New update to the 2023 AGS Beers Criteria highlights safer pharmacologic options for older adults

The American Geriatrics Society (AGS) has released a landmark update to its list of alternatives to medications listed in the 2023 AGS Beers Criteria^® - the most widely adopted guidelines to help clinicians identify potentially inappropriate medications for older adults. This new effort delivers not only a comprehensive suite of safer pharmacologic options, but also a strong emphasis on effective non-pharmacologic treatments for common conditions impacting frail and aging populations.

The AGS panel is comprised of 19 national experts from 14 states, including Noll Campbell, PharmD, M.S., of the Regenstrief Institute and Purdue University College of Pharmacy. Dr. Campbell is the only expert from Indiana. The panel is a multidisciplinary AGS panel of physicians, pharmacists, nurses, psychologists and physical therapists that systematically reviewed and curated alternatives for some of the most challenging prescribing scenarios faced in geriatric practice.

The AGS Beers Criteria^® identifies medications that are more likely to harm than help older adults due to side effects such as sedation, falls, delirium and interactions with other conditions. Recommendations are structured for rapid use in clinical practice, emphasizing clear tables referenced by symptom or diagnosis and supplemented by links to reliable resources for both health professionals and the public.

In practice, we see the risks of potentially inappropriate medications play out in the emergency rooms, clinics, nursing homes or when families are struggling at home. Our aim with this document is to provide support beyond saying 'don't prescribe,' by offering clinicians, patients and families with a list of credible, actionable alternatives - whether it's a safer medicine or a proven lifestyle approach."

Dr. Noll Campbell, PharmD, M.S., of the Regenstrief Institute and Purdue University College of Pharmacy

A novel feature is the inclusion of patient and caregiver-friendly materials, from decision aids and handouts on deprescribing to support for making lifestyle changes - reflecting a modern, team-based and patient-centered approach to medication safety for older adults. All of these resources are generated and hosted by the American Geriatrics Society.

Rigorous, interprofessional approach

Panelists were assigned to eight topic-specific workgroups covering insomnia and anxiety; allergy and pruritus (itchy skin); cardiovascular and anticoagulation therapies; pain; delirium and dementia; diabetes; gastrointestinal syndromes; and genitourinary syndromes.

Each group sought and reviewed high-quality guidelines, best-practice documents and systematic reviews most applicable to common geriatric scenarios. These resources were then distilled into tables of alternatives for 21 common conditions. The panel prioritized U.S.-based guidance but included international sources when more recent or rigorous. Notably, selections focused on both medications and non-pharmacologic alternatives - such as cognitive behavioral therapy for insomnia, exercise and physical therapy for Parkinson's disease, lifestyle changes for constipation and heartburn, and behavioral or dietary interventions for urinary symptoms.

Core principles for safer prescribing

To guide clinicians, the panel offers five key principles.

• Stopping a potentially inappropriate drug is not the ultimate goal; the priority is to help patients feel better and reduce the risk of harm.
• Non-drug (behavioral and lifestyle) strategies should often be first line.
• Always seek the underlying cause of symptoms before prescribing.
• Avoiding a risky drug is important, but clinical judgment and individualization remain critical.
• Use the many available resources for patients, caregivers and clinicians to support implementation and deprescribing.

Balancing real-world practice, research gaps and patient and caregiver needs

The panel acknowledges that guidelines and systematic reviews often lack specificity for the oldest or most complex patients, and that real-life symptoms (e.g., insomnia, involuntary weight loss) are not always tied to a single clear diagnosis. As described in the article's discussion, recommendations remain flexible, encouraging clinicians to tailor approaches according to each individual's clinical status, functional goals and life circumstances.

"We recognize that simply removing a medication may not be enough, especially if symptoms return or worsen," said Dr. Campbell. "Our intent is to provide practical, prioritized alternatives that can be started or considered right away, so that care is both safer and responsive to what matters most to older adults and their caregivers. We want clinicians to have real tools, not just warnings."

Authors are from the following states: Alabama, Arkansas, California, Colorado, Connecticut, Illinois, Indiana, Iowa, Maine, Michigan, Missouri, New York, Texas and Utah.