The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, thousands of older adults end up in the hospital not because of a fall, infection, or heart issue-but because of a medication they were told to take. It sounds backwards, doesn’t it? Medications are supposed to help. But for seniors, some common prescriptions do more harm than good. That’s where the Beers Criteria comes in. It’s not a law. It’s not a suggestion. It’s a science-backed list that tells doctors which drugs to avoid in people 65 and older-and why.

What Exactly Is the Beers Criteria?

The Beers Criteria is a living document, updated every three years by the American Geriatrics Society. It started in 1991 as a simple list of drugs to avoid in nursing homes. Today, it’s a detailed, evidence-based guide used in hospitals, clinics, and pharmacies across the U.S. The latest version came out in May 2023, after experts reviewed over 7,000 studies. That’s more than 20% higher than the previous update. The goal? To cut down on dangerous prescriptions that don’t match the needs of older bodies.

Why does this matter? Seniors make up just 13.5% of the U.S. population, but they take 34% of all prescription drugs. Many are on five, six, or even ten medications at once. That’s called polypharmacy. And with each new pill, the risk of side effects, bad interactions, and hospital stays goes up. The Beers Criteria helps cut through the noise. It doesn’t say every drug on the list is always wrong. It says: Here are the ones that often do more harm than good in older adults.

The Five Categories of Risk

The 2023 Beers Criteria breaks down risky medications into five clear groups. Knowing these helps both doctors and patients ask smarter questions.

• Medications to avoid altogether-These are drugs with strong evidence that they cause more harm than benefit. Think first-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. They’re often sold as sleep aids or allergy pills. But in seniors, they block a brain chemical called acetylcholine. That leads to confusion, memory lapses, dry mouth, constipation, and even falls. The evidence is so clear, the criteria gives them a strong recommendation to avoid.
• Medications to avoid with certain conditions-Some drugs are fine for most people but dangerous if you have another health issue. For example, NSAIDs like ibuprofen or naproxen are common for arthritis pain. But if you have heart failure, they can make it worse by causing fluid buildup. The Beers Criteria says: Don’t use these if you’re at risk.
• Medications to use with caution-These aren’t banned, but they need extra care. Dabigatran (Pradaxa), a blood thinner, is a good example. It’s safer than warfarin for many, but for seniors over 75 or those with reduced kidney function, it raises the risk of serious stomach bleeding. Doctors need to check kidney levels before prescribing.
• Drug-drug interactions to watch for-Some combinations are ticking time bombs. Taking an anticholinergic (like oxybutynin for overactive bladder) with an opioid (like oxycodone for pain) can cause extreme constipation, urinary retention, and mental fogginess. These interactions aren’t always obvious to patients or even some providers.
• Drugs needing kidney dose adjustments-As we age, kidneys slow down. Medications that leave the body through the kidneys can build up to toxic levels if the dose isn’t lowered. Gabapentin, used for nerve pain, is one. If your kidney function drops below 60 mL/min, the dose must be cut. Many prescribers forget this.

The 2023 update added 32 new medications to these lists and removed 18 that newer studies showed were safer than once thought. It’s not static. It evolves.

How It Compares to Other Tools

You might hear about STOPP/START, another tool used in Europe. It’s different. While Beers focuses on individual drugs to avoid, STOPP/START looks at the whole picture: Is this drug appropriate for the condition? Is something missing? Beers is simpler to use in EHRs, which is why 87% of U.S. healthcare systems have built it into their electronic records. STOPP/START is more detailed but harder to automate.

But Beers isn’t perfect. It can flag a drug as inappropriate even when it’s the right choice. For example, antipsychotics like risperidone are listed as risky for dementia-related agitation. But if a senior is having violent outbursts or hallucinations that put them in danger, sometimes the risk of not treating is greater than the risk of the drug. That’s why experienced clinicians use Beers as a guide-not a rulebook.

