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SPECIAL ARTICLES

American Geriatrics Society Updated Beers Criteria forPotentially Inappropriate Medication Use in Older Adults

The American Geriatrics Society 2012 Beers Criteria Update Expert Panel

Potentially inappropriate medications (PIMs) continue tobe prescribed and used as first-line treatment for the mostvulnerable of older adults, despite evidence of poor out-comes from the use of PIMs in older adults. PIMs nowform an integral part of policy and practice and are incor-porated into several quality measures. The specific aim ofthis project was to update the previous Beers Criteria usinga comprehensive, systematic review and grading of the evi-dence on drug-related problems and adverse drug events(ADEs) in older adults. This was accomplished throughthe support of The American Geriatrics Society (AGS) andthe work of an interdisciplinary panel of 11 experts ingeriatric care and pharmacotherapy who applied a modi-fied Delphi method to the systematic review and gradingto reach consensus on the updated 2012 AGS Beers Crite-ria. Fifty-three medications or medication classes encom-pass the final updated Criteria, which are divided intothree categories: potentially inappropriate medications andclasses to avoid in older adults, potentially inappropriatemedications and classes to avoid in older adults with cer-tain diseases and syndromes that the drugs listed can exac-erbate, and finally medications to be used with caution inolder adults. This update has much strength, including theuse of an evidence-based approach using the Institute ofMedicine standards and the development of a partnershipto regularly update the Criteria. Thoughtful application ofthe Criteria will allow for (a) closer monitoring of druguse, (b) application of real-time e-prescribing and interven-tions to decrease ADEs in older adults, and (c) betterpatient outcomes. J Am Geriatr Soc 2012.

Key words: Beers list; medications; Beers Criteria;drugs; older adults

Medication-related problems are common, costly, andoften preventable in older adults and lead to poor out-

comes. Estimates from past studies in ambulatory and long-term care settings found that 27% of adverse drug events(ADEs) in primary care and 42% of ADEs in long-term carewere preventable, with most problems occurring at theordering and monitoring stages of care.1,2 In a study of the2000/2001 Medical Expenditure Panel Survey, the total esti-mated healthcare expenditures related to the use of poten-tially inappropriate medications (PIMs) was $7.2 billion.3

Avoiding the use of inappropriate and high-risk drugsis an important, simple, and effective strategy in reducingmedication-related problems and ADEs in older adults.Methods to address medication-related problems includeimplicit and explicit criteria. Explicit criteria can identifyhigh-risk drugs using a list of PIMs that have been identi-fied through expert panel review as having an unfavorablebalance of risks and benefits by themselves and consideringalternative treatments available. A list of PIMs was devel-oped and published by Beers and colleagues for nursinghome residents in 1991 and subsequently expanded andrevised in 1997 and 2003 to include all settings of geriatriccare.46 Implicit criteria may include factors such as thera-peutic duplication and drugdrug interactions. PIMs deter-mined by explicit criteria (Beers Criteria) have alsorecently been found to identify other aspects of inappropri-ate medication use identified by implicit criteria.7

As summarized in two reviews, a number of investiga-tors in rigorously designed observational studies haveshown a strong link between the medications listed in theBeers Criteria and poor patient outcomes (e.g., ADEs,hospitalization, mortality).714 Moreover, research hasshown that a number of PIMs have limited effectiveness inolder adults and are associated with serious problems suchas delirium, gastrointestinal bleeding, falls, and frac-ture.8,12 In addition to identifying drugs for which saferpharmacological alternatives are available, in manyinstances a safer nonpharmacological therapy could besubstituted for the use of these medications, highlightingthat a less-is-more approach is often the best way toimprove health outcomes in older adults.15

Since the early 1990s, the prevalence of PIM usage hasbeen examined in more than 500 studies, including anumber of long-term care, outpatient, acute care, andcommunity settings. Despite this preponderance of informa-tion, many PIMs continue to be prescribed and used as first-

From The American Geriatrics Society, New York, New York.

Address correspondence to Christine M. Campanelli, The AmericanGeriatrics Society, 40 Fulton Street, 18th Floor, New York, NY 10038.E-mail: [email protected]

DOI: 10.1111/j.1532-5415.2012.03923.x

JAGS 2012

2012, Copyright the AuthorsJournal compilation 2012, The American Geriatrics Society 0002-8614/12/$15.00

line treatment for the most vulnerable of older adults.16,17

These studies illustrate that more work is needed to addressthe use of PIMs in older adults, and there remains an impor-tant role in policy, research, and practice for an explicit listof medications to avoid in older adults. Because an increas-ing number of interventions have been successful in decreas-ing the use of these drugs and improving clinicaloutcomes,18,19 PIMs now form an integral part of policyand practice in the Centers for Medicare and Medicaid Ser-vices (CMS) regulations and are used in Medicare Part D.They are also used as a quality measure in the NationalCommittee for Quality Assurance (NCQA) HealthcareEffectiveness Data and Information Set (HEDIS). Severalstakeholders, including CMS, NCQA, and the PharmacyQuality Alliance (PQA) have identified the Beers Criteria asan important quality measure. In addition, a few studieshave begun to identify nonpharmacological alternatives toinappropriate medications20 and are incorporating BeersCriteria PIMs into electronic health records as an aid toreal-time e-prescribing.19

An update of the Beers Criteria should include a clearapproach to reviewing and grading the evidence forthe drugs to avoid. In addition, the criteria need to beregularly updated as new drugs come to the market, asnew evidence emerges related to the use of these medica-tions, and as new methods to assess the evidence develop.Being able to update these criteria quickly and transpar-ently is crucial to their continued use as decision-makingtools, because regular updates will improve their relevancy,dissemination, and usefulness in clinical practice.

The 2012 update of the Beers Criteria heralds a newpartnership with the American Geriatrics Society (AGS).This partnership allows for regular, transparent, systematicupdates and support for the wider input and disseminationof the criteria by expert clinicians for their use in research,policy, and practice. To keep this tool relevant, theupdated 2012 AGS Beers Criteria must be current withother methods for determining best-practice guidelines. Arigorous systematic review was performed to update andexpand the criteria. As in the past, this update will catego-rize PIMs into two broad groups: medications to avoid inolder adults regardless of diseases or conditions and medi-cations considered potentially inappropriate when used inolder adults with certain diseases or syndromes. A thirdgroup, medications that should be used with caution, hasbeen added. Medications in this group were initially con-sidered for inclusion as PIMs. In these cases, the consensusview of the panel (described below) was that there were asufficient number of plausible reasons why use of the drugin certain individuals would be appropriate but that thepotential for misuse or harm is substantial and thus meritsan extra level of caution in prescribing. In some cases,these medications were new to the market, and evidencewas still emerging.

