Beers Criteria: Potentially Inappropriate Drugs in Older Adults

Every year, thousands of older adults end up in the hospital not because of a new illness, but because of a drug they were prescribed. It’s not always the disease that hurts them-it’s the medicine meant to help. That’s where the Beers Criteria come in. Developed to protect older adults from harmful medications, this list isn’t about banning drugs. It’s about asking: Does this drug do more harm than good for someone over 65?

What Exactly Are the Beers Criteria?

The Beers Criteria are a living guide, updated every few years by the American Geriatrics Society (AGS), that identifies medications likely to cause more harm than benefit in people aged 65 and older. First created in 1991 by Dr. Mark Beers, the list has evolved into the most widely used tool in the U.S. for spotting risky prescriptions in older adults. The latest version, published in 2023, includes 131 specific medication criteria. That’s not just a few pills-it’s a detailed map of where prescribing can go wrong.

It’s not a blacklist. It’s a warning system. The AGS is clear: these guidelines aren’t meant to punish doctors or deny care. They’re meant to spark conversation. A medication flagged by the Beers Criteria might still be right for someone-if their doctor knows why and monitors closely. But too often, these drugs are prescribed on autopilot, especially in nursing homes or during hospital discharges, where time is short and complexity is high.

How the Criteria Are Organized

The 2023 Beers Criteria don’t just say “avoid this drug.” They break things down into five clear sections so clinicians can make smarter choices:

• Medications to avoid in most older adults-These are drugs with high risks and little benefit for nearly everyone over 65. Examples include long-acting benzodiazepines like diazepam and non-benzodiazepine sleep aids like zolpidem. These drugs increase fall risk, confusion, and even dementia progression.
• Medications to avoid with specific conditions-Some drugs are dangerous only if you have certain illnesses. For example, anticholinergics like diphenhydramine (Benadryl) can worsen dementia, urinary retention, or glaucoma. Yet they’re still sold over the counter and often given without thinking.
• Medications to use with caution-These aren’t banned, but they need extra care. NSAIDs like ibuprofen or naproxen can cause stomach bleeds or kidney damage in older adults, especially if they’re also on blood pressure meds. The risk isn’t zero-it’s just higher.
• Medications to avoid with kidney problems-As we age, kidneys slow down. Drugs cleared by the kidneys, like metformin or certain antibiotics, can build up to toxic levels if doses aren’t adjusted. The 2023 update added more specific guidance for kidney function levels.
• Dangerous drug interactions-Some combinations are deadly. Taking an SSRI antidepressant with an NSAID can cause dangerous bleeding. Mixing an antipsychotic with an anticholinergic can trigger delirium. These interactions aren’t rare-they happen daily in clinics and pharmacies.

Each of these categories is backed by evidence. The 2023 update reviewed over 1,500 studies published between 2019 and 2022. That’s not guesswork-it’s science. And it’s why the Centers for Medicare & Medicaid Services (CMS) use the Beers Criteria to measure quality in nursing homes and Medicare Part D programs.

Why Older Adults Are at Higher Risk

It’s not just that older people take more pills. It’s that their bodies change. Liver and kidney function decline. Fat increases, muscle decreases. That changes how drugs move through the body. A 5mg dose of a sleeping pill that’s fine for a 40-year-old can leave an 80-year-old confused, unsteady, and prone to a fall.

Many older adults have multiple chronic conditions-diabetes, heart disease, arthritis, depression. That means they’re often on five, ten, even fifteen medications. This is called polypharmacy. About 40% of older adults in the U.S. take five or more prescriptions. And 20% of them are taking at least one drug flagged by the Beers Criteria.

Here’s the problem: doctors aren’t always trained to see this. Medical school focuses on treating single diseases, not managing complex drug interactions across multiple conditions. Pharmacists are often the first to spot the issue-but they’re not always involved in the prescribing process.

Real-World Impact: When the Criteria Save Lives

A 2014 study looked at older adults stuck in hospitals because they couldn’t go home (called Alternate Level of Care or ALC patients). Nearly half-45.7%-were taking at least one Beers Criteria medication. Many of those drugs were unnecessary: antipsychotics for agitation in dementia, muscle relaxants for back pain, or sedatives for sleep.

When pharmacists intervened-recommending safer alternatives or stopping the drug entirely-hospital stays shortened, falls decreased, and patients reported better quality of life. One patient, an 82-year-old woman with mild dementia, was on lorazepam for sleep and diphenhydramine for allergies. She was falling weekly. After switching to non-drug sleep strategies and replacing the antihistamine with a nasal spray, her falls stopped. Her family said she seemed “like herself again.”

These aren’t isolated cases. Studies show that when hospitals and clinics use the Beers Criteria to review prescriptions, hospital admissions for adverse drug events drop by up to 30%. That’s not just numbers-it’s real people avoiding broken hips, brain bleeds, and emergency rooms.

