1What the 2023 update covers
The American Geriatrics Society (AGS) published the current update in 2023 in the Journal of the American Geriatrics Society (2023 AGS Beers Criteria). It applies to adults 65 and older in ambulatory, acute and institutional care, and it excludes hospice and end-of-life care. Recommendations fall into five lists:
- medications to avoid in most older adults;
- medications to avoid with specific diseases or syndromes, such as a history of falls, delirium or dementia;
- medications to use with caution;
- drug–drug interactions to avoid;
- medications to avoid or dose-reduce as kidney function declines.
Use the list as a screen. Run it at transitions of care (admission, discharge, a new prescriber), when a new symptom appears, and whenever a drug is about to be added to treat what might be a side effect of another.
Each recommendation carries a quality-of-evidence rating and a strength rating. Much of the evidence is observational, so the numbers behind a row are often odds ratios with confidence intervals; interpreting them is the skill covered on p values and confidence intervals. On this site the topic belongs to geriatrics, pediatrics and women’s health.
2Four groups that recur
| Drug group | Main concern named by AGS | Ask before acting |
|---|---|---|
| Strongly anticholinergic drugs, such as first-generation antihistamines and bladder antimuscarinics | Confusion, constipation, dry mouth, urinary retention; the burden adds up across drugs | What is the total anticholinergic load, and which drug contributes most? |
| Benzodiazepines and Z-drug hypnotics | Cognitive impairment, delirium, falls, fractures, motor vehicle crashes | What was it started for, and how long ago? |
| Sulfonylureas | Hypoglycemia, plus higher cardiovascular and all-cause mortality risk than alternatives. The 2023 update moved the whole class to avoid as first- or second-line or add-on therapy unless safer agents face substantial barriers; if one is used, a short-acting agent is preferred | Is the glycemic target still right for this patient? |
| Proton pump inhibitors beyond 8 weeks | C. difficile infection, pneumonia, bone loss and fractures | Is a documented high-risk indication still present? |
3The prescribing cascade
- 01 — A dihydropyridine calcium channel blocker for blood pressure
- 02 — Ankle edema
- 03 — Taken for fluid overload
- 04 — A loop diuretic
- 05 — Urgency, night-time trips to the bathroom, fall risk
4Choosing what to stop first
Match drugs to the problem
Write down the presenting problem (confusion, a fall, a low glucose, constipation) and mark every drug on the list that could cause it.
Weigh what each still does
A listed drug that controls a serious condition with no alternative ranks below one whose indication is weak, unclear or long gone.
Change one thing at a time
Single changes let you attribute what happens next. Drugs that cause dependence or rebound come down gradually.
Fill the gap
Replace the drug with a nondrug measure or a lower-risk option so the original problem is not left untreated.
Set the recheck
Book a date to look again at the problem that started the review.
5Which drug goes first
Read each medication list the way a consult would: find the drug that explains the presentation, then check what it is still treating.
Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.
Case 1 of 6 · 0 answered
How case rounds work
Pick an option to see the verdict and a note on every option. Keys while the round has focus: 1–5 or A–E answer, ← → move between cases. Nothing is saved or sent anywhere.
Case 01
A 78-year-old woman develops fluctuating inattention and disorganized thinking on postoperative day 2 after hip fracture repair. Medications: acetaminophen 1 g every 8 hours, hydromorphone 0.5 mg IV every 4 hours as needed (2 doses/day, pain 3/10), oxybutynin 5 mg three times daily (home medication), melatonin 3 mg at bedtime, metoprolol tartrate 25 mg twice daily, and apixaban 2.5 mg twice daily. Labs and urinalysis are unremarkable. Which medication should be discontinued?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Oxybutynin is a strongly anticholinergic drug that crosses the blood-brain barrier and is on the Beers list to avoid in older adults, especially with delirium. Hydromorphone is the tempting target, but her low-dose as-needed use is controlling pain, and untreated pain itself precipitates delirium. Melatonin is not deliriogenic and may help sleep, and metoprolol has no meaningful anticholinergic burden.
- A
- Correct. Oxybutynin is a centrally acting anticholinergic that Beers says to avoid in older adults, especially with delirium.
- B
- Her low-dose as-needed hydromorphone is controlling pain, and untreated pain itself precipitates delirium.
- C
- Melatonin is not deliriogenic and may even help sleep.
- D
- Metoprolol tartrate carries no meaningful anticholinergic burden.
Case 02
An 81-year-old man with hypertension and BPH fell at home last month. Seated BP is 148/82 mm Hg; standing BP after 3 minutes is 122/70 mm Hg with lightheadedness. Medications: amlodipine 5 mg daily, chlorthalidone 12.5 mg daily, doxazosin 4 mg at bedtime, and finasteride 5 mg daily. Before any antihypertensive is added, which medication should be addressed first to reduce his fall risk?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
His standing drop of 26/12 mm Hg meets criteria for orthostatic hypotension, and a nonselective peripheral alpha-1 blocker such as doxazosin is the most likely cause; the 2023 Beers Criteria advise avoiding it as an antihypertensive in older adults because of orthostasis and falls. Switching BPH therapy to a uroselective agent (or relying on finasteride) addresses the culprit. Amlodipine and low-dose chlorthalidone are first-line antihypertensives less often responsible for orthostasis, and finasteride does not lower BP.
