Every year, millions of older adults in the U.S. take medications that could do more harm than good. This isn’t because doctors are careless - it’s because aging changes how the body handles drugs. What was safe at 50 might be dangerous at 75. That’s where the Beers Criteria comes in. Developed by the American Geriatrics Society (AGS), it’s the most trusted guide in the U.S. for identifying medications that should be avoided or used with extreme caution in people aged 65 and older.

What 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 detailed, evidence-based tool updated every three years. The latest version, released in May 2023, is based on a review of over 7,000 high-quality studies. It’s not just a warning list - it’s a roadmap for safer prescribing. The criteria categorize medications into five groups: drugs that are generally unsafe for seniors, drugs that are risky with specific health conditions, drugs that need caution, harmful drug combinations, and drugs that require dose changes due to kidney problems.

It’s used everywhere - from hospitals to pharmacies to Medicare plans. In fact, Medicare Part D now requires pharmacies to check prescriptions against the Beers Criteria for seniors taking eight or more medications. The goal? Reduce hospital visits caused by bad drug reactions. Right now, about 23% of older adults living at home are on at least one medication flagged by the Beers Criteria. And nearly one in six hospital admissions among seniors is linked to these unsafe drugs.

Medications to Avoid Completely

Some drugs are simply too risky for older adults. The 2023 update kept a firm stance on several classes:

• First-generation antihistamines like diphenhydramine (Benadryl), hydroxyzine, and promethazine. These are still sold over the counter as sleep aids or allergy relief, but they block acetylcholine - a brain chemical critical for memory and focus. The result? Confusion, dizziness, falls, and even long-term cognitive decline. Studies show seniors using these drugs daily are twice as likely to develop dementia over five years.
• Benzodiazepines such as diazepam (Valium) and lorazepam (Ativan) for anxiety or insomnia. These drugs slow brain activity, increasing fall risk by 40%. Even short-term use can lead to dependence. Since the 2023 update, clinics using EHR alerts have cut benzodiazepine prescriptions for seniors over 75 by over 40%.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen. While fine for a young person with a sprained ankle, these drugs raise blood pressure, strain the kidneys, and can trigger heart failure in seniors. For someone with heart disease or high blood pressure, the risk of hospitalization from an NSAID is higher than the benefit of pain relief.

These aren’t "maybe" risks - they’re clear, evidence-backed dangers. The AGS panel gave strong recommendations against them based on data from tens of thousands of older patients.

When Medications Are Risky Based on Health Conditions

The Beers Criteria doesn’t treat all seniors the same. It adjusts warnings based on existing conditions. For example:

• If you have heart failure, NSAIDs are a no-go - they cause fluid retention that makes your heart work harder.
• If you have kidney disease, gabapentin (used for nerve pain) can build up to toxic levels. The 2023 update added specific dose thresholds: if your creatinine clearance drops below 60 mL/min, the dose must be cut in half.
• If you have prostate enlargement, anticholinergics like oxybutynin can cause urinary retention, leading to infections or bladder damage.
• If you have dementia, antipsychotics like risperidone or haloperidol are flagged. These drugs increase stroke risk and death in dementia patients - unless they’re used for severe aggression or psychosis that hasn’t responded to other treatments.

This is where the Beers Criteria shines. It’s not just about the drug - it’s about the person. A medication that’s dangerous for one senior might be necessary for another, depending on their full health picture.

Drug Interactions That Can Be Deadly

Seniors often take five or more medications. That’s a recipe for hidden dangers. The Beers Criteria highlights dangerous combos:

• Anticholinergics + opioids: This mix slows digestion so much it can cause severe constipation, bowel blockage, or even death.
• Warfarin + trimethoprim-sulfamethoxazole: The antibiotic boosts warfarin’s effect, raising bleeding risk dramatically.
• SSRIs + NSAIDs: Both can affect platelets, increasing the chance of stomach bleeding.

These aren’t rare. In fact, a 2022 study found that 38% of seniors on multiple medications had at least one dangerous interaction that wasn’t caught by their doctor. Electronic health record systems that flag these combos have cut adverse events by 28%.

Why the Beers Criteria Is Better Than Other Tools

Europe uses the STOPP/START guidelines, which focus more on whether a drug is appropriate for a specific condition. The Beers Criteria is different. It’s simpler, more direct, and built for U.S. systems. Over 87% of U.S. hospitals have it built into their electronic records. Medicare uses it to audit prescriptions. Pharmacies use it to block unsafe fills.

