J American Geriatrics Society - 2023 - American Geriatrics Society 2023 Updated AGS Beers Criteria For Potentially

Received: 7 March 2023 Accepted: 29 March 2023
DOI: 10.1111/jgs.18372
Journal of the
SPECIAL ARTICLES American Geriatrics Society
American Geriatrics Society 2023 updated AGS Beers

Criteria® for potentially inappropriate medication use
in older adults
By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel
Correspondence
Mary Jordan Samuel, American Geriatrics Abstract
Society, 40 Fulton Street, Suite 809, The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®)
New York, NY 10038, USA.
for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely
Email: [email protected]
used by clinicians, educators, researchers, healthcare administrators, and regu-
lators. Since 2011, the AGS has been the steward of the criteria and has pro-
duced updates on a regular cycle. The AGS Beers Criteria® is an explicit list of
PIMs that are typically best avoided by older adults in most circumstances or
under specific situations, such as in certain diseases or conditions. For the 2023
update, an interprofessional expert panel reviewed the evidence published
since the last update (2019) and based on a structured assessment process
approved a number of important changes including the addition of new cri-
teria, modification of existing criteria, and formatting changes to enhance
usability. The criteria are intended to be applied to adults 65 years old and
older in all ambulatory, acute, and institutionalized settings of care, except hos-
pice and end-of-life care settings. Although the AGS Beers Criteria® may be
used internationally, it is specifically designed for use in the United States and
there may be additional considerations for certain drugs in specific countries.
Whenever and wherever used, the AGS Beers Criteria® should be applied
thoughtfully and in a manner that supports, rather than replaces, shared clini-
cal decision-making.
KEYWORDS
Beers criteria, Beers list, inappropriate prescribing, medications and drugs, older adults
INTRODUCTION residents.1 The 1997 update, led by Dr. Beers, expanded

the criteria to apply to all older adults.2 The criteria was
The Beers Criteria was developed by the late Mark Beers, updated by an interprofessional group in 2003 and the
MD, and colleagues at the University of California Los American Geriatrics Society took over stewardship in
Angeles in 1991, with the purpose of identifying medica- 2010. The 2023 American Geriatrics Society (AGS) Beers
tions for which potential harm outweighed the expected Criteria® (AGS Beers Criteria®) for Potentially Inappro-
benefit and that should be avoided in nursing home priate Medication (PIM) Use in Older Adults is the sev-
enth overall update and fourth since AGS became the
Listen to the GeriPal Podcast with the authors at https://bit.ly/GeriPalEp266 criteria's steward. As with previous updates, the AGS and
Panel Members and Affiliations are provided in Appendix. its expert panel have attempted to preserve the spirit and
2052 © 2023 The American Geriatrics Society. wileyonlinelibrary.com/journal/jgs J Am Geriatr Soc. 2023;71:2052–2081.
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AGS 2023 BEERS CRITERIA® 2053
intent of the original Beers Criteria by providing an

explicit list of PIMs that are best avoided by older adults Key points
in most circumstances or under specific situations, such
as certain diseases, conditions, or care settings. • The intention of the AGS Beers Criteria® is to:
The AGS Beers Criteria® comprises drugs and drug (1) reduce older adults' exposure to potentially
classes that the AGS and its expert panel consider to be inappropriate medications (PIMs) by improv-
potentially inappropriate medications (PIMs) for use in ing medication selection; (2) educate clinicians
older adults. The expert panel organized the criteria into and patients; and (3) serve as a tool for evaluat-
the same five general categories that were used in the ing the quality of care, cost, and patterns of
2019 update: drug use in older adults.
• The target audience for the 2023 AGS Beers
1. Medications considered as potentially inappropriate Criteria® is practicing clinicians and others
(Table 2); who utilize the criteria including healthcare
2. Medications potentially inappropriate in patients with consumers, researchers, pharmacy benefits
certain diseases or syndromes (Table 3); managers, regulators, and policymakers.
3. Medications to be used with caution (Table 4); • The criteria are intended to be applied to adults
4. Potentially inappropriate drug–drug interactions 65 years old and older in all ambulatory, acute,
(Table 5); and and institutionalized settings of care, except
5. Medications whose dosages should be adjusted based hospice and end-of-life care settings.
on renal function (Table 6).
Why does this paper matter?
Using the five categories of criteria as a framework, an
The American Geriatrics Society (AGS) Beers
interprofessional expert panel reviewed new data pub-
Criteria® (AGS Beers Criteria®) for Potentially
lished since the 2019 update (beginning in 2017, the cutoff
Inappropriate Medication (PIM) Use in Older
date for the prior update's literature review) to identify evi-
Adults is widely used by clinicians, educators,
dence that would remove, sustain, or alter existing criteria
researchers, healthcare administrators, and regu-
recommendations, rationale, level of evidence, or strength
lators. Since 2011, the AGS has been the steward
of recommendations. The panel also considered evidence
of the criteria and has produced updates on a reg-
that would support the addition of new criteria. For the
ular cycle. The AGS Beers Criteria® is an explicit
first time, the panel systematically considered usage in the
list of PIMs that are typically best avoided by
United States to determine whether any medications (and
older adults in most circumstances or under spe-
resulting criteria) should be removed because of very low
cific situations, such as in certain diseases or con-
or absent usage in the United States. Finally, the panel
ditions. Although the AGS Beers Criteria® may
aimed to enhance usability by consolidating the formatting
be used internationally, it is specifically designed
of the criteria for clarity and space.
for use in the United States and there may be
additional considerations for certain drugs in spe-
cific countries. Whenever and wherever used, the
OBJECTIVES AGS Beers Criteria® should be applied thought-
fully and in a manner that supports, rather than
The specific aim was to update the 2019 AGS Beers
replaces, shared clinical decision-making.
Criteria® using a comprehensive, systematic review and
grading of the evidence on drug-related problems and
adverse events in older adults. The strategies to achieve
this aim were to:
Incorporate exceptions to the 2023 AGS Beers
• Convene an interprofessional panel of 12 experts in Criteria® that the panel deemed clinically appropri-
geriatric care and pharmacotherapy and three ex- ate. These exceptions were designed to make the cri-
officio representatives from key stakeholder groups teria more individualized to clinical practice and
who would: more diverse and relevant across settings of care
Review evidence published between 2017 and 2022 and populations of older adults.
and use this to update the 2019 AGS Beers Criteria®, Grade the strength and quality of each PIM criterion
with consideration to removing or modifying exist- based on the level of evidence and strength of
ing criteria and adding new criteria. recommendation.
2054 BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
Apply a modified Delphi method, informed by the including the rigor of the evidence review and synthesis
systematic review and grading, to reach a consensus process.4 These methods were adapted from the Grading
on the 2023 update. of Recommendations Assessment, Development and
Evaluation (GRADE) guidelines for clinical practice
guideline development and are consistent with recom-
I N T E N T OF CR I T E R I A mendations from the National Academy of Medicine.5,6
The primary target audience for the 2023 AGS Beers

