FormWeb • Alternative Treatment to Selected Medications in the 2023 American Geriatrics Society Beers Criteria

IHS FormWeb

Approved Formulary

Search by class Show Therapeutic Classes

Staff Telephone Numbers

Add Formweb to your mobile device

Android iOS

IHS FormWeb

Approved Formulary

Alternative Treatment to Selected Medications in the 2023 American Geriatrics Society Beers Criteria - Drug view

Beers Alt. Treatments

NAV Top A B C D E F G H I J K L M N O P Q R S T U V W X Z

Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria^®
Beers Alternatives - Conditions view.Abbreviations Reference

A Beers Links

Beers Criteriaacetaminophen-codeine (Tylenol #3)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriaacetaminophen-HYDROcodone (Lortab, Norco, Vicodin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriaacetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriaacetaminophen-traMADol (Ultracet)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Aciphex - see RABEprazole

Adalat - see NIFEdipine

Aleve - see naproxen

Beers Criteriaalfuzosin (Uroxatral)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin) Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Alora - see estradiol

Beers CriteriaALPRAZolam (Xanax)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Amaryl - see glimepiride

Ambien - see zolpidem

Beers Criteriaamiodarone (Cordarone, Nexterone, Pacerone)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Atrial fibrillation/flutter (rate/rhythm control)
Relevant AGS Beers Criteria^® medications	amiodarone
Recommendation	Avoid as first-line treatment for AF unless patient has heart failure or substantial LVH
Alternatives to consider (recommendations)	Choice of alternatives depends on whether rhythm or rate control is selected. If rhythm control is selected: Preferred therapy varies by clinical scenario including presence or absence of structural heart disease and heart failure (see Resources column for guidelines). For many older adults seeking rhythm control, dofetilide and sotalol are preferred antiarrhythmic agents. Initiation of dofetilide and sotalol require hospitalization, and referral to a specialist should be considered. If the patient has normal LV function, no CAD or prior MI, and no significant structural heart disease (e.g., LVH), other options include dronedarone, flecainide, and propafenone. Non-pharmacologic alternatives for rhythm control include catheter ablation and surgical ablation (Maze procedure). If rate control is selected: Beta-blockers are an appropriate rate-control alternative to digoxin for most patients. If the patient has LVEF > 40%, nondihydropyridine calcium channel blockers (diltiaZEM, verapamil) can also be used. Non-pharmacologic alternatives for rate control include AV nodal ablation with permanent pacemaker.
Resources for patients and caregivers	Information and resources on atrial fibrillation (AHA) https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
Resources for clinicians	Algorithm for drug therapy to maintain sinus rhythm, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 23 (ACC/AHA/ACCP/HRS): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F23 Concise information on antiarrhythmic drugs and monitoring, 2023 ACC/AHA/ACCP/HRS guideline — see Tables 23 -25 (ACC/AHA/ACCP/HRS) https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#T23 Algorithm for AF long-term rate control, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 18 (ACC/AHA/ACCP/HRS 2023): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F18

Beers Criteriaamitriptyline (Elavil)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriaamitriptyline (Elavil)amobarbital (Amytal)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Amytal - see amobarbital

Anafranil - see clomiPRAMINE

Anaprox - see naproxen

Ansaid - see flurbiprofen

Antivert - see meclizine

Apidra - see insulin glulisine

Beers CriteriaARIPiprazole (Abilify)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Artane - see trihexyphenidyl

Beers Criteriaasenapine (Saphris)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriaaspirin [ > 325 mg/day]

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriaaspirin-dipyridamole (Persantine) [aspirin >325 mg/day]

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Atarax - see hydrOXYzine

Ativan - see LORazepam

Beers Criteriaatropine

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaatropineatropine-hyoscyamine-PB-scopolamine (Donnatal)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

B Beers Links

Beers Criteriabaclofen (Lioresal)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Benadryl - see diphenhydrAMINE

Bentyl - see dicyclomine

Beers Criteriabenztropine (Cogentin)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Parkinson's disease
Relevant AGS Beers Criteria^® medications	benztropine and trihexyphenidyl
Recommendation	Avoid
Alternatives to consider (recommendations)	Optimize exercise/strengthening, balance, and physical therapy at time of diagnosis and throughout the course of care. Non-motor symptoms such as psychosis may reflect underlying Parkinson's disease progression, an adverse effect of treatment, or signal other systemic processes (e.g., infection) and warrant comprehensive assessment.^l First-line medication treatment: levodopa (often in combination with carbidopa) and DOPamine agonists are typically preferred. If symptoms are mild or if daily dosing preferred: consider MAO-B inhibitors (rasagiline is best tolerated). Amantadine can be useful for managing levodopa-induced dyskinesia and "off" time in advanced disease but should be used with caution in older populations. If inadequate control of symptoms with medications: surgical therapies such as deep brain stimulation or focused ultrasound can be considered.
Resources for patients and caregivers	Information and resources for care partners (Parkinson's Foundation) https://www.parkinson.org/resources-support/carepartners Information and resources for care partners (Michael J. Fox Foundation) https://www.michaeljfox.org/news/care-partners
Resources for clinicians	2019 Canadian Parkinson's Disease Guideline (Parkinson Canada) https://www.parkinsonclinicalguidelines.ca/wp-content/uploads/2019/10/canadian-guideline-for-parkinson-disease-full.pdf
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Tardive dyskinesia
Relevant AGS Beers Criteria^® medications	benztropine and trihexyphenidyl
Recommendation	Avoid
Alternatives to consider (recommendations)	Strong anticholinergic medications such as benztropine and trihexyphenidyl are not effective treatments for tardive dyskinesia. Reversible causes of tardive dyskinesia should be identified and addressed, including medications and deprescribing attempts (e.g., metoclopramide, haloperidol). For tardive dyskinesia that does not resolve after discontinuing the responsible medication and that is distressing to the patient, clinicians may consider offering an FDA-approved medication (e.g., valbenazine, deutetrabenazine).
Resources for patients and caregivers	Information and resources on TD (NOTD) https://tdhelp.org/resources/ Information and resources on TD (NAMI) https://www.nami.org/about-mental-illness/treatments/mental-health-medications/tardive-dyskinesia/
Resources for clinicians	Brief summary of guidelines for treatment of tardive syndromes (AAN) https://www.aan.com/Guidelines/Home/GetGuidelineContent/613

Beers Criteriabrexpiprazole (Rexulti)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriabrompheniramine (Dimetane, Dimetapp)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriabutalbital (Fioricet, Fiorinal)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

C Beers Links

Caldolor - see ibuprofen

Cambia - see diclofenac

Caplyta - see lumateperone

Beers Criteriacarbinoxamine (Clistin, Karbinal)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Cardura - see doxazosin

Beers Criteriacariprazine (Vraylar)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriacarisoprodol (Soma)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Cataflam - see diclofenac

Catapres - see cloNIDine

Cenestin - see estrogens, conjugated

Beers CriteriachlordiazePOXIDE (Librium)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriachlordiazePOXIDE (Librium)chlordiazePOXIDE-clidinium (Librax)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriachlorpheniramine (Chlor-Trimeton)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriachlorpheniramine (Chlor-Trimeton)chlorpheniramine-HYDROcodone (Tussionex PennKinetic)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriachlorpheniramine (Chlor-Trimeton)chlorpheniramine-HYDROcodone (Tussionex PennKinetic)chlorpheniramine-HYDROcodone-phenylephrine (Hydro-PC II)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers CriteriachlorproMAZINE (Thorazine)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Chlor-Trimeton - see chlorpheniramine

Beers Criteriachlorzoxazone (Parafon Forte DSC)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Climara - see estradiol

Clinoril - see sulindac

Clistin - see carbinoxamine

Beers CriteriacloBAZam (Onfi, Sympazan)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriaclomiPRAMINE (Anafranil)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriaclonazePAM (KlonoPIN)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriacloNIDine (Catapres)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Central alpha-1 agonists including cloNIDine, guanFACINE, others
Recommendation	Avoid cloNIDine as first-line treatment for hypertension; Avoid other central alpha-agonists for the treatment of hypertension
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriaclorazepate (Tranxene)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriacloZAPine (Clozaril)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Clozaril - see cloZAPine

Beers Criteriacodeine

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Cogentin - see benztropine

Compazine - see prochlorperazine

Cordarone - see amiodarone

Coumadin - see warfarin

Beers Criteriacyclobenzaprine (Flexeril)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriacyproheptadine (Periactin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

D Beers Links

Dantrium - see dantrolene

Beers Criteriadantrolene (Dantrium)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Daypro - see oxaprozin

DDAVP - see desmopressin

Demerol - see meperidine

DES - see diethylstilbestrol

Beers Criteriadesipramine (Norpramin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriadesmopressin (DDAVP)