OBJECTIVES

The specific aim is to:Update the previous Beers Criteria using a comprehen-

sive, systematic review and grading of the evidence ondrug-related problems and ADEs in older adults.

The strategies to achieve this aim are to:

1. Incorporate new evidence on currently listed PIMs andevidence from new medications or conditions notaddressed in the previous (2003) update.

2. Grade the strength and quality of each PIM statementbased on level of evidence and strength of recom-mended grading.

3. Convene an interdisciplinary panel of 11 experts ingeriatric care and pharmacotherapy who will apply amodified Delphi method to the systematic review andgrading to reach consensus on the updated 2012 AGSBeers Criteria.

4. Incorporate needed exceptions into the criteria asdeemed clinically appropriate by the panel. These evi-dence-based exceptions will be designed to make thecriteria more individualized to clinical care and morerelevant across settings of care.

INTENT OF CRITERIA

The 2012 AGS Beers Criteria are intended for use in allambulatory and institutional settings of care for popula-tions aged 65 and older in the United States. The primarytarget audience is the practicing clinician. Researchers,pharmacy benefit managers, regulators, and policy-makersalso use the criteria widely. The intentions of the criteriainclude improving the selection of prescription drugs byclinicians and patients, evaluating patterns of drug usewithin populations, educating clinicians and patients onproper drug usage, and evaluating health-outcome, qualityof care, cost, and utilization data.

The goal of the 2012 AGS Beers Criteria is to improvecare of older adults by reducing their exposure to PIMs.This is accomplished by their use as an educational tooland a quality measuretwo uses that are not always inagreement. These criteria are not meant to be applied in apunitive manner. Prescribing decisions are not always clearcut, and clinicians must consider multiple factors. Qualitymeasures must be clearly defined, easily applied, and mea-sured with limited information. The panel considered bothroles during deliberations. The panels review of evidenceat times identified subgroups of individuals who should beexempt from the criteria or for whom only a specific crite-rion applies. Such a criterion may not be easily applied asa quality measure. These applications were balanced withthe needs and complexities of the individual. The panel feltthat a criterion could not be expanded to include all adultsaged 65 and older when only individuals with specificcharacteristics may benefit or be at greater risk of harm.

METHODS

For this new update, the AGS employed a well-testedframework that has long been used for development ofclinical practice guidelines.6,2123 Specifically, the frame-work involved the appointment of an 11-member interdis-ciplinary expert panel with relevant clinical expertise andexperience and an understanding of how the criteria havebeen previously used. To ensure that potential conflicts ofinterest are disclosed and addressed appropriately, panel-ists disclosed potential conflicts of interest with the panelat the beginning. Each panelists potential conflict of inter-

2 AMERICAN GERIATRICS SOCIETY 2012 JAGS

ests are provided toward the end of this article. Thisframework also involved a development process thatincluded a systematic literature review and evaluation ofthe evidence base by the expert panel. Finally, the Instituteof Medicines 2011 report on developing practice guide-lines,23 which included a period for public comments,guided the framework. These three framework principlesare described in greater detail below.

Literature Search

The literature from December 1, 2001 (the end of the pre-vious panels search) to March 30, 2011, was searched toidentify published systematic reviews and meta-analysesthat were relevant to the project. Search terms includedadverse drug reactions, adverse drug events, medicationproblems, polypharmacy, inappropriate drug use, subopti-mal drug therapy, drug monitoring, pharmacokinetics,drug interactions, and medication errors. Terms weresearched alone and in combination. Search limits includedhuman subjects, English language, and aged 65 and older.Data sources for the initial search included Medline, theCochrane Library (Cochrane Database of SystematicReviews), International Pharmaceutical abstracts, andreferences lists of selected articles that the panel co-chairsidentified.

The initial search identified 25,549 citations, of which6,505 were selected for preliminary review. The panel co-chairs reviewed 2,267 citations, of which 844 were excludedfor not meeting the study purpose or not containing primarydata. An additional search was conducted with theadditional terms drugdrug and drugdisease interactions,pharmacoepidemiology, drug safety, geriatrics, and elderlyprescribing. An additional search for randomized clinical tri-als and postmarketing and observational studies publishedbetween 2009 and 2011 was conducted using terms relatedto major drug classes and conditions, delimited by more-general topics (e.g., adverse drug reactions, Beers Criteria,suboptimal prescribing, and interventions). Previoussearches were used to develop additional terms to be

included in subsequent searches, such as a list ofauthors whose work was relevant to the goals of the project.When evidence was sparse on older medications, searcheswere conducted on drug class and individual medicationnames and included older search dates for these drugs. Theco-chairs continually reviewed the updated search resultsfor articles that might be relevant to the project. Panelistswere also asked to forward pertinent citations that might beuseful for revising the previous Beers Criteria or supportingadditions to them.

At the time of the panels face-to-face meeting, the co-chairs had selected 2,169 unduplicated citations for the fullpanel review. This total included 446 systematic reviews ormeta-analyses, 629 randomized controlled trials, and 1,094observational studies. Additional articles were found in amanual search of the reference lists of identified articlesand the panelists files, book chapter, and recent reviewarticles, with 258 citations selected for the final evidencetables to support the list of drugs to avoid.

Panel Selection

After consultation with the AGS, the co-chairs identifiedprospective panel members with recognized expertise ingeriatric medicine, nursing, pharmacy practice, research,and quality measures. Other factors that influenced selec-tion were the desire to have interdisciplinary representa-tion, a range of medical specialties, and representationfrom different practice settings (e.g., long-term care, ambu-latory care, geriatric mental health, palliative care and hos-pice). In addition to the 11-member panel, representativesfrom CMS, NCQA, and PQA were invited to serve as ex-officio members.

Each expert panel member completed a disclosureform that was shared with the entire panel before the pro-cess began. Potential conflicts of interest were resolved bythe panel co-chairs and were available during the opencomment period. Panel members who disclosed affiliationsor financial interests with commercial entities are listedunder the disclosures section of this article.

