Allergy and pruritus, pain, diabetes mellitus, and weight loss in older adults. (Table 1)
Allergic rhinitis and associated symptoms (First-generation antihistamines)
| 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, 2nd or 3rd 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. |
Pruritus (First-generation antihistamines)
| 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 conditions
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 2nd or 3rd 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
• 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. |
Pain (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- Tricyclic antidepressant (TCAs)
- NSAIDs
- meperidine
- Skeletal muscle relaxants
- Combination of gabapentinoids with either opioids or benzodiazepines |
| Recommendation |
- TCAs: Avoid
- NSAIDs: 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)
- meperidine: Avoid
- Skeletal muscle relaxants: Avoidc
- Combination of gabapentinoids with opioids or benzodiazepines: 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
- Gabapentinoidsh
- 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
• 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®. |
Diabetes (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- Sliding scale insulin
- Sulfonylureas |
| Recommendation |
- Sliding scale insulin: Avoid
- Sulfonylureas: 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 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.
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
• 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 |
Weight Loss (involuntary or undesired) (megestrol)
| 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
• 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 |
|
Cardiovascular conditions and anticoagulation in older adults. (Table 2)
Atrial fibrillation/flutter and venous thromboembolism (anticoagulation) (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- warfarin
- rivaroxaban |
| Recommendation |
- warfarin: 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
- rivaroxaban: 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 DOACs
- 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
• 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 |
Atrial fibrillation/flutter (rate/rhythm control) (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- amiodarone
- dronedarone
- digoxin |
| Recommendation |
- amiodarone: Avoid as first-line treatment for AF unless patient has heart failure or substantial LVH
- dronedarone: Avoid in patients with permanent AF or severe or recently decompensated HF; use caution in patients with NYHA class I-II HFrEF
- digoxin: 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
• 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 |
Heart failure (digoxin)
| 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
• 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 |
Hypertension (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- Non-selective peripheral alpha-1 blockers (e.g., doxazosin, prazosin, terazosin)
- Central alpha-1 agonists including cloNIDine, guanFACINE, others
- Immediate-release NIFEdipine |
| Recommendation |
- Non-selective alpha-1 blockers: Avoid use as antihypertensive
- Central alpha-1 agonists: Avoid cloNIDine as first-line treatment for hypertension; Avoid other central alpha-agonists for the treatment of hypertension
- Immediate-release NIFEdipine: 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
• 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 |
|
Central nervous system and neuropsychiatric conditions in older adults. (Table 3)
Insomnia (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- Benzodiazepines
- Z-drugs
- First-generation antihistamines
- Tricyclic Antidepressants
- Barbiturates |
| Recommendation |
(all): 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
• 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). |
Anxiety symptoms (multiple meds: expand section to examine)
| Relevant AGS Beers Criteria® medications |
- Benzodiazepines
- First-generation antihistamines
- Tricyclic Antidepressants
- Barbiturates
- meprobamate |
| Recommendation |
(all): 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, pregabalinh
- 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/
• Algorithm for deprescribing benzodiazepines (deprescribing.org)
https://deprescribing.org/wp-content/uploads/2019/03/deprescribing_algorithms2019_BZRA_vf-locked.pdf
• Other resources on deprescribing benzodiazepines (deprescribing.org)
https://deprescribing.org/resources/deprescribing-guidelines-algorithms/
• Detailed information on tapering benzodiazepines (Ashton)
https://www.benzo.org.uk/manual/
• 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. |
Delirium (Antipsychotics)
Agitation and/or aggression in people with dementia (Antipsychotics)
| 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 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. |
Parkinson's disease (benztropine and trihexyphenidyl)
| 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
• 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. |
Tardive dyskinesia (benztropine and trihexyphenidyl)
| 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/
• Brief summary of guidelines for treatment of tardive syndromes (AAN)
https://www.aan.com/Guidelines/Home/GetGuidelineContent/613 |
|
Gastrointestinal conditions in older adults. (Table 4)
GERD and associated symptoms (Proton pump inhibitors)
| 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 (My GI Health)
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
• 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. |
Gastroparesis (chronic) and associated nausea (metoclopramide)
| 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
• Best practice advice for management of refractory gastroparesis (AGA)
https://www.sciencedirect.com/science/article/pii/S1542356521011514?via%3Dihub
• Gastroparesis guideline, ACG 2022 (ACG)
https://journals.lww.com/ajg/fulltext/2022/08000/acg_clinical_guideline__gastroparesis.15.aspx |
Intestinal cramping and diarrhea (GI antispasmodics)
Constipation (Mineral oil (oral))
|
Genitourinary conditions in older adults. (Table 5)
Nocturia and nocturnal polyuria (desmopressin)
| 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
• 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/ |
Genitourinary syndrome of menopause (GSM) including vasomotor symptoms (hot flashes), vulvovaginal atrophy, and urinary symptoms (Systemic estrogens)
| 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/moisturizersb
- 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/
• 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. |
Recurrent UTIs in Women (Systemic estrogens)
|
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