Genitourinary conditions in older adults. (Table 5) ⇒ Nocturia and nocturnal polyuria
Relevant AGS Beers Criteria^® medications	desmopressin
Recommendation	Avoid for treatment of nocturia or nocturnal polyuria.
Alternatives to consider (recommendations)	Start by addressing non-urological causes of nocturnal polyuria including: Manage fluids (timing, alcohol, caffeine, avoid evening dosing of diuretics) Manage daytime edema (treat contributing causes, use compression stockings, elevate legs during daytime) Address the "SCREeN" conditions: sleep (especially sleep apnea), cardiovascular (congestive heart failure), renal (CKD), endocrine (diabetes), and neurological Behavioral therapies for lower urinary tract symptoms including adjusting fluids and bladder retraining with pelvic floor muscle exercises. For symptoms due to overactive bladder: consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults. For women, also consider vaginal estrogen. For men with BPH-associated lower urinary tract symptoms: consider uroselective alpha-1 blockers, 5-alpha reductase inhibitors.
Resources for patients and caregivers	iUFlow — free app for recording a bladder diary Google Play Store: https://play.google.com/store/apps/details?id=com.paperact.android.iuflow Apple App Store: https://apps.apple.com/us/app/iuflow-voiding-bladder-diary/id935581221 Information and resources on nocturia (Urology Care Foundation) https://www.urologyhealth.org/urology-a-z/n/nocturia Information on causes and non-pharmacologic management of nocturia (sleepfoundation.org) https://www.sleepfoundation.org/physical-health/nocturia-or-frequent-unrination-night
Resources for clinicians	Summary of nocturia diagnosis and treatment pathways — see Figures 2 and 3 (ICS) https://www.ics.org/document/5948 Bladder diary to assess nocturnal polyuria (Urology Care Foundation) https://www.urologyhealth.org/resources/bladder-diary Concise review of diagnosis and management of nocturia (Stat Pearls) https://www.ncbi.nlm.nih.gov/books/NBK518987/

Beers Criteriadexlansoprazole (Kapidex)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Diabeta - see glyBURIDE

Beers CriteriadiazePAM (Valium)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Dibenzyline - see phenoxybenzamine

Beers Criteriadiclofenac (Cambia, Cataflam, Voltaren)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriadicyclomine (Bentyl)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriadiethylstilbestrol (DES)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriadiflunisal (Dolobid)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriadigoxin (Lanoxin)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Atrial fibrillation/flutter (rate/rhythm control)
Relevant AGS Beers Criteria^® medications	digoxin
Recommendation	Avoid as first line therapy for AF or HF. If used for these indications, avoid doses > 0.125 mg/d
Alternatives to consider (recommendations)	Choice of alternatives depends on whether rhythm or rate control is selected. If rhythm control is selected: Preferred therapy varies by clinical scenario including presence or absence of structural heart disease and heart failure (see Resources column for guidelines). For many older adults seeking rhythm control, dofetilide and sotalol are preferred antiarrhythmic agents. Initiation of dofetilide and sotalol require hospitalization, and referral to a specialist should be considered. If the patient has normal LV function, no CAD or prior MI, and no significant structural heart disease (e.g., LVH), other options include dronedarone, flecainide, and propafenone. Non-pharmacologic alternatives for rhythm control include catheter ablation and surgical ablation (Maze procedure). If rate control is selected: Beta-blockers are an appropriate rate-control alternative to digoxin for most patients. If the patient has LVEF > 40%, nondihydropyridine calcium channel blockers (diltiaZEM, verapamil) can also be used. Non-pharmacologic alternatives for rate control include AV nodal ablation with permanent pacemaker.
Resources for patients and caregivers	Information and resources on atrial fibrillation (AHA) https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
Resources for clinicians	Algorithm for drug therapy to maintain sinus rhythm, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 23 (ACC/AHA/ACCP/HRS): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F23 Concise information on antiarrhythmic drugs and monitoring, 2023 ACC/AHA/ACCP/HRS guideline — see Tables 23 -25 (ACC/AHA/ACCP/HRS) https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#T23 Algorithm for AF long-term rate control, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 18 (ACC/AHA/ACCP/HRS 2023): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F18

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Heart failure
Relevant AGS Beers Criteria^® medications	digoxin
Recommendation	Avoid as first line therapy for AF or HF. If used for these indications, avoid doses > 0.125 mg/d
Alternatives to consider (recommendations)	Initiate guideline-directed medical therapy for HFrEF before considering digoxin. First line agents include: sacubitril/valsartan (or an ACEI/ARB if sacubitril/valsartan is not tolerated or unaffordable), beta blocker, MRA, and SGLT2i. hydrALAZINE-nitrates may be used for black patients with NYHA class III-IV HFrEF. Use diuretics as needed for fluid retention. Advanced non-pharmacologic adjuncts for HFrEF include cardiac resynchronization therapy (CRT), which requires referral to a cardiac specialist.
Resources for patients and caregivers	Information and resources on heart failure (AHA) https://www.heart.org/en/health-topics/heart-failure
Resources for clinicians	Algorithm for treatment of HFrEF stages C and D, 2022 AHA/ACC/HFSA guideline — see Figure 6 (AHA/ACC/HFSA): https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063#F6 Additional therapies for HFrEF once GDMT optimized, 2022 AHA/ACC/HFSA guideline — see Figure 7 (AHA/ACC/HFSA): https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063#F7

Dilaudid - see HYDROmorphone

Beers CriteriadimenhyDRINATE (Dramamine)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Dimetane - see brompheniramine

Dimetapp - see brompheniramine

Beers CriteriadiphenhydrAMINE (Benadryl)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Doan's - see magnesium salicylate

Dolobid - see diflunisal

Dolophine - see methadone

Donnatal - see atropine-hyoscyamine-PB-scopolamine

Beers Criteriadoxazosin (Cardura)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriadoxepin (SINEquan) [> 6 mg/day]

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriadoxylamine (Unisom)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Dramamine - see dimenhyDRINATE

Beers Criteriadronedarone (Multaq)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Atrial fibrillation/flutter (rate/rhythm control)
Relevant AGS Beers Criteria^® medications	dronedarone
Recommendation	Avoid in patients with permanent AF or severe or recently decompensated HF; use caution in patients with NYHA class I-II HFrEF
Alternatives to consider (recommendations)	Choice of alternatives depends on whether rhythm or rate control is selected. If rhythm control is selected: Preferred therapy varies by clinical scenario including presence or absence of structural heart disease and heart failure (see Resources column for guidelines). For many older adults seeking rhythm control, dofetilide and sotalol are preferred antiarrhythmic agents. Initiation of dofetilide and sotalol require hospitalization, and referral to a specialist should be considered. If the patient has normal LV function, no CAD or prior MI, and no significant structural heart disease (e.g., LVH), other options include dronedarone, flecainide, and propafenone. Non-pharmacologic alternatives for rhythm control include catheter ablation and surgical ablation (Maze procedure). If rate control is selected: Beta-blockers are an appropriate rate-control alternative to digoxin for most patients. If the patient has LVEF > 40%, nondihydropyridine calcium channel blockers (diltiaZEM, verapamil) can also be used. Non-pharmacologic alternatives for rate control include AV nodal ablation with permanent pacemaker.
Resources for patients and caregivers	Information and resources on atrial fibrillation (AHA) https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
Resources for clinicians	Algorithm for drug therapy to maintain sinus rhythm, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 23 (ACC/AHA/ACCP/HRS): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F23 Concise information on antiarrhythmic drugs and monitoring, 2023 ACC/AHA/ACCP/HRS guideline — see Tables 23 -25 (ACC/AHA/ACCP/HRS) https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#T23 Algorithm for AF long-term rate control, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 18 (ACC/AHA/ACCP/HRS 2023): https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001193#F18

Beers Criteriadroperidol (Inapsine)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

E Beers Links

Elavil - see amitriptyline

Equanil - see meprobamate

Beers Criteriaesomeprazole (NexIUM)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Beers Criteriaestazolam (Prosom)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriaesterified estrogens-methylTESTOSTERone (Estratest H.S.)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Estrace - see estradiol

Beers Criteriaestradiol (Alora, Climara, Estrace, Vivelle-Dot)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Estratest H.S. - see esterified estrogens-methylTESTOSTERone

Beers Criteriaestrogen/progesterone combinations (Premphase, Prempro)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaestrogens, conjugated (Cenestin, Enjuvia)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaestrogens, esterified (Menest)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaestropipate (Ogen, Ortho-Est)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaeszopiclone (Lunesta)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Z-drugs
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Beers Criteriaethinyl estradiol-norethindrone (Femhrt)

