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 a mistake - sometimes it’s just a drug that was fine for a 45-year-old but turns dangerous for someone over 65. 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 doctors and pharmacists use to avoid harmful drugs in seniors. The latest version, released in May 2023, is based on over 7,000 studies and lists 134 medications or drug classes that carry more risk than benefit for older adults.

What the Beers Criteria Actually Says

The Beers Criteria isn’t a list of banned drugs. It’s a practical tool that tells clinicians: these medications can cause more harm than good in people over 65. The list is broken into five clear sections. First, there are drugs that should generally be avoided - no exceptions. That includes first-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. These are often sold over the counter as sleep aids or allergy pills, but they block acetylcholine in the brain. In seniors, that leads to confusion, memory lapses, dry mouth, constipation, and even urinary retention. A 2023 study found seniors taking these drugs were 30% more likely to be admitted for delirium than those who didn’t.

Drugs That Are Risky With Certain Conditions

Some medications are okay for healthy people but dangerous if you have a specific health problem. Take NSAIDs - ibuprofen, naproxen, celecoxib. They’re common for arthritis pain, but if you have heart failure, they can make fluid retention worse and raise blood pressure. The Beers Criteria says: don’t use them at all in heart failure patients. Same with long-term proton pump inhibitors (PPIs) like omeprazole. They’re great for acid reflux, but after six months, they increase the risk of bone fractures, kidney damage, and C. diff infections in older adults. The guideline doesn’t say never use them - it says reassess after six months and consider stopping.

Medications That Need Extra Caution

Then there are drugs that aren’t outright banned, but need serious caution. Dabigatran (Pradaxa), for example, is an anticoagulant used to prevent strokes in atrial fibrillation. But if you’re over 75 or your kidneys aren’t working well (creatinine clearance under 30 mL/min), your risk of serious bleeding skyrockets. Warfarin may be harder to manage, but it’s often safer in this group. Gabapentin is another one. It’s widely prescribed for nerve pain, but it builds up in the body if kidneys are impaired. At normal doses, it can cause dizziness, falls, and confusion. The 2023 update added specific dose reductions: cut the dose by half if creatinine clearance is under 60 mL/min.

Bad Drug Combos

The Beers Criteria also warns about dangerous combinations. One of the most common is mixing anticholinergics - like oxybutynin for overactive bladder - with opioids like oxycodone. Both cause constipation. Together, they can lead to bowel obstruction. Both cause drowsiness. Together, they increase fall risk. Even worse, both suppress mental function. In older adults, this combo can look like dementia - but it’s reversible if you stop the drugs. The 2023 update added 32 new drug pairs to this section, including combinations involving benzodiazepines and sedating antidepressants.

Renal Dosing Is Critical

Kidneys slow down with age. Many drugs are cleared through the kidneys, and if doses aren’t adjusted, they build up to toxic levels. The Beers Criteria now includes renal dosing guidance for 68% of medications that leave the body through the kidneys - up from 52% in 2019. But there’s still a gap. Drugs like metformin, ciprofloxacin, and tramadol all need dose changes based on kidney function. Many doctors still prescribe the standard adult dose. Pharmacists are often the ones catching this - which is why medication reviews by pharmacists reduce adverse events by nearly 30%.

How It Compares to Other Tools

In Europe, many doctors use the STOPP/START criteria instead. STOPP/START looks at both inappropriate prescribing and missed opportunities - like not prescribing a statin when it’s clearly needed. The Beers Criteria is narrower: it focuses on what to avoid. That makes it simpler to use in electronic health records. In the U.S., 87% of hospitals have Beers Criteria alerts built into their systems. Only 42% of European systems use STOPP/START. But Beers has a blind spot: it doesn’t tell you what to prescribe instead. That’s why the July 2025 update added the “Alternative Treatments” list - 147 evidence-based options, from cognitive behavioral therapy for insomnia to tai chi for chronic pain.

Real-World Impact

When clinics use the Beers Criteria properly, results show up fast. One study found a 43% drop in benzodiazepine prescriptions for insomnia in patients over 75 after EHR alerts were turned on. Another hospital saw a 37% reduction in inappropriate prescribing within six months of integrating the guidelines. Medicare now requires all Part D plans to use the Beers Criteria when reviewing prescriptions for beneficiaries taking eight or more drugs. That affects over 12 million people. The FDA has also responded - 17 drugs on the Beers list now carry new geriatric warnings on their labels.

But It’s Not Perfect

The biggest complaint from doctors? Alert fatigue. One primary care physician said their system throws up 12 Beers alerts per patient visit. Many are low-risk or false positives. A patient with dementia might need an antipsychotic for severe aggression - even though the Beers Criteria flags it as inappropriate. That’s why the guidelines stress clinical judgment. The list isn’t a rulebook. It’s a warning sign. Some drugs are necessary, even if they’re on the list. The key is knowing why you’re using them and monitoring closely.

What Patients Should Know

Only 39% of seniors know their medications are being checked against the Beers Criteria. That’s a problem. If you’re over 65 and taking five or more drugs, ask your doctor or pharmacist: “Are any of these on the Beers list?” Don’t be afraid to ask for alternatives. If you’re on diphenhydramine for sleep, ask about melatonin or sleep hygiene. If you’re on an NSAID for back pain, ask about physical therapy or acetaminophen. Many seniors are on drugs they don’t need - and they’ve been taking them for years.

How to Use It

If you’re a patient, the best thing you can do is get a full medication review once a year. Bring all your pills - including supplements and OTCs - to your pharmacist or geriatrician. If you’re a provider, use the free AGS Beers Criteria app. It’s updated quarterly and lets you search by drug, condition, or kidney function. The app saves an average of 8.2 minutes per patient. That’s time you can spend talking to the person, not scrolling through alerts.

What’s Next

The 2026 update will expand renal dosing to cover 100% of kidney-cleared medications. The American Geriatrics Society is also working with Google Health AI to predict which seniors are most at risk for adverse drug events - before they happen. Meanwhile, the market for “senior-friendly” drugs is booming. Over 23 new medications have been developed to replace Beers-listed drugs, and the industry expects it to hit $84 billion by 2027.

The Beers Criteria isn’t magic. It doesn’t fix poor prescribing habits overnight. But when used right - with clinical judgment, patient input, and pharmacist support - it saves lives. It reduces hospital stays. It keeps older adults alert, mobile, and independent. And that’s worth paying attention to.

If you’re over 65 and taking multiple medications, don’t wait for your doctor to bring it up. Ask about the Beers Criteria. Ask if any of your drugs could be replaced. Ask for a full review. Your safety is worth the conversation.