13.2 Beers Criteria 2023 Update & STOPP/START Prescribing Rules
Key Takeaways
- The AGS Beers Criteria® (2023 Update) identifies Potentially Inappropriate Medications (PIMs) in older adults (≥65 years) across 5 distinct categories, applicable to all care settings except hospice and palliative care.
- First-generation antihistamines, tricyclic antidepressants (TCAs), muscle relaxants, and antispasmodics exert high anticholinergic burden, precipitating acute delirium, urinary retention, severe constipation, and falls.
- Long-acting sulfonylureas (glyburide, glimepiride) and sliding-scale regular insulin must be avoided due to unpredictable, profound, and prolonged hypoglycemia in older adults.
- Central alpha-1 blockers (doxazosin, prazosin, terazosin) should not be used as antihypertensives due to severe orthostatic hypotension and syncope risk.
- STOPP/START Criteria (Version 3) provide a dual physiological systems-based framework: STOPP identifies inappropriate overprescribing, while START alerts clinicians to evidence-based therapeutic omissions (underprescribing).
Beers Criteria 2023 Update & STOPP/START Prescribing Rules
Prescribing in older adults requires balancing therapeutic efficacy against heightened physiological vulnerability. Two complementary, internationally recognized explicit prescribing tools guide advanced practice nursing: the American Geriatrics Society (AGS) Beers Criteria® and the Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment (STOPP/START) criteria. For the AGPCNP board exam and daily clinical practice, thorough command of these guidelines is vital for preventing adverse drug events, hospitalizations, and premature mortality.
1. The AGS Beers Criteria® (2023 Update Architecture)
The Beers Criteria apply to all adults aged 65 and older in ambulatory, acute, and institutionalized settings, with the explicit exception of palliative and hospice care, where comfort-directed symptom management supersedes standard avoidance rules.
+---------------------------------------------------------------------------------------------------+
| AGS BEERS CRITERIA® 5 ORGANIZATIONAL CATEGORIES |
| |
| CATEGORY 1: Medications Potentially Inappropriate in Most Older Adults (Independent of Dx) |
| - Drugs with unfavorable risk-benefit profiles across the general geriatric population |
| - Examples: First-generation antihistamines, TCAs, long-acting sulfonylureas, muscle relaxants |
| |
| CATEGORY 2: Medications Inappropriate Due to Specific Drug-Disease / Drug-Syndrome Interactions |
| - Drugs that exacerbate underlying baseline pathology |
| - Examples: NSAIDs in Heart Failure/CKD; Anticholinergics in Dementia/BPH; Benzos in Falls/Hx |
| |
| CATEGORY 3: Medications to Be Used with Caution |
| - Drugs requiring close therapeutic drug monitoring, dose titration, or clinical vigilance |
| - Examples: DOACs (rivaroxaban bleeding risk vs apixaban), Tramadol (hyponatremia/SIADH), SSRIs |
| |
| CATEGORY 4: Clinically Important Drug-Drug Interactions |
| - Dangerous combinations precipitating severe toxicity, falls, bleeding, or respiratory arrest |
| - Examples: Opioids + Benzodiazepines; Anticholinergic + Anticholinergic; Warfarin + NSAIDs |
| |
| CATEGORY 5: Medications to Avoid or Dose-Adjust Based on Kidney Function |
| - Renally cleared agents with narrow therapeutic windows accumulating in CKD |
| - Examples: Gabapentin, Pregabalin, Baclofen, Ciprofloxacin, Enoxaparin, DOACs |
+---------------------------------------------------------------------------------------------------+
2. High-Yield Beers Criteria Drug Classes & 2023 Updates
A. Central Nervous System & Psychotropic Agents
+---------------------------------------------------------------------------------------------------+
