The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, thousands of older adults end up in the hospital not because of a fall or infection, but because of a medication they were prescribed. It’s not always the drug’s fault-it’s often the mismatch between the drug and the person taking it. 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 for identifying medications that may do more harm than good for people aged 65 and older. The 2023 version, based on over 7,000 research studies, lists 134 medications or classes that doctors and pharmacists should rethink before prescribing to seniors.

What the Beers Criteria Actually Tells You

The Beers Criteria isn’t a ban list. It’s a practical tool that helps clinicians spot drugs with risks that outweigh their benefits in older adults. It’s broken into five clear sections:

• Medications to avoid entirely-like diphenhydramine (Benadryl), hydroxyzine, and promethazine. These first-generation antihistamines are common in sleep aids and allergy meds, but they block acetylcholine in the brain. That leads to confusion, memory issues, dry mouth, and constipation-problems that can spiral into falls or delirium in seniors.
• Drugs to avoid with certain conditions-for example, NSAIDs like ibuprofen or naproxen. They’re fine for a young person with a sprained ankle, but for someone with heart failure, they can cause fluid retention and make the heart work harder. The risk isn’t theoretical; studies show NSAID use in heart failure patients increases hospitalization by 30%.
• Drugs to use with caution-like dabigatran (Pradaxa), an anticoagulant. It’s easier to use than warfarin, but for seniors over 75 or those with kidney function below 30 mL/min, the bleeding risk jumps. The same goes for benzodiazepines like lorazepam or diazepam. They’re prescribed for anxiety or insomnia, but they slow reaction time, increase fall risk by up to 50%, and can cause lasting cognitive decline.
• Harmful drug combinations-mixing anticholinergics (like oxybutynin for overactive bladder) with opioids (like oxycodone) is a dangerous combo. Together, they can cause severe constipation, urinary retention, and mental fogginess. This isn’t rare-it happens in nearly 1 in 5 older adults on multiple meds.
• Drugs needing kidney dose adjustments-gabapentin is a good example. It’s often used for nerve pain, but if kidney function drops below 60 mL/min, the drug builds up in the body. That leads to dizziness, drowsiness, and even respiratory depression. Many prescribers don’t check kidney levels before writing the script.

The 2023 update added 32 new medications to the list and removed 18 based on new evidence. That’s how the guidelines stay sharp. What was once considered acceptable may now be flagged as risky, and vice versa.

Why It Matters More Than You Think

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 each one gets its own medication. The result? Polypharmacy. On average, older adults take 5 to 7 medications daily. That’s a recipe for error.

Studies show that 23% of community-dwelling seniors are on at least one Beers-listed drug. And it’s not just a numbers game. Inappropriate prescribing contributes to 15% of all hospital admissions among older adults. Many of these admissions are preventable. One 2021 study found that when clinics actively used the Beers Criteria in their workflow, adverse drug events dropped by 28%.

It’s not just about safety-it’s about quality of life. A senior on an anticholinergic for overactive bladder might stop going out because they’re too confused to navigate the grocery store. Someone on a benzodiazepine for sleep might be too dizzy to walk the dog. These aren’t side effects-they’re life-altering consequences.

How It Compares to Other Tools

There are other guidelines out there, like STOPP/START, popular in Europe. But the Beers Criteria dominates in the U.S., with 87% of healthcare systems integrating it into their electronic health records. Why? Because it’s tied to Medicare Part D. If you’re on Medicare and taking eight or more medications, your pharmacy is required to review your list against the Beers Criteria. That’s not optional-it’s policy.

But it’s not perfect. STOPP/START looks at the whole picture: Is the patient’s condition being treated appropriately? Are they missing a needed drug? Beers focuses on individual drugs. That means sometimes it flags a drug that’s actually necessary. For example, antipsychotics are listed as potentially inappropriate for dementia-related agitation. But for a patient with severe aggression or hallucinations, no other option may work. The Beers Criteria doesn’t account for that nuance.

That’s why experts recommend using it alongside other tools, like the Medication Appropriateness Index, which rates each drug’s appropriateness based on indication, dosage, and duration. The Beers Criteria is a flashlight in a dark room-it shows you the dangers. But you still need to look around.

What’s New in 2025: Alternatives Matter

The biggest shift in the latest update isn’t just the list of bad drugs-it’s the list of good alternatives. In July 2025, the American Geriatrics Society released a companion guide: Alternative Treatments to Selected Medications in the 2023 Beers Criteria. It’s a game-changer.

Instead of just saying “don’t use benzodiazepines for insomnia,” it now says: “Try cognitive behavioral therapy for insomnia (CBT-I).” That’s not a pill-it’s a 6-week program, often covered by Medicare. And it works better long-term than sleeping pills.

For overactive bladder? Try pelvic floor exercises, timed voiding, or fluid management-not oxybutynin.

For chronic pain? Consider physical therapy, heat/cold therapy, or low-dose topical capsaicin before reaching for gabapentin or opioids.

This shift from “avoid” to “replace” is what makes the 2023+ guidelines so powerful. It’s not just about stopping bad drugs-it’s about starting better care.

Real-World Challenges

Doctors and pharmacists aren’t ignoring the Beers Criteria-they’re overwhelmed by it. On average, electronic health systems generate 12 Beers-related alerts per patient visit. That’s too many. Clinicians start tuning them out. One primary care doctor on Medscape said, “I get so many alerts, I don’t know which ones to click anymore.”

That’s called alert fatigue. And it’s dangerous. The fix? Better filtering. Systems that only alert on high-risk combinations-like anticholinergics + opioids-or those with clear evidence of harm in seniors. Pharmacist-led medication reviews are the most effective way to cut through the noise. In clinics that use them, inappropriate prescribing dropped by 40% in under a year.

Cost is another hidden barrier. The Beers Criteria doesn’t talk about price. But 25% of seniors skip doses or don’t fill prescriptions because they can’t afford them. Sometimes, a cheaper, Beers-listed drug is the only option. A 78-year-old on fixed income might choose diphenhydramine over a newer sleep aid because it costs $4 instead of $80. The guidelines don’t solve that-but awareness does. Talking to patients about cost and alternatives is part of the job now.

How to Use It

If you’re a senior or caring for one, here’s what you can do:

1. Ask your doctor or pharmacist: “Are any of my medications on the Beers Criteria list?”
2. Bring your full list-including OTC meds, supplements, and herbal products. Many Beers-listed drugs are in over-the-counter sleep aids, cold medicines, and allergy pills.
3. Ask about alternatives: “Is there a non-drug option? A safer drug?”
4. Check your kidney function-ask for your eGFR number. Many drugs need dose changes if it’s below 60.
5. Don’t stop meds cold-some drugs need to be tapered. Talk to your provider before making changes.

The American Geriatrics Society offers a free mobile app and pocket guide with quarterly updates. It’s been downloaded over 87,000 times. Use it.

The Bigger Picture

The Beers Criteria isn’t just a list. It’s a movement. It’s pushing the healthcare system to treat older adults differently-not as patients with a bunch of diseases, but as whole people with unique needs. It’s why 17 Beers-listed drugs now have FDA-mandated geriatric warnings on their labels. It’s why pharmaceutical companies are developing 23 new “senior-friendly” medications.

And it’s why, despite its flaws, it’s the most widely used tool of its kind in the world-translated into 17 languages and used in 28 countries. The goal isn’t to eliminate all risk. It’s to reduce the preventable kind. Because no senior should be hospitalized because a doctor didn’t know a simple pill could make them sicker.

The Beers Criteria isn’t perfect. But it’s the best tool we have to keep older adults safe, independent, and out of the hospital. And that’s worth paying attention to.