What the Beers Criteria Don’t Do

It’s easy to think the Beers Criteria are rules. They’re not. They’re tools. And like any tool, they can be misused.

Some nursing homes use them as punishment. If a resident is on a flagged drug, the facility gets flagged for poor quality-even if the drug is helping them. That’s not what the AGS intended. The panel behind the 2023 update wrote: “Prescribing decisions are not always clear-cut.”

For example, a person with severe dementia and aggressive behavior might need a low-dose antipsychotic-even though the Beers Criteria say to avoid them. Why? Because non-drug approaches have failed. The family has no other options. In that case, the drug is used carefully, with close monitoring, and only as a last resort. The Beers Criteria don’t forbid this-they just say: Don’t do it without knowing the risks and having a plan.

Another myth: the criteria ignore individual needs. But they don’t. The 2023 update added exceptions for certain subgroups. For instance, a person with Parkinson’s might need an anticholinergic for tremors-even though those drugs are generally avoided in older adults. The key is knowing why you’re making the exception.

How Clinicians Use the Beers Criteria Today

Most doctors don’t memorize 131 drug warnings. So how do they use the criteria? Through tools built into their workflow.

• Electronic Health Records (EHRs): Many systems now flag Beers Criteria drugs when a prescription is entered. A pop-up says: “This drug is potentially inappropriate for patients over 65. Consider alternatives.”
• Mobile apps: The AGS offers a free app for clinicians. You can search by drug name or condition and get the full recommendation in seconds.
• Pocket cards: Pharmacists and geriatricians often carry a laminated card with the top 10 risky drugs. It’s quick, simple, and always at hand.
• Medication reviews: Medicare now requires annual medication reviews for high-risk patients. The Beers Criteria are built into those checklists.

These tools make it easier to catch problems before they happen. But they’re only as good as the person using them. A doctor who ignores the alert because “she’s always taken this” might miss a chance to prevent harm.

Alternatives and Complementary Tools

The Beers Criteria aren’t the only game in town. Another widely used tool is STOPP-START. While Beers focuses on inappropriate prescriptions, STOPP-START also looks at missing prescriptions. For example, it might flag that an older adult with heart failure isn’t on a beta-blocker-something Beers doesn’t address.

Then there’s deprescribing-the process of safely stopping unnecessary meds. The Deprescribing Research Network offers step-by-step guides for tapering off sedatives, antipsychotics, and painkillers. These tools work best when used together. Beers tells you what to avoid. STOPP-START tells you what you might be missing. Deprescribing tells you how to get off safely.

And the AGS itself offers a simple 5-step framework for reviewing meds in patients with multiple conditions. It’s not flashy, but it’s practical: assess the problem, review all meds, prioritize, adjust, and follow up.

What Patients and Families Can Do

You don’t need to be a doctor to use the Beers Criteria. The AGS has a plain-language version at healthinaging.org. You can look up any drug and see if it’s on the list.

Here’s what to ask your doctor or pharmacist:

• “Is this medication still necessary?”
• “Are there safer alternatives?”
• “What happens if we stop this?”
• “Could this be causing my dizziness or confusion?”

Don’t be afraid to bring a list of all your meds-including vitamins, supplements, and over-the-counter drugs. Many harmful interactions come from things people think are “harmless.”

And if you’re caring for an older relative, don’t assume they’re taking meds correctly. Some stop because of side effects and don’t tell anyone. Others take two pills because they forgot if they already did. A simple pill organizer and a weekly check-in can prevent big problems.

The Future of Safer Prescribing

The next big step? Personalization. Right now, the Beers Criteria treat everyone over 65 the same. But not all 65-year-olds are alike. Someone who’s active and healthy at 68 has very different needs than someone with dementia and kidney failure.

Researchers are now testing ways to combine the Beers Criteria with genetic data (pharmacogenomics), real-time kidney function tests, and AI-powered EHR alerts. Imagine a system that knows your age, your kidney numbers, your other meds, and your fall history-and then tells your doctor: “Avoid this drug. Here’s why, and here’s what to use instead.”

That’s not science fiction. It’s coming. But even with better tech, the core idea stays the same: older adults deserve care that’s thoughtful, individualized, and safe. The Beers Criteria are a starting point-not the finish line.

Final Thought: It’s About Respect, Not Rules

The Beers Criteria exist because too many older adults have been harmed by well-intentioned but careless prescribing. They’re not about limiting freedom. They’re about protecting dignity. A person shouldn’t have to live in fear of a pill. They shouldn’t have to choose between pain relief and falling. They shouldn’t be confused because their allergy medicine was never reviewed.

Medication safety isn’t about checking boxes. It’s about listening. It’s about asking: Who is this for? What are they really experiencing? And is this helping-or hurting?

The Beers Criteria give us the language to ask those questions. Now we just have to use them wisely.