Table 1. Designations of Quality and Strength of Evidence

Designation Description

Quality of evidenceHigh Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess

effects on health outcomes ( 2 consistent, higher-quality randomized controlled trials or multiple, consistent observationalstudies with no significant methodological flaws showing large effects)

Moderate Evidence is sufficient to determine effects on health outcomes, but the number, quality, size, or consistency of included studies;generalizability to routine practice; or indirect nature of the evidence on health outcomes ( 1 higher-quality trial with > 100participants; 2 higher-quality trials with some inconsistency; 2 consistent, lower-quality trials; or multiple, consistentobservational studies with no significant methodological flaws showing at least moderate effects) limits the strength of theevidence

Low Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplainedinconsistency between higher-quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack ofinformation on important health outcomes

Strength of recommendationStrong Benefits clearly outweigh risks and burden OR risks and burden clearly outweigh benefitsWeak Benefits finely balanced with risks and burdenInsufficient Insufficient evidence to determine net benefits or risks

JAGS 2012 AMERICAN GERIATRICS SOCIETY UPDATED BEERS CRITERIA 3

Table 2. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in OlderAdults

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 ofcombination products)

BrompheniramineCarbinoxamineChlorpheniramineClemastineCyproheptadineDexbrompheniramineDexchlorpheniramineDiphenhydramine (oral)DoxylamineHydroxyzinePromethazineTriprolidine

Highly anticholinergic; clearancereduced with advanced age, andtolerance develops when used ashypnotic; greater risk ofconfusion, dry mouth,constipation, and otheranticholinergic effects and toxicity.Use of diphenhydramine in specialsituations such as acute treatmentof severe allergic reaction may beappropriate

Avoid Hydroxyzineandpromethazine:high;All others:moderate

Strong

Antiparkinson agentsBenztropine (oral)Trihexyphenidyl

Not recommended for preventionof extrapyramidal symptoms withantipsychotics; more-effectiveagents available for treatmentof Parkinson disease

Avoid Moderate Strong

AntispasmodicsBelladonna alkaloidsClidinium-chlordiazepoxideDicyclomineHyoscyaminePropanthelineScopolamine

Highly anticholinergic, uncertaineffectiveness

Avoid except inshort-term palliativecare to decreaseoral secretions

Moderate Strong

AntithromboticsDipyridamole, oral short acting*(does not apply to extended-release combination with aspirin)

May cause orthostatichypotension; more-effectivealternatives available; intravenousform acceptable for use in cardiacstress testing


Ticlopidine* Safer effective alternativesavailable


Anti-infectiveNitrofurantoin Potential for pulmonary toxicity;

safer alternatives available; lackof efficacy in patients withCrCl < 60 mL/min due toinadequate drug concentrationin the urine

Avoid for long-termsuppression; avoid inpatients withCrCl < 60 mL/min

Moderate Strong

CardiovascularAlpha1 blockers

DoxazosinPrazosinTerazosin

High risk of orthostatichypotension; not recommended asroutine treatment for hypertension;alternative agents have superiorrisk/benefit profile

Avoid use as anantihypertensive

Moderate Strong

Alpha agonists, centralClonidineGuanabenz*Guanfacine*Methyldopa*Reserpine (> 0.1 mg/d)*

High risk of adverse CNS effects;may cause bradycardia andorthostatic hypotension; notrecommended as routinetreatment for hypertension

Avoid clonidine asa first-lineantihypertensive.Avoid others as listed

Low Strong

(Continued)


Table 2. (Contd.)



Quality of

Evidence

Strength of

Recommendation

Antiarrhythmic drugs (Class Ia, Ic,III)

AmiodaroneDofetilideDronedaroneFlecainideIbutilideProcainamidePropafenoneQuinidineSotalol

Data suggest that rate controlyields better balance of benefitsand harms than rhythm control formost older adults.Amiodarone is associated withmultiple toxicities, includingthyroid disease, pulmonarydisorders, and QT- intervalprolongation

Avoid antiarrhythmicdrugs as first-linetreatment of atrialfibrillation

High Strong

Disopyramide* Disopyramide is a potent negativeinotrope and therefore may induceheart failure in older adults;strongly anticholinergic; otherantiarrhythmic drugs preferred

Avoid Low Strong

Dronedarone Worse outcomes have beenreported in patients takingdronedarone who have permanentatrial fibrillation or heart failure. Ingeneral, rate control is preferredover rhythm control for atrialfibrillation

Avoid in patients withpermanent atrialfibrillation or heartfailure

Moderate Strong

Digoxin > 0.125 mg/d In heart failure, higher dosagesassociated with no additionalbenefit and may increase risk oftoxicity; slow renal clearance maylead to risk of toxic effects


Nifedipine, immediate release* Potential for hypotension; risk ofprecipitating myocardial ischemia

Avoid High Strong

Spironolactone > 25 mg/d In heart failure, the risk ofhyperkalemia is higher in olderadults especially if taking> 25 mg/d or taking concomitantNSAID, angiotensinconverting-enzyme inhibitor,angiotensin receptor blocker, orpotassium supplement

Avoid in patients withheart failure or witha CrCl < 30 mL/min

Moderate Strong

Central nervous systemTertiary TCAs, alone or incombination:

AmitriptylineChlordiazepoxide-amitriptylineClomipramineDoxepin > 6 mg/dImipraminePerphenazine-amitriptylineTrimipramine

Highly anticholinergic, sedating,and cause orthostatic hypotension;safety profile of low-dose doxepin( 6 mg/d) is comparable withthat of placebo

Avoid High Strong

Antipsychotics, first (conventional)and second (atypical) generation(see Table 8 for full list)

Increased risk of cerebrovascularaccident (stroke) and mortality inpersons with dementia

Avoid use for behavioralproblems of dementiaunlessnonpharmacologicaloptions have failed andpatient is threat to selfor others

Moderate Strong

ThioridazineMesoridazine

Highly anticholinergic and risk ofQT-interval prolongation


(Continued)


Table 2. (Contd.)



