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TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Organ System/
Recommendation, Rationale,
Therapeutic Category/Drug(s)
Quality of Evidence (QE) & Strength of Recommendation (SR) Avoid except in short-term palliative care to decrease
oral secretions.
Highly anticholinergic, uncertain effectiveness.
This clinical tool, based on The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS 2012 Beers Criteria), has been developed to assist healthcare providers in improving medication safety in older adults. Our purpose is to inform clinical decision-making concerning the prescribing of medications for older adults in order to improve safety and quality of care. AntithromboticsDipyridamole, oral short-acting* (does not Originally conceived of in 1991 by the late Mark Beers, MD, a geriatrician, the Beers Criteria catalogues medications apply to the extended-release combination with May cause orthostatic hypotension; more effective alternatives that cause adverse drug events in older adults due to their pharmacologic properties and the physiologic changes of available; IV form acceptable for use in cardiac stress testing.
aging. In 2011, the AGS undertook an update of the criteria, assembling a team of experts and funding the develop- ment of the AGS 2012 Beers Criteria using an enhanced, evidence-based methodology. Each criterion is rated (qual- ity of evidence and strength of evidence) using the American College of Physicians’ Guideline Grading System, which Safer, effective alternatives available.
is based on the GRADE scheme developed by Guyatt et al. The full document together with accompanying resources can be viewed online at www.americangeriatrics.org. Avoid for long-term suppression; avoid in patients with
CrCl <60 mL/min.
The goal of this clinical tool is to improve care of older adults by reducing their exposure to Potentially Inappropri- Potential for pulmonary toxicity; safer alternatives available; lack of efficacy in patients with CrCl <60 mL/min due to inadequate drug n This should be viewed as a guide for identifying medications for which the risks of use in older adults outweigh n These criteria are not meant to be applied in a punitive manner.
n 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.
Avoid use as an antihypertensive.
These criteria also underscore the importance of using a team approach to prescribing and the use of non- High risk of orthostatic hypotension; not recommended as routine pharmacological approaches and of having economic and organizational incentives for this type of model.
treatment for hypertension; alternative agents have superior risk/ Implicit criteria such as the STOPP/START criteria and Medication Appropriateness Index should be used in a complementary manner with the 2012 AGS Beers Criteria to guide clinicians in making decisions about safe Avoid clonidine as a first-line antihypertensive. Avoid oth-
ers as listed.
The criteria are not applicable in all circumstances (eg, patient’s receiving palliative and hospice care). If a clinician is High risk of adverse CNS effects; may cause bradycardia and not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation orthostatic hypotension; not recommended as routine treatment of the medication as potentially inappropriate can serve as a reminder for close monitoring so that the potential for an adverse drug effect can be incorporated into the medical record and prevented or detected early. Avoid antiarrhythmic drugs as first-line treatment of atrial
fibrillation.
TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Organ System/
Recommendation, Rationale,
Data suggest that rate control yields better balance of benefits and Therapeutic Category/Drug(s)
Quality of Evidence (QE) & Strength of Recommendation (SR) harms than rhythm control for most older adults.
Amiodarone is associated with multiple toxicities, including thyroid First-generation antihistamines (as single disease, pulmonary disorders, and QT interval prolongation. agent or as part of combination products) Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confu- sion, dry mouth, constipation, and other anticholinergic effects/ Disopyramide is a potent negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other Use of diphenhydramine in special situations such as acute treat- ment of severe allergic reaction may be appropriate.
Avoid in patients with permanent atrial fibrillation or
heart failure.
QE = High (Hydroxyzine and Promethazine), Moderate (All others); SR Worse outcomes have been reported in patients taking drone- darone who have permanent atrial fibrillation or heart failure. In general, rate control is preferred over rhythm control for atrial Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
Organ System/
Recommendation, Rationale,
Organ System/
Recommendation, Rationale,
Therapeutic Category/Drug(s)
Quality of Evidence (QE) & Strength of Recommendation (SR) Therapeutic Category/Drug(s)
Quality of Evidence (QE) & Strength of Recommendation (SR) Avoid chronic use (>90 days)
Benzodiazepine-receptor agonists that have adverse events similar Potential for hypotension; risk of precipitating myocardial ischemia.
to those of benzodiazepines in older adults (e.g., delirium, falls, fractures); minimal improvement in sleep latency and duration.
