You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


2019 Beers Criteria for Drug Use in the Elderly, Updated

  • Authors: News Author: Ricki Lewis, PhD; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 3/7/2019
  • Valid for credit through: 3/7/2020, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This article is intended for primary care clinicians, geriatricians, nurses, pharmacists, and other clinicians who care for older adults.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Distinguish the relationship between potentially inappropriate medication use among older adults and the risk for hospitalization
  • Assess medications that are potentially inappropriate for older adults
  • Outline implications to the healthcare team


As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

News Author

  • Ricki Lewis, PhD

    Freelance writer, Medscape, LLC


    Disclosure: Ricki Lewis, PhD, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Sunovion Pharmaceuticals Inc.
    Served as a speaker or a member of a speakers bureau for: Shire

Editor/CME Reviewer

  • Esther Nyarko, PharmD

    Associate CME Clinical Director, Medscape, LLC


    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Accreditation Statements


Interprofessional Continuing Education

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Contact This Provider

    For Nurses

  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

    Contact This Provider

    For Pharmacists

  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number JA0007105-0000-19-069-H01-P).

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit ™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.


2019 Beers Criteria for Drug Use in the Elderly, Updated

Authors: News Author: Ricki Lewis, PhD; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/7/2019

Valid for credit through: 3/7/2020, 11:59 PM EST


Clinical Context

Clinicians are generally aware that medications can result in more severe adverse events among older adults, and the Beers Criteria have helped define those drugs that are best avoided in this population. But is there a link between taking potentially harmful drugs and a higher risk for hospitalization among older adults? Varga and colleagues addressed this issue in a November 2017 issue of the British Journal of Clinical Pharmacology.[1]

Researchers assessed an Italian database that contained health information on 1,480,137 older adults. They evaluated the rates of potentially inappropriate medications (PIMs) among this population, and they performed an adjusted analysis to determine the risk for hospitalization associated with these medications.

More than half of study subjects used at least 1 PIM, and subjects were exposed to a PIM 10.9% of the time during the study period. Nonsteroidal anti-inflammatory drugs were the most common class of PIM, and ketorolac was the PIM associated with the highest rate of hospitalization. The crude rates of hospitalization during time exposed and not exposed to a PIM were 228.1 and 152.1 per 1000 person-years, which translated to an adjusted hazard ratio of 1.16 (95% CI, 1.14-1.18) for hospitalization while receiving a PIM.

The current document updates the Beers criteria for clinicians.

Study Synopsis and Perspective

The American Geriatrics Society (AGS) has released the 2019 update to the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The update was published online January 29 in the Journal of the American Geriatrics Society.[2]

"Medications play an important role in health and well-being for many older people," Donna M. Fick, PhD, RN, co-chair of the expert panel responsible for the 2019 AGS Beers Criteria, said in a news release. "With this new update, we hope the latest information on what makes medications appropriate for older people can play an equally important role in decisions about treatment options that meet the needs of older adults while also keeping them as safe as possible."

The Beers Criteria are intended to improve medication selection, reduce adverse drug events, and provide a tool to assess cost, patterns, and quality of care of drugs used for people aged 65 years or older. It lists drugs that should be avoided in the treatment of older adults, either generally or in patients with specific diseases or conditions. Clinicians, researchers, educators, healthcare administrators, and regulators use the criteria, which were first published in 1991 and have been updated every 3 years since 2011.

The 2019 criteria include 30 medications or medication classes to be avoided in older adults in general, and 40 medications or medication classes that should be used with caution or avoided in certain patients with certain diseases or conditions. Two criteria were added in response to the worsening opioid crisis: not prescribing opioids with benzodiazepines or gabapentinoids.

The criteria dropped 8 seizure medications, 8 drugs for insomnia, and vasodilators for syncope. Some of these drugs were dropped because the problems associated with their use are not unique to older patients. Two (ticlopidine and pentazocine) were dropped because they are no longer available in the United States.

Removed From the Criteria

H2-receptor antagonists were removed from the criteria for dementia because the evidence that they harm people with dementia is weak. These drugs, which relieve gastric reflux, can continue to be used with caution in patients with high risk dementia but should be avoided in older adults with or at high risk of delirium because of potential of inducing or worsening delirium.