| CNS & PSYCHOTROPIC BEERS HIGHLIGHTS |
| |
| BENZODIAZEPINES & 'Z-DRUGS' (Zolpidem, Zaleplon, Eszopiclone) |
| - Rationale: High risk of cognitive impairment, delirium, falls, fractures, motor vehicle crashes|
| - Recommendation: AVOID for treatment of insomnia, agitation, or delirium. |
| - Exception: Severe generalized anxiety disorder refractory to SSRIs, seizure disorders, acute |
| alcohol/benzodiazepine withdrawal, REM sleep behavior disorder, end-of-life care. |
| |
| ANTIPSYCHOTICS (First- and Second-Generation) |
| - Rationale: Increased risk of stroke and all-cause mortality in dementia; severe extrapyramidal|
| symptoms (EPS), tardive dyskinesia, cognitive worsening, falls. |
| - Recommendation: AVOID for behavioral and psychological symptoms of dementia (BPSD) unless |
| non-pharmacologic options have failed AND patient poses severe, imminent danger to self/others|
| |
| TRICYCLIC ANTIDEPRESSANTS (TCAs: Amitriptyline, Imipramine, Doxepin >6 mg/day) |
| - Rationale: Highly anticholinergic, sedating, orthostatic hypotension, cardiac conduction delay|
| - Recommendation: AVOID. (Low-dose doxepin ≤6 mg/day acceptable for sleep maintenance). |
+---------------------------------------------------------------------------------------------------+
B. Cardiovascular & Antithrombotic Agents (2023 Revisions)
| Medication Class / Agent | Beers Recommendation | Specific Clinical Hazards & Mechanisms | Evidence-Based Safe Alternative |
|---|---|---|---|
| Alpha-1 Blockers (Doxazosin, Prazosin, Terazosin) | AVOID as antihypertensive therapy. | Severe orthostatic hypotension, reflex tachycardia, syncope, and falls. | ACE inhibitors, ARBs, CCBs, or Thiazides. (Tamsulosin/Alfuzosin acceptable for BPH as uroselective agents). |
| Central Alpha-2 Agonists (Clonidine, Methyldopa, Guanfacine) | AVOID as routine antihypertensive. | High CNS adverse effects (sedation, depression), bradycardia, orthostatic hypotension, and life-threatening rebound hypertensive crisis upon missed doses. | Standard first-line antihypertensives (ACEi, ARB, DHP-CCB, Thiazide-like diuretic). |
| Digoxin (for AF or Heart Failure) | AVOID as first-line agent. If used, dose $\le 0.125\text{ mg/day}$. | Narrow therapeutic window; impaired renal clearance leads to accumulation; cardiac arrhythmias, nausea, anorexia, vision changes. | Beta-blockers or non-DHP CCBs for rate control in AF; Guideline-Directed Medical Therapy (GDMT) for HFrEF. |
| Amiodarone | AVOID as first-line for AF unless patient has HFrEF. | Multiple systemic toxicities: pulmonary fibrosis, thyroid disease (hypo/hyperthyroidism), hepatotoxicity, corneal microdeposits, QT prolongation. | Rate control strategy with Beta-blockers; catheter ablation for refractory symptoms. |
| Direct Oral Anticoagulants (DOACs: 2023 Update) | Preferred over Warfarin for non-valvular AF/VTE.<br>Rivaroxaban warned: higher GI bleed risk vs Apixaban. | Warfarin requires frequent INR monitoring and high dietary/drug interactions. Rivaroxaban has significantly higher rates of major gastrointestinal bleeding in older adults compared to Apixaban. | Apixaban preferred DOAC in geriatric patients due to superior GI safety profile and efficacy. |
C. Endocrine & Glycemic Agents
- Long-Acting Sulfonylureas (Glyburide, Glimepiride): STRICTLY AVOID. Prolonged half-lives in aging kidneys cause severe, prolonged, and fatal hypoglycemia. Glipizide is short-acting and preferred if a sulfonylurea is strictly unavoidable, but non-sulfonylurea agents are strongly favored.
- Sliding-Scale Regular Insulin: STRICTLY AVOID. Higher risk of severe hypoglycemia without providing superior glycemic control compared to basal-bolus or stable scheduled regimens.