Genitourinary conditions in older adults. (Table 5) ⇒ Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	For GSM-associated bladder symptoms:ⁿ Behavioral interventions, pelvic floor muscle training Vaginal estrogen For pharmacologic management of overactive bladder symptoms, consider β-3 agonists over antimuscarinic agents due their safer adverse event profile in older adults For GSM-associated vaginal atrophy or dyspareunia: Non-hormonal vaginal lubricants/moisturizers^b Pelvic floor physical therapy Intravaginal medications including estrogen, dehydroepiandrosterone (DHEA, prasterone), hyaluronic acid Ospemifene For GSM-associated vasomotor symptoms (e.g., hot flashes):^o Cognitive behavioral therapy, hypnosis SSRIs (PARoxetine, citalopram, escitalopram) or SNRIs (venlafaxine) Gabapentin Neurokinin 3 receptor antagonist (fezolinetant)
Resources for patients and caregivers	Information and resources (IUA): https://www.yourpelvicfloor.org/conditions/genitourinary-syndrome-of-menopause-gsm/ Information and resources (AUGS): https://www.voicesforpfd.org/ Condition fact sheets (AUGS) https://www.augs.org/patient-fact-sheets/
Resources for clinicians	Algorithm for diagnosis and treatment of overactive bladder — see Figure (AUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000003985#F1 Treatment of GSM — see Figure (management algorithm); Table 3 (OTC nonhormone and vaginal moisturizers); Table 4 (non-systemic hormone therapy options) (Clin Obstet Gynecol 2024) https://journals.lww.com/clinicalobgyn/fulltext/2024/03000/clinical_practice_guidelines_for_managing.11.aspx Urinary rehabilitation guidelines on non-pharmacologic management — see Figure 1 (APHPT) https://journals.lww.com/jwphpt/fulltext/2023/10000/clinical_ practice_guidelines__rehabilitation.3.aspx Bladder anticholinergics and dementia risk — white paper (SUFU) https://onlinelibrary.wiley.com/doi/10.1002/nau.25037
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
ⁿ For refractory symptoms, consider advanced therapies (e.g., percutaneous tibial nerve stimulation, botulinum toxin, sacral nerve stimulation).
^o Among the medications listed below, only paroxetine and fezolinetant are FDA-approved for this indication.

Genitourinary conditions in older adults. (Table 5) ⇒ Recurrent UTIs in Women
Relevant AGS Beers Criteria^® medications	Systemic estrogens
Recommendation	Do not initiate systemic estrogen (e.g., oral, transdermal); consider deprescribing among older women already taking this medication; do not use systemic estrogen to manage incontinence (all types)
Alternatives to consider (recommendations)	First-line preventive therapy for recurrent UTIs in most older women is vaginal estrogen. Many experts recommend trialing non-pharmacological and/or non-antibiotic interventions before resorting to suppressive antibiotics. Evidence for other preventive approaches varies in extent and quality. Such approaches include:^b Increasing fluid intake Behavioral modifications methenamine hippurate Cranberry products D-mannose Glycosaminoglycan However, if necessary prophylactic antibiotics such as trimethoprim or fosfomycin may be used.
Resources for patients and caregivers	UTI patient fact sheet (AUGS): English: https://www.voicesforpfd.org/assets/2/6/UTI_LARGE_PRINT.pdf Spanish: https://www.voicesforpfd.org/assets/2/6/UTI_Spanish.pdf What Should I Know About Recurrent UTIs in Older Women? Patient page. (JAMA Intern Med, 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819818
Resources for clinicians	Algorithm for diagnosis and treatment of recurrent UTIs in women, 2019 AUA/CUA/SUFU guideline — see Figure (AUA/CUA/SUFU) https://www.auajournals.org/doi/10.1097/JU.0000000000000296#F1 Overview of recurrent UTIs (StatPearls) https://www.ncbi.nlm.nih.gov/books/NBK557479/ Recurrent Urinary Tract Infection in Older Outpatient Women — clinical review (JAMA Intern Med 2024) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819823 Antibiotic prophylaxis regimens for recurrent UTI in women, 2018 AUGS guideline — see Table 7 (AUGS) https://journals.lww.com/fpmrs/fulltext/2018/09000/american_urogynecologic_society_best_practice.2.aspx
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriaetodolac (Lodine)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

F Beers Links

Fanapt - see iloperidone

Feldene - see piroxicam

Femhrt - see ethinyl estradiol-norethindrone

Beers CriteriafentaNYL (Sublimaze)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Fioricet - see butalbital

Fiorinal - see butalbital

Flexeril - see cyclobenzaprine

Flomax - see tamsulosin

Beers CriteriafluPHENAZine (Prolixin)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriaflurbiprofen (Ansaid, Ocufen)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

G Beers Links

Beers Criteriagabapentin (Neurontin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Geodon - see ziprasidone

Beers Criteriaglimepiride (Amaryl)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sulfonylureas
Recommendation	Avoid as first- or second-line choice for monotherapy or as add-on therapy, unless there are substantial barriers to using safer and more effective agents
Alternatives to consider (recommendations)	Alternatives to sulfonylureas: metFORMIN remains a first-line medication option for most older adults with hyperglycemia. If metFORMIN is chosen, ensure patients are on the maximal tolerated dose (as appropriate given renal function) before increasing other medications. For many older adults, alternatives to sulfonylureas include SGLT2 inhibitors, GLP1-RAs, and DPP4 inhibitors. Selection among agents should be based in part on comorbid conditions, treatment goals, and preferences.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Beers CriteriaglipiZIDE (Glucotrol)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sulfonylureas
Recommendation	Avoid as first- or second-line choice for monotherapy or as add-on therapy, unless there are substantial barriers to using safer and more effective agents
Alternatives to consider (recommendations)	Alternatives to sulfonylureas: metFORMIN remains a first-line medication option for most older adults with hyperglycemia. If metFORMIN is chosen, ensure patients are on the maximal tolerated dose (as appropriate given renal function) before increasing other medications. For many older adults, alternatives to sulfonylureas include SGLT2 inhibitors, GLP1-RAs, and DPP4 inhibitors. Selection among agents should be based in part on comorbid conditions, treatment goals, and preferences.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Glucotrol - see glipiZIDE

Beers CriteriaglyBURIDE (Diabeta, Glynase, Micronase)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sulfonylureas
Recommendation	Avoid as first- or second-line choice for monotherapy or as add-on therapy, unless there are substantial barriers to using safer and more effective agents
Alternatives to consider (recommendations)	Alternatives to sulfonylureas: metFORMIN remains a first-line medication option for most older adults with hyperglycemia. If metFORMIN is chosen, ensure patients are on the maximal tolerated dose (as appropriate given renal function) before increasing other medications. For many older adults, alternatives to sulfonylureas include SGLT2 inhibitors, GLP1-RAs, and DPP4 inhibitors. Selection among agents should be based in part on comorbid conditions, treatment goals, and preferences.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Glynase - see glyBURIDE

Beers CriteriaguanFACINE (Intuniv, Tenex)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Central alpha-1 agonists including cloNIDine, guanFACINE, others
Recommendation	Avoid cloNIDine as first-line treatment for hypertension; Avoid other central alpha-agonists for the treatment of hypertension
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

H Beers Links

Halcion - see triazolam

Haldol - see haloperidol

Beers Criteriahaloperidol (Haldol)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Histex - see triprolidine

Beers Criteriahaloperidol (Haldol)homatropine-HYDROcodone (Hycodan, Hydromet)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

HumaLOG - see insulin lispro

HumuLIN R - see insulin regular

Hycodan - see homatropine-HYDROcodone

Hydromet - see homatropine-HYDROcodone

Beers CriteriaHYDROmorphone (Dilaudid)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Hydro-PC II - see chlorpheniramine-HYDROcodone-phenylephrine

Beers CriteriahydrOXYzine (Atarax, Vistaril)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriahyoscyamine (Hyosyne, Levsin, Levsinex)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Hyosyne - see hyoscyamine

Hytrin - see terazosin

I Beers Links

Beers Criteriaibuprofen (Caldolor, Motrin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriailoperidone (Fanapt)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriaimipramine (Tofranil)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Inapsine - see droperidol