Criteria® is practicing clinicians. The criteria are Panel composition
intended to support shared decision-making about phar-
macologic therapy with adults 65 years old and older in The AGS Beers Criteria® expert panel included 12 inter-
all ambulatory, acute, and institutionalized settings of professional members drawn from medicine, nursing,
care, except hospice and end-of-life care settings. The and pharmacy, 10 of whom had participated in the 2019
intention of the AGS Beers Criteria® is to reduce older update. Panelists had experience in different practice set-
adults' exposure to PIMs by improving medication selec- tings, including ambulatory care, home care, acute hos-
tion; educate clinicians and patients; reduce adverse drug pital care, skilled nursing facilities, and long-term care.
events; and serve as a tool for evaluating the quality of In addition, the panel included ex-officio representa-
care, cost, and patterns of drug use in older adults. Others tives from the Centers for Medicare & Medicaid Ser-
who utilize the criteria include healthcare consumers, vices, the National Committee for Quality Assurance,
researchers, pharmacy benefits managers, regulators, and and the Pharmacy Quality Alliance. Potential conflicts
policymakers. As with previous updates, the panel had of interest were disclosed at the beginning of the pro-
discussions and debates in an effort to attain a balance cess and before each full panel call and are listed in the
between the multiple uses and users. We note that the disclosures section of this paper. Panelists were recused
criteria are a blunt instrument and that we are unable to from discussion in areas in which they had a potential
delineate all specialized use cases and possible exceptions conflict of interest.
to the criteria.
The AGS and the panel remind users of the AGS Beers
Criteria® that the criteria are not to be used in a punitive Literature review
manner. Prescribing for older adults is often a complex
endeavor involving the consideration of many factors, par- Literature searches were conducted in PubMed from
ticularly the preferences and goals of the older person and June 1, 2017, to May 31, 2022. Search terms for each cri-
their family. Deprescribing studies have demonstrated how terion included individual drugs, drug classes, specific
critical patient and family input and buy-in can be to the conditions, and combinations thereof, each with a focus
success of discontinuing medications responsible for actual on “adverse drug events” and “adverse drug reactions,”
or potential harm or that provide little to no therapeutic as well as on any specific focus defined by the expert
value.3 Quality measures must be clearly defined, easily panel. Searches targeted controlled clinical trials, obser-
applied, and measured with limited information and, thus, vational studies, and systematic reviews and meta-
although useful, cannot perfectly distinguish appropriate analyses, with filters for human participants, 65 years old
from inappropriate care. The panel's review of evidence at and older, and the English language. Clinical reviews
times identified subgroups of individuals who should be and guidelines were also included to provide context.
exempt from a given criterion or to whom a specific crite- Case reports, case series, letters to the editor, and edito-
rion should apply. Such a criterion may not be easily rials were excluded.
applied as a quality measure, particularly when such sub- Searches identified 33,965 references; 7352 abstracts
groups cannot be easily identified through structured and were sent to panelists for review, of which 1574 references
readily accessible electronic data (e.g., when diagnoses, the were selected for full-text review. Among these, 451 manu-
purpose of prescribing, or laboratory measures such as kid- scripts were abstracted into evidence tables, and an addi-
ney function are not available). tional 148 were included as background reports.
METHODS Development process
Methods used for the 2023 update of the AGS Beers The full panel convened for a series of conference calls
Criteria® were similar to those used in the 2019 update, between December 2020 and November 2022. Between
the full panel calls, work was conducted via email. In guidelines and the American College of Physicians' evi-
addition, the panel was divided into four workgroups, dence grading framework (Table 1).7,10
each assigned a subset of the criteria, with each work- Using evidence from the 2017–2022 literature review,
group leading the review and synthesis of evidence for its findings from the previous AGS-led 2012, 2015, and 2019
subset of the criteria. updates, and clinical judgment, each workgroup pre-
The panel began its work using an anonymous Delphi sented to the full panel their findings and suggestions for
process to review the 2019 AGS Beers Criteria®. Using a changes (or no change) to the criteria, with ensuing dis-
5-point Likert scale with anchors of “strongly disagree” cussion. For most criteria, a consensus emerged: to leave
and “strongly agree,” criteria receiving three or more panel an existing criterion from the 2019 update unchanged, to
votes of “unsure” or below were brought back for group modify it, to remove it entirely, or to add a new criterion.
discussion and flagged for the individual workgroups to Possible modifications included which drug(s) to include,
review for possible updating. Of note, during the full pro- the recommendation, the rationale, the quality of evi-
cess, all legacy criteria were reviewed for accuracy and dence, and the strength of the recommendation. As noted
appropriateness. Panelists also provided input about drugs in the GRADE guidelines, the strength of recommenda-
to be explored further for possible addition. tion ratings incorporate a variety of considerations,
To guide the evidence selection, review, and synthesis including expert opinion and clinical judgment and con-
process, each workgroup reviewed and updated work- text, and thus do not always align with the quality of evi-
sheets created for the 2019 criteria that identified a priori dence ratings.
which clinical outcomes, indications, and comparison After proposed changes to the criteria were drafted, a
groups were most relevant when considering the evi- second anonymous Delphi process was used to ascertain
dence for each criterion, that is, the “desired evidence” panel consensus on the changes, using the same 5-point
for reviewing each criterion. These discussions were not Likert scale as was previously used. As a general rule, cri-
considered binding but provided guidance for keeping teria receiving three or more panel votes of “unsure” or
the evidence review and synthesis focused on what was disagreement were brought back for group discussion to
most clinically relevant. reach a consensus decision. Final edits after a public
Each workgroup reviewed abstracts from the litera- comment period were approved through the assent of
ture searches for the criteria in its purview and collec- panel members.
tively selected a subset for full-text review. This selection In addition to changes made based on available evi-
process considered the methodologic quality of each dence, the panel decided on several modifications to
study, its relevance to older adults, and its concordance improve the clarity and usability of the AGS Beers
with the desired evidence noted above. After reviewing Criteria®. The panel changed the order and wording of
the full text of each selected article, the workgroup then certain criteria, recommendations, and rationale state-
decided by consensus which papers represented the best ments to improve clarity, avoid possible misinterpreta-
available evidence, based on a balance of these same tions, and maintain consistency of formatting. The order
three key considerations (methodologic quality, relevance of drugs and categories listed in Table 2 was also modi-
to older adults, and concordance with desired evidence). fied for similar reasons. To enhance usability, where fea-
Special emphasis was placed on selecting systematic sible we have listed individual drugs that belong to a
reviews and meta-analyses when available because specified drug class, not including agents that are rarely
resource constraints precluded the panel from conducting or never used in the United States (as defined using the
these types of comprehensive analyses. In general, a methods described immediately below). Note that when
study was considered relevant to older adults if the mean such drug class labels are used, the general intent is that
or median age of participants was at least 65 years, and the criteria apply to all drugs within that class except
especially relevant if most or all participants were older when specified otherwise.
than this age threshold. To simplify and thereby increase usability, the panel
Papers comprising the best available evidence were also voted to omit from key reference tables a number of
abstracted into evidence tables. These tables summarized medications included in previous iterations of the criteria
the design, study population, and findings of each study, that have low or zero usage in the U.S. Drugs that were
and identified markers of methodologic quality moved off the main tables due to low or absent use in the
highlighted by the GRADE criteria for clinical trials and United States are shown in Table 8. We defined low use
observational studies and by the AMSTAR criteria for as <4000 U.S. Medicare beneficiaries aged 65 years or
systematic reviews and meta-analyses.10–12 Each work- older receiving the drug in 2020 based on data from
group then synthesized evidence for each criterion from Medicare Part D Public Use Files (with the <4000 thresh-
the 2017–2022 literature reviews informed by GRADE olds representing approximately <0.01% of Medicare
beneficiaries). Based on group consensus, the panel moved off the main tables to “declutter” the 2023 AGS
decided to retain an explicit listing of certain drugs in key Beers Criteria® and not distract from information on
reference tables despite having <4000 mentions in these commonly used medications in the United States.
files, based on over-the-counter availability and concerns Because medications included in the criteria reflect the
that these drugs are still being used commonly enough to U.S. context, clinicians in other countries should consider
pose a population risk, including in settings not ascer- adaptations that may be warranted due to differing pat-
tainable through Medicare Part D data. Table 8 also terns of medication approval and use.
includes a number of PIMs that are no longer available The initial draft of the 2023 AGS Beers Criteria® was
in the United States because there is no current manufac- reviewed by the AGS Executive Committee, the Chairs/
turer, they have been removed from the market, or avail- Vice Chairs of the AGS Clinical Practice and Models of
able dosage forms limit use to specific uses outside the Care Committee (CPMC), the AGS Ethnogeriatrics Com-
scope of the criteria. These changes should not be inter- mittee, and the AGS Quality & Performance Measure-
preted as condoning the use of these medications—they ment Committee (QPMC) and subsequently released for
are still considered potentially inappropriate in alignment public comment via the AGS website. The availability of
with the 2019 AGS Beers Criteria®5 criteria—but were the criteria for public comment was communicated via
TABLE 1 Designations of quality of evidence and strength of recommendations.
Quality of evidence
Quality of evidence ratings for each criterion are based on a synthetic assessment of 2 complementary approaches to evaluating the quality of
evidence.
ACP-based approach7 GRADE-based approach5

High-quality “Evidence…obtained from 1 or more well-designed and Consider the following 5 factors for the studies that
evidence well-executed randomized, controlled trials (RCTs) comprise the best-available evidence for a given
that yield consistent and directly applicable results. criterion:
This also means that further research is very unlikely 1. Risk of bias: Severity of threats to studies' internal
to change our confidence in the estimate of effect.” validity (eg, randomized vs observational design,
Moderate-quality “Evidence…obtained from RCTs with important the potential for confounding, bias in
evidence limitations…. In addition, evidence from well-designed measurement, etc)
controlled trials without randomization, well-designed 2. Inconsistency: Do different studies provide similar
cohort or case–control analytic studies, and multiple or different estimates of effect size?
time series with or without intervention are in this 3. Indirectness: How relevant are the studies to the
category. Moderate-quality evidence also means that clinical question at hand (eg, nature of the study of
further research will probably have an important population, comparison group, type of outcomes
effect on our confidence in the estimate of effect and measured, etc)?
may change the estimate.” 4. Imprecision: Precision of estimates of effect
5. Publication bias: Risk of bias because of selective
Low-quality “Evidence obtained from observational studies would
publication of results
evidence typically be rated as low quality because of the risk for
bias. Low-quality evidence means that further research
is very likely to have an important effect on our
confidence in the estimate of effect and will probably
change the estimate. However, the quality of evidence
may be rated as moderate or even high, depending on
circumstances under which evidence is obtained from
observational studies.”
ÐÐÐÐÐ
Overall quality of evidence that supports a given criterion: high, moderate, low.
Strength of recommendation
Strength of recommendation ratings for each criterion are based on synthetic integration of the quality of evidence, the frequency and severity
of potential adverse events and their relationship to potential benefits, and clinical judgment.
Strong Harms, adverse events, and risks clearly outweigh the benefits.
Weak Harms, adverse events, and risks may not outweigh the benefits.
Source: Adapted from Qaseem et al.,7 Guyatt et al.,8 Andrews et al.9

TABLE 2 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults.
Organ system, therapeutic Quality of Strength of

category, drug(s)a Rationale Recommendation evidenceb recommendationb
Antihistamines
First-generation antihistamines Highly anticholinergic; clearance reduced with Avoid Moderate Strong
Brompheniramine advanced age, and tolerance develops when used
Chlorpheniramine as hypnotic; risk of confusion, dry mouth,
AGS 2023 BEERS CRITERIA®
Cyproheptadine constipation, and other anticholinergic effects or

Dimenhydrinate toxicity. Cumulative exposure to anticholinergic
Diphenhydramine (oral) drugs is associated with an increased risk of falls,
Doxylamine delirium, and dementia, even in younger adults.
Hydroxyzine Consider total anticholinergic burden during
Meclizine regular medication reviews and be cautious in
Promethazine “young-old” as well as “old-old” adults.
Triprolidine Use of diphenhydramine in situations such as
acute treatment of severe allergic reactions may
be appropriate.
Anti-infective
Nitrofurantoin Potential for pulmonary toxicity, hepatoxicity, Avoid in individuals with CrCl <30 mL/ Low Strong
and peripheral neuropathy, especially with min or for long-term suppression.
long-term use; safer alternatives available.
Cardiovascular and antithrombotics
Aspirin for primary prevention of Risk of major bleeding from aspirin increases Avoid initiating aspirin for primary High Strong
cardiovascular disease markedly in older age. Studies suggest a lack of prevention of cardiovascular disease.
net benefit and potential for net harm when Consider deprescribing aspirin in older
initiated for primary prevention in older adults. adults already taking it for primary
There is less evidence about stopping aspirin prevention.
among long-term users, although similar
principles for initiation may apply.
Note: Aspirin is generally indicated for secondary
prevention in older adults with established
cardiovascular disease.
Warfarin for the treatment of Compared with DOACs, warfarin has higher Avoid starting warfarin as initial therapy High Strong
nonvalvular atrial fibrillation or risks of major bleeding (particularly for the treatment of nonvalvular atrial
venous thromboembolism (VTE) intracranial bleeding) and similar or lower fibrillation or VTE unless alternative
effectiveness for the treatment of nonvalvular options (i.e., DOACs) are
atrial fibrillation and VTE. DOACs are thus the contraindicated or there are substantial
preferred choice for anticoagulation for most barriers to their use.
people with these conditions. For older adults who have been using
warfarin long-term, it may be reasonable
to continue this medication, particularly
among those with well-controlled INRs
(i.e., >70% time in the therapeutic range)
and no adverse effects.
2057
(Continues)
TABLE 2 (Continued)
2058

See also criteria on rivaroxaban (Table 2)
and dabigatran (Table 4) and footnote
regarding choice among DOACs.
Rivaroxaban for long-term treatment of At doses used for long-term treatment of VTE or Avoid for long-term treatment of atrial Moderate Strong
nonvalvular atrial fibrillation or nonvalvular atrial fibrillation, rivaroxaban fibrillation or VTE in favor of safer
venous thromboembolism (VTE) appears to have a higher risk of major bleeding anticoagulant alternatives.
and GI bleeding in older adults than other See also criteria on warfarin (Table 2) and
DOACs, particularly apixaban.c dabigatran (Table 4) and footnote
Rivaroxaban may be reasonable in special regarding the choice between warfarin
situations, for example when once-daily dosing and DOACs and among DOACs.
is necessary to facilitate medication adherence.
All DOACs confer a lower risk of intracranial
hemorrhage than warfarin.c
Dipyridamole, oral short-acting (does May cause orthostatic hypotension; more effective Avoid Moderate Strong
not apply to extended-release alternatives available; IV form acceptable for use in
combination with aspirin) cardiac stress testing.
Non-selective peripheral alpha-1 High risk of orthostatic hypotension and Avoid use as an antihypertensive. Moderate Strong
blockers for the treatment of associated harms, especially in older adults; not
hypertension recommended as routine treatment for
Doxazosin hypertension; alternative agents have superior
Prazosin risk/benefit profile.
Terazosin
Central alpha-agonists for the treatment High risk of adverse CNS effects; may cause Avoid clonidine as first-line treatment for Low Strong
of hypertension bradycardia and orthostatic hypotension; not hypertension.
Clonidine recommended as routine treatment for Avoid other central alpha-agonists for the
Guanfacine hypertension. treatment of hypertension.
Nifedipine, immediate release Potential for hypotension; risk of precipitating Avoid High Strong
myocardial ischemia.
Amiodarone Effective for maintaining sinus rhythm but has Avoid as first-line therapy for atrial High Strong
greater toxicities than other antiarrhythmics used fibrillation unless the patient has heart
in atrial fibrillation; may be reasonable first-line failure or substantial left ventricular
therapy in patients with concomitant heart hypertrophy.
failure or substantial left ventricular hypertrophy
if rhythm control is preferred over rate control.
Dronedarone Worse outcomes in people who have permanent Avoid in individuals with permanent atrial High Strong
atrial fibrillation or severe or recently fibrillation or severe or recently
decompensated heart failure. In some decompensated heart failure. Use caution
circumstances, worse outcomes have also been in patients with HFrEF with less severe
reported in people with HFrEF (e.g., left symptoms (NYHA class I or II).
ventricular ejection fraction ≤35%) who have
BY THE 2023 AMERICAN GERIATRICS SOCIETY BEERS CRITERIA® UPDATE EXPERT PANEL
milder symptoms (NYHA class I or II).
TABLE 2 (Continued)

