8.1 Beers Criteria Essentials
Key Takeaways
- AGS Beers Criteria flag potentially inappropriate medications (PIMs) in older adults; they guide risk–benefit decisions and deprescribing conversations, not automatic discontinuation
- Core categories include drugs generally to avoid, drugs to use with caution, drug–disease/syndrome interactions, clinically important drug–drug interactions, and drugs that need renal dose adjustment or avoidance in reduced kidney function
- High-yield PIM classes for GERO-BC: benzodiazepines/Z-drugs, strong anticholinergics, first-generation antihistamines, chronic NSAIDs, sliding-scale insulin as sole regimen, and antipsychotics used primarily for behavioral and psychological symptoms of dementia (BPSD)
- Beers is one tool among many—pair it with indication review, goals of care, renal function, fall/delirium risk, and shared decision-making
- Teach principles and representative examples; do not memorize or claim to reproduce the full copyrighted AGS list
Purpose of the AGS Beers Criteria
The American Geriatrics Society (AGS) Beers Criteria® identify potentially inappropriate medications (PIMs)—drugs for which risks often outweigh benefits in older adults when safer alternatives exist. For GERO-BC (TCO II-A-3), you are expected to apply Beers principles during medication review, care planning, and interdisciplinary communication—not to recite a proprietary full list.
Beers criteria are a decision-support framework, not a do-not-use blacklist:
| What Beers does | What Beers does not do |
|---|---|
| Flags drugs with unfavorable risk–benefit in many older adults | Automatically require stopping every flagged drug |
| Organizes risks by avoid, caution, disease interaction, drug–drug, and renal dosing | Replace clinical judgment, indication review, or goals of care |
| Supports deprescribing and safer alternatives | Override patient-specific benefit when monitored and necessary |
| Complements polypharmacy and PK aging assessment | Substitute for renal dosing calculators or full interaction checkers |
Exam stance: Seeing a Beers-listed drug should trigger assessment of indication, alternatives, monitoring, and deprescribing opportunity—not reflexive deletion without a plan.
How Categories Are Organized
Think in five functional buckets used across recent AGS updates. Exact drug membership evolves with evidence; the category logic is stable and high-yield:
| Category | Clinical meaning | Nursing cue |
|---|---|---|
| Generally avoid | Strong risk signal for most older adults | Ask: Is there a safer alternative? Why still needed? |
| Use with caution | Elevated risk in some contexts; not always contraindicated | Heighten monitoring; reassess often |
| Drug–disease / syndrome | Drug worsens a specific condition (e.g., delirium, HF, falls) | Match med list to active diagnoses and geriatric syndromes |
| Drug–drug | Combinations with clinically important harm in older adults | Look for CNS depressant stacks, anticholinergic burden, QT/bleeding pairs |
| Renally dose / avoid in CKD | Toxicity rises when clearance falls | Check eGFR/CrCl before assuming “usual adult dose” |
Linking Categories to Everyday Practice
- Screen the regimen for PIMs and high-risk combinations.
- Contextualize with fall history, cognition, GFR, heart failure, PUD/GI bleed risk, and goals.
- Prioritize highest-harm agents (sedatives, strong anticholinergics, anticoagulants + NSAIDs, antipsychotics for BPSD).
- Collaborate with prescribers on taper, substitute, or intensify monitoring.
- Educate the older adult and caregiver on why change is being proposed.
High-Yield PIM Themes (Principles & Examples)
Teach class patterns, not a copyrighted inventory. Representative themes commonly tested in gerontological nursing:
Benzodiazepines and Related Sedative-Hypnotics
Benzodiazepines (and related “Z-drugs” used for insomnia) increase falls, fractures, delirium, cognitive impairment, and motor vehicle risk. Long half-life agents are especially problematic, but short-acting agents are not “safe” in older adults. Prefer nonpharmacologic sleep/anxiety strategies; if a benzo is unavoidable, use lowest effective dose, shortest duration, and a deprescribing plan.
| Concern | Why it matters in aging |
|---|---|
| Sedation & ataxia | Fall and fracture risk |
| Cognitive slowing | Mimics or worsens dementia/delirium |
| Dependence / withdrawal | Abrupt stop can cause rebound anxiety, insomnia, seizures |
| Additive CNS depression | Dangerous with opioids, alcohol, other sedatives |
Anticholinergic Medications
Strong anticholinergics contribute to dry mouth, constipation, urinary retention, blurred vision, tachycardia, confusion, and delirium. Cumulative anticholinergic burden from multiple moderate agents can equal one strong agent. Common sources include some bladder antispasmodics, tricyclic antidepressants, and older antiparkinsonian agents—always verify indication and alternatives.