Avoid in patients with heart failure or with a CrCl <30
In heart failure, the risk of hyperkalemia is higher in older adults if Avoid unless indicated for moderate to severe
hypogonadism.
Potential for cardiac problems and contraindicated in men with Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable Concerns about cardiac effects; safer alternatives available.
Avoid oral and topical patch. Topical vaginal cream: Ac-
ceptable to use low-dose intravaginal estrogen for the
management of dyspareunia, lower urinary tract infec-
Antipsychotics, first- (conventional) and sec- Avoid use for behavioral problems of dementia unless
tions, and other vaginal symptoms.
ond- (atypical) generation (see online for full list) non-pharmacologic options have failed and patient is
Evidence of carcinogenic potential (breast and endometrium); lack threat to self or others.
of cardioprotective effect and cognitive protection in older women.
Evidence that vaginal estrogens for treatment of vaginal dryness is Increased risk of cerebrovascular accident (stroke) and mortality in safe and effective in women with breast cancer, especially at dos- ages of estradiol <25 mcg twice weekly.
QE = High (Oral and Patch), Moderate (Topical); SR = Strong (Oral and Avoid, except as hormone replacement following pituitary
Highly anticholinergic and greater risk of QT-interval prolongation.
gland removal.
Effect on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.
Higher risk of hypoglycemia without improvement in hyperglyce- mia management regardless of care setting.
Avoid benzodiazepines (any type) for treatment of insom-
Minimal effect on weight; increases risk of thrombotic events and nia, agitation, or delirium.
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all ben- Chlorpropamide: prolonged half-life in older adults; can cause zodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults.
Glyburide: higher risk of severe prolonged hypoglycemia in older May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, Avoid, unless for gastroparesis.
Can cause extrapyramidal effects including tardive dyskinesia; risk may be further increased in frail older adults.
Potential for aspiration and adverse effects; safer alternatives avail- Tolerance occurs within 10 days and risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose.
One of the least effective antiemetic drugs; can cause extrapyrami- High rate of physical dependence; very sedating.
TABLE 1: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults
TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-
Organ System/
Recommendation, Rationale,
Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Therapeutic Category/Drug(s)
Quality of Evidence (QE) & Strength of Recommendation (SR) Disease or
Recommendation, Rationale, Quality of Evidence
Syndrome
(QE) & Strength of Recommendation (SR) Not an effective oral analgesic in dosages commonly used; may Increases risk of orthostatic hypotension or brady- cause neurotoxicity; safer alternatives available.
QE = High (Alpha blockers), Moderate (AChEIs, TCAs and Avoid chronic use unless other alternatives are not effec-
antipsychotics); SR = Strong (AChEIs and TCAs), Weak tive and patient can take gastroprotective agent (proton-
(Alpha blockers and antipsychotics) pump inhibitor or misoprostol).
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 pro- ton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by Lowers seizure threshold; may be acceptable in NSAIDs occur in approximately 1% of patients treated for 3–6 patients with well-controlled seizures in whom alter- months, and in about 2%–4% of patients treated for 1 year. These native agents have not been effective.
trends continue with longer duration of use.
Anticholinergics (see online for full list) 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 Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See Non-COX selective NSAIDs) Of all the NSAIDs, indomethacin has most adverse effects.
QE = Moderate (Indomethacin), High (Ketorolac); SR = Strong Anticholinergics (see online for full list) Opioid analgesic that causes CNS adverse effects, including confu- sion and hallucinations, more commonly than other narcotic drugs; Avoid antipsychotics for behavioral problems of is also a mixed agonist and antagonist; safer alternatives available.
dementia unless non-pharmacologic options have Antipsychotics, chronic and as-needed use failed and patient is a threat to themselves or others. Antipsychotics are associated with an increased risk Most muscle relaxants poorly tolerated by older adults, because of of cerebrovascular accident (stroke) and mortality in anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at dosages tolerated by older adults is questionable.