Quality of

Evidence

Strength of

Recommendation

BarbituratesAmobarbital*Butabarbital*ButalbitalMephobarbital*Pentobarbital*PhenobarbitalSecobarbital*

High rate of physical dependence;tolerance to sleep benefits; risk ofoverdose at low dosages

Avoid High Strong

BenzodiazepinesShort and intermediate acting:

AlprazolamEstazolamLorazepamOxazepamTemazepamTriazolam

Long acting:ClorazepateChlordiazepoxideChlordiazepoxide-amitriptylineClidinium-chlordiazepoxideClonazepamDiazepamFlurazepamQuazepam

Older adults have increasedsensitivity to benzodiazepines andslower metabolism of long-actingagents. In general, allbenzodiazepines increase risk ofcognitive impairment, delirium,falls, fractures, and motor vehicleaccidents in older adultsMay be appropriate for seizuredisorders, rapid eye movementsleep disorders, benzodiazepinewithdrawal, ethanol withdrawal,severe generalized anxietydisorder, periproceduralanesthesia, end-of-life care

Avoid benzodiazepines(any type) for treatmentof insomnia, agitation,or delirium

High Strong

Chloral hydrate* Tolerance occurs within 10 days,and risks outweigh benefits inlight of overdose with doses only3 times the recommended dose

Avoid Low Strong

Meprobamate High rate of physical dependence;very sedating


Nonbenzodiazepine hypnoticsEszopicloneZolpidemZaleplon

Benzodiazepine-receptor agoniststhat have adverse events similar tothose of benzodiazepines in olderadults (e.g., delirium, falls,fractures); minimal improvementin sleep latency and duration

Avoid chronic use(> 90 days)

Moderate Strong

Ergot mesylates*Isoxsuprine*

Lack of efficacy Avoid High Strong

EndocrineAndrogens

Methyltestosterone*Testosterone

Potential for cardiac problems andcontraindicated in men withprostate cancer

Avoid unless indicatedfor moderate to severehypogonadism

Moderate Weak

Desiccated thyroid Concerns about cardiac effects;safer alternatives available

Avoid Low Strong

Estrogens with or withoutprogestins

Evidence of carcinogenic potential(breast and endometrium); lack ofcardioprotective effect andcognitive protection in olderwomenEvidence that vaginal estrogensfor treatment of vaginal dryness issafe and effective in women withbreast cancer, especially atdosages of estradiol < 25 lgtwice weekly

Avoid oral and topicalpatch.Topical vaginal cream:acceptable to uselow-dose intravaginalestrogen for themanagement ofdyspareunia, lowerurinary tract infections,and other vaginalsymptoms

Oral and patch:highTopical:moderate

Oral and patch: strongTopical: weak

Growth hormone Effect on body composition issmall and associated with edema,arthralgia, carpal tunnel syndrome,gynecomastia, impaired fastingglucose

Avoid, except ashormone replacementafter pituitary glandremoval

High Strong

(Continued)


Table 2. (Contd.)



Quality of

Evidence

Strength of

Recommendation

Insulin, sliding scale Higher risk of hypoglycemiawithout improvement inhyperglycemia managementregardless of care setting


Megestrol Minimal effect on weight;increases risk of thromboticevents and possibly death in olderadults


Sulfonylureas, long durationChlorpropamideGlyburide

Chlorpropamide: prolongedhalf-life in older adults; can causeprolonged hypoglycemia; causessyndrome of inappropriateantidiuretic hormone secretion.Glyburide: greater risk of severeprolonged hypoglycemia in olderadults

Avoid High Strong

GastrointestinalMetoclopramide Can cause extrapyramidal effects

including tardive dyskinesia; riskmay be even greater in frail olderadults

Avoid, unless forgastroparesis

Moderate Strong

Mineral oil, oral Potential for aspiration andadverse effects; safer alternativesavailable


Trimethobenzamide One of the least effectiveantiemetic drugs; can causeextrapyramidal adverse effects


PainMeperidine Not an effective oral analgesic in

dosages commonly used; maycause neurotoxicity; saferalternatives available

Avoid High Strong

NonCOX-selective NSAIDs, oralAspirin > 325 mg/dDiclofenacDiflunisalEtodolacFenoprofenIbuprofenKetoprofenMeclofenamateMefenamic acidMeloxicamNabumetoneNaproxenOxaprozinPiroxicamSulindacTolmetin

Increases risk of GI bleeding andpeptic ulcer disease in high-riskgroups, including thoseaged > 75 or taking oral orparenteral corticosteroids,anticoagulants, or antiplateletagents. Use of proton pumpinhibitor or misoprostol reducesbut does not eliminate risk. UpperGI ulcers, gross bleeding, orperforation caused by NSAIDsoccur in approximately 1% ofpatients treated for 36 monthsand in approximately 24% ofpatients treated for 1 year. Thesetrends continue with longerduration of use

Avoid chronic useunless other alternativesare not effective andpatient can takegastroprotective agent(proton pump inhibitoror misoprostol)

Moderate Strong

IndomethacinKetorolac, includes parenteral

Increases risk of GI bleeding andpeptic ulcer disease in high-riskgroups. (See above Non-COXselective NSAIDs.)Of all the NSAIDs, indomethacinhas most adverse effects

Avoid Indomethacin:moderateKetorolac: high

Strong

(Continued)


Development Process

The co-chairs and AGS staff edited the survey used in theprevious Beers Criteria development process, excludingproducts no longer marketed. The resulting survey hadthree parts: medications currently listed as potentiallyinappropriate for older adults independent of diseases orconditions, medications currently listed as potentially inap-propriate when used in older adults with certain diseasesor conditions, and new submissions from the panel. Eachpanelist was asked to complete the survey using a 5-pointLikert scale ranging from strongly agree to strongly dis-agree (or no opinion). Ratings were tallied and returned tothe panel along with each panelists original ratings. Twoconference calls allowed for review of survey ratings,discussion, and consensus building.

The panel convened for a 2-day in-person meeting onAugust 2 and 3, 2011, to review the second draft of thesurvey and the results of the literature search. Panel discus-sions were used to define terms and to address questionsof consistency, the inclusion of infrequently used drugs,the best strategies for evaluating the evidence, and the con-solidation or expansion of individual criterion. The panelthen split into four groups, with each assigned a specificset of criteria for evaluation. Groups were assigned as clo-sely as possible according to specific area of clinical exper-tise (e.g., cardiovascular, central nervous system). Groupsreviewed the literature search, selected citations relevant totheir assigned criteria, and determined which citationsshould be included in an evidence table. During thisprocess, panelists were provided copies of abstracts and full-text articles. The groups then presented their findings to thefull panel for comment and consensus. After the meeting,each group met in a conference call to resolve any questionsor to include additional supporting literature.

An independent researcher prepared evidence tables,which were distributed to the four criteria-specific groups.

