Beers Criteria and anticholinergic burden: complementary, not interchangeable

The two frameworks begin with different questions

A burden scale asks how a medication or medication list is classified under a defined anticholinergic instrument. The AGS Beers Criteria ask whether medication use raises a potentially inappropriate prescribing concern in a defined older-adult context. Both can inform review, but they do not produce interchangeable findings.

This distinction explains why a medication may appear in a geriatric criterion even when a particular burden scale assigns a low value or has no public entry. The criterion may concern another mechanism, a drug–disease relationship, an interaction or a conditional use. It is not evidence that the scale’s missing cell should be filled with a new score.

What a source-scale observation contains

In UnifiedACB, a source observation retains the original medication label, version, published value, evidence state and locator. The public table therefore answers a specific provenance question: what did this source document report for this medication entry?

The observation is not silently revised when supplemental clinical information is added. If two scales disagree, their values remain separate. If a source publishes zero, that state remains distinct from absence. These rules make it possible to inspect the original evidence rather than a site-generated synthesis.

What the Beers tables contribute

The 2023 AGS publication organizes several kinds of geriatric prescribing concern. Its general medication criteria, drug–disease or syndrome criteria, interaction criteria and strong-anticholinergic reference list have different roles. Reading only the medicine’s name without its table context can therefore produce an incomplete explanation.

For example, an entry in the strong-anticholinergic reference list identifies a property used elsewhere in the criteria. It does not mean that every disease-specific criterion applies to every person taking that drug. A contextual interpretation identifies the relevant criterion and checks the conditions attached to it.

The selected UnifiedACB overlay is supplemental content drawn from reviewed entries. It is not a replacement for the full publication and does not claim to cover every potentially inappropriate medication situation. Its absence is a coverage statement, not a favorable clinical verdict.

A dose qualification illustrates the difference

Doxepin’s geriatric criterion identifies use above 6 mg per day in the AGS source. That qualification must be explained when the tag is discussed. Knowing the ingredient without knowing the relevant daily dose may be insufficient to determine how the criterion applies.

The public doxepin source observations remain their original scale findings. A Beers dose distinction does not create new doxepin categories within CALS or GABS. The correct presentation shows the ordinal evidence and the dose-qualified geriatric context side by side, with separate attribution.

This is also why tablet strength should not be mistaken for total daily exposure. A source qualification may require information about the actual regimen. When that detail is missing, a focused clarification is more accurate than a confident blanket statement.

A route qualification changes the scope of a statement

Some geriatric criteria specify an administration route. Preserving that wording avoids turning an oral-use concern into a claim about every possible preparation. The same principle applies to exceptions: excluding a route from one criterion does not establish that all uses of that route are harmless.

The scale table may not carry the same route detail. That mismatch should be explained instead of resolved by altering the source observation. A careful answer can state that the geriatric criterion is route-specific while the historical scale entry is less specific.

Disease and interaction context cannot be read from a badge alone

A syndrome-related criterion asks about the person’s clinical context. The relevant concern may involve delirium, cognitive impairment, falls or another condition addressed in the source. A medication name alone does not establish that the condition is present or that a particular criterion is the decisive one.

An interaction concern asks about a combination of exposures. It is not fully represented by looking at one medication profile in isolation. The AGS framework can therefore complement a source-scale comparison by directing attention to the regimen and the clinical setting. It should remain a separately explained layer.

Where readers commonly combine the frameworks incorrectly

One error is to turn a Beers tag into an additional burden point. Another is to overwrite a scale value with the geriatric classification. A third is to assume that a medication outside the selected overlay is safe. Each move assigns the framework a meaning it does not provide.

The opposite error is to dismiss a geriatric criterion because a particular scale has a low category. A burden instrument does not evaluate every prescribing concern. A low anticholinergic classification cannot settle questions about all other medication effects or the appropriateness of an indication.

A combined reading that retains both meanings

First state the source-scale findings and any missing entries. Then identify the supplemental geriatric criterion, its source and the qualification that matters. Finally, connect the evidence to the clinical question without issuing a treatment instruction solely from a category or tag.

For a medication question, the most useful clarification may be route, total daily dose, indication or a relevant condition. Asking only the detail that changes the answer keeps the discussion focused. If the source itself is uncertain, the answer should retain that uncertainty rather than convert it into a simple yes-or-no label.

What the comparison establishes

The frameworks are complementary because they illuminate different parts of medication review. Source scales preserve classifications; geriatric criteria explain context-dependent prescribing concerns. Their combined value comes from keeping their meanings clear, not from merging their labels into an unsupported universal judgment.

References

1. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71:2052-2081. Source
2. Vennard O, Stewart C, Tolia M, Soiza RL, Myint PK. Anticholinergic Medication Burden Scales: A Systematic Review. J Am Geriatr Soc. 2026;74(6):1771-1784. Source
3. American Geriatrics Society Beers Criteria Alternatives Panel. Alternative Treatments to Selected Medications in the 2023 AGS Beers Criteria. J Am Geriatr Soc. 2025;73:2657-2677. Source
4. Fox C, et al. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age Ageing. 2014;43:604-615. Source
5. Ruxton K, Woodman RJ, Mangoni AA. Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: a systematic review and meta-analysis. Br J Clin Pharmacol. 2015;80(2):209-220. doi:10.1111/bcp.12617. Source
6. Egberts A, et al. Anticholinergic Drug Burden and Delirium: A Systematic Review. J Am Med Dir Assoc. 2021;22:65-73.e4. Source
7. UnifiedACB. Preserved public source-observation dataset, v3.0 RC12 final; inspected for this editorial revision. Source

Disclosure

Funding: None. Conflict of interest: None declared for the UnifiedACB educational project.

Educational evidence summary. This content does not provide patient-specific medical advice and does not replace clinical judgment, medication reconciliation, or prescribing guidance.