The American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults is a widely recognized and utilized tool in the healthcare community. The AGS Beers Criteria is regularly updated every 3-4 years to ensure its relevance and accuracy in guiding healthcare professionals in prescribing medications for individuals aged 65 and above.

The updates were conducted based on a thorough assessment of evidence and notable trends since the 2019 update. The criteria were adjusted to incorporate additions, deletions, and revisions that aim to improve clinical application and support shared decision-making. In order to enhance accessibility and user-friendliness, potentially inappropriate medications (PIMs) with low utilization or those no longer available in the United States were removed.

Furthermore, various organizational changes were implemented, such as reordering and grouping certain drugs in the tables, introducing a separate box summarizing anticoagulant use criteria, and including a table listing the removed PIMs. These modifications were made to streamline the information and make it easier for healthcare professionals to navigate and utilize the updated guidelines effectively.

In this installment of our Guidelines Timelines Series, we will look at the differences between the 2019 version of the Beers Criteria and the 2023 version. While we will not delve into every modification made in the updated version, we will focus on the key changes, particularly the significant ones. Without further delay, let us proceed with our review!

AGS Beers Criteria (2023 and 2019)

Major Changes & Key Takeaways: 2023 vs 2019

Medication Updates

  • Warfarin
    • Avoid as Initial Therapy: Warfarin is recommended to be avoided as initial therapy for the treatment of venous thromboembolism (VTE) and non-valvular atrial fibrillation (AF) due to the higher risk of bleeding.
    • Long-term Use: For older adults who have been using warfarin chronically with well-controlled international normalized ratio (INR) levels, continuation may be appropriate.
    • Preference for Alternatives: Direct oral anticoagulants (DOACs) are generally preferred over warfarin unless there are specific contraindications or substantial barriers to their use.
  • Aspirin
    • Primary Prevention: Aspirin should be avoided for the primary prevention of cardiovascular disease (CVD) in older adults due to the increased risk of bleeding.
    • Secondary Prevention: The use of aspirin may be appropriate for secondary prevention in older adults with established CVD.
  • Estrogen
    • Oral and Transdermal Estrogen: These forms of estrogen should be avoided in older women due to the increased risk of breast cancer and blood clots.
    • Topical Vaginal Estrogen: This form may be appropriate for treating vaginal atrophy and for urinary tract infection prophylaxis.
  • Rivaroxaban
    • Avoid Long-term Use: Rivaroxaban is now recommended to be avoided for the long-term treatment of non-valvular atrial fibrillation (AF) and venous thromboembolism (VTE) due to the higher risk of major bleeding and gastrointestinal bleeding.
    • Preferred Alternatives: Direct oral anticoagulants (DOACs) like apixaban (Eliquis) or dabigatran (Pradaxa) are generally preferred over rivaroxaban for initial treatment.
  • Antidepressants
    • Avoid Certain Antidepressants: Tricyclic antidepressants (TCAs) like amitriptyline, amoxapine, clomipramine, desipramine, and doxepin (at doses greater than 6 mg/day) should be avoided due to their strong anticholinergic properties, which can increase the risk of confusion, dry mouth, constipation, and other side effects.
    • Caution with SSRIs and SNRIs: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) should be used with caution in older adults, especially those with a history of falls or fractures, as they can increase the risk of hyponatremia (low sodium levels) and bleeding.
  • Antipsychotics
    • General Avoidance: Antipsychotics, both first and second generation, should generally be avoided in older adults due to the increased risk of stroke, cognitive decline, and mortality.
    • Exceptions: Antipsychotics may be considered if non-pharmacologic options have failed and the patient poses a substantial risk of harm to themselves or others.
    • Parkinson’s Disease: For older adults with Parkinson’s disease, quetiapine, clozapine, and pimavanserin are recognized as exceptions to the general recommendation to avoid antipsychotics.

Medication Removals

  • In the 2023 update, a total of 28 medications have been removed primarily due to low usage or lack of availability on the US market.

Deprescribing Guidance

  • The latest update places a greater focus on deprescribing strategies. The 2023 revision offers comprehensive guidance on the appropriate timing and methods for safely reducing or discontinuing medications that could potentially harm elderly patients. It underscores the significance of effective communication not only with the patient, but also with other healthcare providers and pharmacies.

Thank you for following along with our Guidelines Timelines Series on the American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults. We anticipate the release of the next update by AGS in 2026 or 2027. Sign up for alerts and stay informed on the latest published guidelines and future installments of our Guidelines Timelines.

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