Each panelist independently rated the quality of evidenceand strength of recommendation for each criterion usingthe American College of Physicians Guideline GradingSystem24 (Table 1), which is based on the Grades ofRecommendation Assessment, Development, and Evalua-tion (GRADE) scheme developed previously.25 AGS staffcompiled the panelist ratings for each group and returnedthem to that group, which then reached consensus in con-ference call. Additional literature was obtained andincluded as needed. When group consensus could not bereached, the full panel reviewed the ratings and workedthrough any differences until they reached consensus. Forsome criteria, the panel provided a strong recommenda-tion even though the quality of evidence was low or mod-erate. In such cases, the strength of recommendation wasbased on potential severity of harm and the availability oftreatment alternatives.

RESULTS

Fifty-three medications or medication classes encompassthe final updated 2012 AGS Beers Criteria, which aredivided into three categories (Tables 24). Tables wereconstructed and organized according to major therapeuticclasses and organ systems.

Table 2 shows the 34 potentially inappropriate medi-cations and classes to avoid in older adults. Notable newadditions include megestrol, glyburide, and sliding-scaleinsulin.

Table 3 summarizes potentially inappropriate medica-tions and classes to avoid in older adults with certain dis-eases and syndromes that the drugs listed can exacerbate.Notable new inclusions are thiazolidinediones or glitazoneswith heart failure, acetylcholinesterase inhibitors with his-tory of syncope, and selective serotonin reuptake inhibitorswith falls and fractures.

Table 2. (Contd.)



Quality of

Evidence

Strength of

Recommendation

Pentazocine* Opioid analgesic that causes CNSadverse effects, includingconfusion and hallucinations, morecommonly than other narcoticdrugs; is also a mixed agonist andantagonist; safer alternativesavailable

Avoid Low Strong

Skeletal muscle relaxantsCarisoprodolChlorzoxazoneCyclobenzaprineMetaxaloneMethocarbamolOrphenadrine

Most muscle relaxants are poorlytolerated by older adults becauseof anticholinergic adverse effects,sedation, risk of fracture;effectiveness at dosages toleratedby older adults is questionable


The primary target audience is the practicing clinician. The intentions of the criteria are to improve the selection of prescription drugs by clinicians and

patients; evaluate patterns of drug use within populations; educate clinicians and patients on proper drug usage; and evaluate health-outcome, quality of

care, cost, and utilization data.

* Infrequently used drugs.

CNS = central nervous system; COX = cyclooxygenase; CrCl = creatinine clearance; GI = gastrointestinal; NSAID = nonsteroidal anti-inflammatory drug;TCA = tricyclic antidepressant.Correction made after online publication February 29, 2012: Table 2 has been updated.


Table 3. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in OlderAdults Due to DrugDisease or DrugSyndrome Interactions That May Exacerbate the Disease or Syndrome

Disease or

Syndrome Drug Rationale Recommendation

Quality of

Evidence

Strength of

Recommendation

CardiovascularHeart failure NSAIDs and COX-2 inhibitors

Nondihydropyridine CCBs (avoidonly for systolic heart failure)

DiltiazemVerapamil

Pioglitazone, rosiglitazoneCilostazolDronedarone

Potential to promotefluid retention andexacerbate heartfailure

Avoid NSAIDs: moderateCCBs: moderateThiazolidinediones(glitazones): highCilostazol: lowDronedarone:moderate

Strong

Syncope AChEIsPeripheral alpha blockers

DoxazosinPrazosinTerazosin

Tertiary TCAsChlorpromazine, thioridazine, andolanzapine

Increases risk oforthostatic hypotensionor bradycardia

Avoid Alpha blockers:highTCAs, AChEIs, andantipsychotics:moderate

AChEIs and TCAs:strongAlpha blockersandantipsychotics:weak

Central nervous systemChronicseizuresor epilepsy

BupropionChlorpromazineClozapineMaprotilineOlanzapineThioridazineThiothixeneTramadol

Lowers seizurethreshold; may beacceptable in patientswith well-controlledseizures in whomalternative agents havenot been effective


Delirium All TCAsAnticholinergics (see Table 9for full list)BenzodiazepinesChlorpromazineCorticosteroidsH2-receptor antagonistMeperidineSedative hypnoticsThioridazine

Avoid in older adultswith or at high risk ofdelirium because ofinducing or worseningdelirium in older adults;if discontinuing drugsused chronically, taperto avoid withdrawalsymptoms


Dementia andcognitiveimpairment

Anticholinergics (see Table 9for full list)BenzodiazepinesH2-receptor antagonistsZolpidemAntipsychotics, chronic andas-needed use

Avoid because ofadverse CNS effects.Avoid antipsychotics forbehavioral problems ofdementia unlessnonpharmacologicaloptions have failed, andpatient is a threat tothemselves or others.Antipsychotics areassociated with anincreased risk ofcerebrovascularaccident (stroke) andmortality in personswith dementia

Avoid High Strong

History offalls orfractures

AnticonvulsantsAntipsychoticsBenzodiazepinesNonbenzodiazepine hypnotics

EszopicloneZaleplonZolpidem

TCAs and selectiveserotonin reuptake inhibitors

Ability to produceataxia, impairedpsychomotor function,syncope, and additionalfalls; shorter-actingbenzodiazepines are notsafer than long-actingones

Avoid unless saferalternatives are notavailable; avoidanticonvulsantsexcept for seizuredisorders

High Strong

(Continued)


Table 3. (Contd.)

Disease or


Quality of

Evidence

Strength of

Recommendation

Insomnia Oral decongestantsPseudoephedrinePhenylephrine

StimulantsAmphetamineMethylphenidatePemoline

TheobrominesTheophyllineCaffeine

CNS stimulant effects Avoid Moderate Strong

Parkinsonsdisease

All antipsychotics (see Table 8 forfull list, except for quetiapineand clozapine)Antiemetics

MetoclopramideProchlorperazinePromethazine

Dopamine receptorantagonists withpotential to worsenparkinsonian symptoms.Quetiapine andclozapine appear to beless likely to precipitateworsening ofParkinson's disease


GastrointestinalChronicconstipation

Oral antimuscarinics for urinaryincontinence

DarifenacinFesoterodineOxybutynin (oral)SolifenacinTolterodineTrospium

Nondihydropyridine CCBDiltiazemVerapamil

First-generation antihistamines assingle agent or part ofcombination products

Brompheniramine (various)CarbinoxamineChlorpheniramineClemastine (various)CyproheptadineDexbrompheniramineDexchlorpheniramine (various)DiphenhydramineDoxylamineHydroxyzinePromethazineTriprolidine

Anticholinergics andantispasmodics (see Table 9for full list of drugs with stronganticholinergic properties)

AntipsychoticsBelladonna alkaloidsClidinium-chlordiazepoxideDicyclomineHyoscyaminePropanthelineScopolamineTertiary TCAs (amitriptyline,clomipramine, doxepin,imipramine, and trimipramine)

Can worsenconstipation; agents forurinary incontinence:antimuscarinics overalldiffer in incidence ofconstipation; responsevariable; consideralternative agent ifconstipation develops

Avoid unless noother alternatives

For urinaryincontinence: highAll others:Moderate to low

Weak

(Continued)


Table 4 lists medications to be used with caution inolder adults. Fourteen medications and classes were cate-gorized. Two of these involve recently marketed anti-thrombotics for which early evidence suggests caution foruse in adults aged 75 and older.