Indocin - see indomethacin

Beers Criteriaindomethacin (Indocin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriainsulin aspart (NovoLOG)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sliding scale insulin
Recommendation	Avoid
Alternatives to consider (recommendations)	Alternatives to sliding scale insulin: "Sliding scale insulin" refers to the use of variable doses of short-acting insulin dependent on glucose values without any basal insulin. For patients started on sliding scale due to unstable insulin needs, the addition of basal insulin often allows for the safe discontinuation of sliding scale. For patients whose glucose levels remain uncontrolled on basal insulin, the addition of pre-prandial bolus insulin may be required. If sliding scale measurements do not lead to any insulin for 24 - 48 h, stop sliding scale insulin. For nearly all older adults with Type 2 diabetes, up-titration of basal insulin and other medications can lead to the safe discontinuation of sliding scale insulin within a few weeks.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Beers Criteriainsulin glulisine (Apidra)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sliding scale insulin
Recommendation	Avoid
Alternatives to consider (recommendations)	Alternatives to sliding scale insulin: "Sliding scale insulin" refers to the use of variable doses of short-acting insulin dependent on glucose values without any basal insulin. For patients started on sliding scale due to unstable insulin needs, the addition of basal insulin often allows for the safe discontinuation of sliding scale. For patients whose glucose levels remain uncontrolled on basal insulin, the addition of pre-prandial bolus insulin may be required. If sliding scale measurements do not lead to any insulin for 24 - 48 h, stop sliding scale insulin. For nearly all older adults with Type 2 diabetes, up-titration of basal insulin and other medications can lead to the safe discontinuation of sliding scale insulin within a few weeks.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Beers Criteriainsulin human in Normal Saline (Myxredlin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sliding scale insulin
Recommendation	Avoid
Alternatives to consider (recommendations)	Alternatives to sliding scale insulin: "Sliding scale insulin" refers to the use of variable doses of short-acting insulin dependent on glucose values without any basal insulin. For patients started on sliding scale due to unstable insulin needs, the addition of basal insulin often allows for the safe discontinuation of sliding scale. For patients whose glucose levels remain uncontrolled on basal insulin, the addition of pre-prandial bolus insulin may be required. If sliding scale measurements do not lead to any insulin for 24 - 48 h, stop sliding scale insulin. For nearly all older adults with Type 2 diabetes, up-titration of basal insulin and other medications can lead to the safe discontinuation of sliding scale insulin within a few weeks.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Beers Criteriainsulin lispro (HumaLOG)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sliding scale insulin
Recommendation	Avoid
Alternatives to consider (recommendations)	Alternatives to sliding scale insulin: "Sliding scale insulin" refers to the use of variable doses of short-acting insulin dependent on glucose values without any basal insulin. For patients started on sliding scale due to unstable insulin needs, the addition of basal insulin often allows for the safe discontinuation of sliding scale. For patients whose glucose levels remain uncontrolled on basal insulin, the addition of pre-prandial bolus insulin may be required. If sliding scale measurements do not lead to any insulin for 24 - 48 h, stop sliding scale insulin. For nearly all older adults with Type 2 diabetes, up-titration of basal insulin and other medications can lead to the safe discontinuation of sliding scale insulin within a few weeks.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Beers Criteriainsulin regular (HumuLIN R)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Diabetes
Relevant AGS Beers Criteria^® medications	Sliding scale insulin
Recommendation	Avoid
Alternatives to consider (recommendations)	Alternatives to sliding scale insulin: "Sliding scale insulin" refers to the use of variable doses of short-acting insulin dependent on glucose values without any basal insulin. For patients started on sliding scale due to unstable insulin needs, the addition of basal insulin often allows for the safe discontinuation of sliding scale. For patients whose glucose levels remain uncontrolled on basal insulin, the addition of pre-prandial bolus insulin may be required. If sliding scale measurements do not lead to any insulin for 24 - 48 h, stop sliding scale insulin. For nearly all older adults with Type 2 diabetes, up-titration of basal insulin and other medications can lead to the safe discontinuation of sliding scale insulin within a few weeks.
Resources for patients and caregivers	Diabetes guideline summary for patients (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Patient-Summary_final_508.pdf Information and resources on diabetes (CDC): https://www.cdc.gov/diabetes/index.html
Resources for clinicians	2023 VA/DoD diabetes Guideline summary (VA/DoD): https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoD-Diabetes-CPG-Provider-Summary_final_508.pdf 2023 VA/DoD diabetes Guideline resources, (VA/DoD): https://www.healthquality.va.gov/guidelines/cd/diabetes/index.asp

Intuniv - see guanFACINE

Invega - see paliperidone

J Beers Links

Jantoven - see warfarin

K Beers Links

Kapidex - see dexlansoprazole

Karbinal - see carbinoxamine

Beers Criteriaketorolac (Toradol)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

KlonoPIN - see clonazePAM

L Beers Links

Lanoxin - see digoxin

Beers Criterialansoprazole (Prevacid)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Latuda - see lurasidone

Levsin - see hyoscyamine

Levsinex - see hyoscyamine

Librax - see chlordiazePOXIDE-clidinium

Librium - see chlordiazePOXIDE

Lioresal - see baclofen

Lodine - see etodolac

Beers CriteriaLORazepam (Ativan)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Lortab - see acetaminophen-HYDROcodone

Beers Criterialoxapine (Loxitane)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Loxitane - see loxapine

Beers Criterialumateperone (Caplyta)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Luminal - see PHENobarbital

Lunesta - see eszopiclone

Beers Criterialurasidone (Latuda)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Lyrica - see pregabalin

M Beers Links

Beers Criteriamagnesium salicylate (Doan's)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriameclizine (Antivert)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Megace - see megestrol

Beers Criteriamegestrol (Megace)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Weight Loss (involuntary or undesired)
Relevant AGS Beers Criteria^® medications	megestrol
Recommendation	Avoid
Alternatives to consider (recommendations)	Treatment should focus on non-pharmacologic strategies including: Feeding assistance Identifying and addressing contributing medications (e.g., medications that affect taste or cause dry mouth, nausea, or anorexia) Providing appealing foods Social support Ensuring adequate access to food (e.g., home meal delivery programs, lifting dietary restrictions where appropriate) Consider calorically dense nutritional supplements and referral to a dietician. Evaluate dentition, chewing, and swallowing and refer for swallow evaluation if appropriate. For patients with depression, consider mirtazapine.
Resources for patients and caregivers	Tips on how to gain weight (AARP) https://www.aarp.org/health/healthy-living/info-2023/how-to-gain-weight-safely.html
Resources for clinicians	Overview of unintentional weight loss in older adults (Am Fam Phys 2021) https://www.aafp.org/pubs/afp/issues/2021/0700/p34.html Investigation and management of unintentional weight loss in older adults: review (BMJ 2011) https://www.bmj.com/content/342/bmj.d1732

Mellaril - see thioridazine

Beers Criteriameloxicam (Mobic)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Menest - see estrogens, esterified

Beers Criteriameperidine (Demerol)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	meperidine
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriameprobamate (Equanil, Miltown)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	meprobamate
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriametaxalone (Skelaxin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriamethadone (Dolophine)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriamethocarbamol (Robaxin)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriametoclopramide (Reglan)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Gastroparesis (chronic) and associated nausea
Relevant AGS Beers Criteria^® medications	metoclopramide
Recommendation	Avoid except for short-term management of gastroparesis (do not exceed 12 weeks use)
Alternatives to consider (recommendations)	First line management includes dietary changes: Foods that are soft, small, and easy to chew into small pieces before swallowing (small particle diet) Frequent small meals Avoid fatty, spicy, acidic, and high fiber meals Add soups or liquid-containing meals to diet Follow tips on preparation of fruits and vegetables to minimize discomfort (see Resources column) Consider treatments for symptomatic relief of gastroparesis symptoms, i.e., ginger 1 mg twice daily or ondansetron for nausea. Consider short course of erythromycin 50 - 100 mg 4 times a day, given 30 - 45 min before main meals and at bedtime. For people with diabetes, control glucose.
Resources for patients and caregivers	Causes of and treatments for gastroparesis (ACG) https://gi.org/topics/gastroparesis/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/22ACGMag-gastroparesis-one-pager.pdf Tips on how to prepare fruits and vegetables to minimize discomfort (AGA) https://patient.gastro.org/gastroparesis-nutrition-therapy/ Information on causes and pharmacologic and non-pharmacologic treatments (My GI Health) ~~https://mygi.health/education/diseases/gastroparesis~~
Resources for clinicians	Best practice advice for management of refractory gastroparesis (AGA) https://www.sciencedirect.com/science/article/pii/S1542356521011514?via%3Dihub Gastroparesis guideline, ACG 2022 (ACG) htps://journals.lww.com/ajg/fulltext/2022/08000/acg_clinical_guideline__gastroparesis.15.aspx

Micronase - see glyBURIDE

Beers Criteriamidazolam (Versed)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Miltown - see meprobamate

Beers Criteriamineral oil [oral]

Gastrointestinal conditions in older adults. (Table 4) ⇒ Constipation
Relevant AGS Beers Criteria^® medications	mineral oil (oral)
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. First-line management comprises lifestyle modification including Scheduled toileting after meals Increased fluid intake Increased intake of fiber Exercise and ambulation Consider stimulant laxatives (e.g., senna) and/or osmotic laxatives (e.g., polyethylene glycol, magnesium-containing laxatives).^b For symptoms not responding to above: consider secretagogues (e.g., lubiprostone, linaclotide, plecanitide) and serotonin type 4 agonist (prucalopride).
Resources for patients and caregivers	Information and resources on constipation (ACG) https://gi.org/topics/constipation-and-defection-problems/ Information and resources on constipation (MyGIHealth) ~~https://mygi.health/education/symptoms/constipation~~ ~~https://mygi.health/education/diseases/constipation-and-defecation-problems~~ Brief handout on idiopathic constipation (ACG) https://webfiles.gi.org/links/patients/Chronic_Idiopathic_Constipation_One-Pager_based_on_ACG_AGA_Guidelines_2023.pdf
Resources for clinicians	Overview of management of constipation in older adults (Am Fam Phys 2015) https://www.aafp.org/pubs/afp/issues/2015/0915/p500.html
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Minipress - see prazosin

Mobic - see meloxicam

Beers Criteriamorphine (Oramorph SR, Roxanol)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Motrin - see ibuprofen

Multaq - see dronedarone

Mysoline - see primidone

Myxredlin - see insulin human in Normal Saline

N Beers Links

Beers Criterianabumetone (Relafen)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Naprelan - see naproxen

Naprosyn - see naproxen

Beers Criterianaproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Navane - see thiothixene

