The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, thousands of older adults end up in the hospital because of a medication that shouldn’t have been prescribed in the first place. It’s not always a mistake - sometimes it’s just how things have always been done. But for people over 65, the risks of certain drugs are higher, and the benefits are often lower. That’s where the Beers Criteria comes in. It’s not a law. It’s not a ban. It’s a clear, evidence-based guide that tells doctors and pharmacists: these drugs can hurt more than help in seniors.

What Exactly Is the Beers Criteria?

The Beers Criteria is a living list of medications that should be avoided or used with extreme caution in adults aged 65 and older. It was first created by Dr. Mark Beers in 1991, but it wasn’t until 2011 that the American Geriatrics Society (AGS) officially took it over and turned it into a trusted clinical tool. Since then, it’s been updated every three years. The latest version came out in May 2023, after reviewing over 7,300 studies - more than 20% higher than the previous update.

This isn’t just a list of bad drugs. It’s a detailed framework that breaks down medications into five categories:

• Drugs that are generally inappropriate for older adults
• Drugs to avoid if you have certain health conditions
• Drugs that need extra caution
• Harmful drug combinations
• Drugs that need dose changes if kidneys aren’t working well

The 2023 update added 32 new medications and removed 18 others based on new data. That’s how dynamic this tool is - it changes as science does.

Common Medications on the Beers List

Some of the most widely prescribed drugs for seniors are on this list. That’s what makes it so important - and so surprising to many people.

First-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine are still sold over the counter as sleep aids or allergy meds. But they’re strong anticholinergics. That means they block a brain chemical called acetylcholine, which can cause confusion, memory problems, dry mouth, constipation, and even urinary retention. In older adults, these side effects aren’t just annoying - they can lead to falls, hospital stays, and faster cognitive decline.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen are often used for arthritis pain. But if someone has heart failure, kidney disease, or high blood pressure, these drugs can make those conditions worse. A 2023 study found that NSAID use in seniors with heart failure increased hospital admissions by 38% compared to those who avoided them.

Benzodiazepines like lorazepam (Ativan) and diazepam (Valium) are prescribed for anxiety or insomnia. But they slow down the central nervous system. In older adults, that means dizziness, confusion, and a much higher risk of falls - which are the leading cause of injury-related death in people over 65. One study showed that seniors on benzodiazepines were 70% more likely to fall than those not taking them.

Antipsychotics like risperidone and haloperidol are sometimes used off-label for agitation in dementia. But they carry a black box warning from the FDA: they can increase the risk of stroke and death in elderly patients with dementia-related psychosis. The Beers Criteria says avoid them unless there’s no other option - and even then, use the lowest dose for the shortest time possible.

Why the Beers Criteria Matters

Older adults make up just 13.5% of the U.S. population, but they take 34% of all prescription medications. That’s because they often have multiple chronic conditions - diabetes, arthritis, high blood pressure, heart disease - and each one comes with its own drug. The average senior takes five to seven prescriptions daily. That’s called polypharmacy, and it’s a recipe for trouble.

About 23% of older adults living at home are taking at least one medication flagged by the Beers Criteria. And it’s not just about side effects - it’s about cost, confusion, and quality of life. A 2023 report from the CDC found that 15% of hospital admissions for seniors are caused by medication problems. Many of those could have been prevented.

The Beers Criteria helps cut through the noise. It gives providers a clear checklist to ask: Is this drug still necessary? Is there a safer alternative? Are we treating the symptom or the cause?

How It Compares to Other Tools

There’s another major tool called STOPP/START, popular in Europe. It’s more condition-focused - it says, “If someone has heart failure, don’t give NSAIDs,” rather than just saying “NSAIDs are bad.” That makes it more nuanced. But the Beers Criteria is simpler to use in busy clinics, and it’s built into most U.S. electronic health records.

In fact, 87% of U.S. healthcare systems have Beers Criteria alerts in their systems. That’s compared to just 42% in Europe using STOPP/START. Medicare Part D also requires pharmacies to check prescriptions against the Beers Criteria for patients taking eight or more drugs. That’s a big reason why it’s so dominant here.

