BCGP Study Guide: Understanding the Beers Criteria and Managing Polypharmacy in the Elderly for the Board Exam

BCGP Study Guide: Understanding the Beers Criteria and Managing Polypharmacy in the Elderly for the Board Exam

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The Beers Criteria and polypharmacy management sit at the heart of geriatric pharmacotherapy—and at the core of the BCGP exam. You’re tested not only on what drugs to avoid, but on the reasons behind those choices and how to build safer regimens. This guide gives you a high-yield, practical approach: the big patterns, the why behind each rule, and how to apply them to cases under exam conditions.

Why the Beers Criteria matters for the BCGP exam

The Beers Criteria is a consensus list of potentially inappropriate medications (PIMs) in older adults. It highlights drugs where risks often outweigh benefits in this population. The exam uses it because older adults have higher sensitivity to side effects—especially sedation, bleeding, orthostasis, cognitive decline, and kidney injury. If you can spot a PIM and swap it for a safer option, you reduce harm. The test expects that clinical reasoning.

Key point: Beers is a guide, not a ban list. You can override it when benefits clearly exceed risks, but you need a documented reason and a mitigation plan (monitoring, dose limits, or short duration).

How aging changes drug response

Age changes both pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body). These shifts explain why Beers exists.

  • Absorption: Little change for most drugs. But slowed GI motility and achlorhydria can alter onset (e.g., delayed effect with some oral meds).
  • Distribution: More body fat and less total body water means lipophilic drugs (e.g., benzodiazepines) have longer half-lives, and water-soluble drugs hit higher peaks.
  • Metabolism: Hepatic blood flow and some CYP activity decline. First-pass clearance drops. Sedatives and opioids can accumulate.
  • Elimination: Renal function falls with age. Many adverse events stem from unadjusted renally cleared drugs (e.g., gabapentinoids, DOACs, nitrofurantoin).
  • Pharmacodynamics: Older adults are more sensitive to CNS effects (delirium, falls) and orthostasis because of impaired baroreflexes and brain vulnerability.

Bottom line: Start low, go slow, and monitor closely. The risks you’re avoiding—falls, confusion, bleeding, AKI—are not abstract. They are predictable outcomes of these physiologic changes.

High-yield Beers Criteria categories to memorize

These classes are heavily tested. Know the mechanism of harm and the preferred alternatives.