Nembutal - see PENTobarbital

Neurontin - see gabapentin

NexIUM - see esomeprazole

Nexterone - see amiodarone

Beers CriteriaNIFEdipine (Adalat, Procardia)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Immediate-release NIFEdipine
Recommendation	Avoid
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Norco - see acetaminophen-HYDROcodone

Norflex - see orphenadrine

Norpramin - see desipramine

Beers Criterianortriptyline (Pamelor)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Tricyclic antidepressant (TCAs)
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

NovoLOG - see insulin aspart

Numorphan - see oxyMORphone

Nuplazid - see pimavanserin

O Beers Links

Ocufen - see flurbiprofen

Ogen - see estropipate

Beers CriteriaOLANZapine (ZyPREXA)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriaomeprazole (PriLOSEC)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Beers Criteriaomeprazole-sodium bicarbonate (Zegerid)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Onfi - see cloBAZam

Opana - see oxyMORphone

Beers Criteriaopium

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Oramorph SR - see morphine

Orap - see pimozide

Beers Criteriaorphenadrine (Norflex)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Ortho-Est - see estropipate

Beers Criteriaoxaprozin (Daypro)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Oxaydo - see oxyCODONE

Beers Criteriaoxazepam (Serax)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriaoxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

OxyCONTIN - see oxyCODONE

Oxyfast - see oxyCODONE

Oxy-IR - see oxyCODONE

Beers CriteriaoxyMORphone (Numorphan, Opana)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

P Beers Links

Pacerone - see amiodarone

Beers Criteriapaliperidone (Invega)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Pamelor - see nortriptyline

Beers Criteriapantoprazole (ProtoNix)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Parafon Forte DSC - see chlorzoxazone

Beers Criteriapantoprazole (ProtoNix)PENTobarbital (Nembutal)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Pentothal - see thiopental

Percocet - see acetaminophen-oxyCODONE

Percodan - see oxyCODONE

Periactin - see cyproheptadine

Beers Criteriaperphenazine (Trilafon)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Persantine - see aspirin-dipyridamole

Phenadoz - see promethazine

Phenergan - see promethazine

Beers CriteriaPHENobarbital (Luminal, Solfoton)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers CriteriaPHENobarbital (Luminal, Solfoton)phenoxybenzamine (Dibenzyline)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers CriteriaPHENobarbital (Luminal, Solfoton)phenoxybenzamine (Dibenzyline)phentolamine (Regitine)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriapimavanserin (Nuplazid)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriapimozide (Orap)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriapiroxicam (Feldene)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriaprazosin (Minipress)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriapregabalin (Lyrica)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Premphase - see estrogen/progesterone combinations

Prempro - see estrogen/progesterone combinations

Prevacid - see lansoprazole

PriLOSEC - see omeprazole

Beers Criteriaprimidone (Mysoline)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Procardia - see NIFEdipine

Beers Criteriaprochlorperazine (Compazine)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Prolixin - see fluPHENAZine

Beers Criteriapromethazine (Phenadoz, Phenergan)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Prosom - see estazolam

ProtoNix - see pantoprazole

Q Beers Links

Beers CriteriaQUEtiapine (SEROquel)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

R Beers Links

Beers CriteriaRABEprazole (Aciphex)

Gastrointestinal conditions in older adults. (Table 4) ⇒ GERD and associated symptoms
Relevant AGS Beers Criteria^® medications	Proton pump inhibitors
Recommendation	Avoid use for > 8 weeks unless indicated for high-risk patients or failure to respond to less intensive therapy.
Alternatives to consider (recommendations)	First line interventions are non-pharmacologic; these include: Lifestyle changes (e.g., stop smoking) Dietary behaviors (e.g., avoid trigger foods) Relaxation strategies Weight management Not eating within 2 - 3 hours of bedtime Elevating head of the bed Awareness of the connection between gut and the brain ("gut-brain axis") For breakthrough symptoms: acid-protective therapies containing alginate.^b,m For nocturnal symptoms: nighttime H2 receptor antagonists. For those on twice daily PPI: consider dose reduction to once daily, if not complete discontinuation. For functional heartburn or reflux disease associated with esophageal hypervigilance, reflux hypersensitivity, and/or behavior disorders: consider pharmacologic neuromodulation and/or referral to a behavioral therapist for hypnotherapy, cognitive behavioral therapy, diaphragmatic breathing, and relaxation strategies.
Resources for patients and caregivers	Information and resources about acid reflux (ACG) https://gi.org/topics/acid-reflux/ One-page infographic (ACG) https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of heartburn symptoms https://webfiles.gi.org/docs/patients/GERD-infographic-final_2022.pdf Information on causes and management of acid reflux (My GI Health) ~~https://mygi.health/education/diseases/acid-reflux~~
Resources for clinicians	Best practice advice for management of GERD (AGA) https://gastro.org/clinical-guidance/personalized-approach-to-the-evaluation-and-management-of-gastroesophageal-reflux-disease-gerd/ Proton pump inhibitor deprescribing algorithm (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^m Alginate (alginic acid)-containing therapies are sold under a variety of brand names. They work by creating a low-density gel that floats atop gastric contents, creating a physical barrier to acid reaching the esophageal mucosa. Avoid ingesting a variety of other medications within 2 hours before or after alginate use due to impacts on drug absorption.

Rapaflo - see silodosin

Regitine - see phentolamine

Reglan - see metoclopramide

Relafen - see nabumetone

Restoril - see temazepam

Rexulti - see brexpiprazole

RisperDAL - see risperiDONE

Beers CriteriarisperiDONE (RisperDAL)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriarivaroxaban (Xarelto)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Atrial fibrillation/flutter and venous thromboembolism (anticoagulation)
Relevant AGS Beers Criteria^® medications	rivaroxaban
Recommendation	Avoid for long-term treatment of NVAF or VTE in favor of safer anticoagulants.
Alternatives to consider (recommendations)	Consider other DOACs (e.g., apixaban, edoxaban). Pay attention to indication-specific dosing of DOAC For most people with AF, full dose is preferred. Reduced doses are indicated in renal dysfunction and select other situations. For long-term treatment of VTE, guidelines suggest reducing dose of certain agents after 6 months (e.g., for apixaban, reduce dose to 2.5 mg twice daily after 6 months). In patients with NVAF at moderate to high risk of stroke and high risk of major bleeding with oral anticoagulants, consider non-pharmacologic alternatives, e.g., percutaneous left atrial appendage occlusion and surgical left atrial appendage ligation or removal.
Resources for patients and caregivers	Information and resources on atrial fibrillation (AHA) https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
Resources for clinicians	Flow chart of antithrombotic options in atrial fibrillation, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 10 (ACC/AHA/ACCP/HRS): https://www.ahajournals.org/doi/10.1161/CIR.0000000000001193#F10

Robaxin - see methocarbamol

Roxanol - see morphine

Roxicet - see acetaminophen-oxyCODONE

Roxicodone - see oxyCODONE

Roxybond - see oxyCODONE

S Beers Links

Saphris - see asenapine

Beers Criteriascopolamine (Transderm Scop)

Gastrointestinal conditions in older adults. (Table 4) ⇒ Intestinal cramping and diarrhea
Relevant AGS Beers Criteria^® medications	GI antispasmodics
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and address underlying etiology. Encourage dietary changes: Avoid triggering foods (e.g., gas-producing foods such as beans, broccoli, cabbage) Trial of a low FODMAP diet Gut directed psychotherapies. For diarrhea: antidiarrheals such as loperamide (for short-term use).^b
Resources for patients and caregivers	Information and resources on irritable bowel syndrome (ACG) https://gi.org/topics/irritable-bowel-syndrome/ Information and resources on irritable bowel syndrome (MyGiHealth) ~~https://mygi.health/education/diseases/ibs~~ Information on low FODMAP diet (AGA) https://patient.gastro.org/low-fodmap-diet/
Resources for clinicians	ACG guideline on irritable bowel syndrome (ACG) https://journals.lww.com/ajg/fulltext/2021/01000/acg_clinical_guideline__management_of_irritable.11.aspx Information on low FODMAP diet (ACG) https://gi.org/topics/low-fodmap-diet/
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Beers Criteriascopolamine (Transderm Scop)secobarbital (Seconal)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Seconal - see secobarbital

Serax - see oxazepam

SEROquel - see QUEtiapine

Beers Criteriasilodosin (Rapaflo)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin) Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

SINEquan - see doxepin

Skelaxin - see metaxalone

Solfoton - see PHENobarbital

Soma - see carisoprodol

Sonata - see zaleplon

Stelazine - see trifluoperazine

Sublimaze - see fentaNYL

Sufenta - see SUFentanil

Beers CriteriaSUFentanil (Sufenta)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Beers Criteriasulindac (Clinoril)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	NSAIDs
Recommendation	Avoid non-COX-2 selective NSAIDS for chronic use and avoid short-term scheduled use in combination with systemic steroids, anticoagulants, or antiplatelets unless alternatives are ineffective and patient can take a gastroprotective agent (e.g., PPI)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Sympazan - see cloBAZam

