8.1 2023 AGS Beers Criteria: High-Risk Medications in Older Adults
Key Takeaways
- The 2023 AGS Beers Criteria list potentially inappropriate medications (PIMs) that older adults (typically age 65+) should generally avoid or use only with caution in defined situations
- Beers is a screening and quality tool—not a hard stop list that alone dictates deprescribing or coverage denials
- MTM exam favorites include first-generation antihistamines, benzodiazepines, Z-drugs, glyburide, skeletal muscle relaxants (e.g., cyclobenzaprine), metoclopramide, and strong anticholinergics
- Technicians spot PIMs on the medication list, OTC sleep aids, and refill history, then flag the pharmacist—never independently stop or switch therapy
- Document drug, indication if known, duration, and patient symptoms (confusion, falls, sedation, hypoglycemia) so the pharmacist can assess benefit–risk
2023 AGS Beers Criteria: High-Risk Medications in Older Adults
Quick Answer: The 2023 AGS Beers Criteria name medications that are potentially inappropriate for many adults age 65 and older. In MTM, technicians screen profiles and OTC lists for common PIMs—first-generation antihistamines, benzodiazepines, Z-drugs, glyburide, skeletal muscle relaxants, metoclopramide, and strong anticholinergics—and flag the pharmacist. Beers guides safer selection; it does not authorize technician deprescribing.
Domain 2 of the PTCB Medication Therapy Management Certificate emphasizes patient safety and inappropriate prescribing. Older adults are a high-priority population: age-related changes in kidney and liver clearance, increased sensitivity to sedation and anticholinergic effects, fall risk, and polypharmacy all raise the chance that a “routine” medicine becomes a safety problem. The Beers Criteria give the care team a shared language for those risks.
What the 2023 AGS Beers Criteria Are For
The American Geriatrics Society (AGS) stewards the Beers Criteria and released the 2023 update (published in the Journal of the American Geriatrics Society, DOI 10.1111/jgs.18372). The criteria are an explicit list of potentially inappropriate medications (PIMs)—drugs that are typically best avoided by older adults in most circumstances, or under specific situations such as certain diseases, drug–drug combinations, or reduced kidney function.
The expert panel organized the 2023 criteria into the same five categories used in the prior (2019) update:
| Beers category (2023 framework) | What it helps you spot |
|---|---|
| Medications generally considered potentially inappropriate | Drugs to avoid for most older adults in usual circumstances |
| Medications potentially inappropriate with certain diseases/syndromes | Drug–disease mismatches (e.g., riskier choices in dementia, falls history, heart failure) |
| Medications to be used with caution | Agents that may still be used but need heightened monitoring and shared decision-making |
| Potentially inappropriate drug–drug interactions | Combinations that amplify harm in older adults |
| Medications needing renal dose adjustment or avoidance at low eGFR | Dose or selection problems when kidney function declines |
Stated intentions of Beers include: (1) reduce exposure to PIMs by improving medication selection, (2) educate clinicians and patients, and (3) support evaluation of quality, cost, and drug-use patterns. AGS leaders emphasize a critical boundary: Beers should never solely dictate how medications are prescribed or be used alone to justify restricting health coverage. Individual patients may have a valid, time-limited indication after pharmacist and prescriber assessment.
Exam framing: Beers = screening / quality / education tool for PIMs in older adults, not a technician “auto-stop” list.
High-Yield PIMs Commonly Tested in MTM
You are not expected to memorize every row of the full Beers tables. You are expected to recognize the drug classes that appear repeatedly in CMR prep, TMRs, and safety questions.
First-generation antihistamines
Examples include diphenhydramine, hydroxyzine, chlorpheniramine, and related highly anticholinergic antihistamines often found in OTC “PM” sleep or cold products. In older adults these agents are linked to confusion, dry mouth, constipation, urinary retention, blurred vision, and fall risk; clearance can be reduced with age. Patients may not mention them unless you ask about OTC sleep aids, allergy tablets, and nighttime cold products.
Benzodiazepines
Long- and short-acting benzodiazepines (for example, diazepam, lorazepam, alprazolam, clonazepam) increase sensitivity to sedation, cognitive impairment, delirium, falls, and fractures in older adults. Chronic use may appear “stable” on refill history while still representing a high-priority safety flag for pharmacist review—especially after a fall, near-fall, or new confusion.
Nonbenzodiazepine hypnotics (“Z-drugs”)
Zolpidem, zaleplon, and eszopiclone are often assumed safer than benzodiazepines because they are marketed for sleep. Beers still treats them as high-concern for older adults because of delirium, falls, fractures, and limited durable sleep benefit relative to risk. Spot both prescription Z-drugs and patient comments like “I take the little sleep tablet every night.”
Glyburide (and related sulfonylurea hypoglycemia risk)
Glyburide is a classic exam example of a sulfonylurea with prolonged hypoglycemia risk in older adults. Hypoglycemia can present as confusion, sweating, tremor, falls, or emergency visits. When an older adult’s list includes glyburide—especially with irregular meals, renal impairment notes, or recent low blood sugars—flag for pharmacist assessment of safer diabetes options.