The chemotherapeutic drugs carboplatin, cisplatin, vincristine, and cyclophosphamide were removed from the criteria because the panel considered them to be "highly specialized" and outside the scope of the criteria.

"Use With Caution"

Dextromethorphan/quinidine should be used with caution because it has limited efficacy in alleviating behavioral symptoms of dementia in patients without pseudobulbar affect and because it potentially increases the risk for falls and drug-drug interactions.

Rivaroxaban is to be used with caution for venous thromboembolism or atrial fibrillation in patients older than 75 years because of the risk for gastrointestinal bleeding.

Trimethoprim and sulfamethoxazole can elevate risk for hyperkalemia in patients with decreased kidney function who are receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

Carbamazepine, mirtazapine, oxcarbazepine, serotonin, norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants, and tramadol should be used with caution because they may exacerbate or cause what is known as syndrome of inappropriate antidiuretic hormone secretion. Sodium levels should be monitored closely when using these drugs.

Aspirin should be used with caution for primary protection against cardiovascular disease or colorectal cancer in patients older than 70 years, not 80 years, because new data show that the age at which the risk of bleeding is elevated has fallen.

Serotonin and norepinephrine reuptake inhibitors should be prescribed with caution for patients at risk of falling or sustaining fractures.

Also New

For Parkinson's disease, the general advice to avoid all antipsychotics has been revised to except quetiapine, clozapine, and pimavanserin.

For heart failure, nondihydropyridine and calcium channel blockers should not be prescribed for patients with low ejection fractions, and nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, thiazolidinediones, and dronedarone should be prescribed with caution in patients who have no symptoms of heart failure.

Macrolides (except azithromycin) or ciprofloxacin should not be prescribed with warfarin because of bleeding risk.

Ciprofloxacin and theophylline should not be prescribed because of increased theophylline toxicity.

For patients with reduced kidney function, use of ciprofloxacin is associated with increased risk for tendon rupture and increased central nervous system effects. Use of trimethoprim-sulfamethoxazole is associated with worsening renal failure and hyperkalemia.

"The AGS Beers Criteria are an essential evidence-based tool that should be used as a guide for drugs to avoid in older adults. However, they are not meant to supplant clinical judgment or an individual patient's preferences, values, care goals, and needs, nor should they be used punitively or to excessively restrict access to medications," the authors conclude.

Limitations of the criteria are that consideration was given only to studies published in English, including observational studies, and consideration was not given to subpopulations of patients.

In an accompanying editorial, panel members Michael A. Steinman, MD, from the Division of Geriatrics, the University of California, San Francisco, and Donna Fick, PhD, RN, from the College of Nursing and the College of Medicine, Pennsylvania State University, Hershey, remind readers that the drugs that were deemed unsafe for older patients in the 2019 criteria are potentially inappropriate, not definitely inappropriate, and advise close reading of the details.[3]

"Optimal application of the AGS Beers Criteria involves identifying potentially inappropriate medications and where appropriate offering safer nonpharmacologic and pharmacologic therapies," they write. Clinicians should view the criteria as a starting point for individual prescribing.

"[Ensuring] the safe and effective use of medications by older adults is a cornerstone of high-quality medical care and a superb arena for interprofessional practice.... Use the AGS Beers Criteria well, and use them wisely," Dr Steinman and Dr Fick conclude.

For the 2019 update, an expert panel reviewed evidence published since the last update to evaluate whether to add, remove, or change specific criteria. The 13 members of the panel were physicians, pharmacists, or nurses who had participated in the 2015 update.

The panel fully reviewed 1422 articles. Of those, 377 were abstracted into evidence tables; these articles included 29 controlled clinical trials, 281 observational studies, and 67 systematic meta-analyses and/or reviews. Comments were collected from August 13, 2018, to September 4, 2018, and included 79 comments from 47 individuals, 10 comments from six pharmaceutical companies, and 155 comments from 22 peer organizations.

