What Is the Beers Criteria?
The Beers Criteria is a practical, evidence-based guide that helps doctors and pharmacists avoid prescribing medications that are more likely to harm than help older adults. First created in 1991 by Dr. Mark Beers, it was later taken over and regularly updated by the American Geriatrics Society (AGS). The latest version came out in May 2023, after reviewing over 7,300 studies. It’s not a strict rulebook-it’s a tool. Think of it like a checklist doctors use to spot drugs that could cause confusion, falls, kidney damage, or even hospital stays in people over 65.
Why does this matter? Seniors make up just 13.5% of the U.S. population, but they take a third of all prescription drugs. That’s not because they’re sicker-it’s because they often see multiple doctors, get prescriptions from different specialists, and end up on too many pills at once. This is called polypharmacy, and it’s one of the biggest hidden dangers in senior healthcare.
What Medications Are on the List?
The 2023 Beers Criteria lists 134 medications or drug classes that are flagged as potentially inappropriate for older adults. These aren’t banned-they’re flagged because the risks often outweigh the benefits. Some of the most common ones include:
- First-generation antihistamines like diphenhydramine (Benadryl) and hydroxyzine. These are often sold as sleep aids or allergy meds, but they block acetylcholine in the brain, which can cause memory problems, dry mouth, constipation, and even delirium. Studies show they increase fall risk by up to 50% in seniors.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen. These are fine for short-term use in young people, but in older adults with high blood pressure, heart failure, or kidney issues, they can cause fluid retention, kidney failure, or stomach bleeds.
- Benzodiazepines such as lorazepam (Ativan) and diazepam (Valium). These are sedatives prescribed for anxiety or insomnia, but they slow reaction time and increase fall risk by 60%. The 2023 update specifically warns against using them for sleep in people over 75.
- Antipsychotics like risperidone and haloperidol. These are sometimes used off-label to calm dementia-related agitation, but they raise the risk of stroke and sudden death. The guidelines say they should only be used as a last resort, with close monitoring.
- Gabapentin and other drugs cleared by the kidneys. Many seniors have reduced kidney function, and gabapentin can build up in the body, causing dizziness, confusion, or even breathing problems if not properly dosed.
Since 2019, 32 new drugs were added to the list, and 18 were removed because newer research showed they were safer than previously thought. For example, some older antidepressants like amitriptyline were downgraded after studies showed they’re not much worse than newer ones if used carefully.
How the Criteria Works in Practice
The Beers Criteria doesn’t just say “don’t use this drug.” It’s broken into five clear sections:
- Drugs to avoid altogether-like anticholinergics in people with dementia.
- Drugs to avoid with certain conditions-like NSAIDs if you have heart failure.
- Drugs to use with caution-like dabigatran (Pradaxa) in people over 75 or with poor kidney function.
- Drug interactions to watch for-like combining opioids with anticholinergics, which can cause dangerous constipation or breathing trouble.
- Drugs needing kidney dose adjustments-like metformin or gabapentin, where dosage must drop as kidney function declines.
Doctors don’t just flip through a printed list. Most hospitals and clinics now have the Beers Criteria built into their electronic health records (EHRs). When a doctor types in a prescription for diphenhydramine for an 80-year-old, a pop-up warning appears. It doesn’t block the prescription-it just says, “This drug is flagged by the Beers Criteria. Consider alternatives.”
How It Compares to Other Tools
There are other tools out there, like STOPP/START, which is more common in Europe. STOPP/START looks at both inappropriate drugs and drugs that should be prescribed but aren’t-like blood pressure meds for someone with heart failure who’s not on them. The Beers Criteria focuses only on what not to give.
That’s a strength and a weakness. The Beers Criteria is simpler to use in busy clinics, which is why 87% of U.S. healthcare systems use it, compared to just 42% in Europe. But it can sometimes flag a drug that’s actually necessary-for example, an antipsychotic for a senior with severe, treatment-resistant psychosis. That’s why doctors need to use it as a guide, not a law.
Real-World Impact
When clinics actually use the Beers Criteria properly, results are clear. One study found that hospitals using EHR alerts tied to the Beers Criteria reduced inappropriate prescribing by 37% in just six months. In primary care, benzodiazepine prescriptions for seniors over 75 dropped by 43% after alerts were added.
But adoption is still patchy. Only 41% of U.S. primary care practices consistently apply the criteria, according to the CDC. Why? Because alerts can be overwhelming. One doctor reported getting 12 Beers-related pop-ups per patient visit. If every alert is treated the same, doctors start ignoring them. That’s called “alert fatigue.”
Pharmacists are the real heroes here. They spend time reviewing full medication lists, catching interactions, and suggesting safer alternatives. In one study, 89% of pharmacists said the Beers Criteria made their job more effective. They’re the ones who say, “Try melatonin instead of diphenhydramine for sleep,” or “Switch from ibuprofen to acetaminophen for pain.”