Skeletal muscle relaxants (e.g., cyclobenzaprine)
Agents such as cyclobenzaprine, carisoprodol, methocarbamol, and related muscle relaxants are poorly tolerated in many older adults: anticholinergic effects, sedation, and fall/fracture risk with questionable effectiveness at doses older adults can safely tolerate. “Back spasm” therapy that has continued for months is a common CMR finding.
Metoclopramide
Metoclopramide can cause extrapyramidal effects and tardive dyskinesia; risk is a major reason it appears on PIM lists for older adults. It may still be used short-term for documented gastroparesis at the lowest effective dose, but chronic or unclear-indication use deserves pharmacist review.
Strong anticholinergics
Beyond first-generation antihistamines, strong anticholinergic burden often comes from tricyclic antidepressants (for example, amitriptyline), bladder antimuscarinics such as oxybutynin, and other highly anticholinergic agents. Cumulative confusion, constipation, dry mouth, and urinary retention are the story technicians should capture.
| Drug / class | Why older adults are at risk | Technician screening cue |
|---|---|---|
| Diphenhydramine / 1st-gen antihistamines | Anticholinergic toxicity, sedation, falls | OTC PM sleep/cold products on PMR |
| Benzodiazepines | Cognitive impairment, delirium, falls, fractures | Chronic refill of alprazolam/lorazepam/etc. |
| Zolpidem / zaleplon / eszopiclone | Similar CNS risks; limited sleep benefit vs risk | Nightly hypnotic + fall history |
| Glyburide | Prolonged hypoglycemia | Low glucose logs, meal-skipping, confusion |
| Cyclobenzaprine / muscle relaxants | Sedation, anticholinergic effects, falls | Long-term “muscle spasm” therapy |
| Metoclopramide | Tardive dyskinesia / EPS risk | Chronic use without clear short-term plan |
| Amitriptyline / oxybutynin (strong anticholinergics) | Confusion, constipation, retention, dry mouth | Multiple anticholinergics on one list |
Technician Role: Flag, Do Not Independently Deprescribe
Appropriate technician actions
- Build a complete list including Rx, OTC, herbals, and “as needed” sleep or allergy products.
- Highlight Beers-relevant agents with age (≥65) and any fall, confusion, hypoglycemia, or sedation notes.
- Ask targeted intake questions: “Any nighttime sleep aids? Any muscle relaxers you still take? Any low blood sugars?”
- Document what is on the list, how long if known, and what the patient is experiencing.
- Escalate promptly so the pharmacist can assess indication, safer alternatives, taper plans, or prescriber communication.
Inappropriate technician actions
- Telling the patient to stop a benzodiazepine, Z-drug, or glyburide without pharmacist involvement
- Switching diphenhydramine to another product on your own authority
- Reassuring that a PIM is “fine because they have taken it for years”
- Ignoring OTC diphenhydramine because it is “not a prescription”
Scenario — OTC Sleep Aid on a Beers Screen
Patient (age 78): “I take two diphenhydramine tablets most nights so I can sleep.” Tech: “Thanks for telling me—that is important for your safety review. I’m documenting nightly diphenhydramine and will have the pharmacist talk with you about sleep options that may be safer at your age. Please don’t add more sleep medicines until they advise you.”
Scenario — Chronic Cyclobenzaprine After a Fall
Profile: 71-year-old with cyclobenzaprine 10 mg TID for “back spasm” for 8 months; recent ED visit for fall. Tech action: Flag long-term skeletal muscle relaxant + fall as a Beers-relevant safety concern for pharmacist CMR/TMR review—do not discontinue the drug yourself.
Scenario — Glyburide and Confused Morning Episodes
Caregiver: “Mom gets sweaty and confused before breakfast a few times a week. She is on glyburide.” Tech: Document possible hypoglycemia symptoms with glyburide in an older adult; immediate pharmacist alert—this is a safety MRP, not a paperwork curiosity.
How Beers Findings Flow Through MTM Work
PIM flags support the Medication Therapy Review and often become MAP talking points (“ask your pharmacist/prescriber about safer sleep options”) or pharmacist-to-prescriber interventions. They also connect to adherence and effectiveness: patients may refuse safer alternatives until someone explains fall and confusion risk in plain language.
Remember the chapter theme: Beers helps you see risk; the pharmacist owns clinical deprescribing and therapy change. Your accuracy in spotting first-generation antihistamines, benzodiazepines, Z-drugs, glyburide, muscle relaxants, metoclopramide, and strong anticholinergics makes older-adult MTM safer and exam-ready.
What is the primary purpose of the 2023 AGS Beers Criteria in older-adult medication review?
Which medication is a classic Beers-relevant concern because of prolonged hypoglycemia risk in older adults?
A 76-year-old patient’s PMR lists nightly over-the-counter diphenhydramine for sleep. What is the MOST appropriate technician action?
Why should an MTM technician NOT independently stop a patient’s long-term lorazepam after seeing benzodiazepines on the Beers Criteria?