First-Generation Antihistamines
Agents such as diphenhydramine and related first-generation antihistamines are highly anticholinergic and sedating. Older adults often take them OTC for sleep or colds without disclosing them. Prefer second-generation antihistamines when an antihistamine is needed for allergy; avoid using diphenhydramine as a routine sleep aid.
NSAIDs
Chronic NSAIDs raise risk of GI bleeding, peptic ulcer disease, hypertension worsening, heart failure exacerbation, and acute kidney injury—especially with ACE inhibitors/ARBs + diuretics (“triple whammy”) or concurrent anticoagulants/antiplatelets. Prefer acetaminophen (within safe limits) for many musculoskeletal pains; if NSAID is used, shortest course, gastroprotection when indicated, and renal/BP monitoring.
Sliding-Scale Insulin (as Sole Strategy)
Sliding-scale insulin alone treats hyperglycemia reactively without addressing basal needs, increasing hypoglycemia and glycemic volatility—poorly tolerated in frail older adults. Preferred approaches emphasize basal coverage (when insulin is indicated), scheduled prandial dosing matched to intake, and individualized targets that prioritize hypoglycemia avoidance over tight A1C in limited-life-expectancy or high-risk patients.
Antipsychotics and BPSD
Antipsychotics for behavioral and psychological symptoms of dementia (BPSD) carry boxed-warning–level concern for increased mortality in older adults with dementia-related psychosis, plus stroke, falls, sedation, and metabolic effects. Use only when nonpharmacologic approaches fail and behavior poses serious harm; target the lowest effective dose and time-limited trials with clear exit criteria.
| Scenario | Prefer first | Medication role |
|---|---|---|
| Nighttime wandering / agitation | Environment, routine, pain/constipation/UTI check | Antipsychotic last resort |
| Insomnia | Sleep hygiene, treat apnea/pain/depression | Avoid diphenhydramine / chronic benzos |
| Osteoarthritis pain | PT, acetaminophen, topical agents | Limit systemic NSAIDs |
| Hyperglycemia variability | Meal-aligned insulin plan, deprescribe sliding-scale-only | Structured regimen |
Clinical Application Tips for GERO-BC
- Brown-bag + Beers lens: OTCs and herbals often hide anticholinergics and NSAIDs.
- Syndrome pairing: New falls or delirium → audit sedatives, anticholinergics, antipsychotics, opioids.
- Renal lens: Many “usual doses” become PIMs when GFR declines—even if the drug is not on an “avoid” list for all older adults.
- Document the why: If a PIM continues, chart indication, failed alternatives, monitoring plan, and shared decision.
- Deprescribe thoughtfully: Taper CNS agents; do not stop chronically used benzos or high-dose anticholinergics abruptly without a plan.
Integration With Other Domains
Beers work sits downstream of polypharmacy identification and PK aging changes, and upstream of care planning and safety interventions. A Beers flag that is ignored while falls continue is a quality gap; a Beers flag that triggers a collaborative deprescribing plan is evidence-based gerontological nursing.
What is the primary clinical purpose of the AGS Beers Criteria in gerontological nursing practice?
An 84-year-old with dementia has escalating nighttime agitation. Nonpharmacologic strategies have not yet been optimized. Which action best reflects Beers-aligned nursing advocacy regarding antipsychotics?
Which regimen pattern is most consistent with a Beers-related concern about insulin use in older adults?
A nurse reviews an older adult’s OTC sleep aid containing diphenhydramine. Which Beers-relevant category best explains the concern?