What Are the Alternatives?
The 2023 update included something new: a list of safer alternatives. This was a game-changer. Instead of just saying “don’t use this,” it now says, “Here’s what you can use instead.”
- For insomnia: Instead of benzodiazepines or diphenhydramine, try cognitive behavioral therapy for insomnia (CBT-I)-it’s more effective long-term and has no side effects.
- For chronic pain: Skip NSAIDs. Try physical therapy, low-dose acetaminophen, or topical capsaicin.
- For anxiety: Avoid benzodiazepines. Try SSRIs like sertraline, or mindfulness-based stress reduction.
- For BPH (enlarged prostate): Skip oxybutynin. Try tamsulosin or lifestyle changes like limiting evening fluids.
Even better, many of these alternatives cost less. For example, CBT-I can be done via app or group sessions for under $100, while a year’s supply of sleeping pills can cost $500 or more.
Why Some Doctors Resist
Not everyone loves the Beers Criteria. Dr. Jerry Avorn from Harvard points out a big gap: it ignores cost. Many seniors skip their meds because they’re too expensive. Sometimes, a flagged drug like diphenhydramine is the only affordable sleep aid they can get. The criteria doesn’t help with that dilemma.
Also, in palliative care, some “inappropriate” drugs are necessary. A dying patient with severe agitation might need an antipsychotic-even if the Beers Criteria says not to. Guidelines are meant to help, not hurt. That’s why experienced clinicians know to bend the rules when the situation demands it.
What Seniors and Families Should Know
Most older adults have no idea their meds are being reviewed against the Beers Criteria. A 2023 survey found that 61% of seniors weren’t even aware such a list existed. That’s a problem.
If you or a loved one is over 65 and takes five or more medications, ask your doctor or pharmacist: “Are any of these on the Beers Criteria list?” Don’t be afraid to ask for alternatives. Bring a full list of everything you take-including vitamins, supplements, and over-the-counter drugs. Many seniors don’t realize that Benadryl or Pepto-Bismol count as medications too.
The American Geriatrics Society offers a free mobile app and pocket guide with the latest list. It’s updated quarterly. You can download it and bring it to appointments.
What’s Next?
The 2026 update will expand kidney dosing guidance to cover every drug cleared by the kidneys-not just 68% of them, like now. The AGS is also teaming up with Google Health AI to build predictive tools that flag patients most at risk before they even get a dangerous prescription.
Meanwhile, drug companies are rushing to make “senior-friendly” alternatives. The market for these drugs is expected to hit $84 billion by 2027. That’s good news-if the new drugs are truly safer and not just more expensive versions of the old ones.
The Beers Criteria isn’t perfect. But it’s the best tool we have to keep older adults safe from the hidden dangers of medication. When used wisely, it doesn’t just prevent side effects-it improves quality of life. Less confusion. Fewer falls. Better sleep. More independence.
Frequently Asked Questions
Is the Beers Criteria only for people in nursing homes?
No. The Beers Criteria applies to all adults aged 65 and older, whether they live at home, in assisted living, or in a nursing facility. It was originally developed for nursing homes in 1991, but today it’s used in hospitals, clinics, pharmacies, and home care settings across the U.S.
Can I stop taking a Beers-listed medication on my own?
Never stop a prescribed medication without talking to your doctor. Some drugs, like blood pressure or antidepressant medications, can cause dangerous withdrawal symptoms if stopped suddenly. If you’re concerned about a drug on the Beers list, ask your doctor or pharmacist for a safer alternative or a gradual taper plan.
Why are antihistamines like Benadryl on the list?
First-generation antihistamines like diphenhydramine (Benadryl) have strong anticholinergic effects, meaning they block a brain chemical called acetylcholine. In older adults, this can cause confusion, memory loss, dry mouth, constipation, urinary retention, and even delirium. Studies show they increase the risk of dementia with long-term use. Safer options for allergies or sleep include loratadine (Claritin) or melatonin.
Does Medicare require doctors to follow the Beers Criteria?
Yes, for certain beneficiaries. Since 2024, Medicare Part D requires all prescription drug plans to use the Beers Criteria when managing medications for dual-eligible patients (those on both Medicare and Medicaid). Pharmacists must review the medication lists of people taking eight or more prescriptions, and flag any Beers-listed drugs. This doesn’t mean the drug is denied-it means it’s reviewed for safety.
Are there any apps or tools to check if my meds are on the Beers list?
Yes. The American Geriatrics Society offers a free mobile app called “AGS Beers Criteria” that’s updated quarterly. You can search by drug name or browse the full list. It also includes alternatives and dosing tips for kidney problems. Many pharmacies also have internal tools that flag Beers-listed drugs when filling prescriptions.