  • Anticholinergics (strong): diphenhydramine, benztropine, amitriptyline, dicyclomine, oxybutynin IR.
    • Why: Block central muscarinic receptors → confusion, delirium; peripheral effects → constipation, urinary retention, dry mouth, blurry vision; increased falls.
    • Instead: For sleep, avoid meds; if needed, low-dose melatonin. For OAB, mirabegron or ER antimuscarinics with fewer CNS effects; minimize dose.
  • Benzodiazepines and Z-drugs: lorazepam, clonazepam, diazepam; zolpidem, eszopiclone, zaleplon.
    • Why: Sedation, ataxia, cognitive impairment; higher fracture and delirium risk; prolonged half-life with age.
    • Instead: CBT-I for insomnia; for anxiety, SSRI/SNRI (with careful monitoring) or buspirone.
  • Antipsychotics for dementia-related behaviors: risperidone, quetiapine, olanzapine, haloperidol.
    • Why: Increased stroke and mortality in dementia; sedation and orthostasis; anticholinergic load with some agents.
    • Use only if: Non-drug strategies fail and the patient is a danger to self/others. Use the lowest dose, shortest time, and attempt regular tapers.
  • TCAs (tertiary) and strong SNRIs for pain/depression: amitriptyline, imipramine; caution with venlafaxine/duloxetine in falls risk.
    • Why: Anticholinergic and alpha-1 blockade → orthostasis, falls; conduction effects.
    • Instead: Nortriptyline (if TCA needed) at low dose, or duloxetine with fall monitoring; consider topical agents.
  • NSAIDs (chronic use): ibuprofen, naproxen, diclofenac; also COX-2 inhibitors.
    • Why: GI bleeding, kidney injury, fluid retention; worsen hypertension and heart failure.
    • Instead: Acetaminophen, topical NSAIDs, non-drug options; if oral NSAID needed, use lowest dose, shortest duration, plus GI protection when indicated.
  • PPIs (beyond 8 weeks, without a strong indication): omeprazole, pantoprazole.
    • Why: Bone loss, fractures, C. difficile, hypomagnesemia with chronic use.
    • Limit: Use for clear indications (e.g., erosive esophagitis, Barrett’s). Reassess and step down when possible.
  • Diabetes high-risk choices: Sliding-scale insulin alone; long-acting sulfonylureas (glyburide; caution with glimepiride).
    • Why: Unpredictable glucose swings and prolonged hypoglycemia due to reduced clearance.
    • Instead: Metformin if renal function allows; DPP-4 inhibitors; SGLT2 inhibitors with attention to volume status; basal insulin if needed with careful titration.
  • Skeletal muscle relaxants: cyclobenzaprine, carisoprodol, methocarbamol.
    • Why: Anticholinergic effects, sedation; minimal evidence for benefit in chronic use.
    • Instead: Physical therapy, heat/ice, topical analgesics.
  • Androgens and megestrol: testosterone (without confirmed hypogonadism), megestrol.
    • Why: Fluid retention, thrombosis, limited functional benefit; megestrol raises mortality and offers little sustained weight gain.
  • Nitrofurantoin (with low renal function or long-term prophylaxis):
    • Why: Ineffective at low urinary concentrations and increased pulmonary/hepatic toxicity; avoid when CrCl < 30 mL/min and for chronic suppression.
  • Alpha-1 blockers for hypertension: doxazosin, terazosin.
    • Why: Orthostatic hypotension, syncope; falls.
    • Instead: Thiazide diuretics, ACE inhibitors/ARBs, or dihydropyridine CCBs based on comorbidities.
  • Systemic estrogens (oral/transdermal):
    • Why: Risk of VTE, stroke, and certain cancers; limited benefits in older adults.
    • Exception: Low-dose vaginal estrogen is acceptable for genitourinary syndrome of menopause.

Drug–disease interactions you must recognize

Clinical context matters. The same drug can be acceptable in one patient and dangerous in another.

  • Dementia or cognitive impairment: Avoid anticholinergics, benzodiazepines, and Z-drugs. They worsen confusion and functional status.
  • Delirium (current or history): Avoid sedatives and anticholinergics; limit antipsychotics to severe agitation threatening safety.
  • History of falls/fractures: Avoid benzodiazepines, Z-drugs, antipsychotics, TCAs, opioids, and strong SNRIs/SSRIs unless benefits clearly outweigh risks.
  • Heart failure: Avoid NSAIDs (including COX-2), non-dihydropyridine CCBs in reduced EF, and TZDs due to fluid retention.
  • Parkinson disease: Avoid most antipsychotics; if needed, prefer quetiapine, clozapine, or pimavanserin because of lower motor symptom worsening.
  • Peptic ulcer disease or high GI bleed risk: Avoid NSAIDs; if unavoidable, co-prescribe a PPI and choose the lowest effective dose.
  • Chronic constipation: Avoid anticholinergics and opioids when possible; they worsen motility.
  • Urinary retention/BPH: Avoid strong anticholinergics that can precipitate retention.
  • Chronic kidney disease: Avoid or adjust nephrotoxic drugs (e.g., NSAIDs) and renally cleared meds according to creatinine clearance.