T Beers Links

Beers Criteriatamsulosin (Flomax)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin) Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriatemazepam (Restoril)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Tenex - see guanFACINE

Beers Criteriaterazosin (Hytrin)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Hypertension
Relevant AGS Beers Criteria^® medications	Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
Recommendation	Avoid use as antihypertensive
Alternatives to consider (recommendations)	Non-pharmacologic options include the DASH diet, exercise and weight loss, treatment of obstructive sleep apnea (if present). First-line drug therapies for HTN include thiazide diuretics, calcium channel blockers, ACEIs, and ARBs. Beta blockers may be indicated in some cases (e.g., recent MI or acute coronary syndrome, HFrEF, AF, or angina). Alternatives to immediate-release NIFEdipine include other calcium channel blockers (e.g., amLODIPine, felodipine, NIFEdipine ER). Additional agents for use in patients with resistant HTN include spironolactone and hydrALAZINE, after considering other causes of resistant HTN (e.g., medication non-adherence, hyperaldosteronism).
Resources for patients and caregivers	Information and resources on hypertension (AHA) https://www.heart.org/en/health-topics/high-blood-pressure DASH diet information and recipes (NIH) https://www.nhlbi.nih.gov/education/dash-eating-plan
Resources for clinicians	Selection of initial medication for management of HTN, 2017 AHA/ACC/AGS/other guideline — see Section 8.1.6 (2017 AHA/ACC/AGS/other) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065 Recommendations for HTN management in people with stable ischemic heart disease, 2017 AHA/ACC/AGS/other guideline — see Section 9.1 (2017 AHA/ACC/AGS/other multispecialty) https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Beers Criteriaterazosin (Hytrin)thiopental (Pentothal)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Barbiturates
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriathioridazine (Mellaril)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriathiothixene (Navane, Navane)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Thorazine - see chlorproMAZINE

Beers CriteriatiZANidine (Zanaflex)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Skeletal muscle relaxants
Recommendation	Avoid^c
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^c This recommendation from the AGS Beers Criteria^® covers skeletal muscle relaxants such as cyclobenzaprine and methocarbamol but does not include antispasticity agents such as baclofen and tizanidine.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Tofranil - see imipramine

Toradol - see ketorolac

Beers CriteriatraMADol (Ultram)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Transderm Scop - see scopolamine

Tranxene - see clorazepate

Beers Criteriatriazolam (Halcion)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pain
Relevant AGS Beers Criteria^® medications	Combination of gabapentinoids with either opioids or benzodiazepines
Recommendation	Avoid combination (except when cross-tapering opioids and gabapentinoids)
Alternatives to consider (recommendations)	Use patient-reported outcomes pre-and post-intervention to identify clinically meaningful improvements in pain response to therapeutic options. Improving function should be a key goal in pain management. Consider non-pharmacological approaches for first-line management of chronic pain, alone or in combination with medications. Non-pharmacological options consistently recommended across guidelines for chronic pain vary by the type of pain, and may include the following:^d Education interventions Exercise therapy of any type (e.g., aerobic, aquatic, strengthening, yoga, Tai Chi) Physical therapy interventions Needling therapies (e.g., acupuncture) Psychological interventions (e.g., cognitive behavioral therapy, operant therapy, multicomponent biopsychosocial care, mindfulness-based interventions) Peripheral electric and/or magnetic stimulation, repetitive transcranial magnetic stimulation (rTMS) Pharmacologic approaches should be targeted to the type of pain (nociceptive, neuropathic).^b,e For nociceptive pain: Instead of meperidine, choose a different opioid. Instead of skeletal muscle relaxants or long-term use of NSAIDs, consider the following: Short term use of NSAIDs Topical NSAIDs (e.g., diclofenac gel) COX-2 selective inhibitors Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine Acetaminophen Intra-articular corticosteroids For neuropathic pain: Instead of TCAs, consider the following:^g SNRIs Gabapentinoids^h Other topical agents, including capsaicin, rubefacients and related agents (e.g., menthol-containing ointments)^f, lidocaine
Resources for patients and caregivers	Physical activity and self-management education programs for arthritis (CDC) https://www.cdc.gov/arthritis/programs/index.html Resources for pain assessment and management (GeriatricPain.org, U.Iowa) https://geriatricpain.org/ Managing osteoarthritis symptoms (NCOA) https://www.ncoa.org/article/how-seniors-can-manage-osteoarthritis-symptoms Information and resources on physical therapy (APTA) https://www.choosept.com/symptoms-conditions Brochures about risks of and opportunities to deprescribe NSAIDS, chronic opioids, and other medications used for pain (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts
Resources for clinicians	Simplified summary, 2022 Canadian PEER chronic pain guideline — see Figure 1 (PEER) https://www.cfp.ca/content/68/3/179#F1 Guidance on deprescribing NSAIDs (Primary Health Tasmania) https://www.primaryhealthtas.com.au/wp-content/uploads/2023/03/A-guide-to-deprescribing-non-steroidal-anti-inflammatory-drugs.pdf
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.
^d Other therapies for which there is not enough consensus to recommend for or against that may be used depending on the type of pain include non-pharmacologic options such as chiropractic therapy, hydrotherapy, manual therapy, massage therapy, dry needling, heat and cold therapy, electrotherapy, taping and braces, shoe orthotics, and footwear, and pharmacologic and related options such as glucocorticoid injection (hip and polyarticular osteoarthritis), intraarticular hyaluronic acid injections, platelet-rich plasma injections, stem cell injection, glucosamine and chondroitin individually or combined (glenohumeral joint osteoarthritis), nutraceuticals, and cannabidiol (CBD)-containing therapies.
^e For refractory symptoms, referral to a pain specialist may be helpful to consider advanced therapies, for example, injections, implantable devices, surgery.
^f Use caution with the quantity and duration of use of methyl salicylate-containing products (e.g., limit to ≤ 7 days of continuous use) due to the risk of systemic salicylate toxicity. Methyl salicylate is commonly included in varying concentrations in menthol-based topical agents sold under brand names BenGay, Icy Hot, Salonpas, and others. See the product label for product-specific instructions.
^g Refer to AGS Beers Criteria^® for cautions about these alternative medications.
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	Benzodiazepines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Beers Criteriatrifluoperazine (Stelazine, Stelazine)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriatrihexyphenidyl (Artane)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Parkinson's disease
Relevant AGS Beers Criteria^® medications	benztropine and trihexyphenidyl
Recommendation	Avoid
Alternatives to consider (recommendations)	Optimize exercise/strengthening, balance, and physical therapy at time of diagnosis and throughout the course of care. Non-motor symptoms such as psychosis may reflect underlying Parkinson's disease progression, an adverse effect of treatment, or signal other systemic processes (e.g., infection) and warrant comprehensive assessment.^l First-line medication treatment: levodopa (often in combination with carbidopa) and DOPamine agonists are typically preferred. If symptoms are mild or if daily dosing preferred: consider MAO-B inhibitors (rasagiline is best tolerated). Amantadine can be useful for managing levodopa-induced dyskinesia and "off" time in advanced disease but should be used with caution in older populations. If inadequate control of symptoms with medications: surgical therapies such as deep brain stimulation or focused ultrasound can be considered.
Resources for patients and caregivers	Information and resources for care partners (Parkinson's Foundation) https://www.parkinson.org/resources-support/carepartners Information and resources for care partners (Michael J. Fox Foundation) https://www.michaeljfox.org/news/care-partners
Resources for clinicians	2019 Canadian Parkinson's Disease Guideline (Parkinson Canada) https://www.parkinsonclinicalguidelines.ca/wp-content/uploads/2019/10/canadian-guideline-for-parkinson-disease-full.pdf
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Tardive dyskinesia
Relevant AGS Beers Criteria^® medications	benztropine and trihexyphenidyl
Recommendation	Avoid
Alternatives to consider (recommendations)	Strong anticholinergic medications such as benztropine and trihexyphenidyl are not effective treatments for tardive dyskinesia. Reversible causes of tardive dyskinesia should be identified and addressed, including medications and deprescribing attempts (e.g., metoclopramide, haloperidol). For tardive dyskinesia that does not resolve after discontinuing the responsible medication and that is distressing to the patient, clinicians may consider offering an FDA-approved medication (e.g., valbenazine, deutetrabenazine).
Resources for patients and caregivers	Information and resources on TD (NOTD) https://tdhelp.org/resources/ Information and resources on TD (NAMI) https://www.nami.org/about-mental-illness/treatments/mental-health-medications/tardive-dyskinesia/
Resources for clinicians	Brief summary of guidelines for treatment of tardive syndromes (AAN) https://www.aan.com/Guidelines/Home/GetGuidelineContent/613

Trilafon - see perphenazine

Beers Criteriatriprolidine (Histex, Zymine)

