The Beers Criteria: Potentially Inappropriate Medications for Seniors

Every year, thousands of older adults end up in the hospital because of medications that were supposed to help them. Not because they took too much, but because they took the wrong ones. The Beers Criteria exists to stop that.

What Exactly Is the Beers Criteria?

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 a lot of pills. And with age comes changes in how the body processes medicine-slower kidneys, weaker liver function, more sensitive brains. What’s safe for a 40-year-old might be dangerous for a 75-year-old.

Five Ways the Beers Criteria Protects Seniors

The 2023 Beers Criteria doesn’t just say “don’t use this.” It breaks things down into five clear categories to help providers make smarter choices.

1. Medications to avoid entirely-These are drugs with risks that almost always outweigh benefits. Examples: first-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. They’re often used for sleep or allergies, but they block acetylcholine, a brain chemical. That leads to confusion, dry mouth, constipation, and even falls. Moderate-quality evidence shows these drugs increase dementia risk over time.
2. Medications dangerous with certain conditions-NSAIDs like ibuprofen and naproxen are fine for healthy people, but they can cause fluid retention and worsen heart failure. For someone with congestive heart failure, even a daily Tylenol might be safer than an NSAID.
3. Medications to use with caution-Some drugs aren’t outright banned, but need extra care. Dabigatran (Pradaxa), an anticoagulant, increases bleeding risk in people over 75 or with kidney function below 30 mL/min. Warfarin might be a better choice here, even though it needs blood tests.
4. Harmful drug combinations-Mixing an anticholinergic (like oxybutynin for overactive bladder) with an opioid (like oxycodone) is a recipe for trouble. Both slow down gut movement and brain activity. The result? Severe constipation, urinary retention, and mental fog. These combos are a common cause of hospital visits.
5. Drugs needing kidney dose adjustments-Gabapentin, used for nerve pain, is cleared by the kidneys. If kidney function drops below 60 mL/min, the dose must be lowered. Otherwise, it builds up and causes dizziness, drowsiness, or even seizures.

The 2023 update added 32 new medications to the list and removed 18 based on new data. That’s how the science evolves. What was once considered safe might now be flagged-and vice versa.

How It Compares to Other Tools

There’s another guideline called STOPP/START, popular in Europe. It looks at both inappropriate prescriptions (STOPP) and missed opportunities (START). But in the U.S., the Beers Criteria dominates. Why? Because it’s built into Medicare’s rules.

Medicare Part D, which covers prescription drugs for seniors, now requires pharmacies and care teams to use the Beers Criteria when reviewing medications for people taking eight or more drugs. Over 87% of U.S. electronic health records have Beers alerts built in. In Europe, only 42% of systems use STOPP/START.

But Beers isn’t perfect. It flags medications based on the drug alone-not the reason it was prescribed. For example, antipsychotics like risperidone are on the list for dementia-related agitation. But in rare cases, when a patient is violent or hallucinating dangerously, the benefit might outweigh the risk. STOPP/START accounts for this better. Beers doesn’t.

Real Impact: Numbers That Matter

The Beers Criteria isn’t just theory. It saves lives.

When clinics use it properly, adverse drug events drop by 28%. One study found benzodiazepine prescriptions for insomnia in patients over 75 fell by 43% after EHR alerts were added. That’s huge. Benzodiazepines like lorazepam and diazepam increase fall risk by 50% in seniors.

But here’s the problem: 68% of geriatricians say the alerts help. But 32% of primary care doctors say they’re overwhelmed. One provider reported 12 Beers alerts per patient visit. That’s alert fatigue. When everything glows red, nothing stands out.

Pharmacists, who do detailed medication reviews, report 89% satisfaction. They’re trained to dig through the noise. Nurses and physicians often aren’t.

Implementation Challenges

Knowing the list isn’t enough. Using it consistently is harder.

Only 41% of primary care practices apply the Beers Criteria regularly, according to the CDC. Why? Time. Training. Lack of support.

Hospitals that succeed assign pharmacist-led teams to review flagged prescriptions. They don’t just delete the drug-they offer alternatives. For insomnia, instead of zolpidem (which is flagged), they suggest cognitive behavioral therapy. For chronic pain, they recommend physical therapy or acetaminophen over NSAIDs.

Renal dosing is another sticking point. Sixty-three percent of clinics struggle with adjusting doses for kidney problems. That’s why the 2026 update will expand kidney-specific guidance to cover 100% of medications cleared by the kidneys-up from 68% now.

What’s New in 2025: Alternatives Matter

In July 2025, the AGS released a companion guide: Alternative Treatments to Selected Medications in the 2023 Beers Criteria. This isn’t just “avoid this.” It’s “try this instead.”

For example:

• Instead of diphenhydramine for sleep: melatonin (low dose), sleep hygiene training, or light therapy.
• Instead of gabapentin for nerve pain: duloxetine (if no contraindications), physical therapy, or acupuncture.
• Instead of antipsychotics for agitation: environmental changes, music therapy, or caregiver education.

This shift-from warning to offering solutions-is a game-changer. It turns a list of “don’ts” into a roadmap for better care.

What’s Missing: The Cost Problem

Here’s a hard truth: sometimes the safer drug costs $200 a month. The flagged drug costs $5.

One in four seniors on Medicare skip doses or cut pills because of cost. The Beers Criteria doesn’t address this. Dr. Jerry Avorn from Harvard says this is a major flaw. A doctor might know clonazepam is risky for a senior with dementia-but if the alternative (a non-benzodiazepine sleep aid) is unaffordable, what’s the right choice?

That’s why some experts recommend pairing Beers with the Medication Appropriateness Index, which includes cost, adherence, and patient goals.

What Seniors Should Know

Most seniors don’t know their meds are being checked against the Beers Criteria. A 2023 survey found 61% of older adults were unaware their prescriptions were being reviewed for safety.

Ask your doctor or pharmacist: “Is this medication on the Beers Criteria list? Is there a safer option?”

Don’t assume your meds are fine just because they were prescribed years ago. Your body changes. Your other meds change. Your needs change.

Bring a full list of everything you take-including over-the-counter drugs, vitamins, and supplements-to every appointment. Many flagged medications are hidden in cold medicines, sleep aids, or antihistamines.

Final Thoughts: A Tool, Not a Rulebook

The Beers Criteria isn’t about taking away treatment. It’s about replacing risky choices with safer ones. It’s about respecting the aging body, not just treating symptoms.

It’s not flawless. It’s not perfect. But it’s the most widely used, evidence-backed tool we have to protect older adults from harm caused by their own medicine.

As the 2026 update rolls out-with AI tools in development and global translations expanding-it will keep getting better. The goal isn’t to eliminate all risk. It’s to reduce the preventable kind.