Digoxin for first-line treatment of atrial Use in atrial fibrillation: should not be used as a Avoid this rate control agent as first-line Atrial fibrillation; Strong
fibrillation or heart failure first-line agent because there are safer and therapy for atrial fibrillation. heart failure: low
more effective alternatives for rate control. Avoid as first-line therapy for heart Dosage > 0.125 mg/
Use in heart failure: evidence for benefits and harms failure. See rationale for caution about day: moderate
of digoxin is conflicting and of lower quality; most withdrawal in long-term users with
(but not all) evidence concerns use in HFrEF. HFrEF.
There is strong evidence for other agents as first- If used for atrial fibrillation or heart
line therapy to reduce hospitalizations and failure, avoid dosages >0.125 mg/day.
mortality in adults with HFrEF. In heart failure,
higher dosages are not associated with additional
benefits and may increase the risk of toxicity. Use
caution in discontinuing digoxin among current
users with HFrEF, given limited evidence
suggesting worse clinical outcomes after
discontinuation.
Decreased renal clearance of digoxin may lead to
an increased risk of toxic effects; further dose
reduction may be necessary for those with
Stage 4 or 5 chronic kidney disease.
Central nervous system
Antidepressants with strong Highly anticholinergic, sedating, and cause Avoid High Strong
anticholinergic activity, alone or in orthostatic hypotension; the safety profile of
combination low-dose doxepin (≤6 mg/day) is comparable to
Amitriptyline that of placebo.
Amoxapine
Clomipramine
Desipramine
Doxepin >6 mg/day
Imipramine
Nortriptyline
Paroxetine
Antiparkinsonian agents with strong Not recommended for prevention or treatment of Avoid Moderate Strong
anticholinergic activity extrapyramidal symptoms due to
Benztropine (oral) antipsychotics; more effective agents available
Trihexyphenidyl for the treatment of Parkinson disease.
Antipsychotics, first- (typical) and Increased risk of stroke and greater rate of Avoid, except in FDA-approved Moderate Strong
second- (atypical) generation cognitive decline and mortality in persons with indications such as schizophrenia,
Aripiprazole dementia. Additional evidence suggests an bipolar disorder, Parkinson disease
Haloperidol association of increased risk between psychosis (see Table 3), adjunctive
Olanzapine antipsychotic medication and mortality treatment of major depressive disorder,
Quetiapine independent of dementia. or for short-term use as an antiemetic.
Risperidone
2059
Othersd
(Continues)
TABLE 2 (Continued)
2060

Avoid antipsychotics for behavioral problems of
dementia or delirium unless documented
nonpharmacologic options (e.g., behavioral
interventions) have failed and/or the patient is
threatening substantial harm to self or others.
If used, periodic deprescribing attempts should
be considered to assess ongoing need and/or
the lowest effective dose.
Barbiturates High rate of physical dependence, tolerance to Avoid High Strong

Butalbital sleep benefits, greater risk of overdose at low
Phenobarbital dosages.
Primidone
Benzodiazepines The use of benzodiazepines exposes users to risks Avoid Moderate Strong
Alprazolam of abuse, misuse, and addiction. Concomitant
Chlordiazepoxide (alone or in use of opioids may result in profound sedation,
combination with amitriptyline or respiratory depression, coma, and death.
clidinium) Older adults have increased sensitivity to
Clobazam benzodiazepines and decreased metabolism of
Clonazepam long-acting agents; the continued use of
Clorazepate benzodiazepines may lead to clinically
Diazepam significant physical dependence. In general, all
Estazolam benzodiazepines increase the risk of cognitive
Lorazepam impairment, delirium, falls, fractures, and
Midazolam motor vehicle crashes in older adults.
Oxazepam May be appropriate for seizure disorders, rapid
Temazepam eye movement sleep behavior disorder,
Triazolam benzodiazepine withdrawal, ethanol
withdrawal, severe generalized anxiety
disorder, and periprocedural anesthesia.
Nonbenzodiazepine benzodiazepine Nonbenzodiazepine benzodiazepine receptor Avoid Moderate Strong
receptor agonist hypnotics (“Z-drugs”) agonist hypnotics (“Z-drugs”) have adverse
Eszopiclone events similar to those of benzodiazepines in
Zaleplon older adults (e.g., delirium, falls, fractures,
Zolpidem increased emergency room visits/
hospitalizations, motor vehicle crashes);
minimal improvement in sleep latency and
duration.
Meprobamate High rate of physical dependence; very sedating. Avoid Moderate Strong
Ergoloid mesylates (dehydrogenated Lack of efficacy. Avoid High Strong
ergot alkaloids)
TABLE 2 (Continued)

Endocrine
Androgens Potential for cardiac problems; potential risks in Avoid unless indicated for confirmed Moderate Weak
Methyltestosterone men with prostate cancer. hypogonadism with clinical symptoms.

Testosterone
Estrogens with or without progestins Evidence of carcinogenic potential (breast and Do not initiate systemic estrogen (e.g., oral Oral and patch: high Oral and patch:
(includes natural and synthetic estrogen endometrium); lack of cardioprotective effect tablets or transdermal patches). Vaginal cream or strong
preparations) and cognitive protection in older women. Consider deprescribing among older vaginal tablets: Topical vaginal
For women who start HRT at age 60 and older, women already using this medication. moderate cream or tablets:
the risks of HRT are greater than the benefits, Vaginal cream or vaginal tablets: weak
as HRT is linked to a higher risk of heart acceptable to use low-dose intravaginal
disease, stroke, blood clots, and dementia. estrogen for the management of
Evidence indicates that vaginal estrogens for the dyspareunia, recurrent lower urinary
treatment of vaginal dryness are safe and tract infections, and other vaginal
effective; women with a history of breast cancer symptoms.
who do not respond to nonhormonal therapies
are advised to discuss the risks and benefits of
low-dose vaginal estrogen (e.g., dosages of
estradiol <25 mcg twice weekly) with their
healthcare provider.
Insulin, sliding scale (insulin regimens Higher risk of hypoglycemia without Avoid Moderate Strong
containing only short- or rapid-acting improvement in hyperglycemia management
insulin dosed according to current regardless of care setting. Avoid insulin
blood glucose levels without regimens that include only short- or rapid-
concurrent use of basal or long-acting acting insulin dosed according to current blood
insulin) glucose levels without concurrent use of basal
or long-acting insulin. This recommendation
does not apply to regimens that contain basal
insulin or long-acting insulin.
Sulfonylureas (all, including short- and Sulfonylureas have a higher risk of cardiovascular Avoid sulfonylureas as first- or second-line Hypoglycemia: High Strong
longer-acting) events, all-cause mortality, and hypoglycemia monotherapy or add-on therapy unless CV events and all-
Gliclazide than alternative agents. Sulfonylureas may there are substantial barriers to the use
cause mortality:
Glimepiride increase the risk of cardiovascular death and of safer and more effective agents.
Moderate
Glipizide ischemic stroke. If a sulfonylurea is used, choose short-
Glyburide (Glibenclamide) CV death and
Among sulfonylureas, long-acting agents (e.g., acting agents (e.g., glipizide) over long-
ischemic stroke:
glyburide, glimepiride) confer a higher risk of acting agents (e.g., glyburide,
Low
prolonged hypoglycemia than short-acting glimepiride).
agents (e.g., glipizide).
Desiccated thyroid Concerns about cardiac effects; safer alternatives Avoid Low Strong
available.
(Continues)
2061
TABLE 2 (Continued)
2062

Megestrol Minimal effect on weight; increases the risk of Avoid Moderate Strong
thrombotic events and possibly death in older
adults.
Growth hormone Impact on body composition is small and Avoid, except for patients rigorously High Strong
associated with edema, arthralgia, carpal diagnosed by evidence-based criteria
tunnel syndrome, gynecomastia, and impaired with growth hormone deficiency due to
fasting glucose. an established etiology.
Gastrointestinal
Proton-pump inhibitors Risk of C. difficile infection, pneumonia, GI Avoid scheduled use for >8 weeks unless C. difficile, bone loss, Strong
Dexlansoprazole malignancies, bone loss, and fractures. for high-risk patients (e.g., oral and fractures:
Esomeprazole corticosteroids or chronic NSAID use), High
Lansoprazole erosive esophagitis, Barrett's esophagitis, Pneumonia and GI
Omeprazole pathologic hypersecretory condition, or
malignancies:
Pantoprazole demonstrated need for maintenance
Moderate
Rabeprazole treatment (e.g., because of failure of
drug discontinuation trial or
H2-receptor antagonists).
Metoclopramide Can cause extrapyramidal effects, including Avoid, unless for gastroparesis with a Moderate Strong
tardive dyskinesia; the risk may be greater in duration of use not to exceed 12 weeks
frail older adults and with prolonged exposure. except in rare cases.
GI antispasmodics with strong Highly anticholinergic, uncertain effectiveness. Avoid Moderate Strong
anticholinergic activity
Atropine (excludes ophthalmic)
Clidinium-chlordiazepoxide
Dicyclomine
Hyoscyamine
Scopolamine
Mineral oil, given orally Potential for aspiration and adverse effects; safer Avoid Moderate Strong
alternatives available.
Genitourinary
Desmopressin High risk of hyponatremia; safer alternative Avoid for treatment of nocturia or Moderate Strong
treatments for nocturia (including non- nocturnal polyuria.
pharmacologic).
Pain medications
Non-COX-2-selective NSAIDs, oral: Increased risk of GI bleeding or peptic ulcer Avoid chronic use unless other Moderate Strong
Aspirin >325 mg/day disease in high-risk groups, including those alternatives are not effective and the
Diclofenac >75 years old or taking oral or parenteral patient can take a gastroprotective agent
Diflunisal corticosteroids, anticoagulants, or antiplatelet (proton-pump inhibitor or misoprostol).
Etodolac agents; use of proton-pump inhibitor or Avoid short-term scheduled use in
Flurbiprofen misoprostol reduces but does not eliminate combination with oral or parenteral
TABLE 2 (Continued)