D. Gastrointestinal & Pain Medications
- Proton Pump Inhibitors (PPIs): AVOID scheduled use >8 weeks unless clear indication (Barrett's esophagus, chronic high-dose NSAID requirement, severe erosive esophagitis, Zollinger-Ellison). Risks include C. diff infection, bone loss/fractures, hypomagnesemia, and B12 deficiency.
- Chronic Oral NSAIDs (Systemic non-selective and COX-2): AVOID chronic use. High risk of peptic ulcer disease, upper GI bleeding, acute kidney injury, worsening hypertension, and acute decompensation of heart failure.
- Skeletal Muscle Relaxants (Cyclobenzaprine, Carisoprodol, Methocarbamol, Metaxalone): AVOID. Poorly tolerated due to strong anticholinergic properties, sedation, weakness, and heightened fracture risk.
3. The Anticholinergic Burden & Cognitive Trajectory
Drugs with anticholinergic (antimuscarinic) properties block acetylcholine transmission in both the peripheral autonomic nervous system and the central nervous system.
+---------------------------------------------------------------------------------------------------+
| ANTICHOLINERGIC BURDEN & SYSTEMIC PATHOLOGY |
| |
| [CENTRAL NERVOUS SYSTEM MANIFESTATIONS] |
| - Acute Delirium & Confusion |
| - Acceleration of Chronic Cognitive Decline (Dementia) |
| - Sedation, Dizziness, Impaired Psychomotor Performance, Falls |
| - Visual Hallucinations & Sleep Architecture Disruption |
| |
| [PERIPHERAL AUTONOMIC MANIFESTATIONS] |
| - Eyes: Mydriasis, blurred vision, precipitation of Acute Angle-Closure Glaucoma |
| - Mouth: Severe Xerostomia (dry mouth) -> Dental caries, impaired chewing, oral candidiasis |
| - Gastrointestinal: Decreased peristalsis -> Severe Constipation, Bowel Impaction, Paralytic Ileus|
| - Genitourinary: Detrusor hyporeflexia -> Urinary Retention, Overflow Incontinence, UTIs |
| - Cardiovascular: Sinus Tachycardia, palpitations, arrhythmia |
| - Thermoregulation: Anhidrosis (decreased sweating) -> Hyperthermia, Heat Stroke |
+---------------------------------------------------------------------------------------------------+
Anticholinergic Cognitive Burden (ACB) Scale
The Anticholinergic Cognitive Burden (ACB) scale quantifies cumulative exposure to anticholinergic medications:
- Score 1 (Mild / Possible Anticholinergic): Atenolol, Captopril, Furosemide, Haloperidol, Metoprolol, Prednisone, Ranitidine, Trazodone.
- Score 2 (Moderate Anticholinergic): Amantadine, Belladonna, Carbamazepine, Cyclobenzaprine, Oxcarbazepine.
- Score 3 (Severe / Definite Anticholinergic): Amitriptyline, Atropine, Chlorpheniramine, Clemastine, Dimenhydrinate, Diphenhydramine, Doxepin (>6 mg), Hydroxyzine, Hyoscyamine, Meclizine, Nortriptyline, Oxybutynin, Paroxetine, Promethazine, Scopolamine, Tolterodine.
Clinical Significance: A cumulative ACB Score $\ge 3$ is independently associated with a 50% increase in incident dementia, doubled fall risk, and significantly higher 2-year mortality. The AGPCNP must calculate total ACB and systematically eliminate Score 2 and Score 3 agents.
4. STOPP / START Criteria (Version 3)
Developed by European geriatric consensus panels and validated internationally, the STOPP/START criteria are structured by physiological organ systems to assist clinicians in identifying both errors of commission (overprescribing inappropriate drugs) and errors of omission (underprescribing indicated evidence-based therapies).
