The Centers for Medicare and Medicaid Services (CMS) has introduced two new Part D Star Measures for 2025 to support the ongoing efforts of enhancing medication safety and improving health outcomes for older adults. The new measures are aligned with the American Geriatrics Society Beers Criteria¹ of medications that are potentially inappropriate for use in older adults. By focusing on the concurrent use of opioids and benzodiazepines, as well as managing polypharmacy with anticholinergic medications, healthcare providers play a vital role in enhancing patient safety and improving health outcomes.

Concurrent use of opioids and benzodiazepines (COB – 1x)

Older adults are especially vulnerable to the adverse effects of benzodiazepines due to advanced age and changes in pharmacokinetics and pharmacodynamics. 

• Common adverse effects of benzodiazepines include drowsiness, dizziness, weakness, and slowed breathing.
• The use of benzodiazepines among older adults has been associated with intellectual and cognitive impairment (e.g., anterograde amnesia, diminished short-term recall, increased forgetfulness), psychomotor impairment (e.g., slowed reaction time, diminished speed) and increased risk of falls. 
• While there may be situations where prescribing benzodiazepines to a patient receiving opioids is appropriate, clinicians should generally avoid prescribing opioids and benzodiazepines concurrently whenever possible.

Did you know? 

• The American Geriatrics Society Beers Criteria® recommend against the use of all benzodiazepines because they can increase the risk of cognitive impairment, delirium, falls, and fractures in older adults.
• Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents.

Tips for success

• Discuss the benefits, risks, and availability of non-opioid therapies (chiropractic, acupuncture, physical therapy, etc.) with your patient.
• Coordinate care with all the patient’s treating providers to avoid co-prescribing.
• If co-prescribing is necessary, follow the five central principles from CMS for co-prescribing benzodiazepines and opioids²:

1. Avoid initial combination by offering alternative approaches such as cognitive behavioral therapy or other medication classes.
2. If new prescriptions are needed, limit the dose and duration.
3. Taper long-standing medications gradually and, whenever possible, discontinue.
4. Continue long-term co-prescribing only when necessary and monitor the patient closely.
5. Provide rescue medication (e.g., naloxone) to high-risk patients and their caregivers as co-prescribing places the patient at a high risk of opioid overdose.

• Educate the patient on the side effects of medications, including the risk of addiction and what to do if side effects appear.
• Reinforce the treatment plan and evaluate the medication regimen. Consider the presence or absence of side effects and potential costs and provide clear written instructions for the medication schedule.

Polypharmacy: Use of multiple anticholinergic medications in older adults (Poly-ACH – 1x)

Though the definition of polypharmacy may vary among doctors and groups, it is recognized that the more medicines a person takes, the higher the chance of overmedication, side effects, oversedation, and other problems. Anticholinergics (ACH) are common in treating conditions such as allergies, gastrointestinal disorders, and chronic obstructive pulmonary disease (COPD).

It is widely recognized that the use of multiple ACH medications in the geriatric population is associated with adverse drug events, increased fall risk, and cognitive decline³.

• ACH medications are associated with multiple side effects, including confusion, constipation, dry mouth, blurred vision, and urinary retention. For each additional medication, a person’s risk of suffering an ADE increases by 7-10%⁴. 
• Estimates of the prevalence of any anticholinergic use in older adults have varied from 37-63%⁵.
  • 1 year of positive Poly-ACH was linked with $1,163 in additional healthcare costs, $1,169 higher at two years, and $964 at three years⁶.

Tips for success

• Leverage available data identifying prescribing that meets polypharmacy criteria. Share lists with providers in the practice for review.
• Review the indication and duration for each anticholinergic medication at every visit and discontinue any medication in which potential harm outweighs the benefits.
• Discuss the benefits, risks, and availability of safer alternatives or non-pharmacological treatment options (e.g., cognitive behavioral therapy) with patient.
• Educate the patient on risks and side effects of using multiple anticholinergic medications such as cognitive decline, blurry vision, increased fall risk, and what to do if side effects appear.
• Review medication appropriateness based on current evidence and guidelines while considering the patient’s co-morbid conditions, goals, and holistic picture.

¹By 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. doi:10.1111/jgs.18372

²SE19011 - Reduce Risk of Opioid Overdose Deaths by Avoiding and Reducing Co-Prescribing Benzodiazepines

³https://www.hopkinsmedicine.org/health/wellness-and-prevention/polypharmacy-in-adults-60-and-older

⁴lown-eliminating-medication-overload-web.pdf

⁵Increasing prevalence of anticholinergic medication use in older people in England over 20 years: cognitive function and ageing study I and II

⁶https://www.ajmc.com/view/anticholinergic-polypharmacy-in-medicare-not-common-but-still-problematic-study-says