Ibuprofen risk. Upper GI ulcers, gross bleeding, or corticosteroids, anticoagulants, or
Indomethacin perforation caused by NSAIDs occur in 1% of antiplatelet agents unless other
Ketorolac patients treated for 3–6 months and in 2%–4% alternatives are not effective and the
Meloxicam of patients treated for 1 year; these trends patient can take a gastroprotective agent
Nabumetone continue with longer duration of use. Also can (proton-pump inhibitor or misoprostol).
Naproxen increase blood pressure and induce kidney
Oxaprozin injury. Risks are dose-related.
Piroxicam
Sulindac
Indomethacin Increased risk of GI bleeding/peptic ulcer disease Avoid Moderate Strong
Ketorolac (oral and parenteral) and acute kidney injury in older adults. Of all
the NSAIDs, indomethacin has the most
adverse effects, including a higher risk of
adverse CNS effects.
Meperidine Oral analgesic not effective in dosages commonly Avoid Moderate Strong
used; may have a higher risk of neurotoxicity,
including delirium, than other opioids; safer
alternatives available.
Skeletal muscle relaxants Muscle relaxants typically used to treat Avoid Moderate Strong
Carisoprodol musculoskeletal complaints are poorly tolerated
Chlorzoxazone by older adults due to anticholinergic adverse
Cyclobenzaprine effects, sedation, and increased risk of fractures;
Metaxalone effectiveness at dosages tolerated by older adults
Methocarbamol is questionable.
Orphenadrine This criterion does not apply to skeletal muscle
relaxants typically used for the management of
spasticity (i.e., baclofen and tizanidine)
although these drugs can also cause substantial
adverse effects.
Abbreviations: CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; CV, cardiovascular; DOACs, direct oral anticoagulants; GI, gastrointestinal; HFrEF, heart failure with
reduced ejection fraction; HRT, hormone replacement therapy; INR, international normalized ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; NYHA, New York Heart Association; SIADH,
syndrome of inappropriate antidiuretic hormone secretion; VTE, venous thromboembolism.
a
Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations. Unless stated otherwise, all drugs within a stated drug
class are considered potentially inappropriate in the context of the criterion in which they appear, even if not listed in this table.
b
Quality of evidence and strength of recommendation ratings apply to all drugs and recommendations within each criterion unless stated otherwise.
c
When selecting among DOACs and choosing a dose, pay special consideration to kidney function (see Table 6), indication, and body weight.
d
Antipsychotics used in the United States include: First-generation (“typical”)—chlorpromazine, fluphenazine, haloperidol, perphenazine; Second-generation (“atypical”)—aripiprazole, brexpiprazole,
cariprazine, clozapine, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, ziprasidone. This list does not include antipsychotics rarely or never used in the U.S. among older
adults.
2063
AGS' regular communication channels for reaching the account of having low usage in the United States, not
public. AGS members were also encouraged to submit being currently available in the United States, or for other
comments with multiple posts included on the weekly reasons. A summary of modifications and additions to the
member listserv and notices in MyAGSOnline, the criteria is shown in Tables 9 and 10. Online supplemental
society's online member community. AGS also made out- Appendix S1 contains a list of drugs removed from the
reach to 47 organizations to alert them to the public com- AGS Beers Criteria® since the 2012 update.
ment period and with a request that they provide expert, In Table 2, the rationale for anticholinergic drugs to
external review. Fifty-eight total comment forms were avoid has been expanded to recognize the risks associated
submitted comprising more than 200 comments and sug- with concurrent use (cumulative anticholinergic burden)
gestions; the expert panel reviewed these and modified and is also recognized in Tables 3 and 5. The criterion for
the criteria and accompanying text based on the strength the use of aspirin for the primary prevention of cardiovas-
of the evidence supporting each recommended change cular disease has been revised and moved from the “use
and clinical judgment. The AGS Executive Committee with caution” table (Table 4) to Table 2, with the new
and CPMC Chair and Vice Chair reviewed the resulting recommendation being to avoid initiating aspirin for the
draft of the 2023 AGS Beers Criteria®. The Criteria went primary prevention of cardiovascular disease in older
through peer review by the Journal of the American Geri- adults (in agreement with the U.S. Preventive Services
atrics Society (JAGS). Task Force's recommendation).13 For older adults who
are already taking aspirin for primary prevention, the
panel recommends deprescribing be considered, pending
RESULTS any new data on this issue.
Changes to the criteria involving anticoagulation
Noteworthy changes to PIMS for older were discussed at length, including the proposed
adults changes, the supporting literature, and ramifications. The
recommendation for rivaroxaban has changed from “use
The drugs and drug class criteria included in the 2023 with caution” to “avoid” for long-term treatment of non-
AGS Beers Criteria® are listed in Tables 2–6. To enhance valvular atrial fibrillation and venous thromboembolism
clarity, a special box that summarizes the criteria for anti- (VTE), with the rationale being that observational studies
coagulants (warfarin, rivaroxaban, and dabigatran) has and network meta-analyses find that this drug confers a
been added (Box 1). Table 7 is a list of drugs with strong higher risk of major and gastrointestinal bleeding in
anticholinergic properties referred to in Tables 2, 3, and 5. older adults than other direct-acting oral anticoagulants
Table 8 is a list of drugs from the 2019 AGS Beers Criteria (DOACs), particularly apixaban, but also dabigatran. The
that the panel still considers to be PIMs (unless specified panel recognizes there may be circumstances when rivar-
otherwise) but which are now moved off of Tables 2–7 on oxaban may be a reasonable choice, including for other
BOX 1 Synthesis of anticoagulation recommendations.
Explanation Recommendation
This criterion summarizes recommendations for warfarin Warfarin: Avoid starting warfarin as initial therapy for the
(Table 2), rivaroxaban (Table 2), and dabigatran treatment of venous thromboembolism (VTE) or nonvalvular
(Table 4)—anticoagulants to avoid or to use with caution. atrial fibrillation unless alternative options (e.g., DOACs) are
A “use with caution” recommendation reflects less concern contraindicated or there are substantial barriers to their use.
and/or less clear evidence than an “avoid” For older adults who have been using warfarin long-term, it
recommendation. See individual criteria on these may be reasonable to continue this medication, particularly
medications for more information about anticoagulant- among those with well-controlled INRs (i.e., >70% time in the
related recommendations. therapeutic range) and no adverse effects.
When selecting among DOACs and choosing a dosage, pay Rivaroxaban: Avoid rivaroxaban for long-term treatment of
special consideration to kidney function (see Table 6), nonvalvular atrial fibrillation or VTE in favor of safer
indication, and body weight. anticoagulant alternatives.
Dabigatran: Use caution in selecting dabigatran over other
DOACs (e.g., apixaban) for long-term treatment of nonvalvular
atrial fibrillation or VTE.
T A B L E 3 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions that may
exacerbate the disease or syndrome.
Strength of
Disease or syndrome Drug(s)a Rationale Recommendation Quality of evidenceb recommendationb
Cardiovascular
Heart failure Cilostazol Potential to promote fluid retention and/or Avoid: Cilostazol, Strong
Dextromethorphan-quinidine exacerbate heart failure (NSAIDs and COX-2 Cilostazol dextromethorphan-
inhibitors, non-dihydropyridine CCBs, Dextromethorphan-quinidine quinidine, COX-2
Nondihydropyridine calcium channel thiazolidinediones); potential to increase mortality inhibitors: Low
blockers (CCBs) -------------------------------
in older adults with heart failure (cilostazol and Avoid in heart failure with
Diltiazem Non-dihydropyridine
dronedarone); concerns about QT prolongation reduced ejection fraction:
Verapamil CCBs, NSAIDs:
(dextromethorphan-quinidine).
Nondihydropyridine calcium Moderate
Dronedarone Note: This is not a comprehensive list of medications channel blockers (CCBs) Dronedarone,
NSAIDs and COX-2 inhibitors to avoid in patients with heart failure. Diltiazem thiazolidenediones:
Thiazolidinediones Verapamil High
Pioglitazone -------------------------------
Use with caution in patients with
heart failure who are
asymptomatic; avoid in
patients with symptomatic
heart failure:
Dronedarone
NSAIDs and COX-2 inhibitors
Thiazolidinediones
Pioglitazone
Syncope Antipsychotics (selected) Antipsychotics listed and tertiary TCAs increase the Avoid High Antipsychotics, non-
Chlorpromazine risk of orthostatic hypotension. selective peripheral
Olanzapine AChEIs cause bradycardia and should be avoided in alpha-1 blockers:
Cholinesterase inhibitors (AChEIs) older adults whose syncope may be due to Weak
Donepezil bradycardia. AChEIs, tertiary TCAs:
Galantamine Strong
Rivastigmine Non-selective peripheral alpha-1 blockers cause
Non-selective peripheral alpha-1 orthostatic blood pressure changes and should be
blockers avoided in older adults whose syncope may be due
Doxazosin to orthostatic hypotension.
Prazosin
Terazosin
Tertiary tricyclic antidepressants
(TCAs)
Amitriptyline
Clomipramine
Doxepin
Imipramine
(Continues)
2065
2066
TABLE 3 (Continued)
Strength of
Central nervous system
Delirium Anticholinergics (see Table 7) Avoid in older adults with or at high risk of delirium Avoid, except in situations listed H2-receptor antagonists: Strong
c because of the potential of inducing or worsening under the rationale statement. Low
Antipsychotics
delirium.
All others: Moderate
Benzodiazepines Antipsychotics: avoid for behavioral problems of
Corticosteroids (oral and parenteral)d dementia or delirium unless nonpharmacologic
options (eg, behavioral interventions) have failed
H2-receptor antagonists or are not possible and the older adult is
Cimetidine threatening substantial harm to self or others. If
Famotidine used, periodic deprescribing attempts should be
Nizatidine considered to assess ongoing need and/or the
lowest effective dose.
Nonbenzodiazepine benzodiazepine
receptor agonist hypnotics (“Z- Corticosteroids: if needed, use the lowest possible
drugs”) dose for the shortest duration and monitor for
Eszopiclone delirium.
Zaleplon Opioids: emerging data highlights an association
Zolpidem between opioid administration and delirium. For
Opioids older adults with pain, use a balanced approach,
including the use of validated pain assessment
tools and multimodal strategies that include
nondrug approaches to minimize opioid use.
Dementia or cognitive Anticholinergics (see Table 7) Avoid because of adverse CNS effects. See criteria on Avoid Moderate Strong
impairment individual drugs for additional information.
Antipsychotics, chronic use or
persistent as-needed usec Antipsychotics: increased risk of stroke and greater
rate of cognitive decline and mortality in people
Benzodiazepines with dementia. Avoid antipsychotics for
Nonbenzodiazepine benzodiazepine behavioral problems of dementia or delirium
receptor agonist hypnotics (“Z- unless documented nonpharmacologic options
drugs”) (e.g., behavioral interventions) have failed and/or
Eszopiclone the patient is threatening substantial harm to self
Zaleplon or others. If used, periodic deprescribing attempts
Zolpidem should be considered to assess ongoing need
and/or the lowest effective dose.
History of falls or Anticholinergics (see Table 7) May cause ataxia, impaired psychomotor function, Avoid unless safer alternatives are Antidepressants, opioids: Strong
fractures syncope, or additional falls. not available. Moderate
Antidepressants (selected classes)
Antidepressants (selected classes): evidence for risk
SNRIs Antiepileptics: avoid except for All others: High
of falls and fractures is mixed; newer evidence
SSRIs seizures and mood disorders.
suggests that SNRIs may increase falls risk.
Tricyclic antidepressants (TCAs)
Benzodiazepines: shorter-acting ones are not safer Opioids: avoid except for pain
Antiepileptics than long-acting ones. management in the setting of
If one of the drugs must be used, consider reducing severe acute pain.
Antipsychoticsc
the use of other CNS-active medications that
Benzodiazepines increase the risk of falls and fractures
TABLE 3 (Continued)
Strength of
History of falls and Nonbenzodiazepine benzodiazepine (i.e., anticholinergics, selected antidepressants,
fractures, cont'd receptor agonist hypnotics (“Z- antiepileptics, antipsychotics, sedative/hypnotics
drugs”) including benzodiazepines and,
Eszopiclone nonbenzodiazepine benzodiazepine receptor
Zaleplon agonist hypnotics, opioids) and implement other
Zolpidem strategies to reduce fall risk.

