You are reviewing the chart of a 78-year-old female with generalized anxiety disorder, chronic low back pain, and osteoarthritis. Her current medication list includes acetaminophen, lisinopril, atorvastatin, and clonazepam (Klonopin) 0.5 mg twice daily. According to the 2023 AGS Beers Criteria, which of the medication classes on her chart should be AVOIDED in older adults?

Question

Accepted Answer

✅ B. Benzodiazepines (clonazepam)
The American Geriatrics Society (AGS) Beers Criteria explicitly recommend AVOIDING benzodiazepines (both short- and long-acting) in adults aged 65 and older due to increased sensitivity and slowed metabolism. Benzodiazepines in this population cause cognitive impairment, delirium, daytime sedation, motor vehicle crashes, and most importantly falls and fractures. Elderly patients on benzodiazepines have roughly a doubled hip-fracture risk. The only accepted geriatric uses are short-term for severe generalized anxiety disorder when other treatments have failed, seizure disorders, alcohol withdrawal, periprocedural anesthesia, and end-of-life care. There is also an FDA black-box warning against combining benzodiazepines with opioids (additive respiratory depression and death).

❌ A. ACE inhibitors (lisinopril)
ACE inhibitors are not on the Beers avoid list. They remain first-line for hypertension and heart failure in older adults, though monitor for hyperkalemia, AKI, and cough. They are preferred in diabetics with albuminuria regardless of age.

❌ C. HMG-CoA reductase inhibitors (atorvastatin)
Statins are NOT on the Beers avoid list. For secondary prevention they are continued lifelong regardless of age. For primary prevention in the very elderly (over 75) the benefit is less clear, but no blanket avoidance is recommended. Myopathy risk rises with drug interactions (CYP3A4 inhibitors), not age alone.

❌ D. Acetaminophen
Acetaminophen is the preferred first-line analgesic in older adults (per Beers and the American Geriatrics Society persistent pain guidelines), because it avoids the renal, GI, and cardiovascular harms of NSAIDs. It is explicitly recommended in this age group at doses up to 3 to 4 g/day with caution for hepatic disease.

:::danger
Two critical pharmacology rules for the elderly: (1) Benzodiazepines are on the Beers list — they cause falls, fractures, delirium, and cognitive impairment. Avoid them, and if they are used taper slowly. (2) Never combine benzodiazepines with opioids — the FDA black-box warning is for fatal respiratory depression, and the risk is highest in older adults.
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Benzodiazepines

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