Real Impact in Clinics

When hospitals and clinics use the Beers Criteria properly, results show up fast. One study found a 28% drop in adverse drug events after staff started using the list. Another found that when EHRs automatically flagged Beers-listed drugs during prescribing, inappropriate medication use dropped by 37% in just six months.

Dr. Lisa Chen, a geriatrician in California, said after adding Beers alerts to her clinic’s system, benzodiazepine prescriptions for insomnia in patients over 75 fell by 43%. That’s huge. Benzodiazepines like lorazepam and zolpidem increase fall risk and confusion. Replacing them with non-drug options-like sleep hygiene routines or cognitive behavioral therapy-works better and safer.

But there’s a downside. Some doctors are overwhelmed. One survey found primary care providers get an average of 12 Beers alerts per patient visit. That’s alert fatigue. When every alert sounds like an emergency, you start ignoring them. The trick is smart integration: Only trigger alerts for high-risk drugs, and pair them with alternatives.

What’s Replacing the Risky Drugs?

The 2025 update to the Beers Criteria went a step further. It didn’t just list bad drugs-it started listing good replacements. For insomnia, instead of diphenhydramine or zolpidem, try sleep hygiene, light therapy, or CBT-I (Cognitive Behavioral Therapy for Insomnia). For overactive bladder, physical therapy and timed voiding often work better than oxybutynin. For pain, non-drug options like exercise, acupuncture, or heat packs are first-line now. Even when drugs are needed, safer alternatives exist: duloxetine for nerve pain instead of gabapentin; citalopram instead of amitriptyline for depression.

The American Geriatrics Society now offers a free mobile app and pocket guide with these alternatives. It’s been downloaded over 87,000 times. Clinicians report saving an average of 8.2 minutes per patient because they don’t have to look up alternatives separately.

Why So Many Seniors Still Get Risky Prescriptions

Despite the evidence, only 41% of primary care practices consistently use the Beers Criteria. Why? Several reasons:

• Time-Doctors are rushed. A 15-minute visit doesn’t leave room for deep medication reviews.
• Lack of training-Many clinicians weren’t taught geriatric pharmacology in medical school.
• Cost-Some safer alternatives are more expensive. A senior on a fixed income might choose the cheaper, riskier drug.
• Assumptions-Doctors sometimes think, “They’ve been on this for years, it must be fine.” But older bodies change. What was safe at 70 isn’t always safe at 85.

And here’s a silent problem: Most seniors don’t know their meds are being evaluated against Beers. A 2023 survey found 61% of older adults had never heard of it. That means they’re not asking questions. They’re just taking pills.

What Patients Can Do

If you or a loved one is over 65 and on multiple medications, here’s what to do:

1. Ask your doctor: “Are any of my medications on the Beers Criteria list?”
2. Request a full medication review with a pharmacist-especially if you take eight or more drugs.
3. Don’t stop anything on your own. But do ask: “Is there a safer alternative?” or “Could this be stopped?”
4. Use the free Beers Criteria app or print the list from the American Geriatrics Society website. Bring it to appointments.

Medicare Part D now requires drug plans to use the Beers Criteria for beneficiaries on eight or more medications. That means your plan’s pharmacist should already be reviewing your list. But if they don’t bring it up, ask.

The Bigger Picture

The Beers Criteria isn’t about taking away drugs. It’s about making sure seniors get the right ones. It’s about preventing hospital trips, falls, memory loss, and confusion caused by medicines meant to help. It’s about dignity, safety, and quality of life.

Pharmaceutical companies are responding. Twenty-three new “senior-friendly” drugs have been developed to replace Beers-listed ones. The market for these is projected to hit $84 billion by 2027. The FDA has already required 17 Beers-listed drugs to add geriatric warnings to their labels.

But progress isn’t fast enough. In resource-limited settings, 63% of Beers-listed medications have no affordable alternative. That’s a global problem. In the U.S., we have tools. We just need to use them.

The Beers Criteria isn’t magic. It’s a tool. And like any tool, it only works if people know how to use it-and if they’re allowed to use it without being buried in alerts or pressured by cost.