Beers criteria list pdf

Thoughtful application of the criteria will allow for closer monitoring of drug use, application of real-time e-prescribing and interventions to decrease ADEs in older adults, and better patient outcomes. Regular updates will allow for the evidence for medications on the list to be assessed routinely, making it more relevant and sensitive to patient outcomes, with the goal of evaluating and managing drug use in older adults while considering the dynamic complexities of the healthcare system.

Department of Veterans Affairs. Susan E. The development of this paper was supported in part by an unrestricted grant from the John A. Hartford Foundation. Beizer is an author and editor for LexiComp, Inc. Dubeau serves as a consultant for Pfizer, Inc. 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.

He also has held shares with CardinalHealth in the past 12 months. 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. Sponsor's Role: AGS staff participated in the final technical preparation and submission of the manuscript. Conflict of Interest: Drs.

Author Contributions: All panel members contributed to the concept, design, and preparation of the manuscript. National Center for Biotechnology Information , U. J Am Geriatr Soc. Author manuscript; available in PMC Apr 1. Christine M. Author information Copyright and License information Disclaimer.

Copyright notice. The publisher's final edited version of this article is available at J Am Geriatr Soc. See other articles in PMC that cite the published article. Abstract Potentially inappropriate medications PIMs continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults.

Keywords: Beers list, medications, Beers Criteria, drugs, older adults. The strategies to achieve this aim are to: Incorporate new evidence on currently listed PIMs and evidence from new medications or conditions not addressed in the previous update.

Literature Search The literature from December 1, the end of the previous panel's search to March 30, , was searched to identify published systematic reviews and meta-analyses that were relevant to the project. 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.

Development Process The co-chairs and AGS staff edited the survey used in the previous Beers Criteria development process, excluding products no longer marketed. Table 1 Designations of Quality and Strength of Evidence. Open in a separate window. 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 Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; greater risk of confusion, dry mouth, constipation, and other anticholinergic effects and toxicity.

Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Avoid High Strong Benzodiazepines Avoid antipsychotics for behavioral problems of dementia unless nonpharmacological options have failed, and patient is a threat to themselves or others.

Table 8 First- and Second-Generation Antipsychotics. Table 9 Drugs with Strong Anticholinergic Properties. Footnotes Conflict of Interest: Drs. Incidence and preventability of adverse drug events among older persons in the ambulatory setting.

The incidence of adverse drug events in two large academic long-term care facilities. Am J Med. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care. Explicit criteria for determining inappropriate medication use in nursing home residents.

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Am J Manag Care. Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: A systematic review. Jano E, Aparasu RR. Healthcare outcomes associated with Beers' Criteria: A systematic review. Use of the Beers Criteria to predict adverse drug reactions among first-visit elderly outpatients. Inappropriate medication use as a risk factor for self-reported adverse drug effects in older adults. Incident use and outcomes associated with potentially inappropriate medication use in older adults.

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Drugs Aging. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Fick D, Semla T. Improving medication use in gerontological nursing: Now is the time for interdisciplinary collaboration and translation. J Gerontol Nurs. Inappropriate medications in elderly ICU survivors: Where to intervene?

Use of a computer-based reminder to improve sedative-hypnotic prescribing in older hospitalized patients. Alternatives to potentially inappropriate medications for use in e-prescribing software: Triggers and treatment algorithms. BMJ Qual Saf. Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: Results of a randomized, controlled trial. The development of clinical practice guidelines and guidance statements of the American College of Physicians: Summary of methods.

Ann Intern Med. The Anticholinergic Risk Scale and anticholinergic adverse effects in older persons. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: Associations with serum anticholinergic activity.

J Clin Pharmacol. Impact of anticholinergics on the aging brain: A review and practical appllication. Aging Health. Inappropriate prescribing for elderly Americans in a large outpatient population. Health outcomes associated with potentially inappropriate medication use in older adults.

Res Nurs Health. Is inappropriate medication use a major cause of adverse drug reactions in the elderly? Br J Clin Pharmacol. Association of adverse drug reactions with drug-drug and drug-disease interactions in frail older outpatients.

Age Ageing. Designing and executing randomized clinical trials involving elderly persons. Fighting against age discrimination in clinical trials. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. Support Center Support Center. External link. Please review our privacy policy.

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.

Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefits. Benefits finely balanced with risks and burden. Insufficient evidence to determine net benefits or risks.

First-generation antihistamines as single agent or as part of combination products. Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; greater risk of confusion, dry mouth, constipation, and other anticholinergic effects and toxicity. Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate. Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more-effective agents available for treatment of Parkinson disease.

Highly anticholinergic, uncertain effectiveness. Avoid except in short-term palliative care to decrease oral secretions. May cause orthostatic hypotension; more-effective alternatives available; intravenous form acceptable for use in cardiac stress testing. 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. Data suggest that rate control yields better balance of benefits and harms than rhythm control for most older adults. For epilepsy, anticonvulsants such as: lamotrigine Lamictal levetiracetam Keppra. Sleeping Aids zolpidem Ambien zaleplon Sonata eszopiclone Lunesta. Ask your healthcare provider about non-medication sleep hygiene techniques.

Pain Medication People with chronic kidney disease or chronic renal failure should avoid all non-aspirin, nonsteroidal anti-inflammatory medications NSAIDs. These alternatives listed are for moderate pain: acetaminophen Tylenol topical capsaicin products lidocaine patches serotonin—norepinephrine reuptake inhibitors SNRIs such as: - duloxetine Cymbalta - venlafaxine Effexor. Benzodiazepines often used to treat anxiety and sleep disorders as well as other conditions People with a history of falls should avoid benzodiazepines, such as: alprazolam Xanax lorazepam Ativan diazepam Valium.