+---------------------------------------------------------------------------------------------------+
| STOPP vs. START CRITERIA: A DUAL FRAMEWORK |
| |
| STOPP (Screening Tool of Older Persons' Prescriptions) |
| - Primary Objective: Deprescribe inappropriate, redundant, or dangerous medications. |
| - Focus: Errors of Commission (Stopping unnecessary or high-risk drugs). |
| |
| START (Screening Tool to Alert to Right Treatment) |
| - Primary Objective: Initiate evidence-based, disease-modifying therapies in older adults. |
| - Focus: Errors of Omission (Starting beneficial, indicated drugs that were inappropriately withheld)|
+---------------------------------------------------------------------------------------------------+
High-Yield STOPP / START Clinical Concordance
| Physiological System | STOPP Rules (Inappropriate Prescribing to Discontinue) | START Rules (Evidence-Based Prescribing to Initiate) |
|---|---|---|
| Cardiovascular | • Beta-blocker combined with Verapamil/Diltiazem (severe risk of complete heart block).<br>• Loop diuretic for dependent edema without clinical heart failure.<br>• Aspirin for primary prevention of cardiovascular disease in older adults. | • ACE inhibitor or ARB in systolic heart failure (HFrEF) and/or chronic kidney disease with proteinuria.<br>• Statin therapy in established secondary ASCVD (CAD, stroke, PAD).<br>• DOAC anticoagulation in non-valvular AF with $\text{CHA}_2\text{DS}_2\text{-VASc} \ge 2$. |
| Central Nervous System | • Tricyclic antidepressants in patients with dementia, glaucoma, cardiac conduction abnormalities, or prostatism.<br>• Prolonged benzodiazepines ($\ge 4$ weeks). | • Cholinesterase inhibitor (Donepezil, Rivastigmine) for mild-to-moderate Alzheimer's disease or Lewy body dementia.<br>• SSRI (Sertraline, Escitalopram) for major depressive disorder. |
| Gastrointestinal | • PPIs for uncomplicated peptic ulcer disease at full therapeutic dose for $>8$ weeks.<br>• Chronic loperamide or diphenoxylate for non-specific diarrhea. | • Fiber supplementation or osmotic laxatives (Polyethylene glycol) for chronic constipation.<br>• PPI co-prescription when chronic oral NSAID or dual antiplatelet therapy is unavoidable in high-risk patients. |
| Musculoskeletal & Bone | • Systemic corticosteroids for osteoarthritis pain.<br>• Long-term NSAID therapy in Stage 3–5 CKD or heart failure. | • Bisphosphonates, Denosumab, or Vitamin D/Calcium in patients with established osteoporosis, fragility fractures, or chronic systemic corticosteroid therapy. |
| Endocrine & Metabolic | • Sulfonylureas with long half-lives (Glyburide, Glimepiride) in Type 2 Diabetes.<br>• Non-selective beta-blockers in diabetes prone to frequent hypoglycemia. | • SGLT2 inhibitors in patients with Type 2 Diabetes, Heart Failure (HFrEF/HFpEF), or CKD with albuminuria.<br>• Annual Influenza, Pneumococcal (PCV20 or PCV15+PPSV23), and Recombinant Zoster (Shingrix) vaccines. |
5. Safe Alternative Pharmacotherapy Selection Matrix
When discontinuing a Beers Criteria medication, the AGPCNP must provide safe, evidence-based pharmacological or non-pharmacological alternatives:
+---------------------------------------------------------------------------------------------------+
| SAFE DRUG SUBSTITUTION MATRIX FOR PRIMARY CARE |
| |
| CLINICAL INDICATION AVOID (Beers PIM) SAFE GERIATRIC ALTERNATIVE |
| ------------------- ----------------- -------------------------- |
| Insomnia / Sleep Diphenhydramine, Zolpidem, Cognitive Behavioral Therapy (CBT-I),|
| Temazepam, Doxepin >6 mg Melatonin 1-3 mg, Doxepin ≤6 mg |
| |
| Allergic Rhinitis / Diphenhydramine, Hydroxyzine, Intranasal Fluticasone, Loratadine, |
| Urticaria Chlorpheniramine, Promethazine Cetirizine, Fexofenadine |