Table 5 is a summary of medications that were movedto another category or modified since the last update, andTables 6 and 7 summarize medications that were removedor added since the last update. Nineteen medications andmedication classes were dropped from the 2003 to the2012 update of the criteria based on consensus of thepanel and evidence or a rationale to justify their exclusionfrom the list. In several cases, medications were removedbecause they had been taken off the U.S. market since the2003 update (e.g., propoxyphene) or because of insuffi-cient or new evidence that was evaluated by the panel(e.g., ethacrynic acid). Table 8 includes a list of theantipsychotics included in the statements. Table 9 is thelist of anticholinergic medications to be avoided in olderadults compiled from drugs rated as having strong anticho-linergic properties in the Anticholinergic Risk Scale,26

Anticholinergic Drug Scale,27 and Anticholinergic BurdenScale.28

DISCUSSION

The 2012 AGS Beers Criteria is an important andimproved update of previously established criteria widely

used by healthcare providers, educators, and policy-makersand as a quality measure. Previously, as many as 40% ofolder adults received one or more medications on this list,depending on the care setting.2931 The new criteria arebased upon methods for determining best-practice guide-lines that included a rigorous systematic literature review,the use of an expert consensus panel, and grading of thestrength of evidence and recommendations.

The updated criteria should be viewed as a guidelinefor identifying medications for which the risks of their usein older adults outweigh the benefits. The medications thathave a high risk of toxicity and adverse effects in olderadults and limited effectiveness, and all medications inTable 2 (Independent of Diagnosis or Condition) shouldbe avoided in favor of an alternative safer medication or anondrug approach. The drugdisease or syndrome inter-actions summarized in Table 3 are particularly importantin the care of older adults because they often take multiplemedications for multiple comorbidities. Their occurrencemay have greater consequences in older adults because ofage-related decline in physiological reserve. Recent studiesin which drugdisease interactions have been shown to beimportant risk factors for ADEs highlight their impor-tance.32

This list is not meant to supersede clinical judgmentor an individual patients values and needs. Prescribingand managing disease conditions should be individualizedand involve shared decision-making. The historical lack of

Table 3. (Contd.)

Disease or


Quality of

Evidence

Strength of

Recommendation

History of gastricor duodenalulcers

Aspirin (>325 mg/d)NonCOX-2 selective NSAIDs

May exacerbate existingulcers or cause newor additional ulcers

Avoid unless otheralternatives are noteffective and patientcan takegastroprotectiveagent(proton pumpinhibitoror misoprostol)

Moderate Strong

Kidney and urinary tractChronic kidneydisease StagesIV and V

NSAIDsTriamterene (alone or incombination)

May increase risk ofkidney injury

Avoid NSAIDs: moderateTriamterene: low

NSAIDs: strongTriamterene: weak

Urinaryincontinence(all types)in women

Estrogen oral and transdermal(excludes intravaginal estrogen)

Aggravation ofincontinence

Avoid in women High Strong

Lower urinarytract symptoms,benign prostatichyperplasia

Inhaled anticholinergic agentsStrongly anticholinergic drugs,except antimuscarinics for urinaryincontinence (see Table 9for complete list)

May decrease urinaryflow and causeurinary retention

Avoid in men Moderate Inhaled agents:strongAll others: weak

Stress or mixedurinaryincontinence

Alpha blockersDoxazosinPrazosinTerazosin

Aggravation ofincontinence

Avoid in women Moderate Strong




CCB = calcium channel blocker; AChEI = acetylcholinesterase inhibitor; CNS = central nervous system; COX = cyclooxygenase; NSAID = nonsteroidalanti-inflammatory drug; TCA = tricyclic antidepressant.


inclusion of many older adults in drug trials3335 and therelated lack of alternatives in some individual instancesfurther complicate medication use in older adults. Theremay be cases in which the healthcare provider determinesthat a drug on the list is the only reasonable alternative(e.g., end-of-life or palliative care). The panel hasattempted to evaluate the literature and best-practiceguidelines to cover as many of these instances as possible,but not all possible clinical situations can be anticipated insuch a broad undertaking. In these cases, the list can beused clinically not only for prescribing medications, but

also for monitoring their effects in older adults. If a pro-vider is not able to find an alternative and chooses to con-tinue to use a drug on this list in an individual patient,designation of the medication as potentially inappropriatecan serve as a reminder for close monitoring so that ADEscan be incorporated into the electronic health record andprevented or detected early. These criteria also underscorethe importance of using a team approach to prescribing,of the use of nonpharmacological approaches, and ofhaving economic and organizational incentives for thistype of model.

Table 4. 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications to Be Usedwith Caution in Older Adults

Drug Rationale Recommendation

Quality

of

Evidence

Strength of

Recommendation

Aspirin for primaryprevention of cardiac events

Lack of evidence of benefit versus risk inindividuals aged 80

Use with caution in adultsaged 80

Low Weak

Dabigatran Greater risk of bleeding than withwarfarin in adults aged 75; lack ofevidence for efficacy and safety inindividuals with CrCl < 30 mL/min

Use with caution in adultsaged 75 or if CrCl < 30 mL/min

Moderate Weak

Prasugrel Greater risk of bleeding in older adults;risk may be offset by benefit inhighest-risk older adults (e.g., with priormyocardial infarction or diabetesmellitus)

Use with caution in adultsaged 75

Moderate Weak

AntipsychoticsCarbamazepineCarboplatinCisplatinMirtazapineSerotoninnorepinephrinereuptake inhibitorSelective serotoninreuptake inhibitorTricyclic antidepressantsVincristine

May exacerbate or cause syndrome ofinappropriate antidiuretic hormonesecretion or hyponatremia; need tomonitor sodium level closely whenstarting or changing dosages in olderadults due to increased risk

Use with caution Moderate Strong

Vasodilators May exacerbate episodes of syncope inindividuals with history of syncope

Use with caution Moderate Weak




CrCl = creatinine clearance.