Opioids
Parkinson disease Antiemetics Dopamine-receptor antagonists with the potential to Avoid Moderate Strong
Metoclopramide worsen parkinsonian symptoms
Prochlorperazine
Exceptions: clozapine, pimavanserin, and quetiapine
Promethazine
appear to be less likely to precipitate the
Antipsychotics (except clozapine, worsening of Parkinson disease than other
pimavanserin, and quetiapine) antipsychotics.
Gastrointestinal
History of gastric or Aspirin May exacerbate existing ulcers or cause Avoid unless other alternatives Moderate Strong
duodenal ulcers Non-COX-2 selective NSAIDs new/additional ulcers are not effective and the patient
can take a gastroprotective
agent (i.e., proton-pump
inhibitor or misoprostol).
Kidney/urinary tract
Urinary incontinence Non-selective peripheral alpha-1 Aggravation of incontinence (alpha-1 blockers), Avoid in women Non-selective peripheral Non-selective
(all types) in women blockerse lack of efficacy (oral estrogen) See also recommendation on alpha-1 blockers: peripheral alpha-1
Doxazosin estrogen (Table 2) Moderate blockers: Strong
Prazosin Estrogen: High Estrogen: Strong
Terazosin
Estrogen, oral and transdermal
(excludes intravaginal estrogen)
Lower urinary tract Strongly anticholinergic drugs, except May decrease urinary flow and cause urinary Avoid in men Moderate Strong
symptoms, benign antimuscarinics for urinary retention
prostatic hyperplasia incontinence (see Table 7)
Abbreviations: AChEI, acetylcholinesterase inhibitor; CCBs, calcium channel blockers; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; COX, cyclooxygenase; CrCl, creatinine clearance;
NSAIDs, nonsteroidal anti-inflammatory drugs; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.
a
Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations. Unless stated otherwise, all drugs within a stated drug class are
considered potentially inappropriate in the context of the criterion in which they appear, even if not listed in this table.
b
c
May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest
possible duration.
d
Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible
duration.
e
Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
2067
T A B L E 4 2023 American Geriatrics Society Beers Criteria® for potentially inappropriate medications: drugs to be used with caution in
older adultsa.
Quality of Strength of
Drug(s)b Rationale Recommendation evidencec recommendationc
Dabigatran for long-term Increased risk of GI bleeding compared Use caution in selecting Moderate Strong
treatment of nonvalvular with warfarin (based on head-to-head dabigatran over other DOACs
atrial fibrillation or venous clinical trials) and of GI bleeding and (e.g., apixaban) for long-term
thromboembolism (VTE) major bleeding compared with apixaban treatment of nonvalvular
(based on observational studies and atrial fibrillation or VTE.
meta-analyses) in older adults when See also criteria on warfarin
used for long-term treatment of and rivaroxaban (Table 2)
nonvalvular atrial fibrillation or VTE. and footnoted regarding
choice among DOACs.
Prasugrel Both increase the risk of major bleeding in Use with caution, particularly Moderate Strong
Ticagrelor older adults compared with clopidogrel, in adults 75 years old and
especially among those 75 years old and older.
older. However, this risk may be offset If prasugrel is used, consider a
by cardiovascular benefits in select lower dose (5 mg) for those
patients. 75 years old and older.
Antidepressants (selected) May exacerbate or cause SIADH or Use with caution Moderate Strong
Mirtazipine hyponatremia; monitor sodium levels
SNRIs closely when starting or changing
SSRIs dosages in older adults.
TCAs
Antiepileptics (selected)
Carbamazepine
Oxcarbazepine
Antipsychotics
Diuretics
Tramadol
Dextromethorphan- Limited efficacy in patients with Use with caution Moderate Strong
quinidine behavioral symptoms of dementia (does
not apply to the treatment of
pseudobulbar affect). May increase the
risk of falls and concerns with clinically
significant drug interactions and with
use in those with heart failure (see
Table 3).
Trimethoprim- Increased risk of hyperkalemia when used Use with caution in patients on Low Strong
sulfamethoxazole concurrently with an ACEI, ARB, or ACEI, ARB, or ARNI and
ARNI in presence of decreased CrCl. decreased CrCl.
Sodium-glucose co- Older adults may be at increased risk of Use with caution. Moderate Weak
transporter-2 (SGLT2) urogenital infections, particularly Monitor patients for urogenital
inhibitors women in the first month of treatment. infections and ketoacidosis.
Canigliflozin An increased risk of euglycemic diabetic
Dapagliflozin ketoacidosis has also been seen in older
Emplaglifozin adults.
Ertuglifozin
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor;
CrCl, creatinine clearance; DOAC, direct oral anticoagulant; GI, gastrointestinal; SIADH, syndrome of inappropriate antidiuretic hormone secretion;
SGLT2, sodium glucose co-transporter-2; SNRIs, serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs,
tricyclic antidepressants; VTE, venous thromboembolism.
a
“Use with caution” recommendations reflect concern about the balance of benefits and harms of medication compared with alternatives in the
situation when those concerns do not rise to the level of “avoid” recommendations in other Tables because of limited evidence, a lesser degree of
potential harm compared with alternative therapies, and/or extenuating clinical circumstances.
b
Under each drug class, drugs commonly used in the United States are listed, except in cases where doing so is infeasible due to space considerations.
Unless stated otherwise, all drugs within a stated drug class are considered potentially inappropriate in the context of the criterion in which they
appear, even if not listed in this table.
c
d
When selecting among DOACs and choosing a dosage, pay special consideration to kidney function (see Table 6), indication, and body weight.
clinical conditions and in special circumstances such as sulfonylureas (e.g., glimepiride, chlorpropramide, or glybur-
when a once-daily DOAC is necessary to facilitate medi- ide, which is also known as glibenclamide).
cation adherence, and that all DOACs have a lower risk Changes to the criteria involving PIMs exacerbating
of intracranial hemorrhage than warfarin. specific drug diseases and drug syndromes (Table 3) are
Warfarin has been added to Table 2 as a medication relatively minimal. The combination of dextromethor-
to be avoided when starting initial therapy for VTE or phan/quinidine was added to the list of drugs to avoid
nonvalvular atrial fibrillation unless alternatives in patients with heart failure. In the criterion of PIMs
(e.g., DOACs) are contraindicated or there are substantial to avoid in older adults with a history of falls or frac-
barriers to the use of an alternative. The distinction tures, the level of evidence for antidepressants has been
between starting warfarin as initial therapy versus main- lowered to “moderate.” Modifications and clarifications
taining warfarin among current long-term users (espe- were made to the criteria for delirium, dementia, and
cially those with well-controlled international Parkinson disease, including adding opioids to the list
normalized ratio [INR] levels) reflects different evidence of drugs that can exacerbate delirium. The update con-
for these scenarios as well as considerations of shared tinues to stress the need to avoid antipsychotics and
decision-making. The AGS is concerned that there are other medications for behavioral problems of dementia
significant barriers to the use of newer alternatives and delirium as their use is frequently associated with
including high out-of-pocket drug costs and formulary harm and increased during and after pandemic
restrictions. These barriers could lead to inequitable lockdowns.14–16 The use of behavioral interventions
access to DOACs that may be safer for older adults. We and search for modifiable triggers for behavior14,17
urge policymakers, insurers, and organizations in the remains the preferred management strategy and should
pharmaceutical supply chain to ensure that out-of-pocket be clearly documented in the health record. The use of
costs and access restrictions are not a barrier to safe and antipsychotics and other medications listed in these cri-
effective anticoagulation for all of us as we age. AGS and teria should be a last resort in collaboration and with
the expert panel recognize that cost and access will con- the use of shared decision-making with older adults
tinue to be a factor in individualized decision-making and their care partners. Many evidence-based
between warfarin and DOACs and among different approaches for behavior in persons with dementia are
DOACs until payment policies are enacted that support now available including the Describe, Investigate, Cre-
equitable access for all individuals regardless of their eco- ate, Evaluate (DICE) approach and others.18,19 We
nomic and insurance status. The recommendation for remind readers that the AGS Beers Criteria® do not
dabigatran remains as “use with caution” for the long- apply to care in hospice and at the end of life, in which
term treatment of nonvalvular atrial fibrillation and VTE setting decision-making about these and other drugs
(Table 4) because of evidence suggesting an increased may require other considerations.
risk of gastrointestinal and major bleeding compared As mentioned above, the criteria for aspirin and rivar-
with alternatives such as apixaban. oxaban have been moved from Table 4 to Table 2. Tica-
Another change from the 2019 criteria pertains to the grelor has been added to the criterion about prasugrel,
initiation and continuation of estrogen in postmeno- advising that it be used with caution, particularly among
pausal women. The initiation of oral and transdermal adults 75 years old and older because of concerns of
estrogen is to be avoided in older women; topical vaginal major bleeding. A new criterion was added advising that
estrogen remains appropriate for its major indications of sodium-glucose co-transporter-2 (SGLT2) inhibitors be
symptomatic vaginal atrophy or urinary tract infection used with caution because of the increased risk of uro-
prophylaxis. Deprescribing should be considered for older genital infection and euglycemic diabetic ketoacidosis,
women already using nonvaginal estrogen replacement. and recommends monitoring early during treatment. Of
The recommendation for sulfonylureas has been expanded note, the panel recognizes the value of SGLT2-inhibitors
to avoid all sulfonylureas as first- or second-line monother- but also wishes to emphasize that patients taking these
apy or add on-therapy in recognition of their association drugs should be monitored actively for possible adverse
with a higher risk of cardiovascular events, all-cause mor- effects.
tality, and hypoglycemia than alternative choices. Here the The panel worked to clarify and consolidate the clini-
panel recognizes there may be substantial barriers to or cally important drug–drug interactions (Table 5), most
pressures opposing the recommendation, including finan- notably the use of multiple agents with anticholinergic
cial ones, with similar considerations as those discussed activity, the concurrent use of ≥3 CNS-active drugs from
above for anticoagulants. If a sulfonylurea must be used, specific therapeutic categories (which now include skele-
then a short-acting agent is preferred because of the higher tal muscle relaxants), and the addition of SSRIs to the list
risk of prolonged hypoglycemia with longer-acting of warfarin drug–drug interactions.
TABLE 5 2023 American Geriatrics Society Beers Criteria® for potentially clinically important drug–drug interactions that should be avoided in older adults.
2070
Interacting drug or Quality of Strength of