But it’s not perfect. The Beers Criteria can flag a drug that’s actually appropriate for a specific person. For example, an antipsychotic might be the only thing that keeps a dementia patient from hurting themselves or others. That’s why it’s not a rulebook - it’s a guide. The goal isn’t to eliminate every flagged drug. It’s to make sure the decision to use it is intentional, informed, and monitored.

Real Impact: What Happens When It’s Used

When clinics actually use the Beers Criteria - not just as a pop-up alert, but as part of their routine review process - things change.

One study showed that when pharmacists reviewed medications using the criteria, they reduced inappropriate prescribing by 28%. In another, a hospital system saw a 43% drop in benzodiazepine prescriptions for seniors over 75 after adding Beers alerts to their EHR.

The American Medical Association found that practices using the criteria saw a 19% drop in inappropriate prescribing within two years. That’s not just numbers - it’s fewer falls, fewer ER visits, fewer hospital stays.

But there’s a catch. Many doctors say they get overwhelmed by alerts. One survey found that primary care providers see an average of 12 Beers-related alerts per patient visit. That leads to “alert fatigue” - where important warnings get ignored because there are too many.

The solution? Don’t rely on alerts alone. The most successful clinics have pharmacists leading medication reviews. They sit down with patients, go through every pill, and ask: “Why are you taking this? Has it helped? Are you having side effects?”

What Are the Alternatives?

The 2023 update included something new: the Alternative Treatments List. For every flagged drug, it suggests safer options.

Instead of diphenhydramine for sleep, try cognitive behavioral therapy for insomnia (CBT-I). It’s just as effective, without the brain fog.

Instead of NSAIDs for joint pain, consider physical therapy, weight loss, or acetaminophen (with caution - it has its own risks too).

Instead of antipsychotics for agitation, try music therapy, structured routines, or reducing environmental triggers like noise and clutter.

These aren’t just “nice to have” ideas. They’re backed by studies showing real improvement in symptoms, without the dangerous side effects.

Challenges and Gaps

The Beers Criteria doesn’t talk about cost. And that’s a big problem. For many seniors, the “safe” alternative might be too expensive. A $100-a-month drug might be better than a $300 one - even if the cheaper one is flagged. A 2023 study in JAMA Internal Medicine pointed out that 25% of Medicare patients skip doses because they can’t afford their meds. The Beers Criteria doesn’t help with that.

Also, 63% of essential medications on the list have no affordable substitute in low-income countries. That’s why global adoption is still limited.

Another gap? Renal dosing. Only 68% of drugs that leave the body through the kidneys have clear dosage adjustments in the 2023 version. The 2026 update plans to fix that.

How to Use It - For Patients and Providers

If you’re a senior or caring for one, ask your doctor or pharmacist: “Am I on any of the Beers Criteria drugs? Is there a safer option?”

Don’t be afraid to ask for a full medication review. Bring all your pills - including vitamins and OTC meds - to your appointment. Many people don’t realize that Benadryl or melatonin can be flagged too.

If you’re a provider, don’t just rely on alerts. Use the Beers Criteria as a conversation starter. Use the free AGS pocket guide or mobile app. It’s updated quarterly and saves an average of 8.2 minutes per patient.

And if you’re in a clinic or hospital, push for pharmacist-led reviews. That’s where the biggest wins happen.

What’s Next?

The Beers Criteria is evolving. The AGS is working with Google Health AI to build predictive models that flag patients most at risk before they even get a dangerous prescription. The 2026 update will expand kidney dosing guidance to cover every drug that leaves the body through the kidneys.

Meanwhile, pharmaceutical companies are developing new drugs designed specifically for older adults - ones that avoid the pitfalls of older medications. The market for these “senior-friendly” drugs is expected to hit $84 billion by 2027.

But technology alone won’t fix this. The real change comes when doctors, pharmacists, and patients start talking - honestly - about what’s working, what’s not, and what’s worth the risk.

Final Thoughts

The Beers Criteria isn’t about taking away medications. It’s about making sure the right ones are still being used - and that the wrong ones are replaced with something better.

It’s about dignity. It’s about safety. It’s about helping older adults live longer, healthier lives - not just survive on a pile of pills.

And if you’re over 65, or caring for someone who is - don’t wait for your doctor to bring it up. Ask about it. Your life could depend on it.