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Allergic rhinitis and associated symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Identify and avoid allergens, where possible. Irrigate nasal passages with purified saline solution (distilled or sterilized water only) with a neti pot or similar system. Do not use unsterilized tap water. If using an oral antihistamine, 2^nd or 3^rd generation agents are preferred, e.g.,loratadine, cetirizine, levocetirizine, fexofenadine.^a,b For nasal symptoms: Nasal antihistamine sprays (e.g., azelastine or olopatadine, which are absorbed less than oral agents and have fewer adverse effects) Nasal corticosteroids (e.g., fluticasone, budesonide, triamcinolone) Nasal mast cell stabilizers (e.g., cromolyn) For ocular symptoms: eye drops (ocular antihistamines or decongestants, artificial tears).
Resources for patients and caregivers	Information on allergic rhinitis (UpToDate) https://www.uptodate.com/contents/allergic-rhinitis-beyond-the-basics#H1 Self-care for allergic rhinitis (MedlinePlus) https://medlineplus.gov/ency/patientinstructions/000547.htm Instructions on how to self-administer nasal sprays — see Figure 4 (BSACI) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162111/figure/f4/ Instructions on safe use of Neti pots and nasal irrigation devices (FDA) https://www.fda.gov/consumers/consumer-updates/rinsing-your-sinuses-neti-pots-safe
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1) ⇒ Pruritus
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Generalized pruritus is generally not responsive to antihistamines unless specifically due to a histamine-mediated etiology like urticaria. Tailor treatment of generalized pruritus to the etiology, typically either dry skin, medications (opioids, CNS medications, diuretics, many others), or underlying medical conditions. For dry skin, consider: Hydrating emollient twice daily Short showers (< 3 min) in lukewarm water Humidifiers For other causes of generalized pruritus, address underlying condition For localized pruritus, consider topical agents such as: Topical anesthetics (e.g., lidocaine, pramoxine) Cooling agents (e.g., menthol) Topical steroids (e.g., hydrocortisone, triamcinolone) Topical antihistamines (e.g., topical doxepin) Capsaicin If using an oral antihistamine, prefer 2^nd or 3^rd generation agents, e.g., loratadine, cetirizine, levocetirizine, fexofenadine.^a,b
Resources for patients and caregivers	Information on causes of itching (AAFP) https://www.aafp.org/pubs/afp/issues/2022/0100/p55-s1.html Information on causes of itching and self-care (MedlinePlus) https://medlineplus.gov/itching.html
Resources for clinicians	Chronic pruritus review (JAMA 2024) https://jamanetwork.com/journals/jama/fullarticle/2819296
^a Second and third generation oral antihistamines are less sedating and have fewer anticholinergic effects than first generation antihistamines. Among second and third generation agents, fexofenadine is among the least sedating even at high doses.
^b Counsel patients to follow directions on over-the-counter products including amount and duration of use. Community and other pharmacists can be valuable resources for information and counseling.

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Anxiety symptoms
Relevant AGS Beers Criteria^® medications	First-generation antihistamines
Recommendation	Avoid
Alternatives to consider (recommendations)	Clarify whether symptoms are related to an underlying psychiatric disorder, e.g., Generalized Anxiety Disorder, Panic Disorder, PTSD. Some anxiety symptoms may be an appropriate response to life events and can be addressed through non-pharmacologic supports until symptoms improve. Evaluate other conditions that may be contributing to anxiety, such as comorbid medical disorders, mental health disorders (e.g., major depression), substance misuse, and medications. This is of special importance for new-onset anxiety, as late-life onset of anxiety disorders is uncommon. Non-pharmacologic interventions are first-line therapy for many psychiatric disorders that present with anxiety. Tailor such treatment to the specific diagnosis; examples of options include individual or group psychotherapy approaches including cognitive behavioral therapy, acceptance and commitment therapy, mindfulness-based stress reduction, and imagery rehearsal therapy (for nightmares). If pharmacologic therapy is indicated, consider agents with a safer adverse effect profile for older adults, including the following. Note that the AGS Beers Criteria^® cautions use of SSRIs and SNRIs in older adults with a history of falls, due to increased fall risk:^j Generalized Anxiety Disorder: escitalopram, sertraline, venlafaxine, DULoxetine, busPIRone, pregabalin^h Panic Disorder: sertraline, escitalopram, venlafaxine Social Anxiety Disorder: escitalopram, sertraline, venlafaxine (also: beta-blocker, e.g. propranolol, for performance-only anxiety) PTSD, global symptoms: sertraline, venlafaxine PTSD, nightmares: prazosin
Resources for patients and caregivers	Brochure on why and how to stop anti-anxiety medications (EMPOWER) https://www.deprescribingnetwork.ca/patient-handouts Information and resources on anxiety (ADAA) https://adaa.org/ Information and resources on PTSD (VA) https://www.ptsd.va.gov/index.asp Self-help books https://www.abct.org/self-help-book-recommendations/
Resources for clinicians	Algorithm for deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf Other resources on deprescribing benzodiazepines (deprescribing.org)</span https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Detailed information on tapering benzodiazepines (Ashton) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ Information and resources on PTSD (VA) https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp
^h Gabapentinoids (gabapentin, pregabalin) should not be used concurrently with opioids due to increased risk of severe adverse events, as noted in the AGS Beers Criteria^®.
^j Among the medications within each disorder listed below, the following are approved by FDA: Generalized anxiety disorder — escitalopram, venlafaxine, duloxetine, buspirone; Panic disorder — venlafaxine; Social anxiety disorder — sertraline, venlafaxine; PTSD (global symptoms) — sertraline, venlafaxine. For management of generalized anxiety disorder, buspirone and pregabalin can be used as monotherapy or as an augmentation agent.

Tussionex PennKinetic - see

Tylenol #3 - see acetaminophen-codeine

Tylox - see acetaminophen-oxyCODONE

U Beers Links

Ultracet - see acetaminophen-traMADol

Ultram - see traMADol

Unisom - see doxylamine

Uroxatral - see alfuzosin

V Beers Links

Valium - see diazePAM

Versed - see midazolam

Vicodin - see acetaminophen-HYDROcodone

Vistaril - see hydrOXYzine

Vivelle-Dot - see estradiol

Voltaren - see diclofenac

Vraylar - see cariprazine

W Beers Links

Beers Criteriawarfarin (Coumadin, Jantoven)

Cardiovascular conditions and anticoagulation in older adults. (Table 2) ⇒ Atrial fibrillation/flutter and venous thromboembolism (anticoagulation)
Relevant AGS Beers Criteria^® medications	warfarin
Recommendation	Avoid as initial therapy for non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) unless alternatives are contraindicated or there are substantial barriers to using alternatives. For patients using warfarin chronically, may be reasonable to continue depending on circumstances
Alternatives to consider (recommendations)	Consider other DOACs (e.g., apixaban, edoxaban). Pay attention to indication-specific dosing of DOAC For most people with AF, full dose is preferred. Reduced doses are indicated in renal dysfunction and select other situations. For long-term treatment of VTE, guidelines suggest reducing dose of certain agents after 6 months (e.g., for apixaban, reduce dose to 2.5 mg twice daily after 6 months). In patients with NVAF at moderate to high risk of stroke and high risk of major bleeding with oral anticoagulants, consider non-pharmacologic alternatives, e.g., percutaneous left atrial appendage occlusion and surgical left atrial appendage ligation or removal.
Resources for patients and caregivers	Information and resources on atrial fibrillation (AHA) https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
Resources for clinicians	Flow chart of antithrombotic options in atrial fibrillation, 2023 ACC/AHA/ACCP/HRS guideline — see Figure 10 (ACC/AHA/ACCP/HRS): https://www.ahajournals.org/doi/10.1161/CIR.0000000000001193#F10

X Beers Links

Xanax - see ALPRAZolam

Xarelto - see rivaroxaban

Xtampza - see oxyCODONE

Z Beers Links

Beers Criteriazaleplon (Sonata)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Z-drugs
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Zanaflex - see tiZANidine

Zegerid - see omeprazole-sodium bicarbonate

Beers Criteriaziprasidone (Geodon)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Delirium
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	First-line management includes multicomponent nonpharmacological interventions such as the AGS CoCare: HELP Program. No pharmacologic treatment is recommended as a routine response to delirium in all populations. Antipsychotics or sedatives may be considered for short term use (e.g., hours to days) to address severe behavioral disturbances that pose a substantial risk to patients or staff and are refractory to non-pharmacologic interventions. Such use should be accompanied by discussion and documentation of risk and prevention of prolonged use.^k
Resources for patients and caregivers	Information and resources on delirium (DeliriumCentral.org) https://www.deliriumcentral.org/family-members-patients/ Guidance for families (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/
Resources for clinicians	Delirium prevention, assessment, and management tools (ADS) https://americandeliriumsociety.org/patients-families/family-guidance/ AGS CoCare: HELP program (AGS; requires paid subscription) https://www.americangeriatrics.org/programs/ags-cocarer Delirium management algorithms (International Delphi panel) htps://pmc.ncbi.nlm.nih.gov/articles/instance/10861222/bin/NIHMS1959412-supplement-Additional_File_2.pdf Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^k When pharmacologic strategies are used, where feasible, minimize use of other high-risk medications identified in the AGS Beers Criteria^® (see European Society of Anaesthesiology and Intensive Care Medicine 2024 Guidelines for Postoperative Delirium).

