Practice Guidelines

Beers Criteria for Inappropriate Medication Use in Older Patients: An Update from the AGS


Key Points for Practice

• Avoid most antipsychotics in patients with Parkinson disease complicated by psychosis, although quetiapine, clozapine, and pimavanserin may be used with caution.

• Avoid using rivaroxaban and dabigatran in older adults because of a higher bleeding risk than warfarin and other direct oral anticoagulants.

• Avoid tramadol use because of the risk of hyponatremia from syndrome of inappropriate antidiuretic hormone secretion.

• Avoid prescribing opioids with benzodiazepines or gabapentinoids because the combinations increase the risk of severe respiratory depression.

From the AFP Editors

The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (i.e., at least 65 years of age), originally developed by Mark H. Beers in 1991, continue to be used by the American Geriatrics Society (AGS) to provide guidance regarding medications that should be avoided in most older patients or in certain situations. The goals are to improve medication selection, educate physicians and patients, avoid adverse effects, and help evaluate care quality and medication use trends for older adults. The 2019 update uses the five criteria outlined in 2015; these include medications that should typically be avoided in most older patients, medications that should be avoided in older patients with certain conditions, medications that should be used with caution because of benefits that may offset risks, medication interactions, and changes in dosing based on kidney function. In addition to these criteria, decisions about medications should take into account a variety of factors, including stopping medications when they are no longer beneficial.



In this update, some medications were removed from the list of potentially inappropriate medications for most older patients and for those with certain conditions, as well as the list of those that should be used cautiously. Numerous medications, including bupropion (Wellbutrin), pseudoephedrine, vasodilators, and caffeine, were removed because they have the same effects on all patients without a difference in

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of Practice Guidelines published in AFP is available at



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