Dangerous drug–drug combinations and anticholinergic burden

Beers warns against additive harm. The exam likes these patterns:

  • Opioids + benzodiazepines or gabapentinoids: Respiratory depression and sedation → high overdose and fall risk.
  • Two or more strong anticholinergics: Delirium risk rises sharply with cumulative burden. Track the total, not just single agents.
  • Three or more CNS-active drugs: Any combo (e.g., antidepressant + antipsychotic + benzodiazepine) increases falls and confusion.
  • Warfarin + strong inhibitors (e.g., TMP/SMX, amiodarone): Bleeding risk spikes; require close INR checks or alternative choices.
  • Serotonergic stacks: Tramadol, linezolid, or triptans added to SSRIs/SNRIs can trigger serotonin toxicity. Watch for agitation, tremor, hyperreflexia.
  • QT-prolonging combinations: Additive effects with antipsychotics, macrolides, some antiarrhythmics. Risk factors include age, electrolytes, and baseline QTc.

Renal and hepatic dosing essentials

Most medication harm in older adults can be prevented with correct dosing and monitoring.

  • Estimate renal function with Cockcroft–Gault for drug dosing. Do not “round” serum creatinine to 1.0 mg/dL; it underestimates clearance and leads to underdosing or errors.
  • Weight in Cockcroft–Gault: Use actual body weight; consider adjusted weight if markedly obese and ideal body weight if underweight. Be consistent and justify your method.
  • Renal red flags: Gabapentin/pregabalin (sedation, falls), DOACs (bleeding), metformin (lactic acidosis in severe CKD), nitrofurantoin (ineffective/toxic at low CrCl).
  • Hepatic impairment: Reduce or avoid drugs with high first-pass metabolism and narrow therapeutic windows (e.g., many benzodiazepines, opioids). Monitor for encephalopathy with CNS-active meds.

A practical workflow for polypharmacy management

Use a reproducible process. The exam rewards clear, stepwise reasoning.

  • 1. Define goals of care: Life expectancy, function, and patient priorities. Time-to-benefit matters—avoid preventives that outlast expected benefit window.
  • 2. Compile the full medication list: Include OTCs, herbals, PRNs, patches, inhalers, injectables.
  • 3. Reconcile each drug: Indication, dose, duration, duplication, interactions, renal/hepatic fit, affordability, and adherence.
  • 4. Screen with tools: Beers Criteria, STOPP/START, and anticholinergic burden scales to flag risks and omissions.
  • 5. Prioritize problems: Target meds with high harm and low benefit first (e.g., benzo + opioid, strong anticholinergics, redundant PPIs).
  • 6. Plan deprescribing or optimization: Choose substitutions, dose reductions, or discontinuations with monitoring and taper plans.
  • 7. Educate and document: Explain the why; schedule follow-ups; record the plan and expected outcomes.

Deprescribing tactics and taper examples

Stopping the wrong way causes withdrawal, rebound, and mistrust. Show you can taper safely.

  • Benzodiazepines: Reduce total daily dose by 10–25% every 1–2 weeks; slower if long-term use. Switch to a longer-acting agent only if needed for a smoother taper. Add CBT-I and non-drug strategies.
  • PPIs: If no ongoing indication, step down: reduce dose, switch to every-other-day, then stop; use H2 blockers or antacids PRN to manage rebound acid hypersecretion.
  • Opioids: Typical taper 10% per week; slower for long-term high doses. Add non-opioid analgesics and non-drug therapies. Watch for withdrawal and mood changes.
  • Antipsychotics for BPSD: If no benefit in 4 weeks, taper off. If beneficial, reassess every 3 months and attempt a gradual dose reduction.
  • Gabapentinoids: Taper over 1–2 weeks to avoid withdrawal symptoms (anxiety, insomnia, sweating).
  • Beta-blockers and clonidine: Taper to prevent rebound tachycardia or hypertension.

Reducing falls, delirium, and cognitive harm

Falls and delirium are common endpoints in case questions. Your goal is to identify and remove contributors.

