Intro: A Round of Beers

The 2023 Beers Criteria flags potentially inappropriate medications in adults 65 and older, but it was built largely for chronic prescribing rather than single-dose emergency care. In the ED, the value is less in blanket drug bans than in spotting drug-disease interactions, renal pitfalls, and safer alternatives for older adults.

Beers Criteria in Emergency Care

• Core purpose and scope: The Beers Criteria is a six-table medication safety framework for adults 65 and older across ambulatory, acute, and institutional settings, excluding hospice and end-of-life care.
• Chronic care versus ED reality: Most recommendations were written by internists for longer-term therapy, so direct application to one-time ED treatment can misfire when acute indications outweigh baseline medication risk.
• Highest-yield ED tables: The drug-drug, drug-disease, anticholinergic, and renal adjustment tables are the most practical bedside pieces because they flag interactions and context that often matter immediately.
• Named medication examples: Amiodarone appears as potentially inappropriate first-line therapy for atrial fibrillation, and TMP-SMX gets a caution flag with ACE inhibitors, ARBs, or reduced creatinine clearance.
• Safer alternative signal: The 2023 update favors apixaban over rivaroxaban when a DOAC is needed because bleeding risk is lower. We get into how to use that kind of preference in the episode.

Limits of Blanket Medication Alerts

• Nuance over pop-up medicine: A Beers alert is not a stop sign; the real question is whether the risk comes from the drug itself, the renal function, the comorbidity, or the combination.
• Nitrofurantoin renal exception: Nitrofurantoin can be a reasonable choice for uncomplicated UTI when renal function is adequate, illustrating how a generic potentially inappropriate label can push clinicians toward worse options.
• Appropriate ED exceptions: Aspirin, nifedipine, diphenhydramine, and benzodiazepines may all trigger concern in older adults, yet each has legitimate emergency indications when the immediate problem changes the risk-benefit balance.
• Alert fatigue consequences: Excess warnings dilute the important ones, driving alarm fatigue, frustration, burnout, and the risk that clinicians ignore the alerts that truly signal harm.
• Smarter decision support: A better prescribing tool would integrate diagnosis, medication list, renal function, and comorbidities instead of firing generic warnings. We lay out why STOPP/START and newer AI-style tools may fit that role better in the chapter.

References:

1. By the 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(7):2052-2081.  PMID: 37139824