Avoid unless safer alternatives are not avail-
able; avoid anticonvulsants except for seizure.
*Infrequently used drugs. Table 1 Abbreviations: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin Ability to produce ataxia, impaired psychomotor receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastroin- function, syncope, and additional falls; shorter-acting testinal; NSAIDs, nonsteroidal anti-inflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone benzodiazepines are not safer than long-acting ones.
secretion; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence TABLE 2: 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
Recommendation, Rationale, Quality of Evidence
Syndrome
(QE) & Strength of Recommendation (SR) Heart failure NSAIDs and COX-2 inhibitors Nondihydropyridine CCBs (avoid only for Potential to promote fluid retention and/or exacer- Parkinson’s All antipsychotics (see online publica- tion for full list, except for quetiapine and Dopamine receptor antagonists with potential to QE = Moderate (NSAIDs, CCBs, Dronedarone), High (Thia- zolidinediones (glitazones)), Low (Cilostazol); SR = Strong Quetiapine and clozapine appear to be less likely to precipitate worsening of Parkinson disease.
TABLE 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-
TABLE 2: 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 Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome Disease or
Recommendation, Rationale, Quality of Evidence
Disease or
Recommendation, Rationale, Quality of Evidence
Syndrome
(QE) & Strength of Recommendation (SR) Syndrome
(QE) & Strength of Recommendation (SR) Avoid in men.
Oral antimuscarinics for urinary inconti- Avoid unless no other alternatives.
May decrease urinary flow and cause urinary reten- antimuscarinics for urinary incontinence Can worsen constipation; agents for urinary incon- tinence: antimuscarinics overall differ in incidence of QE = Moderate; SR = Strong (Inhaled agents), Weak (All constipation; response variable; consider alternative Avoid in women.
QE = High (For Urinary Incontinence), Moderate/Low (All Table 2 Abbreviations: CCBs, calcium channel blockers; AChEIs, acetylcholinesterase inhibitors; CNS, central ner- First-generation antihistamines as single vous system; COX, cyclooxygenase; NSAIDs, nonsteroidal anti-inflammatory drugs; SR, Strength of Recommenda- tion; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants; QE, Quality of Evidence TABLE 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in
Recommendation, Rationale, Quality of Evidence (QE) & Strength of Recommenda-
Aspirin for primary preven- Use with caution in adults ≥80 years old.
Lack of evidence of benefit versus risk in individuals ≥80 years old.
Use with caution in adults ≥75 years old or if CrCl <30 mL/min.
Increased risk of bleeding compared with warfarin in adults ≥75 years old; lack of Anticholinergics/antispasmodics (see online evidence for efficacy and safety in patients with CrCl <30 mL/min for full list of drugs with strong anticholinergic Use with caution in adults ≥75 years old.
Greater risk of bleeding in older adults; risk may be offset by benefit in highest- risk older patients (eg, those with prior myocardial infarction or diabetes).
Use with caution.
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.
Avoid unless other alternatives are not ef-
fective and patient can take gastroprotective
agent (proton-pump inhibitor or misoprostol).
May exacerbate existing ulcers or cause new/addi- Use with caution.
May exacerbate episodes of syncope in individuals with history of syncope.
Table 3 Abbreviations: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin–norepinephrine reuptake inhibitors; SR, Strength of Recommendation; TCAs, tricyclic antidepressants; QE, Quality of Evidence May increase risk of acute kidney injury.
Developed with support from the Robert Wood Johnson Foundation and the John A. Hartford Foundation. QE = Moderate (NSAIDs), Low (Triamterene); SR = Strong Avoid in women.
AGSLeading change. Improving care for older adults. 800-247-4779 ot 212-308-1414

Source: http://agingwa.org/wp-content/uploads/Beers-Criteria-Pocket-Card.pdf