The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, millions of older adults in the U.S. take medications that could do more harm than good. This isn’t due to poor doctors or careless patients-it’s because many common drugs, even those prescribed for decades, carry hidden dangers for people over 65. The Beers Criteria exists to change that. Developed by the American Geriatrics Society (AGS), it’s the most trusted guide in the U.S. for identifying medications that should be avoided, used with caution, or replaced in older adults. If you or a loved one is on multiple prescriptions, this isn’t just a clinical guideline-it’s a lifeline.

What Exactly Is the Beers Criteria?

The Beers Criteria started in 1991 as a simple list of drugs to avoid in nursing homes. Today, it’s a living, updated tool used in hospitals, clinics, pharmacies, and even Medicare plans. The latest version came out in May 2023, after experts reviewed over 7,300 studies. It’s not a list of banned drugs. It’s a smart, evidence-based filter that helps doctors ask: Is this medication still the best choice for someone in their 70s, 80s, or beyond?

Why does this matter? 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 often lead to multiple prescriptions. And with age, the body changes. Kidneys slow down. Liver metabolism drops. The brain becomes more sensitive to side effects. What was safe at 50 can become dangerous at 75.

The Five Rules of the 2023 Beers Criteria

The 2023 update organizes its guidance into five clear categories. Each one helps clinicians spot risks before they become emergencies.

1. Medications to Avoid Completely - These drugs have clear, strong evidence of harm with little benefit. Examples include first-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. They’re often used for sleep or allergies, but they block acetylcholine, a brain chemical critical for memory and focus. The result? Confusion, falls, and even long-term cognitive decline. Studies show these drugs increase dementia risk by up to 50% in long-term users.
2. Medications to Avoid With Certain Conditions - A drug might be fine for most people but dangerous with specific health issues. For example, NSAIDs like ibuprofen or naproxen are common for arthritis, but they can worsen heart failure, raise blood pressure, or cause kidney damage. If someone has heart failure or chronic kidney disease, these drugs are often off-limits.
3. Medications to Use With Caution - These aren’t banned, but they need extra care. Dabigatran (Pradaxa), an anticoagulant, is a good example. It’s safer than warfarin for many, but for people over 75 or with kidney function below 30 mL/min, the risk of internal bleeding spikes. Dose adjustments aren’t optional-they’re essential.
4. Dangerous Drug Interactions - Some combinations are a recipe for disaster. Taking an anticholinergic (like oxybutynin for overactive bladder) with an opioid (like oxycodone for pain) can cause severe constipation, urinary retention, and mental fog. These interactions don’t always show up on standard drug interaction checkers. The Beers Criteria flags them specifically.
5. Medications Needing Kidney Dose Adjustments - Over half of all medications are cleared by the kidneys. As kidney function declines with age, doses must drop. Gabapentin, often used for nerve pain or seizures, is a classic case. At normal doses, it can cause dizziness, falls, and confusion in seniors. The 2023 update now requires specific dosing rules based on creatinine clearance-something many providers still overlook.

The 2023 list includes 134 medications or classes. That’s 32 more than in 2019, and 18 were removed because newer evidence showed they were safer than once thought. This isn’t static-it evolves with science.

How It Compares to Other Tools

You might hear about STOPP/START, another guideline used mostly in Europe. It’s different. STOPP/START focuses on why a drug is prescribed. If a senior has heart failure and is on an NSAID, STOPP says: “Stop this because of your condition.” The Beers Criteria says: “NSAIDs are risky for anyone over 65 with heart failure.”

The Beers Criteria wins in the U.S. because it’s built into Medicare systems. If you’re on Medicare Part D and take eight or more medications, your pharmacist is required to review your list against the Beers Criteria. Nearly 87% of U.S. electronic health records now have automated Beers alerts. In contrast, only 42% of European systems use STOPP/START.

But it’s not perfect. The Beers Criteria can flag a drug as inappropriate-even if it’s the only thing keeping someone comfortable. For example, antipsychotics like risperidone are flagged for dementia-related agitation. But in rare cases, when a person is in severe distress and non-drug options have failed, they may still be necessary. That’s why the 2025 update added an Alternatives List-offering non-drug options like cognitive behavioral therapy for insomnia instead of benzodiazepines.

Real Impact in Practice

When used right, the Beers Criteria saves lives. One study found that clinics using EHR alerts based on the 2023 criteria cut benzodiazepine prescriptions for seniors over 75 by 43% in just one year. That’s 43% fewer people at risk of falls, fractures, and hospital stays.

But it’s not always smooth. Many doctors say they get overwhelmed. One primary care physician reported 12 Beers alerts per patient visit. That’s alert fatigue. When every alert sounds like an emergency, important ones get ignored. The key is smart integration-filtering alerts by risk level, not just listing every flagged drug.

Pharmacists, on the other hand, love it. Eighty-nine percent say it gives them the clarity they need to speak up during medication reviews. They’re often the first to spot a dangerous combo that a doctor missed.

What You Can Do

Most seniors don’t know their meds are being checked against the Beers Criteria. Only 39% of patients surveyed said they’d ever heard of it. That’s a problem. You can’t advocate for your health if you don’t know what to ask.

• Ask your doctor: “Are any of my medications on the Beers Criteria list?”
• Request a full medication review with a pharmacist-especially if you take five or more pills daily.
• Don’t assume a drug is safe just because it’s been prescribed for years. Your body changes. So should your meds.
• Use the free AGS Beers Criteria mobile app. It’s updated quarterly and lets you search by drug name or condition.

Also, ask about alternatives. For pain, can you try physical therapy instead of NSAIDs? For sleep, can you try sleep hygiene and CBT instead of diphenhydramine? The 2025 Alternatives List gives clear, evidence-backed options for nearly every flagged drug.

The Bigger Picture

The Beers Criteria isn’t just about avoiding bad drugs-it’s about rethinking how we treat older adults. Too often, we treat symptoms with pills instead of root causes. A fall isn’t just a fracture-it’s a sign that a medication might be making balance worse. Insomnia isn’t just a sleep issue-it might be caused by a drug that’s too strong for aging kidneys.

Medicare now requires Beers reviews for 12.7 million beneficiaries. The FDA has added geriatric warnings to 17 Beers-listed drugs. Pharmaceutical companies are developing 23 new “senior-friendly” alternatives. This isn’t a niche guideline anymore-it’s reshaping how medicine is delivered to older adults.

Still, gaps remain. One in four seniors skips doses because they can’t afford their meds. The Beers Criteria doesn’t address cost. A cheaper, risky drug might be the only option. And in rural areas or low-income clinics, EHR alerts aren’t always available. Implementation is uneven.

That’s why the 2026 update will focus on kidney dosing for every drug eliminated through the kidneys-not just 68%, but 100%. And AI tools are being tested to predict which patients are most at risk before a bad reaction even happens.

Final Thought

The Beers Criteria doesn’t say “never use this drug.” It says: “Think harder. Look closer. Ask better questions.” It’s not about limiting treatment-it’s about making sure treatment actually helps, not hurts. For older adults, that distinction can mean the difference between independence and hospitalization, between clarity and confusion, between life and a preventable fall.