The Beers Criteria: Potentially Inappropriate Medications for Seniors

Daniel Whittaker

Every year, thousands of seniors end up in the hospital not because of a fall or a heart attack, but because of a medication they were prescribed. It’s not always a mistake - sometimes, it’s just that the drug was never meant for someone their age. That’s where the Beers Criteria comes in. Developed by the American Geriatrics Society and updated every three years, it’s the most trusted guide in the U.S. for spotting medications that do more harm than good in adults 65 and older. This isn’t just a list of bad drugs - it’s a practical tool used by doctors, pharmacists, and care teams to keep older adults safe.

What Exactly Is the Beers Criteria?

The Beers Criteria isn’t a suggestion. It’s a living, evidence-based standard. First created in 1991 by Dr. Mark Beers, it was adopted by the American Geriatrics Society in 2011 and has been refined with new research ever since. The latest version, released in May 2023, is based on over 7,300 high-quality studies - a 22% increase from the previous update. It’s now used in nearly 9 out of 10 U.S. healthcare systems, especially in Medicare Part D programs, where it’s required for patients taking eight or more medications.

It’s not about banning drugs. It’s about recognizing when the risks outweigh the benefits. For example, a drug that works fine for a 40-year-old might cause confusion, falls, or kidney damage in a 75-year-old. The Beers Criteria flags these situations so providers can step in before harm happens.

The Five Categories of Risk

The 2023 Beers Criteria breaks down risky medications into five clear groups. Each one helps clinicians make smarter choices.

• Medications to avoid entirely - These are drugs with strong evidence of harm in older adults. First-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine are on this list. They’re often sold as sleep aids or allergy meds, but they block acetylcholine in the brain - leading to memory problems, dry mouth, constipation, and even delirium. The evidence is so clear that the AGS gives them a strong recommendation against use.
• Medications dangerous with certain conditions - Some drugs are fine for most people but risky if you have heart failure, kidney disease, or dementia. NSAIDs like ibuprofen and naproxen, for example, can worsen heart failure and raise blood pressure. They’re also linked to stomach bleeding, especially in seniors on blood thinners.
• Medications to use with caution - These aren’t banned, but they need extra care. Dabigatran (Pradaxa), a blood thinner, increases bleeding risk in people over 75 or with poor kidney function. Gabapentin, often prescribed for nerve pain, builds up in the body if kidneys aren’t working well - leading to dizziness and falls. Dose adjustments are critical.
• Harmful drug combinations - Mixing medications can be deadly. Combining anticholinergics (like oxybutynin for overactive bladder) with opioids (like oxycodone) can cause severe constipation, urinary retention, and mental confusion. These interactions are often missed because each drug seems fine on its own.
• Drugs needing kidney-based dosing - As we age, kidneys slow down. Many drugs are cleared through the kidneys, so standard doses become toxic. The Beers Criteria now includes specific dose limits for 68% of these medications, with plans to cover 100% by 2026. If a senior’s creatinine clearance is below 30 mL/min, their meds need to be adjusted - or changed.

The 2023 update added 32 new medications to the list and removed 18 that were no longer considered risky. That’s how it stays current - not by guesswork, but by science.

Why It Matters: The Real-World Impact

Seniors make up just 13.5% of the U.S. population but take 34% of all prescription drugs. About 23% of older adults living at home are on at least one medication flagged by the Beers Criteria. And it’s not just discomfort - it’s hospitalization. Studies show that inappropriate prescribing contributes to 15% of all hospital admissions among seniors.

When healthcare teams use the Beers Criteria properly, the results are dramatic. One study found a 28% drop in adverse drug events - like falls, confusion, or internal bleeding - after clinics started using the guidelines. In one clinic, benzodiazepine prescriptions for insomnia dropped by 43% in patients over 75 after EHR alerts were turned on.

But it’s not perfect. Some doctors complain about “alert fatigue.” If an electronic health record pops up 12 Beers Criteria warnings during a single visit, it’s easy to ignore them all. And sometimes, the criteria flag a drug that’s actually needed - like antipsychotics for severe dementia-related aggression. The guidelines don’t replace clinical judgment; they support it.

What’s Being Done Instead?

The 2025 update to the Beers Criteria includes something new: a list of alternatives. For every flagged drug, there’s now a recommendation for what to use instead.

• Instead of diphenhydramine for sleep: Cognitive behavioral therapy for insomnia (CBT-I), melatonin, or low-dose trazodone.
• Instead of NSAIDs for arthritis pain: Physical therapy, acetaminophen (within safe limits), or topical capsaicin.
• Instead of benzodiazepines for anxiety: Mindfulness, exercise, or selective serotonin reuptake inhibitors (SSRIs) like sertraline.

These aren’t just guesses. They’re backed by clinical trials. The American Geriatrics Society now recommends non-drug options first - because they’re safer and often more effective long-term.

Who Uses It - and Who Doesn’t?

Pharmacists are the biggest fans. Nearly 9 out of 10 say the Beers Criteria helps them catch dangerous prescriptions during medication reviews. Geriatricians use it daily. But primary care doctors? Only 41% consistently apply it, according to CDC data.

Why the gap? Time. Training. Technology. Many clinics don’t have EHR alerts turned on. Others don’t have pharmacists on staff. And some doctors just don’t know the list well enough.

The good news? The American Geriatrics Society offers a free mobile app and pocket guide with quarterly updates. Over 87,000 people have downloaded it. Users report saving over 8 minutes per patient visit - time that can be spent talking to the patient instead of flipping through a manual.

The Big Picture: Cost, Access, and Equity

There’s a dark side to the Beers Criteria that doesn’t get talked about enough. Many seniors can’t afford the safer alternatives. A study found that 25% of Medicare patients skip doses or don’t fill prescriptions because of cost. Sometimes, a cheaper but risky drug is the only option.

And globally, the problem is worse. In low-income countries, 63% of the medications on the Beers List have no affordable replacement. That’s why the World Health Organization calls the criteria “a luxury tool” in some settings - even if it’s the gold standard in the U.S.

The pharmaceutical industry is responding. Over 23 new “senior-friendly” drugs have been developed to replace Beers-listed ones. The market for these medications is expected to hit $84 billion by 2027. But until those drugs are covered by insurance and available everywhere, the Beers Criteria will always be just half the solution.

What Seniors and Families Should Know

If you or a loved one is on multiple medications, ask these questions:

• Is this drug on the Beers Criteria list?
• Is there a safer alternative - even a non-drug one?
• Has my kidney function been checked recently?
• Am I taking any meds that might interact with each other?

Don’t be afraid to ask your pharmacist to review all your meds - including over-the-counter ones. Many don’t realize that Benadryl, sleep aids, and antacids can be just as risky as prescription drugs.

And if your doctor says a flagged drug is necessary, ask why. Is it because nothing else works? Or because it’s easier to prescribe? The Beers Criteria isn’t a rulebook - it’s a conversation starter.

What’s Next for the Beers Criteria?

The 2026 update will expand kidney dosing guidance to cover every medication cleared by the kidneys. The American Geriatrics Society is also partnering with Google Health AI to build predictive tools that flag seniors at highest risk - before they even start a risky drug.

It’s not about eliminating medications. It’s about using them wisely. For older adults, the goal isn’t to take fewer pills - it’s to take the right ones. And with the Beers Criteria, we’re getting better at telling the difference.