  • Falls: Review meds that lower BP or cognition: benzodiazepines, Z-drugs, antipsychotics, TCAs, opioids, alpha-1 blockers, high-dose diuretics, and polypharmacy itself.
  • Orthostatic hypotension: Measure lying/standing vitals. Lower doses, change timing, switch agents (e.g., from doxazosin to an ACE inhibitor), and ensure hydration.
  • Delirium prevention: Minimize psychoactives and anticholinergics; treat pain and constipation; promote sleep hygiene; maintain vision/hearing aids.
  • Cognition: Cut anticholinergic load, avoid sedatives, and simplify regimens. For dementia behaviors, prioritize non-drug approaches (structure, reassurance, environment).

Case-style exam pearls

  • Insomnia in an 82-year-old on lorazepam PRN and diphenhydramine: Both increase confusion and falls. Plan: taper lorazepam, stop diphenhydramine, teach sleep hygiene, consider melatonin 1–3 mg.
  • Worsening edema and dyspnea in HF on ibuprofen: NSAIDs cause sodium/water retention and blunt diuretics. Stop NSAID, use acetaminophen or topical NSAID, and reassess diuretics.
  • New falls in a patient on sertraline, trazodone HS, and oxycodone: Three CNS-active drugs. Reduce sedative burden: taper trazodone, optimize pain with non-opioids, consider PT.
  • Recurrent UTIs with CrCl 25 mL/min on nitrofurantoin prophylaxis: Avoid due to poor efficacy and toxicity risk. Stop; consider alternative prophylaxis strategies and non-drug measures.
  • Agitation in dementia treated with risperidone 1 mg BID for 6 months: Reassess need. Attempt dose reduction; emphasize non-pharm strategies. If continued, use lowest dose and document risk–benefit.
  • Type 2 diabetes on glyburide with A1c 6.6% and falls: Overtreated and hypoglycemia risk. Stop glyburide; set a higher A1c goal (e.g., 7.5–8.0%) based on health status; consider metformin or DPP-4 inhibitor if needed.

Documentation, patient talk, and shared decisions

Your plan is safer and more durable when patients understand it. This also appears on the exam as “next best step” questions.

  • Explain the why: “This medicine can cause confusion and falls. That’s why we’re lowering the dose.”
  • Offer options: “We can switch to a safer alternative or taper off and use non-drug tools.”
  • Set expectations: “You may have rebound symptoms for a week. We’ll manage them and check in.”
  • Coordinate with the team: Communicate changes to prescribers, caregivers, and pharmacists. Update the med list everywhere.

Rapid review checklist

  • Memorize high-risk classes: Anticholinergics, benzos/Z-drugs, antipsychotics in dementia, chronic NSAIDs, long-term PPIs, long-acting sulfonylureas, skeletal muscle relaxants, alpha-1 blockers for HTN, nitrofurantoin in low CrCl, systemic estrogens.
  • Connect drugs to diseases: Dementia/delirium → avoid sedatives/anticholinergics; HF → avoid NSAIDs; Parkinson → avoid most antipsychotics.
  • Spot bad combos: Opioid + benzo/gabapentinoid; multiple CNS-active drugs; stacking anticholinergics; warfarin + strong inhibitors.
  • Renal dosing: Use Cockcroft–Gault; do not round SCr; adjust or avoid renally cleared meds.
  • Deprescribing: Taper benzos, opioids, antipsychotics, clonidine, beta-blockers; step down PPIs; plan follow-up.
  • Falls plan: Reduce sedatives, manage orthostasis, encourage PT and home safety.
  • Pain plan: Prefer acetaminophen and topicals; avoid chronic NSAIDs; use duloxetine or gabapentinoids with renal dosing and monitoring.
  • Sleep plan: Behavioral first; avoid diphenhydramine and Z-drugs; consider melatonin.
  • Diabetes plan: Avoid sliding-scale insulin and glyburide; set realistic A1c targets based on frailty and comorbidity.

Master the patterns, not just the list. If you can explain why a drug is risky, you can adapt to any case, defend your choices, and pass the BCGP with confidence. More importantly, you’ll make safer, simpler plans that older adults can live with—and benefit from.

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