The Beers Criteria is a set of guidelines that identifies medications considered potentially inappropriate for adults aged 65 and older. Maintained by the American Geriatrics Society (AGS), it serves as a reference tool for doctors, pharmacists, and caregivers to reduce the risk of harmful drug side effects in older people. About 40% of adults over 65 are currently prescribed at least one medication on the list.
Why Older Adults Need a Separate Drug Safety List
As you age, your body processes medications differently. Your liver slows down its ability to break down certain drugs, your kidneys become less efficient at filtering them out, and your brain becomes more sensitive to sedating effects. A medication that works perfectly fine for a 40-year-old can cause confusion, dangerous falls, or organ damage in a 75-year-old at the same dose.
The Beers Criteria exists to flag these risks. It was first developed in 1991 by geriatrician Mark Beers and has been updated regularly since then, with the most recent version published in 2023. The criteria are not a hard ban on any medication. They’re designed to support conversations between patients and their doctors, helping ensure that the benefits of a drug genuinely outweigh the risks for someone’s age and health profile.
The Five Categories of Risk
The criteria organize potentially problematic medications into five lists:
- Medications to avoid in most older adults (outside of hospice and palliative care), regardless of other health conditions.
- Medications to avoid with specific health conditions, where a pre-existing problem like dementia or a history of falls makes the drug especially dangerous.
- Drug combinations to avoid because of harmful interactions between two or more treatments taken together.
- Medications to use with caution because they carry a meaningful risk of side effects, even though they may still be appropriate in some cases.
- Medications that need dose adjustments based on kidney function, since reduced kidney performance changes how quickly drugs leave the body.
This structure means a medication might appear on more than one list. A drug could be fine for most older adults but flagged specifically for someone with cognitive impairment or poor kidney function.
Medications Most Commonly Flagged
Two drug classes appear repeatedly across the criteria because of how sharply their risks increase with age.
Anticholinergic Medications
Anticholinergics are a broad group of drugs used for everything from allergies and overactive bladder to sleep aids and certain antidepressants. They work by blocking a chemical messenger in the nervous system, which is also why they cause side effects like dry mouth, constipation, and blurred vision. In older adults, the problems go further: cumulative exposure to these drugs is linked to increased risk of falls, delirium, and dementia. The body clears them more slowly with age, so the effects build up.
Taking more than one anticholinergic medication at a time compounds the danger, raising the likelihood of cognitive decline and fractures. The criteria recommend avoiding them entirely in older adults who have dementia, are at risk of delirium, or have a history of falls.
Benzodiazepines
Benzodiazepines are commonly prescribed for anxiety, insomnia, and muscle spasms. Older adults are more sensitive to their sedating effects and slower to metabolize longer-acting versions, which means the drugs can linger in the body and accumulate. The risks include cognitive impairment, delirium, falls, fractures, physical dependence, and motor vehicle crashes. When combined with opioid painkillers, the risk of overdose, severe sedation, and respiratory failure rises dramatically. Like anticholinergics, they’re flagged for avoidance in people with dementia, delirium risk, or fall history.
Safer Alternatives the Criteria Recommend
The Beers Criteria isn’t just a list of drugs to avoid. Companion guidance highlights safer options for many of the conditions these medications treat.
For insomnia, rather than reaching for benzodiazepines or sedating antihistamines, cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line approach. It’s a structured program that addresses the thought patterns and habits that keep you awake. If medication is still needed short-term, newer sleep aids that work through different brain pathways carry less risk of dependence and next-day grogginess.
For chronic pain, the criteria steer away from older antidepressants, oral anti-inflammatory drugs like ibuprofen, and muscle relaxants. Instead, the emphasis is on exercise therapy, physical therapy, and psychological approaches. When a drug is needed, topical options (pain-relieving gels and patches applied to the skin) or acetaminophen are preferred because they avoid the systemic side effects that come with pills.
For acid reflux, long-term use of proton pump inhibitors (PPIs) beyond eight weeks is flagged. Lifestyle changes, weight management, and elevating the head of the bed at night are recommended first. For breakthrough symptoms, milder acid-reducing medications are safer long-term alternatives.
For diabetes management in older adults, certain older insulin regimens and sulfonylureas carry a higher risk of dangerous blood sugar drops. Newer classes of diabetes drugs offer blood sugar control with a lower risk of these episodes, and some provide additional benefits for heart and kidney health.
How Common the Problem Actually Is
Potentially inappropriate prescribing in older adults is not a niche concern. Nearly half of nursing home residents are exposed to at least one medication on the Beers list, and that prevalence has increased over time rather than decreased. In the broader population of adults over 65, the 40% figure means tens of millions of people are taking a flagged medication at any given time.
This doesn’t mean every one of those prescriptions is wrong. In some cases, a Beers-listed drug is the best available option after weighing the alternatives. But the numbers suggest that many older adults are taking medications whose risks haven’t been fully reconsidered as they’ve aged. Prescriptions started at 55 often carry forward into the 70s and 80s without reassessment.
How the Criteria Are Used in Practice
The AGS is explicit that the Beers Criteria should support clinical decision-making, not replace it. A medication appearing on the list doesn’t mean it should be stopped immediately or never prescribed. It means the prescribing decision deserves a closer look, weighing the individual’s full health picture, other medications, kidney function, and personal preferences.
Pharmacists use the criteria to flag potential issues during medication reviews. Hospitals and nursing facilities use them as quality benchmarks. Insurance plans sometimes reference them when evaluating prescribing patterns. For patients and caregivers, the criteria offer a useful framework for asking informed questions: “Is this medication on the Beers list? Is there a safer alternative? Has my kidney function been checked recently enough to know this dose is right?”
If you’re over 65, or caring for someone who is, reviewing the current medication list against the Beers Criteria with a pharmacist or doctor is one of the most practical steps you can take to reduce the risk of drug-related harm. Deprescribing, the careful process of tapering or stopping unnecessary medications, is increasingly recognized as an important part of healthcare for older adults.