The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, thousands of seniors end up in the hospital because of medications that should never have been prescribed to them in the first place. It’s not always the fault of doctors or pharmacists. Often, it’s because the drugs they’re taking - even if they’ve been on them for years - are simply too risky for older bodies. That’s where the Beers Criteria comes in. It’s not a suggestion. It’s a lifeline.

What Exactly Is the Beers Criteria?

The Beers Criteria is a list of medications that doctors and pharmacists are warned to avoid in adults aged 65 and older. It’s not a blanket ban. It’s a smart, evidence-based guide that says: "This drug might help, but in someone your age, the odds of harm are too high." Developed by Dr. Mark Beers in 1991 and now maintained by the American Geriatrics Society (AGS), it’s been updated every three years. The latest version, released in May 2023, is the most thorough yet, based on over 7,000 studies.

Why does this matter? Seniors make up just 13.5% of the U.S. population, but they take 34% of all prescription drugs. That’s not because they’re sicker - it’s because multiple conditions pile up, and prescriptions stack on top of each other. One in five older adults is taking at least one medication that the Beers Criteria says they shouldn’t. And that’s linked to 15% of all hospital stays for seniors.

What Medications Are on the List?

The 2023 Beers Criteria identifies 134 medications or drug classes that pose higher risks than benefits for older adults. These fall into five clear categories:

• Medications to avoid entirely: First-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. These are common in sleep aids and allergy meds, but they block acetylcholine - a brain chemical critical for memory and focus. The result? Confusion, dizziness, falls, and even delirium. Even one dose can be dangerous for someone over 70.
• Medications dangerous with certain conditions: NSAIDs like ibuprofen and naproxen. For someone with heart failure or high blood pressure, these can cause fluid retention and make their heart work harder. A simple pain reliever becomes a heart risk.
• Medications to use with extreme caution: Anticoagulants like dabigatran (Pradaxa). While safer than warfarin for many, in seniors over 75 or with kidney problems, the risk of internal bleeding jumps significantly. Dosing matters - a lot.
• Drug combinations to avoid: Mixing anticholinergics (like oxybutynin for overactive bladder) with opioids (like oxycodone) can lead to severe constipation, urinary retention, and cognitive decline. It’s not just one bad drug - it’s the combo.
• Drugs needing kidney dose adjustments: Gabapentin, used for nerve pain, is cleared by the kidneys. In older adults with reduced kidney function, it builds up and causes drowsiness, dizziness, and falls. Many prescribers still give the same dose as to a 30-year-old.

Since 2019, 32 new drugs were added to the list, and 18 were removed because newer evidence showed they were safer than previously thought. That’s the power of science - the list isn’t static. It evolves.

How Is It Different From Other Tools?

You might hear about STOPP/START, another set of guidelines used mostly in Europe. The big difference? STOPP/START looks at the whole picture: "Is this drug needed for this condition?" The Beers Criteria says: "This drug is risky - don’t use it, even if the condition seems to fit." That’s both a strength and a weakness. Beers is blunt. It’s easier to program into an EHR system. In the U.S., 87% of hospitals and clinics use it. Medicare Part D requires it for patients taking eight or more medications. But sometimes, it flags a drug that’s actually necessary. For example, antipsychotics are on the list for dementia-related agitation - but if a patient is violent or hallucinating and other options have failed, the risk of not treating may be higher than the risk of the drug.

That’s why experts say: Don’t use Beers alone. Use it with clinical judgment. It’s a red flag, not a death sentence.

How Do Doctors Actually Use It?

The best way it’s used? Integrated into electronic health records. When a doctor tries to prescribe diphenhydramine to a 78-year-old, the system pops up: "Beers Criteria Alert - Avoid in older adults. Consider non-drug options for insomnia." One study found that clinics using these alerts reduced benzodiazepine prescriptions for insomnia by 43% in seniors over 75. Another found a 28% drop in adverse drug events overall. That’s not just numbers - that’s fewer falls, fewer ER visits, fewer broken hips.

But there’s a catch. Too many alerts. One primary care doctor reported getting 12 Beers alerts per patient visit. When the system screams too often, doctors start ignoring it. That’s called "alert fatigue." The key is smart filtering - only flagging high-risk interactions, not every minor one.

Pharmacists are the unsung heroes here. In 89% of cases, they’re the ones catching these issues during medication reviews. They’re the ones asking: "Why are you still on this?" and offering safer alternatives.

What Are the Alternatives?

The 2025 update to the Beers Criteria added something huge: the Alternatives List. For every flagged drug, it now suggests what to use instead.

• Instead of diphenhydramine for sleep: Try sleep hygiene - consistent bedtime, no screens before bed, avoiding caffeine after noon.
• Instead of NSAIDs for joint pain: Physical therapy, weight management, topical capsaicin, or acetaminophen (within safe limits).
• Instead of gabapentin for nerve pain: Low-dose duloxetine or pregabalin (with kidney dose adjustment), or non-drug options like TENS units.
• Instead of antipsychotics for agitation in dementia: Environmental changes - reduce noise, increase daylight, engage in familiar activities. If needed, use low-dose risperidone only after other options fail.

These aren’t just guesses. They’re backed by clinical trials. Cognitive behavioral therapy for insomnia (CBT-I) is as effective as sleeping pills - and lasts longer without side effects. And it’s covered by Medicare.

Why Isn’t Everyone Using It?

Despite its proven value, only 41% of primary care practices in the U.S. consistently apply the Beers Criteria. Why?

• Time. Doctors are rushed. Reviewing a 12-medication list for a 78-year-old takes 10 minutes - and most visits are 15.
• Cost. Some Beers-listed drugs are cheap. Alternatives might cost $100 a month. For seniors on fixed incomes, price matters more than guidelines. One study found 25% of Medicare patients skip meds because they can’t afford them - even if they’re unsafe.
• Legacy prescriptions. Many seniors have been on these drugs for decades. No one ever asked if they still needed them.
• Lack of awareness. Sixty-one percent of seniors don’t know their meds are being checked against the Beers Criteria. They assume their doctor knows best - and they’re right. But they need to be part of the conversation.

What Can Seniors and Families Do?

You don’t need to be a doctor to protect yourself or a loved one. Here’s how:

1. Ask for a full medication review at least once a year. Bring every pill bottle - including supplements and over-the-counter meds.
2. Ask: "Is this still necessary? Are there safer options?" Don’t be shy.
3. Check if your pharmacist offers a Medication Therapy Management (MTM) service. It’s free under Medicare Part D if you take multiple meds.
4. Download the free AGS Beers Criteria app. It’s updated quarterly. Use it to check any new prescription before filling it.
5. Speak up if you feel drowsy, confused, or unsteady. These aren’t "just aging" - they could be drug side effects.

The goal isn’t to stop all meds. It’s to stop the wrong ones. To replace dangerous ones with safer ones. To give seniors more years of independence - not more hospital beds.

The Bigger Picture

The Beers Criteria isn’t just a list. It’s a movement. It’s changing how we think about aging and medicine. The pharmaceutical industry is responding - 23 new "senior-friendly" drugs are in development. The FDA now requires geriatric warnings on 17 Beers-listed medications. Medicare is making it mandatory. And AI tools are being trained to predict which seniors are most at risk.

But technology won’t fix this alone. People will. Doctors who pause before prescribing. Pharmacists who ask tough questions. Families who speak up. And seniors who know their bodies well enough to say: "This doesn’t feel right." The Beers Criteria is the map. You’re the navigator. Don’t let anyone else drive.