The New Playbook for Ditching Dangerous Senior Meds
A new tool presented at the American Geriatrics Society (AGS) 2025 Annual Scientific Meeting may give clinicians practical and safer alternatives to risky medications for patients.
Developed as a companion to the widely cited AGS Beers Criteria, the new Alternatives List was unveiled by a panel of clinicians and researchers who spent months identifying and reviewing safer options for high-risk medications. The list has pharmacologic and nonpharmacologic approaches and is tailored to the realities of treating geriatric patients.
Originally updated in 2023, the AGS Beers Criteria outlines medications that may be inappropriate for use in older adults who are not receiving end-of-life care.
'The real goal is to help older adults feel better and function better while reducing the risk of medication harms,' said Michael Steinman, MD, geriatrician and professor of medicine at the University of California San Francisco, who led the development of the list.
Eight workgroups covered 21 conditions commonly linked to potentially inappropriate medications, such as insomnia, anxiety, and allergic rhinitis. Clinicians from a range of disciplines — pharmacy, nursing, psychology, physical therapy, and medicine — collaborated to ensure the recommendations were practical, evidence-informed, and clinically relevant.
Yet even assembling the list came with challenges.
'Treatments for common conditions are often not well-studied in older adults, and practice guidelines often give little information on how approaches to treating these conditions should be modified to meet the unique needs of older adults,' Steinman told Medscape Medical News .
Each entry on the list includes commonly used medications flagged in the Beers Criteria, safer nonpharmacologic and pharmacologic alternatives, and resources for clinicians and patients.
'We focused on what clinicians actually see and treat every day,' Steinman said. 'If someone's taking diphenhydramine for sleep or allergies, what should we be recommending instead? That's what this tool answers.'
During the panel, members of the AGS-convened work group shared insights from the development process.
Judith Beizer, PharmD , clinical professor of pharmacology at St. John's University College of Pharmacy and Health Sciences in New York City, highlighted treatment considerations for gastroesophageal reflux disease, a condition often treated with medications deemed high-risk for older adults.
'We know that proton pump inhibitors (PPI) are often continued far longer than necessary,' Beizer said.
Beizer presented a range of safer alternatives for long-term PPI use to treat gastroesophageal reflux disease, emphasizing first-line nonpharmacologic strategies such as avoiding trigger foods, elevating the head of the bed, and modifying meal timing.
When pharmacologic intervention is necessary, Beizer recommended transitioning to H2 blockers like famotidine or using antacids with alginic acid while tapering patients off PPIs.
'It's not just about stopping the medication,' she said. 'It's about doing so thoughtfully and supporting the patient through the transition.'
The panel also addressed nocturia, another condition in older adults that is often treated with desmopressin, a drug the Beers Criteria advises avoiding due to the risk for hyponatremia.
Instead of using this drug, clinicians should conduct a comprehensive review of underlying causes of nocturia using the SCREeN approach, which examines sleep disorders, cardiovascular health, renal function, endocrine issues, neurologic conditions, and medication side effects, Beizer said.
'Nocturia is a symptom, not a diagnosis,' she said. 'We have to explore the root cause before prescribing.'
Alternative approaches to treating nocturia include bladder retraining, fluid management, and, in certain cases, pharmacologic agents such as beta-3 agonists or, for men with benign prostatic hyperplasia, alpha blockers and 5-alpha reductase inhibitors. For women, Beizer noted that vaginal estrogen could be beneficial.
Steinman said that the tool is not just about safer prescribing but about creating a more individualized approach to care.
'Deprescribing is not just about stopping a medication — it's about communication and trust,' he said. 'Sometimes a potentially inappropriate medication is still the right choice, but that decision should come after weighing risks, exploring safer alternatives, and engaging in shared decision-making.'
But implementing alternatives — especially nondrug strategies — can be difficult in time-constrained primary care settings. Steinman acknowledged this reality but offered solutions.
'The list is designed to be easy to use in busy practice settings,' he said.
In some cases, nonpharmacologic strategies can take longer to explain than simply writing a prescription, he said. But clinicians can hand patients off to nurses or other staff to offer more detailed explanations.
'Building buy-in takes time, but that time can be shared across multiple visits and supported by handouts or other team members,' he said.
Clinicians will soon be able to access the Alternatives List in an upcoming issue of the Journal of the American Geriatrics Society , GeriatricsCareOnline.org, and HealthinAgingOnline.org. The AGS Beers Criteria Alternatives List is still evolving, with plans to be updated as evidence grows, panelists said.
Steinman reported no relevant disclosures. Beizer reported serving as an editor for Wolters Kluwer.
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