Table 5. Medications Moved to Another Category or Modified Since 2003 Beers Criteria

Independent of Diagnoses or Condition Considering Diagnoses

Amphetamines (excluding methylphenidate hydrochloride and anorexics) Fluoxetine, citalopram, fluvoxamine, paroxetine, and sertraline withsyndrome of inappropriate antidiuretic hormone secretion

All barbiturates (except phenobarbital) except when used to control seizures Olanzapine with obesityNaproxen, oxaprozin, and piroxicam Vasodilators with syncopeNitrofurantoinNon-cyclooxygenase selective nonsteroidal anti-inflammatory drugs(excludes topical)Oral short-acting dipyridamole; does not apply to the extended-releasecombination with aspirinOxybutyninReserpine in doses >0.25 mg


These criteria have some limitations. First, eventhough older adults are the largest consumers of medica-tion, they are often underrepresented in drug trials.33,35

Thus, using an evidence-based approach may underesti-mate some drug-related problems or lead to a weakerevidence grading. As stated previously, the intent of theupdated 2012 AGS Beers Criteria, as an educational tooland quality measure, is to improve the care of olderadults by reducing their exposure to PIMs. Second, itdoes not address other types of potential PIMs that arenot unique to aging (e.g., dosing of primarily renallycleared medications, drugdrug interactions, therapeuticduplication). Third, it does not comprehensively addressthe needs of individuals receiving palliative and hospicecare, in whom symptom control is often more importantthan avoiding the use of PIMs. Finally, the search strate-gies used might have missed some studies published inlanguages other than English and studies available inunpublished technical reports, white papers, or othergray literature sources.

Regardless, this update has many strengths, includingthe use of an evidence-based approach using the Instituteof Medicine standards and the development of a partner-ship to regularly update the criteria. Thoughtful applica-tion of the criteria will allow for closer monitoring of druguse, application of real-time e-prescribing and interven-tions to decrease ADEs in older adults, and better patientoutcomes. Regular updates will allow for the evidence formedications on the list to be assessed routinely, making itmore relevant and sensitive to patient outcomes, with thegoal of evaluating and managing drug use in older adultswhile considering the dynamic complexities of the health-care system.

PANEL MEMBERS AND AFFILIATIONS

The following individuals were members of the AGS Panelto update the 2012 AGS Beers Criteria: Donna Fick, PhD,RN, FGSA, FAAN, School of Nursing and College ofMedicine, Department of Psychiatry, Pennsylvania State

University, University Park, PA (co-chair); Todd Semla,PharmD, MS, BCPS, FCCP, AGSF, U.S. Department ofVeterans Affairs National Pharmacy Benefits ManagementServices and Northwestern University, Chicago, IL (co-chair); Judith Beizer, PharmD, CGP, FASCP, St. JohnsUniversity, New York, NY; Nicole Brandt, PharmD,BCPP, CGP, University of Maryland, Baltimore, MD; Rob-ert Dombrowski, PharmD, Centers for Medicare and Med-icaid Services, Baltimore, MD (nonvoting member);Catherine E. DuBeau, MD, University of MassachusettsMedical School, Worcester, MA; Nina Flanagan, CRNP,CS-BC, Binghamton University, Dunmore, PA; JosephHanlon, PharmD, MS, BCPS, FASHP, FASCP, FGSA,AGSF, Department of Medicine (Geriatric Medicine)School of Medicine, University of Pittsburgh and GeriatricEducation and Research and Clinical Center, VeteransAdministration Health System, Pittsburgh, PA; Peter Holl-mann, MD, AGSF, Blue Cross Blue Shield of RhodeIsland, Cranston, RI; Sunny Linnebur, PharmD, FCCP,BCPS, CGP, Skaggs School of Pharmacy and Pharmaceuti-cal Sciences, University of Colorado, Aurora, CO; DavidNau, PhD, RPh, CPHQ, Pharmacy Quality Alliance, Inc,Baltimore, MD (nonvoting member); Bob Rehm, NationalCommittee for Quality Assurance, Washington, DC (non-voting member); Satinderpal Sandhu, MD, MetroHealthMedical Center and Case Western Reserve UniversitySchool of Medicine, Cleveland, OH; Michael Steinman,MD, University of California at San Francisco and SanFrancisco Veterans Affairs Medical Center, San Francisco,CA.

ACKNOWLEDGMENTS

The decisions and content of the 2012 AGS Beers Criteriaare those of the AGS and the panelists and are not neces-sarily those of the U.S. Department of Veterans Affairs.

Sue Radcliff, Independent Researcher, Denver, Colo-rado, provided research services. Susan E. Aiello, DVM,ELS, provided editorial services. Christine Campanelli andElvy Ickowicz, MPH, provided additional research and

Table 6. Medications Removed Since 2003 Beers Criteria

Independent of Diagnoses Considering Diagnoses

Cimetidine (H2 antihistamines added as aclass; see Table 7)

Antispasmodics and muscle relaxants; CNS stimulants: dextroamphetamine,methylphenidate, methamphetamine, pemoline, with cognitive impairment

Cyclandelate CNS stimulants: dextroamphetamine, methylphenidate, methamphetamine,pemoline, and fluoxetine with anorexia and malnutrition

Daily fluoxetine Clopidogrel with blood clotting disorders or receiving anticoagulant therapyFerrous sulfate >325 mg/d Guanethidine with depressionGuanadrel High-sodium content drugs with heart failureGuanethidine Monoamine oxidase inhibitors with insomniaHalazepam Oxybutynin and tolterodine with bladder outlet obstructionLong-term use of stimulant laxatives: bisacodyl,cascara sagrada, and neoloid except in thepresence of opiate analgesic use

Pseudoephedrine and diet pills with hypertension

Mesoridazine Tacrine with Parkinsons diseasePropoxyphene and combination productsTripelennamine

CNS = central nervous system.


administrative support. The development of this paper wassupported in part by an unrestricted grant from the JohnA. Hartford Foundation.