Object drug or class class Risk rationale Recommendation evidencea recommendationa
RAS inhibitors (ACEIs, Another RAS inhibitor Increased risk of hyperkalemia. Avoid routinely using 2 or more RAS Moderate Strong
ARBs, ARNIs, aliskiren) or a potassium- inhibitors, or a RAS inhibitor and
or potassium-sparing sparing diuretic potassium-sparing diuretic,
diuretics (amiloride, concurrently in those with chronic
triamterene) kidney disease Stage 3a or higher.
Opioids Benzodiazepines Increased risk of overdose and adverse Avoid Moderate Strong
events.
Opioids Gabapentin Increased risk of severe sedation-related Avoid; exceptions are when Moderate Strong
Pregabalin adverse events, including respiratory transitioning from opioid therapy to
depression and death. gabapentin or pregabalin, or when
using gabapentinoids to reduce opioid
dose, although caution should be
used in all circumstances.
Anticholinergic Anticholinergic Use of more than one medication with Avoid; minimize the number of Moderate Strong
anticholinergic properties increases the anticholinergic drugs (Table 7).
risk of cognitive decline, delirium, and
falls or fractures.
Antiepileptics (including Any combination of ≥3 Increased risk of falls and of fracture with Avoid concurrent use of ≥3 CNS-active High Strong
gabapentinoids) of these CNS-active the concurrent use of ≥3 CNS-active drugs (among types as listed at left);
Antidepressants (TCAs, drugs agents (antiepileptics including minimize the number of CNS-active
SSRIs, and SNRIs) gabapentinoids, antidepressants, drugs.
antipsychotics, benzodiazepines,
Antipsychotics nonbenzodiazepine benzodiazepine
Benzodiazepines receptor agonist hypnotics, opioids, and
skeletal muscle relaxants).
Nonbenzodiazepine
benzodiazepine receptor
agonist hypnotics (i.e.,
“Z-drugs”)
Opioids
Skeletal muscle relaxants
Lithium ACEIs Increased risk of lithium toxicity. Avoid; monitor lithium concentrations. Moderate Strong
ARBs
ARNIs
Lithium Loop diuretics Increased risk of lithium toxicity. Avoid; monitor lithium concentrations. Moderate Strong
Non-selective peripheral Loop diuretics Increased risk of urinary incontinence in Avoid in older women, unless Moderate Strong
alpha-1 blockersb older women. conditions warrant both drugs.
Phenytoin Trimethoprim- Increased risk of phenytoin toxicity Avoid Moderate Strong
sulfamethoxazole
The anticoagulants also dominated the panel's atten-
Abbreviations: ACEIs, angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor blockers; ARNIs, angiotensin receptor-neprilysin inhibitors; CNS, central nervous system; INR, international normalized
recommendationa
tion when updating drugs to avoid or reduce doses with
varying levels of kidney function (Table 6). The criterion
Strength of
for apixaban has been removed given the evidence for its
ratio; NSAIDs, nonsteroidal anti-inflammatory drugs; RAS, renin-angiotensin system; SNRIs = serotonin-norepinephrine reuptake inhibitors; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic
safe use in patients with end-stage renal disease. Rivarox-
Strong
Strong
Strong aban's dosing in reduced kidney function is variable and
is based on indication; thus, the criteria refer to the prod-
uct label. Baclofen has been added with a recommenda-
Quality of
evidencea
Moderate
Moderate
Moderate
tion to avoid its use when eGFR is <60 mL/min because

of the increased risk for encephalopathy in older adults.
Finally, the use of NSAIDs by patients with a CrCl
<30 mL/min was moved from Table 3 to Table 6 for con-
sistency of presentation.
Avoid when possible; if used together,
DISCUSSION
monitor INR closely.
The AGS Beers Criteria® continues to evolve to address

Recommendation
the changing landscape of available medications and

emerging data about their harms and benefits. Some of
the most notable updates from the 2019 criteria include a
Avoid
Avoid
series of new and revised criteria regarding anticoagu-

lants and expanding the “avoid” recommendation for sul-
fonylureas, which previously focused on long-acting
Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
sulfonylureas but now includes all medications in this

class (in particular, avoiding them as first- or second-line
Increased risk of theophylline toxicity
Increased risk of theophylline toxicity
therapy, while still advising that if a sulfonylurea is used,

shorter-acting ones pose less risk of hypoglycemia than
longer-acting ones).
Increased risk of bleeding.
Note: This table is not a comprehensive list of all drug–drug interactions relevant for older adults.
The introductory section of this article describes the

intent of the criteria. In addition, we strongly encourage
readers to understand and apply the guidance on how to
Risk rationale
interpret the recommendations, apply them to policy and

practice, use best practices for deprescribing, and under-
stand the criteria's strengths and limitations. These are
explained below.
Macrolides (excluding
Interacting drug or
sulfamethoxazole
Interpreting recommendations
azithromycin)
Trimethoprim-
Ciprofloxacin
Ciprofloxacin
Amiodarone
The original Beers Criteria used “avoid” as a recommen-

Cimetidine
dation, meaning “the medication should be avoided

SSRIs
class
except under unusual circumstances.”1 Such circum-

stances include (but are not limited to) when a safer
alternative did not achieve the desired therapeutic out-
come. Thus, PIMs “would be chosen infrequently
(Continued)
through such careful considerations of benefit and risk.”1

Object drug or class
“Avoid” in the 2023 AGS Beers Criteria® has the same

meaning. “Avoid” is not defined as an absolute contrain-
Theophylline
Theophylline
antidepressants.
dication unless specified in the medication's label. It is

TABLE 5
Warfarin
the expert panel's intent that when a PIM is chosen, it is

done so through shared decision-making that includes
recognition of its potential harms and consideration of
b
a
T A B L E 6 2023 American Geriatrics Society Beers Criteria® for medications that should be avoided or have their dosage reduced with
varying levels of kidney function in older adults.
CrCl (mL/min)
at which action Quality of Strength of
Drug is required Rationale Recommendation evidence recommendation
Anti-infective
Ciprofloxacin <30 Increased risk of CNS Dosages used to treat Moderate Strong
effects (e.g., seizures, common infections
confusion) and tendon typically require
rupture. reduction when CrCl
<30 mL/min.
Nitrofurantoin <30 Potential for pulmonary Avoid if CrCl <30 mL/ Low Strong
toxicity, hepatoxicity, min
and peripheral
neuropathy, especially
with long-term use. (See
also Table 2).
Trimethoprim- <30 Increased risk of Reduce dosage if CrCl is Moderate Strong
sulfamethoxazole worsening of kidney 15–29 mL/min.
function and Avoid if CrCl <15 mL/
hyperkalemia; risk of min.
hyperkalemia especially
prominent with
concurrent use of an
ACE, ARB, or ARNI.
Cardiovascular and antithrombotics
Amiloride <30 Hyperkalemia and Avoid Moderate Strong
hyponatremia
Dabigatran <30 Lack of evidence for Avoid when CrCl Moderate Strong
efficacy and safety in <30 mL/min; dose
individuals with a CrCl adjustment is advised
<30 mL/min. Label when CrCl >30 mL/min
dose for patients with in the presence of drug–
CrCl 15–30 mL/min drug interactions.
based on
pharmacokinetic data.
Dofetilide <60 QTc prolongation and Reduce dose if CrCl is 20– Moderate Strong
torsades de pointes. 59 mL/min.
Avoid if CrCl <20 mL/
min.
Edoxaban 15–50 Lack of evidence of Reduce dose if CrCl is 15– Moderate Strong
<15 or > 95 efficacy or safety in 50 mL/min.
patients with CrCl Avoid if CrCl <15
<30 mL/min. or > 95 mL/min.
Enoxaparin <30 Increased risk of bleeding Reduce dose Moderate Strong
Fondaparinux <30 Increased risk of bleeding Avoid Moderate Strong
Rivaroxaban <50 Lack of efficacy or safety Avoid if CrCl <15 mL/ Moderate Strong
evidence in people with min.
CrCl <15 mL/min; Reduce the dose if CrCl is
limited evidence for 15–50 mL/min
CrCl 15–30 mL/min. following manufacturer
dosing
recommendations based
on indication-specific
dosing.
TABLE 6 (Continued)
CrCl (mL/min)
at which action Quality of Strength of
Drug is required Rationale Recommendation evidence recommendation
Spironolactone <30 Hyperkalemia Avoid Moderate Strong
Triamterene <30 Hyperkalemia and Avoid Moderate Strong
hyponatremia
Central nervous system and analgesics
Baclofen eGFR <60 Increased risk of Avoid baclofen in older Moderate Strong
encephalopathy adults with impaired
requiring hospitalization kidney function (eGFR
in older adults with <60 mL/min). When
eGFR <60 mL/min or baclofen cannot be
who require chronic avoided, use the lowest
dialysis. effective dose and
monitor for signs of
CNS toxicity, including
altered mental status.
Duloxetine <30 Increased GI adverse Avoid Moderate Weak
effects (nausea,
diarrhea)
Gabapentin <60 CNS adverse effects Reduce dose Moderate Strong
Levetiracetam ≤80 CNS adverse effects Reduce dose Moderate Strong
NSAIDs (non- < 30 May increase the risk of Avoid Moderate Strong
selective, COX-2 acute kidney injury and
selective, and a further decline in
nonacetylated kidney function
salicylates, oral and
parenteral)a
Pregabalin <60 CNS adverse effects Reduce dose Moderate Strong
Tramadol <30 CNS adverse effects Immediate release: reduce Low Weak
dose
Extended-release: avoid
Gastrointestinal
Cimetidine <50 Mental status changes Reduce dose Moderate Strong
Famotidine <50 Mental status changes Reduce dose Moderate Strong
Nizatidine <50 Mental status changes Reduce dose Moderate Strong
Hyperuricemia
Colchicine <30 GI, neuromuscular, and Reduce dose; monitor for Moderate Strong
bone marrow toxicity adverse effects.
Probenecid <30 Loss of effectiveness Avoid Moderate Strong
Note: This table is not a comprehensive list of all drugs that should be avoided or dose-adjusted in older adults with renal impairment.
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CNS,
central nervous system; CrCl, creatinine clearance; eGFR, estimated glomerular filtration rate; GI, gastrointestinal.
a
NSAIDs include: Non-selective: diclofenac, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketorolac, meloxicam, nabumetone, naproxen,
oxaprozin, piroxicam, sulindac; COX-2 selective: celecoxib; Nonacetylated salicylates: diflunisal, magnesium salicylate. This list does not include NSAIDs rarely
or never used in the U.S. among older adults.
the older person's preferences and goals of care. As in The panel also deliberated about and recognizes that
previous updates to the AGS Beers Criteria®, the panel clinicians and older adults may face substantial financial
has included caveats about when choosing a PIM may be pressures to use PIMs—such as when a safer treatment
reasonable, for example, a benzodiazepine for alcohol option incurs substantially higher out-of-pocket costs—
withdrawal. and that drug affordability is an important consideration
TABLE 7 Drugs with strong anticholinergic properties. for many older adults and their caregivers. In general,
Antidepressants the panel did not account for drug costs to different
Amitriptyline stakeholders when making decisions about which PIMs
Amoxapine to include in the criteria. However, costs of care may play
Clomipramine an important role in shared decision-making, and the
Desipramine panel strongly encourages policymakers and health plans
Doxepin (>6 mg/day) to ensure that safer alternatives to PIMs are affordable so
Imipramine that access to safe, appropriate treatment is not limited
Nortriptyline and inequities are not exacerbated. In addition to drug
Paroxetine costs, costs of avoidable drug-related harms should be
Antiemetics considered as well.
Prochlorperazine While most of the criteria (i.e., those listed in Tables 2,
Promethazine 3, 5, and 6) generally use the “avoid” recommendation
Antihistamines (first-generation) noted above, Table 4 comprises drugs to “use with cau-
Brompheniramine
tion.” The intent of this “use with caution” table is to high-
Chlorpheniramine
light drugs that raise some cause for concern but not to the
Cyproheptadine
level of an “avoid” recommendation. This can occur
Dimenhydrinate
because the evidence for the concern is limited or lacks
Diphenhydramine
consistency, the degree of harm relative to alternative ther-
Doxylamine
apies is not high enough to warrant an “avoid” recommen-
Hydroxyzine
dation, or extenuating clinical circumstances are often
Meclizine
Promethazine
present. The panel encourages clinicians to recognize the
Triprolidine potential harms of these medications and, as the moniker
Antimuscarinics (urinary incontinence)a states, to use them with caution. We also remind readers
Darifenacin that drugs removed from the AGS Beers Criteria® due to
Fesoterodine low usage or unavailability in the United States (Table 8)
Flavoxate are still considered potentially inappropriate per recom-
Oxybutynin mendations of the 2019 AGS Beers Criteria® update.
Solifenacin Unless specified otherwise, the criteria are designed
Tolterodine to apply to adults 65 years old and older. The panel recog-
Trospium nizes that drug-related harms are typically more pro-
Antiparkinsonian agents nounced in the “old-old” than in the “young-old” and in
Benztropine persons with complex multimorbidity and frailty. Thus,
Trihexyphenidyl two older adults of the same age can have markedly dif-
Antipsychotics ferent risks of drug-related harm. Certain criteria include
Chlorpromazine a specific age cutoff; these are provided when the evi-
Clozapine dence is specific to that age group. However, for most cri-
Olanzapine teria, the evidence base is insufficient to set a specific age
Perphenazine threshold for applying the criteria or to set a threshold
Antispasmodics
for other factors that can increase the risk of medication-
Atropine
related harms (e.g., functional and cognitive status, the
Clidinium-chlordiazepoxide
burden of multimorbidity, and polypharmacy). We
Dicyclomine
encourage clinicians to use common sense in applying
Homatropine
the criteria in clinical practice.
Hyoscyamine
For some criteria, the panel distinguished between initi-
Scopolamine
ating a medication versus continuing one already in long-
Skeletal muscle relaxants
Cyclobenzaprine
standing use. Such distinctions were considered by the
Orphenadrine panel in cases when the evidence suggested differential risk
of harm in these two scenarios, when the evidence primar-
Note: This table is not a comprehensive list of all medications with
anticholinergic properties. ily addressed initiation rather than a continuation, and/or
a
Data on whether certain bladder antimuscarinics confer greater when other professional society recommendations made
adverse cognitive effects than others lack consistent quality. this distinction. In a number of these criteria, the criteria
Oxybutynin has the best evidence for adverse cognitive effects.
However, caution is warranted for all bladder antimuscarinics recommend avoiding initiating the drug in nonusers and
given their potential anticholinergic effects.20 considering deprescribing among current users.
TABLE 8 Medications/criteria removed since 2019 American Geriatrics Society Beers Criteria®a.
Medication/Criterion Reason for removalb