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Agitation and/or aggression in people with dementia
Relevant AGS Beers Criteria^® medications	Antipsychotics
Recommendation	Avoid except in FDA-approved indications (e.g., schizophrenia, adjunctive treatment of major depression) or short-term use as an antiemetic
Alternatives to consider (recommendations)	Evaluate and address potential contributing factors to agitation and/or aggression in people with dementia, including clinical conditions (e.g., pain, constipation, urinary retention, acute illness), medication adverse effects, and environmental stressors. Non-pharmacological strategies are first line and may need to be modified as the disease progresses and symptoms change. If Non-pharmacologic interventions fail to adequately manage agitation and/or aggression, pharmacologic interventions such as antipsychotics may be considered when the patient is at risk of harming themselves or others and risks are discussed with surrogate decision-makers. If started, use the lowest possible dose for the least amount of time, combine with non-pharmacological strategies, and perform ongoing assessment of clinical effects and risk/benefit ratio to minimize duration of use.^l Similar principles of evaluating potential contributors and attempting non- pharmacologic management strategies apply for other types of behavioral and psychological symptoms of dementia (e.g., apathy, anxiety, delusions).
Resources for patients and caregivers	Information for caregivers about managing BPSD (Alzheimer's Association) https://www.alz.org/help-support/caregiving/stages-behaviors
Resources for clinicians	Resources on dementia and BPSD (NIA) https://www.nia.nih.gov/health/health-care-professionals-information/alzheimers-and-related-dementias-resources# tools Guidance on deprescribing antipsychotics (deprescribing.org) https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
^l brexpiprazole is the only atypical antipsychotic that is FDA-approved for agitation associated with Alzheimer's dementia, and pimavanserin is the only atypical antipsychotic that is FDA-approved for psychosis associated with Parkinson's disease. However, like other antipsychotics, these medications carry a boxed warning for increased mortality risk in older adults with dementia. Therefore, all antipsychotic medications should be limited to situations where the patient is at risk of harming themselves or others, used at the lowest possible dose for the least amount of time, and should be combined with non-pharmacological strategies.

Beers Criteriazolpidem (Ambien)

Central nervous system and neuropsychiatric conditions in older adults. (Table 3) ⇒ Insomnia
Relevant AGS Beers Criteria^® medications	Z-drugs
Recommendation	Avoid
Alternatives to consider (recommendations)	Assess for health conditions and other factors contributing to sleep disruption (e.g., sleep environment, pain, medications or substances which interfere with sleep, obstructive sleep apnea). Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia in older adults. CBT-I may be delivered by a trained provider or via other formats (e.g., Digital CBT-I; see Resources column); evidence supports both. Core components of CBT-I include sleep restriction, stimulus control therapy, cognitive therapy, relaxation, and sleep hygiene. However, sleep hygiene alone is not effective for chronic insomnia. If CBT-I alone is unsuccessful, use shared decision-making when considering adding short-term pharmacological therapy. Medications which may be safer (but not completely safe) and have evidence of effectiveness for insomnia in older adults include low-dose doxepin (up to 6 mg), dual orexin receptor antagonists (e.g., daridorexant, lemborexant, suvorexant), and ramelteon, all for short-term use. However, formal, evidence-based guidelines addressing efficacy and/or safety of these medications in older adults are not available. There is insufficient evidence to recommend traZODone, mirtazapine, melatonin, and other medications commonly prescribed for older adults with insomnia disorder. Guidelines do not recommend these drugs for insomnia disorder in adults of any age.
Resources for patients and caregivers	Digital CBT-I tools. Examples include: Insomnia Coach Digital CBT-I app (VA), https://mobile.va.gov/app/insomnia-coach SleepEZ Digital CBT-I (VA), https://veterantraining.va.gov/insomnia/ Curated list of Digital CBT-I and other resources (Sleepwell), https://mysleepwell.ca/cbti/sleepwell-recommends/ Sleep hygiene recommendations (as a component of CBT-I) (AASM) https://sleepeducation.org/healthy-sleep/healthy-sleep-habits/ Self-help books for insomnia (see footnote)ⁱ
Resources for clinicians	Insomnia toolkit for clinicians (AASM) https://aasm.org/clinical-resources/insomnia-toolkit/ Sleep education resources(AASM) https://sleepeducation.org/resources-for-health-care-professionals/ CBT-I provider training online course (CBTIweb) https://cbtiweb.org/
ⁱ Books to recommend to patients and caregivers include: End the Insomnia Struggle (Colleen Ehrnstrom and Alisha Brosse); Goodnight Mind: Turn Off Your Noisy Thoughts and Get a Good Night's Sleep (Colleen Carney and Rachel Manber); Hello Sleep (Jade Wu); No More Sleepless Nights (Pater Hauri and Shirley Linde); Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach (Jack Edinger and Colleen Carney); Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic Pain (Colleen Carney and Rachel Manber); Say Good Night to Insomnia (Gregg Jacobs); The Insomnia Workbook (Stephanie Silberman); The One-Week Insomnia Cure: Learn to Solve Your Sleep Problems (Jason Ellis).

Zymine - see triprolidine

ZyPREXA - see OLANZapine

Abbreviations

AAFP = American Association of Family Physicians; AAN = American Academy of Neurology; AASM = American Academy of Sleep Medicine; ABCT = Association for Behavioral and Cognitive Therapies; ACC = American College of Cardiology; ACCP = American College of Clinical Pharmacy; ACEI = angiotensin converting enzyme inhibitor; ACG = American College of Gastroenterology; ADAA = Anxiety and Depression Association of America; ADS = American Delirium Society; AF = atrial fibrillation; AGA = American Gastroenterological Association; AGS = American Geriatrics Society; AHA = American Heart Association; APHPT = Academy of Pelvic Health Physical Therapy; APTA = American Physical Therapy Association; ARB = angiotensin receptor blocker; AUA = American Urological Association; AUGS = American Urogynecologic Society; BPH = benign prostatic hyperplasia; BPSD = behavioral and psychological symptoms of dementia; BSACI = British Society for Allergy and Clinical Immunology; CAD = coronary artery disease; CBT-I = cognitive behavioral therapy for insomnia; CKD = chronic kidney disease; CNS = central nervous system; CRT = cardiac resynchronization therapy; CUA = Canadian Urological Association; DASH = Dietary Approaches to Stop Hypertension; DOAC = direct-acting oral anticoagulant; DoD = US Department of Defense; DPP4 = dipeptidyl peptidase-4; EAU = European Association of urology; ER = extended release; FODMAP = Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (carbohydrates that are more difficult to digest); GDMT = guideline-directed medical therapy; GERD = gastroesophageal reflux disease; GLP1 = glucagon-like peptide 1; GSM = genitourinary syndrome of menopause; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HFSA = Heart Failure Society of America; HRS = Heart Rhythm Society; HTN = hypertension;ICS = International Continence Society; IUS = International Urogynecological Society; LV = left ventricular; LVEF = left ventricular ejection fraction; LVH = left ventricular hypertrophy; MI = myocardial infarction; MAO???B = Monoamine Oxidase B; MRA = mineralocorticoid receptor antagonist; NAMI = National Alliance on Mental Illness; NCOA = National Council on Aging; NIA = National Institute on Aging; NOTD = National Organization for Tardive Dyskinesia; NSAID = non-steroidal anti-inflammatory drug; NVAF = non-valvular atrial fibrillation; NYHA = New York Heart Association; PTSD = post-traumatic stress disorder; SGLT2 = sodium glucose co-transporter-2; SGLT2i = sodium glucose co-transporter-2 inhibitor; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; SUFU = Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction; TCA = tricyclic antidepressant; UTI = urinary tract infection; VA = US Department of Veterans Affairs.; VTE = venous thromboembolism; Z-drugs = non-benzodiazepine benzodiazepine receptor agonists (zolpidem, zaleplon, zopiclone, eszopiclone).

Reference

American Geriatrics Society Beers Criteria^® Alternatives Panel, M. A. Steinman, T. P. Semla, K. M. Akgün, et al., "Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria^®", Journal of the American Geriatrics Society 73, no. 9 (2025): 2657–2677, https://doi.org/10.1111/jgs.19500.

Pharmacy Contact Info:

Main Inpatient Pharmacy: ext 4599, 3503
Fax: 704-878-7283

Director of Pharmacy - Randi Raynor, PharmD: ext 4501
Clinical Coordinator - Laura Rollings, PharmD: ext 4597
Pharmacy Informaticist - Stephen Pringle, PharmD: ext 7645
Pharmacy Technician Supervisor - Amy Wingler, CPhT: ext 7385
Pharmacy Automation Coordinator (Omnicell) - Melissa Fulford, CPhT: ext 3556

This site is intended for the staff of Iredell Health System. While others may view accessible pages, Iredell Health System makes no warranty, express or implied, as to the use of this information outside of Iredell Health System. The content of this policy and procedure document serves as guidance to the delivery of quality patient care. Care providers are expected to exercise critical thinking and situational awareness skills, and in specific situations to take such action as is necessary for the delivery of quality patient care.