary
• 10 Medications Older Adults Should Avoid
• Avoiding Overmedication and Harmful Drug Reactions
• What to Do and What to Ask Your Healthcare Provider if a Medication You
Take is Listed in the Beers Criteria
• My Medication Diary - Printable Download
• Eldercare at Home: Using Medicines Safely - Illustrated PowerPoint
Presentation
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