Independent of diagnosis or condition (Table 2)
Carbinoxaminec Low use
c
Clemastine Low use
c
Dextrobromphiniramine Not on the U.S. market
c
Dexchlorpheniramine Low use
Pyrilaminec Not on the U.S. market
c
Belladonna alkaloids Not on the U.S. market
c
Methscopolamine Low use
c
Propantheline Not on the U.S. market
Guanabenz Not on the U.S. market
Methyldopa Not on the U.S. market
Reserpine (>0.1 mg/day) Not on the U.S. market
c
Disopyramide Low use
c
Protriptyline Low use
c
Trimipramine Low use
Amobarbital Low use, available only as an injection
Butobarbital Low use
Mephobarbital Not on the U.S. market
Pentobarbital Not on the U.S. market
Secobarbital Not on the U.S. market
Flurazepam Low use
Quazepam Low use
Isoxsuprine Not on the U.S. market
Chlorpropamide Not on the U.S. market
Fenoprofen Low use
Ketoprofen Low use
Meclofenamate Low use
Mefenamic acid Low use
Tolmetin Not on the U.S. market
Considering disease and syndrome interactions (Table 3)
Heart failure
Rosiglitazone Not on the U.S. market
Syncope
Thioridazinec Low use
Delirium
Meperidine Specific mention of meperidine was removed from this criterion because it is subsumed
under the general category of opioids, which was added to this criterion.
Ranitidine Removed from the U.S. market
Clinically important drug–drug interactions (Table 5)
Corticosteroids, oral or Incorporated into oral NSAIDs criterion in Table 2
parenteral + NSAIDs
Warfarin + NSAIDs Incorporated into oral NSAID criterion in Table 2 (i.e, recommendation to avoid short-term
regular, scheduled use of NSAIDs in older adults taking an anticoagulant)
(Continues)
TABLE 8 (Continued)
Medication/Criterion Reason for removalb

Medications that should be avoided or have their dosage reduced with reduced kidney function (Table 6)
Apixaban in patients with Emerging evidence and clinical experience supporting safe use at lower
CrCl <25 mL/min levels of renal function.
Ranitidine Removed from the U.S. market
Drugs with strong anticholinergic properties (Table 7)
Loxapine Low use
Trifluoperazone Low use
Abbreviations: CrCl, creatinine clearance; NSAIDs, nonsteroidal anti-inflammatory drugs.

a
Drugs removed from Tables 2–6 on account of low usage or unavailability in the U.S. are still considered potentially inappropriate per recommendations in the
2019 AGS Beers Criteria®4 update. Enhanced attention to these drugs may be necessary for countries outside the U.S., where they may be more widely used.
b
Not on the U.S. market = no product is currently marketed in the U.S. (although a product could be marketed in the future); this is not the same as being
removed from the U.S. market.
c
Removed from Table 7 as well.
TABLE 9 Medications/criteria added since 2019 American Geriatrics Society Beers Criteria®.
Medication/Criterion Reason for addition