But it’s not perfect. One criticism is that it flags drugs as "inappropriate" even when they’re needed. For example, an antipsychotic might be the only thing keeping a dementia patient from hurting themselves or others. The Beers Criteria doesn’t always account for that. That’s why experts say it should be used with clinical judgment - not as a rulebook.

Still, when used right, it works. A 2021 study showed that clinics using the Beers Criteria reduced dangerous prescriptions by 28% and cut hospital visits by 19% within a year. That’s real impact.

How It’s Used in Real Clinics

Implementation isn’t automatic. Many doctors still miss it. But the best practices are clear:

• Electronic alerts: When a doctor tries to prescribe diphenhydramine to a 78-year-old, the EHR pops up a warning with alternatives. Epic Systems reports a 37% drop in flagged prescriptions within six months of adding the alert.
• Pharmacist reviews: Pharmacies are now the frontline. A 2023 survey found 89% of pharmacists say the Beers Criteria improved their ability to catch risky meds during medication reviews.
• Education: The AGS offers a free 2.5-hour course. Over 14,000 clinicians took it in 2023. The average provider takes 4-6 weeks to feel confident using the criteria.

There’s a tool for every setting: a free mobile app, a pocket guide, and even printable checklists. The app has been downloaded over 87,000 times. Users say it saves about 8 minutes per patient - time that can be spent talking to the patient instead of flipping through pages.

What’s New in 2023 - and What’s Coming

The 2023 update added 32 new medications to the list and removed 18. Why? New data. For example:

• Dabigatran (Pradaxa) was flagged for caution in seniors over 75 or with kidney function below 30 mL/min due to higher bleeding risk than warfarin.
• Meperidine (Demerol) was added as unsafe - it builds up a toxic metabolite in the kidneys that can cause seizures.
• Chlorpropamide, an old diabetes drug, was removed because it’s rarely used anymore.

And in July 2025, the AGS released something groundbreaking: Alternative Treatments to Selected Medications in the 2023 Beers Criteria. This guide doesn’t just say "don’t use" - it says "use this instead." For insomnia, it recommends cognitive behavioral therapy over benzodiazepines. For pain, it suggests physical therapy or acetaminophen over NSAIDs. For agitation, it points to environmental changes and non-drug therapies.

Looking ahead, the 2026 update will add kidney dosing guidance for every single drug cleared by the kidneys. Right now, only 68% of those drugs have clear rules. That gap is closing.

Challenges and Criticisms

Not everyone is thrilled. Some doctors say they get too many alerts - 12 per visit on average - and start ignoring them. This "alert fatigue" is real. Others say the criteria ignore cost. For example, a senior might be forced to switch from a cheap generic anticholinergic to a more expensive alternative. But what if they can’t afford it? The Beers Criteria doesn’t help there.

Harvard’s Dr. Jerry Avorn pointed out that 25% of seniors skip doses because of cost. Sometimes, the safest drug isn’t the most expensive one - it’s the one they’ll actually take. The Beers Criteria doesn’t solve that.

And then there’s awareness. Only 39% of seniors know their meds are being checked against the Beers Criteria. Patients need to be part of the conversation. If you’re over 65 and take multiple meds, ask: "Are any of these on the Beers list? Is there a safer option?"

What You Can Do

If you or a loved one is over 65 and on multiple medications:

• Ask your doctor or pharmacist: "Is any of my medication on the Beers Criteria list?"
• Bring a full list of all meds - including supplements and OTC drugs.
• Ask: "Is there a non-drug option?" For sleep, pain, or anxiety, therapy, exercise, or lifestyle changes often work better and safer.
• Don’t stop a drug on your own. Talk first.

The goal isn’t to cut meds - it’s to replace risky ones with safer ones. Sometimes, the best treatment is no pill at all.

Next Steps

If you’re a senior or caring for one, start with a medication review. Don’t wait for a crisis. Ask your pharmacist to run your list against the Beers Criteria. If you’re a provider, use the free AGS app or EHR alerts - they’re designed to save time, not add burden. The goal isn’t to eliminate drugs. It’s to make sure every pill you take is truly necessary - and safe.