The following organizations with special interest andexpertise in the appropriate use of medications in olderadults provided peer review of a preliminary draft of thisguideline: American Academy of Family Physicians; Ameri-can Academy of Nurse Practitioners; American Academyof Nursing; American College of Clinical Pharmacy; Amer-ican College of Obstetrics and Gynecology; AmericanCollege of Physicians; American College of Surgeons;American Medical Association; American Medical Direc-tors Association; American Society of Anesthesiologists;American Society of Consultant Pharmacists; Centers forMedicare and Medicaid Services; Gerontological AdvancedPractice Nurses Association; Gerontological Society of

Table 7. Medications Added Since 2003 Beers Criteria

Independent of Diagnoses

Considering Diagnoses

Medication Corresponding Diagnosis or Syndrome

Aspirin for primary prevention of cardiac events Acetylcholinesterase inhibitors SyncopeAntiarrhythmic drugs, Class 1a, 1c, III Anticonvulsants History of falls or fracturesBelladonna alkaloids H1 and H2 antihistamines DeliriumBenztropine (oral) Aspirin >325 mg History of gastric or duodenal ulcersBrompheniramine Brompheniramine Chronic constipationCarbinoxamine Caffeine InsomniaChloral hydrate Carbamazepine SIADH or hyponatremiaClemastine Carbinoxamine Chronic constipationClomipramine Carboplatin SIADH or hyponatremiaClonazepam Clemastine (various) Chronic constipationDabigatran Clozapine Chronic seizures or epilepsyDesiccated thyroid Cisplatin SIADH or hyponatremiaDexbrompheniramine Cyclooxygenase-2 inhibitors Heart failureDoxylamine Darifenacin Chronic constipationDronedarone Desipramine Falls and fracturesEstazolam Dexbrompheniramine Chronic constipationEszopiclone Dexchlorpheniramine Chronic constipationFirst- and second-generation antipsychotics Doxylamine Chronic constipationFlurazepam Estrogen, transdermal Urinary incontinence (all types) in womenGlyburide Eszopiclone History of falls or fracturesGrowth hormone Fesoterodine Chronic constipationGuanabenz Inhaled anticholinergics Lower urinary tract symptoms and

benign prostatic hyperplasiaGuanfacine Maprotiline Chronic seizures or epilepsyInsulin, sliding scale Mirtazapine SIADH or hyponatremiaMegestrol Nondihydropyridine calcium channel blockers Heart failureMetoclopramide Nortriptyline Falls and fracturesOral doxepin >6 mg/d Pioglitazone Heart failurePhenobarbital Prochlorperazine Parkinson diseasePrasugrel Rosiglitazone Heart failurePrazosin Scopolamine Chronic constipationScopolamine Serotonin-norepinephrine reuptake inhibitors SIADH or hyponatremiaSpironolactone Solifenacin Chronic constipationTestosterone Thiothixene Chronic seizures or epilepsyTrihexyphenidyl Thioridazine SyncopeTrimipramine Triamterene Chronic kidney disease Stages IV and VTriprolidine Triprolidine Chronic constipationZaleplon Trospium Chronic constipationZolpidem Vincristine SIADH or hyponatremia

Zaleplon History of falls or fracturesZolpidem Dementia and cognitive impairment

SIADH = syndrome of inappropriate antidiuretic hormone secretion.

Table 8. First- and Second-Generation Antipsychotics

First-Generation

(Conventional) Agents

Second-Generation

(Atypical) Agents

Chlorpromazine AripiprazoleFluphenazine AsenapineHaloperidol ClozapineLoxapine IloperidoneMolindone LurasidonePerphenazine OlanzapinePimozide PaliperidonePromazine QuetiapineThioridazine RisperidoneThiothixene ZiprasidoneTrifluoperazineTriflupromazine


America; National Academies of Practice, Academy ofPharmacy; National Committee for Quality Assurance;Pharmacy Quality Alliance; Society for General InternalMedicine; Society of Hospital Medicine.

Conflict of Interest: Drs. Dombrowski, Flanagan,Hanlon, Hollmann, Rehm, Sandhu, and Steinman indi-cated no conflicts of interest. Dr. Beizer is an author andeditor for LexiComp, Inc. She is on the Pharmacy andTherapeutics Committee for Part D at Medco Health Solu-tions. Dr. Brandt is on the Pharmacy and TherapeuticsCommittees at Omnicare and receives grants from Talyst(research grant), Econometrics (research grant), HealthResources and Services Administration (educational grant),and the State of Maryland Office of Health Care Quality(educational grant). Dr. Dubeau serves as a consultant forPfizer, Inc. (urinary incontinence) and the New EnglandResearch Institute (nocturia). Dr. Fick is partially sup-ported by the National Institute of Health (NIH) forNational Institute of Nursing Research grants R01NR011042 and R01NR012242. Dr. Hanlon is supportedin part by National Institute on Aging grants and contracts(R01AG027017, P30AG024827, T32 AG021885,K07AG033174, R01AG034056), a National Institute ofNursing Research grant (R01 NR010135), and Agency forHealthcare Research and Quality grants (R01 HS017695,R01HS018721). Dr. Linnebur receives an honorarium forserving as a member of the Pharmacy and Therapeutics

Committee for Colorado Access (a health plan servingindigent children and adults and Medicare members). Dr.Nau works for the PQA, which has received demonstra-tion project grants from Pfizer, Inc., Merck & Co, Inc, sa-nofi-aventis, and GlaxoSmithKline. He also has held shareswith CardinalHealth in the past 12 months. Dr. Semlareceives honoraria from the AGS for his contribution as anauthor of Geriatrics at Your Fingertips and for serving asa Section Editor for the Journal of the American GeriatricsSociety. He is a past President and Chair of the AGSBoard of Directors. His spouse is an employee of AbbottLaboratories. He serves on the Omnicare Pharmacy andTherapeutics Committee. He is an author and editor forLexiComp, Inc.

Author Contributions: All panel members contributedto the concept, design, and preparation of the manuscript.

Sponsors Role: AGS staff participated in the finaltechnical preparation and submission of the manuscript.

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Table 9. Drugs with Strong Anticholinergic Properties

AntihistaminesBrompheniramineCarbinoxamineChlorpheniramineClemastineCyproheptadineDimenhydrinateDiphenhydramineHydroxyzineLoratadineMeclizine

Antiparkinson agentsBenztropineTrihexyphenidyl

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Antimuscarinics(urinary incontinence)

DarifenacinFesoterodineFlavoxateOxybutyninSolifenacinTolterodineTrospium

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