Warfarin Emerging data and changes in national recommendations/expert guidance
Heart failure
Dextromethorphan-quinidine Supported by package insert
Delirium
Opioids Emerging data
History of falls or fractures Emerging data and consistency across recommendations
Anticholinergics
Use with caution (Table 4)
Ticagrelor Emerging data
Sodium-glucose co-transporter-2 (SGLT2) inhibitors Emerging data and clinical concern
Skeletal muscle relaxants added to any combination Concern for adverse effects when used in combination with
of ≥3 of these CNS-active drugs other CNS-active drugs
Lithium + ARBs and ARNIs Supported by data and reference sources
Warfarin + SSRIs Supported by data
Baclofen Data supporting concern
Note: The updated version of the criteria includes specific lists of drugs that were not included in prior versions. These lists are meant to enhance clarity and
searchability, and unless stated otherwise do not change the intent of the prior version of the criteria.
Abbreviations: ARBs, angiotensin receptor blockers; ARNIs, angiotensin receptor-neprilysin inhibitors; CNS, central nervous system; SSRIs, selective serotonin
reuptake inhibitors.
Applying the criteria to policy and practice providers, and health systems on how to use (and not
use) the AGS Beers Criteria®, as these recommendations
The panel continues to be aware of and discuss the con- are applicable to the 2023 update.21,22 Key recommenda-
troversies and misinformation about the proper interpre- tions from those articles are summarized in Table 11.
tation of the AGS Beers Criteria®. As such, the panel Certain clarifications to items in the table and additional
advises users of the criteria to read and use guidance considerations that arose during the 2023 update panel
from companion articles written to accompany the 2015 discussion merit special note. First, as noted above, differ-
and 2019 AGS Beers Criteria® that advise patients, ent older adults may have markedly different risks of
TABLE 10 Medications/criteria modified since 2019 American Geriatrics Society Beers Criteria®.
Medication/Criterion Modification
Aspirin Moved from Table 4 to Table 2 on basis of new evidence.
Rivaroxaban Moved from Table 4 to Table 2 on basis of accumulating evidence
Dronedarone Clarified to reflect data about potential risks in people with non-severe forms of
heart failure
Digoxin Added statement clarifying that caution should be used discontinuing digoxin among
current users with HFrEF.
Antidepressants with strong Clarified that this criterion refers to antidepressants with strong anticholinergic
anticholinergic activity activity
Antipsychotics Updated language to reflect new evidence and enhance clarity
Benzodiazepines Clarified language
Androgens Clarified that androgens pose potential risks but are not firmly contraindicated in
men with a history of prostate cancer.
Estrogens, systemic Provided additional information, supported by data
Sulfonylureas Expanded criterion from long-acting sulfonylureas to all sulfonylureas given data
supporting adverse outcomes for all sulfonylureas.
Proton pump inhibitors Noted additional adverse outcomes in the rationale statement given supporting data.
NSAIDs, oral Clarified application in high-risk scenarios for short-term use (i.e., including drug–
drug interactions such as with warfarin)
Skeletal muscle relaxants Clarified language to differentiate skeletal muscle relaxants typically used for
musculoskeletal complaints from those used to treat spasticity.
Syncope—TCAs Clarified that the tertiary TCAs referenced by this criterion include those listed here.
Amitriptyline
Clomipramine
Doxepin
Imipramine
Dementia Modified language to reflect data and enhance clarity
Antipsychotics
Delirium Updated rationale to comment on opioids and enhance clarity
History of falls or fracture Antidepressants Level of evidence lowered from “high” to “moderate” based on evidence; updated
rationale to reflect new evidence and enhance clarity.
Parkinson disease Rationale shortened for clarity.
Urinary incontinence in women Modified language to enhance clarity
Use with caution (Table 4)
Prasugrel Adding dosing consideration, supported by American College of Cardiology/
American Heart Association guidelines.
Dextromethorphan-quinidine Added heart failure concerns, supported by package insert.
Trimethoprim-sulfamethoxazole Added ARNIs for completeness (given that they contain ARBs).
Opioid + benzodiazepine Modified to include risk for adverse effects; supported by data.
Anticholinergic + anticholinergic Modified to recognize specific adverse events.
Use of ≥3 CNS active agents Clarified classes of medications of concern; level of evidence raised to “high.”
Warfarin Consolidated interacting drugs into a list versus reporting as separate lines for each
interaction.
(Continues)
TABLE 10 (Continued)
Medication/Criterion Modification
Nitrofurantoin Existing recommendations from Table 2 are duplicated in Table 6 to enhance clarity
and usability.
Trimethoprim-sulfamethoxazole Added clarifying language to support clinical usability.
Rivaroxaban Clarified CrCl cutoffs per available evidence and package insert.
NSAIDs Moved this criterion from Table 3 for greater consistency; clarified language.
Abbreviations: ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; CNS, central nervous system; CrCl, creatinine clearance.
a
In addition to the changes listed above, a number of formatting and other changes were made to enhance clarity and usability without changing the meaning
of the criteria. This includes specific lists of drugs that were not included in prior versions; these lists are meant to enhance clarity and searchability, and unless
stated otherwise do not change the intent of the prior version of the criteria.
experiencing severe medication-related harms, with T A B L E 1 1 Principles for how patients, clinicians, health
advanced age, cognitive and physical impairment, multi- systems, and payors should use the AGS Beers Criteria®.
morbid burden, frailty, renal impairment, and a high Medications in the AGS Beers Criteria® are potentially
degree of polypharmacy each conferring risk. A person's inappropriate, not definitely inappropriate.
underlying risk of experiencing drug-related harms Read the rationale and recommendations statements for each
should inform decisions about using drugs in the criteria. criterion. The caveats and guidance listed there are
Second, close attention to the recommendations is essen- important.
tial to avoid misinterpretation; many criteria note excep- Understand why medications are included in the AGS Beers
tions and other considerations and should not be overly Criteria® and adjust your approach to those medications
simplified as “avoid in everyone over age 65.” Third, the accordingly.
risk of harm arises not just from drugs considered in isola- Optimal application of the AGS Beers Criteria® involves
tion but from how multiple drugs affect an older adult identifying PIMs and, when appropriate, offering safer
when given together. Thus, evaluations of medication nonpharmacologic and pharmacologic therapies.
appropriateness should be made in the context of the total- The AGS Beers Criteria® should be a starting point for a
ity of a person's medication regimen and their goals of care. comprehensive process of identifying and improving
Fourth, the intent of the AGS Beers Criteria® is not simply medication appropriateness and safety.
to swap out a better drug in place of a worse one. In many Access to medications included in the AGS Beers Criteria®
cases, nonpharmacologic treatments (or no treatment at should not be excessively restricted by prior authorization
all) may be preferable. Finally, the panel affirms the impor- and/or health plan coverage policies.
tance of shared decision-making in selecting and changing The AGS Beers Criteria® are not equally applicable to all
treatment regimens. There may be situations in which ini- countries (because of cross-national differences in drug
tiating or continuing a drug on the criteria is reasonable availability).
because it is consistent with an older person's stated prefer- Source: Adapted from Steinman et al.21,22
ences, values, and treatment goals.
• https://deprescribing.org/resources/—deprescribing
Deprescribing resources, especially evidence-based guidelines and
easy-to-use algorithms about when and how to stop
Successful deprescribing of medications on the AGS common types of medications
Beers Criteria® involves much more than a clinician sim- • https://www.deprescribingnetwork.ca/professionals—
ply telling an older person to stop taking a medication. resources for healthcare professionals, including
Communication gaps and misunderstandings, patient deprescribing-oriented patient handouts about medica-
reluctance and fear of stopping, coordination among mul- tions that are commonly inappropriate for older adults
tiple clinicians, dosage tapering, withdrawal symptoms,
and conveying stop orders to pharmacies are just some of Systemic solutions are essential as well, for example
the challenges that can arise. The panel encourages clini- increasing the adoption of the CancelRx Script Standard
cians to be aware of and develop skills to address these to communicate to pharmacies when a drug is stopped
challenges. Useful resources include: and should no longer be refilled.
Strengths and limitations support clinicians in practice, the AGS has released the
2023 AGS Beers Criteria® App as well as a pocket card,
As with previous versions of the AGS Beers Criteria®, this both of which can be accessed via GeriatricsCareOnline.org.
update is subject to the same limitations. First, the evi- As with past updates, the AGS has also created a suite of
dence available is often plagued by the small number of public education materials that are available for free at
clinical trials in older adults or by the lack of inclusion of HealthinAging.org, a resource created by the AGS Founda-
a sufficient number of older adults to conduct an age- tion for Health in Aging to bring the expertise of geriatrics
specific analysis. The panel often relied on observational to the public. It is the hope of the AGS and the 2023 AGS
studies and meta-analyses for evidence of harm and Beers Criteria® expert panel that the updated criteria will
whether the harm was more common or resulted in more be used as intended—to improve drug therapy and out-
serious outcomes in older adults. comes for all of us as we age by identifying and reducing
Second, the lack of diversity in study populations was prescribing of PIMs in older adults through a process of
another challenge to the panel. Inadequate enrollment of shared decision-making that focuses on goals of care.
underrepresented, disproportionately affected, and
understudied populations in clinical trials is a distress- AUTHOR CONTRIBUTIONS
ingly well-described phenomenon. In the evidence the All panel members contributed to the concept and
panel reviewed, a seemingly larger number of studies design, acquisition of subjects and/or data, analysis, and
identified were generated within a specific country, pos- interpretation of data, and preparation of the manuscript.
sibly contributing to greater racial and ethnic homogene-
ity among study participants. Even when more diverse ACKNOWLEDGMENTS
populations were included in a study, there was often The decisions and content of the 2023 AGS Beers
inadequate power to determine outcomes by specific Criteria® are those of the AGS and the panel members
groups. Third, the criteria include only medications and are not necessarily those of the U.S. government or
available in the United States. Clinicians outside the the U.S. Department of Veterans Affairs.
United States, with access to different medications from Sue Radcliff, Independent Researcher from Denver,
the same drug class as those the criteria recommends Colorado, provided research services. Jirong Yue provided
avoiding, will need to adapt the criteria to their local con- additional research services. Susan E. Aiello, DVM, ELS,
text. Fourth, it is possible that our literature search did provided editorial services. Laura Banks, Aimee Cegelka,
not identify all published evidence that would have been Elvy Ickowicz, MPH, and Mary Jordan Samuel provided
pertinent. Our search strategy did not include unpub- additional research, technical, and administrative support.
lished studies, papers not published in English, white Thanks to the AGS Executive Committee and the Chairs/
papers, abstracts, technical reports, or other evidence Vice Chairs of the AGS CPMC, Ethnogeriatrics, and QPMC
published in the “gray literature.” Committees. The panel must also acknowledge the work of
Despite its limitations, the 2023 AGS Beers Criteria® the late Mark H. Beers, MD, whose vision for a better qual-
has its strengths. The panel and staff are highly experi- ity of care for older adults remains active through tools like
enced; most have participated in updating the criteria the AGS Beers Criteria®.
since 2012, and some since 2003. Their familiarity with The following organizations with special interest and
the process and modified Delphi technique is an advan- expertise in the appropriate use of medications in older
tage. The panel also included ad hoc members from adults provided peer review of a preliminary draft of this
important stakeholders, namely the Centers for Medicare guideline: AMDA—The Society for Post-Acute and Long-
and Medicaid, the National Committee for Quality Assur- Term Care Medicine, American Academy of Neurology,
ance, and the Pharmacy Quality Alliance, who provided American Academy of Nursing, American Association of
valuable insight and feedback throughout the process. Clinical Endocrinologists, American College of Clinical
Robust internal review and external public comment pro- Pharmacy, American College of Emergency Physicians,
cesses are additional strengths. American Pharmacists Association, American Public
Health Association, American Psychiatric Nurses Associ-
ation, American Society of Anesthesiologists, American
C O N C L U S IO N Society of Consultant Pharmacists, American Society of
Health-System Pharmacists, American Society of
The 2023 update of the AGS Beers Criteria® includes Nephrology, American Urological Association, Centers
many modifications including a number of new and sig- for Medicare and Medicaid Systems, Gerontological
nificantly modified criteria and many minor changes in for- Advanced Practice Nurses Association, National Council
matting and wording to enhance clarity and usability. To on Aging, National Committee on Quality Assurance,
Nurses Improving Care for Healthsystem Elders, Phar- 9. Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE
macy Quality Alliance, and Society of Urodynamics, guidelines: 15. Going from evidence to recommendation-
Female Pelvic Medicine & Urogenital Reconstruction. determinants of a recommendation's direction and strength.
J Clin Epidemiol. 2013;66(7):726-735.
10. Balshem H, Helfand M, Schunemann HJ, et al. GRADE guide-
FUNDING INFORMATION lines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;
There was no sponsor for this paper. 64(4):401-406. doi:10.1016/j.jclinepi.2010.07.015
11. Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines: 4. Rat-
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University, Queens, NY; Nicole Brandt, PharmD, MBA,

How to cite this article: By the 2023 American BCPP, BCGP, FASCP, University of Maryland, Baltimore,
Geriatrics Society Beers Criteria® Update Expert MD; Rachel Digmann, PharmD, Pharmacy Quality
Panel. American Geriatrics Society 2023 updated Alliance, Alexandria, VA (nonvoting member); Robert
AGS Beers Criteria® for potentially inappropriate Dombrowski, PharmD, Centers for Medicare and Medic-
medication use in older adults. J Am Geriatr Soc. aid Services, Baltimore, MD (nonvoting member); Cather-
2023;71(7):2052‐2081. doi:10.1111/jgs.18372 ine E. DuBeau, MD, Dartmouth-Hitchcock Medical
Center, Lebanon, NH; Donna M. Fick, PhD, RN, FGSA,
AGSF, FAAN, College of Nursing and Medicine, The
Pennsylvania State University, University Park, PA; Nina
A P P END I X A : PANEL MEMBERS AND Flanagan, PhD, GNP-BC, APHM-BC, Binghamton Univer-
AFFILIATIONS sity, Vestal, NY; Claudene George, MD, MS, RPh, Monte-
fiore Medical Center, The Bronx, NY; Rachel Harrington,
The following individuals were members of the AGS Panel PhD, National Committee for Quality Assurance,
convened to update the 2023 AGS Beers Criteria®: (co- Washington, DC (nonvoting member); Peter Hollmann,
chair) Todd P. Semla, PharmD, MS, BCPG, FCCP, AGSF, MD, AGSF, Brown Medicine, Providence, RI; Holly
Northwestern University Feinberg School of Medicine, Holmes, MD, MS,AGSF, McGovern Medical School at UT
Chicago, IL; (co-chair) Michael Steinman, MD, University Health, Houston, TX; Rosemary Laird, MD, MHSA, AGSF,
of California San Francisco and San Francisco Veterans Winter Park Memorial Hospital, Winter Park, FL; and
Affairs Medical Center, San Francisco, CA; (co-chair) Sunny Linnebur, PharmD, FCCP, BCPS, BCGP, FASCP,
Judith Beizer, PharmD, BCGP, FASCP, AGSF, St. John's University of Colorado, Aurora, CO.

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Received: 7 March 2023 Accepted: 29 March 2023

American Geriatrics Society 2023 updated AGS Beers

INTRODUCTION residents.1 The 1997 update, led by Dr. Beers, expanded

intent of the original Beers Criteria by providing an

The primary target audience for the 2023 AGS Beers

METHODS Development process

TABLE 1 Designations of quality of evidence and strength of recommendations.

ACP-based approach7 GRADE-based approach5

Source: Adapted from Qaseem et al.,7 Guyatt et al.,8 Andrews et al.9

Organ system, therapeutic Quality of Strength of

Cyproheptadine constipation, and other anticholinergic effects or

Organ system, therapeutic Quality of Strength of

milder symptoms (NYHA class I or II).

Organ system, therapeutic Quality of Strength of

Organ system, therapeutic Quality of Strength of

Barbiturates High rate of physical dependence, tolerance to Avoid High Strong

Organ system, therapeutic Quality of Strength of

Methyltestosterone men with prostate cancer. hypogonadism with clinical symptoms.

Organ system, therapeutic Quality of Strength of

Organ system, therapeutic Quality of Strength of

BOX 1 Synthesis of anticoagulation recommendations.

Zolpidem strategies to reduce fall risk.

Interacting drug or Quality of Strength of

The anticoagulants also dominated the panel's atten-

tion to avoid its use when eGFR is <60 mL/min because

The AGS Beers Criteria® continues to evolve to address

the changing landscape of available medications and

series of new and revised criteria regarding anticoagu-

sulfonylureas but now includes all medications in this

therapy, while still advising that if a sulfonylurea is used,

The introductory section of this article describes the

interpret the recommendations, apply them to policy and

The original Beers Criteria used “avoid” as a recommen-

dation, meaning “the medication should be avoided

except under unusual circumstances.”1 Such circum-

through such careful considerations of benefit and risk.”1

“Avoid” in the 2023 AGS Beers Criteria® has the same

dication unless specified in the medication's label. It is

the expert panel's intent that when a PIM is chosen, it is

Medication/Criterion Reason for removalb

Medication/Criterion Reason for removalb

Abbreviations: CrCl, creatinine clearance; NSAIDs, nonsteroidal anti-inflammatory drugs.

Medication/Criterion Reason for addition

University, Queens, NY; Nicole Brandt, PharmD, MBA,

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