Gerontology, Palliative Care & Prevention · Topic 2 of 13

Polypharmacy & the Beers Criteria

Geriatrics · prescribing in older adults

Polypharmacy & the Beers Criteria

Older adults on five or more drugs: suspect a drug for every new symptom, start low, check AGS Beers 2023, and deprescribe what no longer helps.

Key numbers

Beers: inappropriate drugs at 65 plusage ≥ 65

Polypharmacy: 5 or more medications≥ 5 drugs

Start low, go slowstart ⅓–½ usual dose

Avoid scheduled PPIs beyond 8 weeksPPI > 8 weeks

01 · What it isBeers: inappropriate drugs at 65 plus

The AGS Beers Criteria (2023 update) list potentially inappropriate medications for adults 65 and older in ambulatory, acute and institutional care — not hospice or end-of-life care — and support, not replace, clinical judgment.

02 · What it isPolypharmacy: 5 or more medications

Polypharmacy = regular use of 5 or more medications (hyperpolypharmacy = 10 or more); it raises the risk of adverse effects, interactions and nonadherence, and is linked to frailty, longer stays and mortality.

03 · The ruleNew symptom? Suspect a drug first

Treat any new symptom in an older adult as drug-related until proven otherwise to avoid a prescribing cascade — e.g., amlodipine edema treated with a diuretic, or cholinesterase-inhibitor incontinence treated with oxybutynin.

What it is

Core idea

More fat, less water: altered drug distributionWith age, more body fat prolongs lipophilic drugs (diazepam), less body water raises levels of water-soluble drugs (digoxin, aminoglycosides), and low albumin raises free phenytoin and warfarin.

Management

Orders

Start low, go slow must knowStart at the lowest dose — about one-third to one-half the usual adult dose for narrow-therapeutic-index drugs, frail patients or drugs that may worsen another condition — then titrate while watching for adverse effects.

Dose by estimated clearance, not creatinineRenal elimination falls with age while serum creatinine stays normal (less muscle): estimate creatinine clearance and adjust renally cleared drugs (DOACs, enoxaparin, digoxin, metformin); Beers Table 6 lists drugs to reduce or avoid by CrCl.

Avoid strongly anticholinergic drugsAvoid strongly anticholinergic drugs — first-generation antihistamines (diphenhydramine, hydroxyzine), TCAs such as amitriptyline, paroxetine, oxybutynin, benztropine — and minimize total anticholinergic burden: they cause delirium, falls, constipation and urinary retention.

Avoid benzodiazepines and Z-drugsAvoid benzodiazepines and Z-drugs (zolpidem, eszopiclone, zaleplon): they raise risk of cognitive impairment, delirium, falls, fractures and motor vehicle crashes (hospital sleep management in the Sleep Disturbance sheet).

No sliding-scale-only insulin; avoid sulfonylureasAvoid sliding-scale-only short- or rapid-acting insulin without basal insulin, and avoid sulfonylureas as first- or second-line or add-on therapy unless safer agents are not feasible — if used, prefer short-acting glipizide (hypoglycemia, CV events).

Prefer DOACs; avoid starting warfarinFor atrial fibrillation or VTE, avoid starting warfarin unless DOACs are contraindicated, avoid rivaroxaban for long-term treatment (more major and GI bleeding than apixaban), and use dabigatran with caution.

No new aspirin for primary preventionAvoid starting aspirin for primary prevention of cardiovascular disease in older adults and consider deprescribing it in those already taking it; aspirin remains indicated for secondary prevention.

Avoid scheduled PPIs beyond 8 weeksAvoid scheduled proton-pump inhibitors beyond 8 weeks (C. difficile, pneumonia, bone loss and fractures) unless high risk — chronic NSAID or corticosteroid use, erosive esophagitis, Barrett esophagus or a failed taper.

Avoid chronic NSAIDs, indomethacin and ketorolacAvoid chronic oral NSAIDs unless alternatives fail and a PPI or misoprostol is given, avoid combining them with steroids, anticoagulants or antiplatelets, and avoid indomethacin and ketorolac entirely (GI bleeding, AKI).

Avoid 3 or more CNS-active drugsAvoid combining 3 or more CNS-active drugs (antiepileptics including gabapentinoids, antidepressants, antipsychotics, benzodiazepines, Z-drugs, opioids, skeletal muscle relaxants) because falls and fractures rise.

Antipsychotics only as a last resortAvoid antipsychotics for behavioral symptoms of dementia or delirium unless nonpharmacologic measures have failed and/or the patient threatens substantial harm; they raise stroke risk, cognitive decline and mortality in dementia.

Deprescribe; taper benzodiazepines graduallyReview the list regularly and stop drugs that are no longer needed or whose risk exceeds benefit; taper dependence-forming drugs such as benzodiazepines gradually, since abrupt stops can cause withdrawal seizures.

Reconcile at every transition of careReconcile medications at admission, transfer and discharge: hospital-only drugs (sedative-hypnotics, laxatives, PPIs) are often continued unnecessarily, and needed home drugs are unintentionally omitted.

Commonly confused

Tell apart

STOPP flags harms; START flags omissionsSTOPP/START (version 3) complements Beers: STOPP identifies potentially inappropriate medications and START identifies omitted beneficial drugs — underprescribing also harms older adults.

More detail

Reference

Show 6 reference facts

For drugs whose hepatic (CYP450) metabolism falls with age, clearance typically drops 30–40%; phase I oxidation is affected more than phase II conjugation, so phase II–metabolized drugs are preferred when feasible.

Nitrofurantoin: avoid with CrCl < 30 mL/min or for long-term suppression (pulmonary toxicity, hepatotoxicity, neuropathy).

Hospitalization for adverse drug effects is 4–7 times more common in older adults, most often from anticoagulants, antibiotics, diabetes drugs, opioids and antipsychotics.

First-pass metabolism falls about 1% per year after age 40, so oral nitrates, propranolol, verapamil and nifedipine reach higher levels; drugs reach steady state only after 5–6 half-lives, delaying toxicity.

Limit citalopram to 20 mg/day and escitalopram to 10 mg/day in older adults because of QT prolongation.

Use prasugrel and ticagrelor with caution at 75 or older (more major bleeding than clopidogrel); if prasugrel is used, consider 5 mg.

Pearl

Before adding a drug for a new symptom, ask which drug caused it.

Sources · 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71:2052–2081 · Merck Manual Professional — Overview of Pharmacologic Therapy in Older Adults · Merck Manual Professional — Pharmacokinetics in Older Adults · Merck Manual Professional — Medication-Related Problems in Older Adults · Merck Manual Professional — Drug Categories of Concern in Older Adults · The hidden risks of polypharmacy: potentially inappropriate prescribing with STOPP/START criteria version 3 — a cross-sectional study. PLoS One 2025 · FDA Drug Safety Communication (Sept 2020) — Boxed Warning updated for the benzodiazepine class: dependence and withdrawal; use a gradual taper · Merck Manual Professional — Hospital Care and Older Adults (adverse drug effects) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).