Medication Management in Older Adults

Introduction to Beers Criteria

• The American Geriatrics Society recommends avoiding 30 individual medications or medication classes in older adults, plus over 40 additional medications requiring caution in specific diseases or conditions 1, 2

Core Categories of Potentially Inappropriate Medications

• The American Geriatrics Society identifies central nervous system agents, such as benzodiazepines and nonbenzodiazepine hypnotics, as high-risk medications that increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults 1, 2, 3
• The American Geriatrics Society recommends avoiding antipsychotics in older adults due to increased mortality risk, particularly in patients with dementia 2
• The American Geriatrics Society identifies tricyclic antidepressants as causing anticholinergic effects and orthostatic hypotension in older adults 1
• The American Geriatrics Society recommends avoiding NSAIDs in older adults due to increased risk of gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation 2, 3
• The American Geriatrics Society recommends avoiding thiazolidinediones in heart failure patients due to worsening fluid retention 2

Disease-Specific Medications to Avoid

• The American Geriatrics Society recommends avoiding benzodiazepines, nonbenzodiazepine hypnotics, antipsychotics, opioids, and SNRIs in patients with a history of falls or fractures 1, 2, 4, 5
• The American Geriatrics Society recommends avoiding anticholinergics, benzodiazepines, and antipsychotics in patients with dementia or cognitive impairment 2, 4
• The American Geriatrics Society recommends avoiding NSAIDs, thiazolidinediones, and calcium channel blockers in patients with heart failure 2, 3

Medications Requiring Caution

• The American Geriatrics Society recommends using dextromethorphan/quinidine with caution due to limited efficacy, significant drug interactions, and increased fall risk 2, 4
• The American Geriatrics Society recommends using rivaroxaban with caution in adults ≥75 years due to higher bleeding risk for venous thromboembolism or atrial fibrillation treatment 2, 4
• The American Geriatrics Society recommends using aspirin for primary prevention with caution in adults ≥70 years due to bleeding risk exceeding cardiovascular benefit 2, 4

Critical Drug-Drug Interactions to Avoid

• The American Geriatrics Society recommends avoiding concurrent use of opioids and benzodiazepines due to severe respiratory depression and death risk 1, 2
• The American Geriatrics Society recommends avoiding concurrent use of opioids and gabapentinoids due to increased risk of adverse effects 1, 2
• The American Geriatrics Society recommends avoiding concurrent use of TMP-SMX and warfarin due to increased bleeding risk 1

Kidney Function-Based Dose Adjustments

• The American Geriatrics Society recommends avoiding or reducing the dose of ciprofloxacin, TMP-SMX, dofetilide, and edoxaban in patients with reduced kidney function due to increased risk of adverse effects 1, 2

Implementation Strategy

• The American Geriatrics Society recommends applying the Beers Criteria systematically at every care transition to identify and deprescribe inappropriate medications 6, 3
• The American Geriatrics Society recommends prioritizing removal of medications with the highest morbidity and mortality risks first, such as benzodiazepines, opioids, antipsychotics, and NSAIDs 3
• The American Geriatrics Society recommends using validated screening tools, such as the Beers Criteria and STOPP/START, during comprehensive medication reviews 3

Beers Criteria for Benzodiazepines and Antidepressants in Older Adults

Medication Safety

• Benzodiazepines, including temazepam, are associated with increased risk of death and falls in older populations, according to the American Geriatrics Society 7, 8
• The American Geriatrics Society identifies benzodiazepines as high-risk central nervous system agents that cause clinically significant harm in older adults, including respiratory depression, cognitive impairment, and overdose risk 7
• Temazepam should not be combined with opioids due to severe respiratory depression and death risk, as highlighted in the 2019 Beers Criteria update 9

Antidepressant Selection

• Sertraline, an SSRI, is not listed as a medication to avoid in older adults, according to the Beers Criteria 7, 8
• SNRIs, but not SSRIs like sertraline, were added to the list of antidepressants to avoid in persons with a history of falls or fractures in the 2019 Beers Criteria update 9
• The American Geriatrics Society recommends monitoring sertraline use in older adults for hyponatremia, bleeding risk, and serotonin syndrome with drug interactions 7

Clinical Implications

• The 2019 Beers Criteria update distinguishes between SSRIs and SNRIs, adding SNRIs but not SSRIs to the fall/fracture avoidance list, which matters clinically when selecting antidepressants for older adults with fall history 9

Gabapentin Use in Older Adults

Introduction to Gabapentin Safety

• The American Geriatrics Society recommends avoiding the concurrent use of opioids and gabapentinoids in older adults, except when transitioning from opioids to gabapentinoids as an alternative, due to the increased risk of respiratory depression, overdose, and death 10

Clinical Considerations

• The American Geriatrics Society advises screening for concurrent opioid use before initiating gabapentin therapy in older adults 10
• The American Geriatrics Society warns against combining gabapentin with benzodiazepines and opioids, as the use of three or more CNS agents concurrently increases fall risk 10
• The American Geriatrics Society suggests considering gabapentin as part of the total CNS medication burden, which includes antidepressants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, antiepileptics, and opioids, as this collective use increases fall risk 10

Medication Management

• The American Geriatrics Society recommends reviewing kidney function, as gabapentin requires dose adjustment in renal impairment 10

Buspirone and the American Geriatrics Society Beers Criteria

Inclusion Status in the Beers Criteria

• Buspirone is not listed as a potentially inappropriate medication for older adults in the American Geriatrics Society (AGS) Beers Criteria, including both the 2023 update and the 2019 version, which together enumerate roughly 30 individual drugs or drug classes to avoid in this population. 11

• While the AGS Beers Criteria specifically identify problematic anxiolytics and central nervous system agents—such as benzodiazepines, non‑benzodiazepine hypnotics, and certain antidepressants—buspirone is notably absent from these enumerated lists. 11