Get to Know the 2023 BEERS Criteria®

American Geriatrics Society 2023 updated its AGS Beers Criteria® for potentially inappropriate medication use in older adults (65+), released on May 4, 2023. Practicing clinicians can use the list to improve selection of medications when possible, says the AGS.

Medication dangers to nursing home patients

Dr. Mark Beers, MD and colleagues at the University of California Los Angeles first developed the list to identify “medications for which potential harm outweighed the expected benefit and that should be avoided in nursing home residents,” explains the American Geriatrics Society. The medications are “best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions.” As explained by Dr. Steven Posar, Founder and CEO of GuideStar Eldercare:

The BEERS criteria, revised by an expert panel, identifies the quality of evidence behind each recommendation, as well as the strength of each recommendation.

BEERS medication categories

The BEERS criteria group potentially inappropriate medications into five categories:

• Medications considered as potentially inappropriate. This list includes common drugs such as aspirin, warfarin, and insulin administered on a sliding scale. Also on the list are certain classes of antihypertensives, proton pump inhibitors, GI antispasmodics, antidepressants, barbiturates, and not surprisingly, antipsychotics, along with many drug classes. With antipsychotics, the AGS cites “increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia.” (Learn more about the dangers of antipsychotics for nursing home patients.) Their recommendation: “Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.”
• Medications potentially inappropriate in patients with certain diseases or syndromes because of drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome. For example, a patient who has syncope is at heightened risk of orthostatic hypotension when given antipsychotics, they note. In another example, for a patient who experiences delirium, an anti-cholinergic drug could actually worsen the condition, they point out.
• Medications to be used with caution. For example, selected antidepressants could cause hyponatremia, so sodium levels must be closely monitored.
• Potentially inappropriate drug–drug interactions. As an example, “Use of more than one medication with anticholinergic properties increases the risk of cognitive decline, delirium, and falls or fractures.”
• Medications whose dosages should be adjusted based on renal function: The BEERS list specifies at what threshold of reduced creatinine clearance a dosage should be adjusted for a variety of medication classes.

Reduce adverse drug events

Using the BEERS criteria can improve clinical care and reduce adverse drug events, says the AGS. “Prescribing for older adults is often a complex endeavor involving the consideration of many factors, particularly the preferences and goals of the older person and their family. Deprescribing studies have demonstrated how critical patient and family input and buy-in can be to the success of discontinuing medications responsible for actual or potential harm or that provide little to no therapeutic value.”

Medication decisions

The AGS cautions against over-simplifying interpretation of the BEERS criteria and encourages unique analysis in each clinical situation. They note, “Different older adults may have markedly different risks of experiencing severe medication-related harms, with advanced age, cognitive and physical impairment, multimorbid burden, frailty, renal impairment, and a high degree of polypharmacy each conferring risk.” They also offer recommendations and resources for deprescribing medications when warranted.

Especially for the most frail or vulnerable nursing home patients, and those with multiple health conditions, attention to BEERS Criteria can improve quality of care. At GuideStar, our clinical teams bring in the diverse medical expertise, including neurology, psychiatry, and psychology, to build a comprehensive clinical picture and manage medications for the best possible outcomes. As pioneers in antipsychotic stewardship, we’re here to help you.