For anxiety: buspirone Buspar selective serotonin reuptake inhibitors SSRIs such as: - citalopram Celexa - sertraline Zoloft For sleep: Ask your healthcare provider about non-medication sleep hygiene techniques. Hormone Therapy Estrogen pills and patches. For vaginal dryness: topical estrogen creams For hot flashes and night sweats: gabapentin Neurontin serotonin—norepinephrine reuptake inhibitors SNRIs selective serotonin reuptake inhibitors SSRIs.

Table 8. Table 9. Table Recommendation Grading. Authoring Organization American Geriatrics Society. Document Type Guideline. External Publication Status Published. Country of Publication US. Target Patient Population Older adults taking one or more medications.

Target Provider Population All healthcare providers that care for older patients. Inclusion Criteria Male, Female, Older adult.

Intended Users Healthcare business administration, nurse, nurse practitioner, community pharmacist, health systems pharmacist, pharmacy technician, physician, physician assistant.

Scope Treatment, Management, Prevention. Previous Next. No matches found. Clear All. Inclusion Criteria. Recommendation Scope. Please enable JavaScript in your browser to complete this form. Submit Feedback. To continue viewing this pocket guide, please purchase it. Designations of Quality of Evidence and Strength of Recommendations.

Quality of Evidence. Quality of evidence ratings for each criterion are based on synthetic assessment of two complementary approaches to evaluating the quality of evidence. ACP-based approach. GRADE-based approach. High-quality evidence. Consider the following five factors for the studies that comprise the best-available evidence for a given criterion: 1.

Publication bias: Risk of bias due to selective publication of results. Moderate-quality evidence. Low-quality evidence. Overall quality of evidence that supports a given criterion: high, moderate, low. Strength of Evidence. Disease or Syndrome. Heart Failure. Avoid: Cilostazol Avoid in heart failure with reduced ejection fraction: Nondihydropyridine CCBs diltiazem, verapamil Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure: NSAIDs and COX-2 inhibitors Thiazolidinediones pioglitazone,rosiglitazone Dronedarone.

As noted, avoid or use with caution. AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia. Central Nervous System. Anticholinergics Antipsychotics Benzodiazepines Corticosteroids oral and parenteral H2-receptor antagonists Cimetidine Famotidine Nizatidine Ranitidine Meperidine Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics: eszopiclone, zaleplon, zolpidem.

H2-receptor antagonists: low, strong All others: moderate, strong. Dementia or Cognitive Impairment. Anticholinergics Benzodiazepines Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics Eszopiclone Zaleplon Zolpidem Antipsychotics, chronic and as-needed use. History of falls or fractures. May cause ataxia, impaired psychomotor function, syncope, additional falls; shorteracting benzodiazepines are not safer than long-acting ones.

Avoid unless safer alternatives are not available; avoid antiepileptics except for seizure and mood disorders Opioids: avoid except for pain management in the setting of severe acute pain eg, recent fractures or joint replacement. Opioids: moderate, strong All others: high, strong. Parkinson Disease. Antiemetics Metoclopramide Prochlorperazine Promethazine All antipsychotics except quetiapine, clozapine, pimavanserin. Dopamine-receptor antagonists with potential to worsen parkinsonian symptoms Exceptions: Pimavanserin and clozapine appear to be less likely to precipitate worsening of Parkinson disease.

Moderate, strong. History of gastric or duodenal ulcers. Avoid unless other alternatives are not effective and patient can take gastroprotective agent ie, proton-pump inhibitor or misoprostol. Chronic kidney disease stage 4 or higher. May increase risk of acute kidney injury and further decline of renal function. Urinary incontinence in women. Estrogen oral and transdermal excludes intravaginal estrogen Peripheral alpha-1 blockers Doxazosin Prazosin Terazosin.

May decrease urinary flow and cause urinary retention. Avoid in women. Estrogen: high, strong Peripheral alpha-1 blockers: moderate, strong. Lower urinary tract symptoms, benign prostatic hyperplasia. Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence. Lack of efficacy oral estrogen and aggravation of incontinence alpha-1 blockers.

Avoid in men. Object Drug and Class. Interacting Drug and Class. Risk Rationale. Increased risk of hyperkalemia. Avoid routine use in those with chronic kidney disease stage 3a or higher. Increased risk of overdose. Gabapentin, pregabalin. Increased risk of severe sedation-related adverse events, including respiratory depression and death. Avoid; exceptions are when transitioning from opioid therapy to gabapentin or pregabalin, or when using gabapentinoids to reduce opioid dose, although caution should be used in all circumstances.

Increased risk of cognitive decline. Avoid; minimize number of anticholinergic drugs. Any combination of three or more of these CNS-active drugs. Increased risk of falls all and of fracture benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics. Combinations including benzodiazepines and nonbenzodiazepine, benzodiazepine receptor agonist hypnotics or opioids: high, strong All other combinations: moderate, strong.

Corticosteroids, oral or parenteral. Increased risk of peptic ulcer disease or gastrointestinal bleeding. Avoid; if not possible, provide gastrointestinal protection.

Increased risk of lithium toxicity. Avoid; monitor lithium concentrations. Loop diuretics. Increased risk of urinary incontinence in older women. Avoid in older women, unless conditions warrant both drugs. Increased risk of phenytoin toxicity.

Increased risk of theophylline toxicity. Increased risk of bleeding.