One coauthor consults for Wolters-Klewer. Another coauthor consults for Institute for HealthCare Improvement, is section editor for SLACK Inc, and received a grant from IMPAQ on MTM. Another coauthor consults for the Colorado Access Pharmacy and Therapeutics Committee. Another coauthor is an editor for Lexi-Comp. Another coauthor reviews physicians for CVS/Caremark. The remaining authors have disclosed no relevant financial relationships. Dr Fick consults for SLACK Inc and Precision Health Economics. Dr Steinman consulted for

J Am Geriatr Soc. Published online January 29, 2019.

Study Highlights

  • The Beers Criteria are designed for use by practicing clinicians. The authors encourage their application for teaching and measuring quality of care, but not as a punitive measure.
  • The authors acknowledge that drugs on their list are not always inappropriate for a given patient. Clinical rationale and shared decision-making are the most important elements for safe prescribing.
  • A multidisciplinary team of 13 healthcare providers assessed 377 articles published between 2015 and 2017 to create the current update.
  • H2-receptor antagonists were removed from the "avoid" list among adults with dementia or cognitive impairment. The degree of evidence that these drugs cause negative cognitive effects is weak. Use of H2-receptor antagonists is not recommended in patients with delirium and remain on the “avoid” list for this indication.
  • Glimepiride was added to the list of sulfonylureas, which can increase the risk for severe prolonged hypoglycemia.
  • Serotonin-norepinephrine reuptake inhibitors were added to the list of drugs to avoid among adults with a history of falls or fractures.
  • Although most antipsychotic medications should be avoided among patients with Parkinson disease, quetiapine, clozapine, and pimavanserin may be preferred in this setting.
  • Nondihydropyridine calcium channel blockers should not be used among patients with heart failure. Nonsteroidal anti-inflammatory drugs and thiazolidinediones should be used with caution in cases of heart failure.
  • The age limit for the safe use of aspirin as primary prophylaxis against cardiovascular disease and colorectal cancer was lowered from 80 to 70 years.
  • Rivaroxaban was added to dabigatran as increasing the risk for gastrointestinal bleeding compared with warfarin and other direct oral anticoagulants among adults at age 75 years and older.
  • Dextromethorphan/quinidine is deemed inappropriate in the treatment of the behavioral symptoms of dementia. This drug has limited evidence of efficacy and may increase the risk for falls and drug interactions. This recommendation did not apply to the treatment of pseudobulbar affect.
  • Multiple drugs should be avoided because of their associated risk for hyponatremia and syndrome of inappropriate diuretic hormone, including carbamazepine, diuretics, tramadol, and multiple forms of antidepressants.
  • Trimethoprim-sulfamethoxazole was cited for its associated risk for hyperkalemia when used with a renin-angiotensin inhibitor in the setting of reduced creatinine clearance. Trimethoprim-sulfamethoxazole can also increase the risk for phenytoin toxicity and bleeding among patients treated with warfarin. Finally, trimethoprim-sulfamethoxazole was added to the warning list among older adults with renal dysfunction.
  • Nonsteroidal anti-inflammatory drugs should be avoided if possible among older adults, especially for prolonged periods of treatment. The authors note that indomethacin is associated with the highest rate of adverse effects of all nonsteroidal anti-inflammatory drugs.
  • Ciprofloxacin can cause neurological adverse effects among adults with reduced renal function, and it can promote a higher risk for tendon rupture among these patients.

Clinical Implications

  • A previous study found that more than half of older adults used at least 1 PIM, and participants were exposed to a PIM during more than 10% of the study period. Nonsteroidal anti-inflammatory drugs were the most common class of PIM. Use of a PIM was independently associated with a higher risk for hospitalization.
  • The current update to the Beers Criteria includes warnings regarding glimepiride, trimethoprim-sulfamethoxazole, ciprofloxacin, rivaroxaban and nonsteroidal anti-inflammatory drugs; as well as the deletion of multiple drugs from the list due to availability. There is a clear warning for the avoidance of dextromethorphan/quinidine in the treatment of behavioral symptoms of dementia.
  • Implications for the Healthcare Team: The healthcare team should proactively reconcile medications for older adults and eliminate PIMs when possible. Health care professionals should engage in active communication with each other and across care transitions to enable appropriate selection of medication for the elderly. The beers guideline should be utilized as an essential tool to identify and improve medication appropriateness and safety.

Post-Assessment Question

  • Print