| |
| Overactive Bladder / Oxybutynin, Tolterodine, Pelvic floor PT, Mirabegron, |
| Urge Incontinence Hyoscyamine, Solifenacin Vibegron, Trospium (quaternary amine)|
| |
| Chronic Osteoarthritis Chronic oral Ibuprofen, Meloxicam, Topical Diclofenac gel, Acetaminophen|
| Pain Naproxen, Indomethacin (max 2-3 g/day), Physical Therapy |
| |
| Acute Muscle Spasm Cyclobenzaprine, Carisoprodol, Heat/ice therapy, physical therapy, |
| Methocarbamol, Metaxalone gentle stretching, short-term APAP |
| |
| Neuropathic Pain Amitriptyline, Imipramine, Duloxetine, Topical Lidocaine 5% |
| High-dose Pregabalin patch, Gabapentin (renally adjusted) |
+---------------------------------------------------------------------------------------------------+
6. Board-Yield Summary & Clinical Pearls
+---------------------------------------------------------------------------------------------------+
| ANCC AGPCNP CLINICAL EXAM PEARLS |
| |
| - On board examinations, if an older adult presents with acute urinary retention or sudden |
| confusion after taking an OTC cold/sleep aid, look immediately for Diphenhydramine. |
| |
| - For overactive bladder, Beta-3 adrenergic agonists (Mirabegron, Vibegron) avoid anticholinergic|
| cognitive effects entirely. If an antimuscarinic is required, Trospium is a quaternary amine |
| that does not readily cross the blood-brain barrier. |
| |
| - In older adults with Atrial Fibrillation, Apixaban has demonstrated a superior gastrointestinal|
| safety profile compared to Rivaroxaban, Dabigatran, and Warfarin. |
| |
| - NEVER initiate an alpha-1 blocker (Doxazosin, Terazosin) as monotherapy for hypertension in |
| an older adult due to high rates of orthostatic hypotension, syncope, and catastrophic falls. |
+---------------------------------------------------------------------------------------------------+
A 74-year-old male with mild cognitive impairment, benign prostatic hyperplasia (BPH), and generalized osteoarthritis presents to the primary care clinic complaining of worsening sleep-onset insomnia and nighttime restlessness for the past 6 weeks. His spouse mentions that he has been taking an over-the-counter PM sleep aid containing diphenhydramine 50 mg every night. Today, the patient is unusually drowsy, disoriented to date, and complains of extreme dry mouth and straining to urinate. Which of the following is the most accurate pharmacological appraisal and immediate management plan by the AGPCNP?
An AGPCNP is conducting a comprehensive medication review for a 71-year-old female with essential hypertension, osteoarthrosis of the knees, and Stage 2 chronic kidney disease (eGFR 68 mL/min/1.73m²). During the review, the NP notes that the patient was started on doxazosin 4 mg daily by another provider 3 months ago for blood pressure management. The patient reports frequent episodes of lightheadedness and unsteadiness within 2 minutes of standing from a seated position, though she has not fallen. Her sitting BP is 138/82 mmHg; standing BP at 2 minutes is 114/68 mmHg with a pulse of 76 bpm. How should the AGPCNP intervene based on current prescribing guidelines?
An 80-year-old male with a history of permanent non-valvular atrial fibrillation, prior ischemic stroke 3 years ago (CHA2DS2-VASc = 5), heart failure with preserved ejection fraction (HFpEF), and moderate chronic kidney disease (CrCl 38 mL/min) is admitted for outpatient medication optimization. He is currently maintained on warfarin 3 mg daily with a fluctuating INR (ranging between 1.4 and 4.2 over the past 6 months) and oxybutynin 10 mg daily for urge incontinence. Applying the Beers Criteria and STOPP/START guidelines, which combination of therapeutic modifications is most appropriate?