- A
- Finasteride shrinks the prostate without lowering BP, so it does not explain his orthostasis.
- B
- Low-dose chlorthalidone is a first-line antihypertensive and a less likely cause of a 26 mm Hg standing drop.
- C
- Correct. Doxazosin is a nonselective alpha-1 blocker that Beers advises avoiding as an antihypertensive in older adults because of orthostasis and falls.
- D
- Amlodipine is a first-line agent and is rarely the main driver of orthostatic hypotension.
Case 03
A 72-year-old woman has had difficulty falling and staying asleep at least 4 nights a week for 6 months, with daytime fatigue. Sleep apnea has been excluded, and her depression screen is negative. She asks for ‘a sleeping pill.’ Which treatment is most appropriate to start?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
Cognitive behavioral therapy for insomnia (stimulus control, sleep restriction, sleep hygiene, cognitive work) is first-line for chronic insomnia per ACP and AASM and has durable benefit without drug risk. Zolpidem and other Z-drugs are on the 2023 Beers list because of falls, fractures, and delirium. Diphenhydramine is strongly anticholinergic, and AASM suggests against trazodone for sleep-onset or maintenance insomnia because of weak evidence and orthostasis.
- A
- Diphenhydramine is strongly anticholinergic and on the Beers list for older adults.
- B
- Z-drugs are on the 2023 Beers list because of falls, fractures and delirium.
- C
- Correct. Cognitive behavioral therapy for insomnia is first-line for chronic insomnia and gives durable benefit without drug risk.
- D
- Trazodone has weak evidence for insomnia and causes orthostasis; AASM suggests against it for this use.
Case 04
An 80-year-old woman who lives alone has fallen twice in 3 months, once at night on the way to the bathroom. She has taken zolpidem 10 mg at bedtime for 2 years for chronic insomnia and says she cannot sleep without it. She has no depression or dementia. Which recommendation is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
The Beers criteria advise avoiding Z-drugs in older adults and specifically in those with falls, so zolpidem should be tapered (to avoid rebound insomnia) while cognitive behavioral therapy for insomnia, the first-line treatment, is started. Reducing to 5 mg is the tempting compromise, but it still carries the fall and fracture risk. Diphenhydramine is strongly anticholinergic, and temazepam is a benzodiazepine; both are also Beers drugs to avoid.
- A
- Diphenhydramine trades one Beers drug for another, with strong anticholinergic effects.
- B
- Temazepam is a benzodiazepine with the same fall and fracture risk.
- C
- Correct. Beers advises avoiding Z-drugs, above all after falls; a gradual taper with CBT for insomnia addresses both problems.
- D
- A lower zolpidem dose is a tempting compromise, but it still carries fall and fracture risk.
Case 05
An 81-year-old woman has type 2 diabetes, nonvalvular atrial fibrillation, and hypertension; eGFR is 58 mL/min/1.73 m². Medications: apixaban 5 mg twice daily, glimepiride 4 mg daily, metformin 500 mg twice daily, lisinopril 20 mg daily, and atorvastatin 20 mg daily. A1c is 6.6%, and she reports two episodes of shakiness and sweating before lunch this month. Using the 2023 AGS Beers Criteria, which medication should be deprescribed first?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
The 2023 Beers Criteria advise avoiding all sulfonylureas in older adults because of prolonged hypoglycemia, and her A1c of 6.6% is already below the 7.0–7.5% target with symptomatic lows. Apixaban is the DOAC Beers prefers (warfarin and rivaroxaban are the ones to avoid), and metformin is appropriate at an eGFR of 58. Statin continuation at 81 is an individualized decision, but it is not the drug causing her current harm.
- A
- Metformin is appropriate at an eGFR of 58 and does not cause hypoglycemia on its own.
- B
- Statin continuation at 81 is an individual decision, but it is not causing her lows.
- C
- Apixaban is the DOAC Beers prefers; stopping it would expose her to stroke.
- D
- Correct. Beers 2023 advises avoiding sulfonylureas in older adults; her A1c is 6.6% and she has symptomatic lows.
Case 06
An 84-year-old woman (weight 58 kg; SCr 1.1 mg/dL) with atrial fibrillation is being discharged home after treatment for pneumonia. Discharge orders include apixaban 2.5 mg twice daily, metoprolol succinate 50 mg daily, acetaminophen 650 mg every 6 hours as needed, and diphenhydramine 25 mg at bedtime started in the hospital for sleep. Which order should the pharmacist recommend discontinuing before discharge?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
Diphenhydramine is a strongly anticholinergic first-generation antihistamine that the 2023 Beers Criteria say to avoid in older adults, because it causes confusion, falls, and urinary retention that drive readmissions. Apixaban 2.5 mg twice daily is the correct reduced dose because she meets two criteria (age ≥80 and weight ≤60 kg). Metoprolol for rate control and as-needed acetaminophen are appropriate.
- A
- Correct. Diphenhydramine is a strongly anticholinergic antihistamine that Beers says to avoid, as it drives confusion and falls.
- B
- Metoprolol for rate control in AF is appropriate and should continue.
- C
- Age 84 and weight 58 kg meet two criteria, so apixaban 2.5 mg twice daily is the right dose.
- D
- As-needed acetaminophen is a safe analgesic choice for an older adult.
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