The Beers List, formally known as the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, is a set of guidelines for healthcare professionals. Its purpose is to improve the safety of prescribing medications for older adults by identifying drugs that pose risks that outweigh their benefits in this population. The list serves as a screening tool to help reduce adverse drug events (ADEs), which are a significant cause of illness and hospitalization among older individuals. It informs clinical decision-making, helping practitioners select safer alternatives when possible.
The Origin and Target Population
The concept originated in 1991 when Dr. Mark Beers and colleagues first published a list of potentially inappropriate medications for nursing home residents. The list was later expanded to include all settings of geriatric care, with the American Geriatrics Society (AGS) officially taking over the stewardship and regular updating of the criteria since 2011. This consistent review process ensures the list remains current with emerging medical evidence and newly approved medications.
The primary target population for the Beers Criteria is adults aged 65 and older in all care settings, excluding hospice and end-of-life care. Aging causes physiological changes that alter how the body processes medications, which makes this population uniquely vulnerable. For example, a decrease in kidney function can slow the elimination of certain drugs, causing them to build up to toxic levels in the body.
Older adults frequently manage multiple chronic conditions, often requiring several different medications at once, a practice known as polypharmacy. These multiple prescriptions increase the likelihood of harmful drug-drug interactions and cumulative side effects. The criteria address these heightened risks, which include an increased potential for falls, cognitive impairment, and delirium. The Beers List offers a systematic method to evaluate complex medication regimens and promote safer prescribing practices.
Classifying High-Risk Medications
The Beers Criteria organizes potentially inappropriate medications (PIMs) into distinct categories to address different types of risk in older adults. This categorization helps clinicians understand the specific reason a medication is flagged, whether due to inherent properties or interactions with other conditions. The complete list of PIMs functions as a detailed warning system for different clinical scenarios.
Medications Generally Avoided
The most direct category includes drugs that should almost always be avoided by older adults due to a high risk of adverse effects, regardless of a person’s other medical conditions. These medications have a poor risk-benefit balance, meaning safer and equally effective alternatives are typically available. A common example is certain first-generation antihistamines, such as diphenhydramine, which possess strong anticholinergic properties that can lead to confusion, dry mouth, and urinary retention.
Other medications in this category include specific muscle relaxants and some older types of anxiety drugs, like certain benzodiazepines, which are associated with an increased risk of falls, fractures, and cognitive decline. These adverse outcomes are linked to the drug’s effects on the central nervous system, which are amplified in the aging brain. The criteria flag these medications because their potential for harm often outweighs any short-term benefit they may provide.
Medications to Use With Caution
This section identifies medications that may be acceptable under limited circumstances but require heightened clinical monitoring or dose adjustments. This group includes drugs where the potential for harm is significant, often depending on the patient’s overall health and dose. Certain antidepressants, for example, may increase the risk of falls or cause Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), leading to dangerously low sodium levels.
This cautious approach also applies to some anticoagulants, which are necessary for many conditions but carry an elevated risk of severe bleeding in older adults. The criteria advise that if a medication from this group is used, the patient must be closely watched for side effects, and the lowest effective dose should be maintained. These cautions acknowledge that for some individuals, the benefit of treating a condition might justify the carefully managed risk.
Drug-Disease/Syndrome Interactions
The criteria also list medications that are potentially inappropriate for older adults who have specific diseases or syndromes because the drug can worsen the existing condition. For instance, certain non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with heart failure because they can cause fluid retention. Similarly, certain antipsychotic medications carry a warning for individuals with dementia, as their use is linked to an increased risk of stroke and cognitive decline.
This section emphasizes that the appropriateness of a drug often depends on the patient’s entire clinical profile, not just the medication itself. The criteria also address medications whose dose should be adjusted based on the patient’s kidney function, as impaired renal function is common in older adults and affects drug clearance. These detailed interactions ensure that prescribing is tailored to the individual’s unique health challenges.
Practical Use and Common Misconceptions
Healthcare providers use the Beers Criteria as a screening tool during medication reviews to identify and question prescriptions that could be harmful to an older patient. This process is often part of “deprescribing,” which involves carefully reducing or stopping medications whose risks have increased over time. The list helps initiate a conversation between the provider and the patient about medication safety and alternatives.
A frequent misconception is that the Beers List is a mandatory ban on all listed medications. The criteria are explicitly labeled as “potentially” inappropriate because they are a guide, not a regulatory mandate, and do not replace the judgment of a skilled clinician. In rare cases, a medication on the list may still be the best option for a patient, such as when the benefit clearly outweighs the risk. The criteria encourage shared decision-making, where the provider discusses the risks and benefits with the patient to determine the most appropriate course of action.
Patients and caregivers can use the information to be informed partners in their healthcare. If a medication on the list is prescribed, it is appropriate to ask the doctor or pharmacist why that specific drug was chosen and what side effects to watch for. This informed dialogue ensures that any decision to continue or discontinue a medication is made thoughtfully, prioritizing the individual patient’s unique needs and goals of care.