Getting older comes with certain privileges: experience, perspective, senior discounts, and the right to roll your eyes when someone calls 1995 “ancient history.” Unfortunately, aging also changes how the body handles medications. A drug that worked perfectly well at age 45 may cause dizziness, confusion, bleeding, or other problems at age 75.
That is where the Beers Criteria comes in. More formally known as the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, this clinical resource helps healthcare professionals identify medications that may carry more risk than benefit for many people age 65 and older.
The key word is potentially. The Beers Criteria is not a giant red “NEVER TAKE THIS” stamp. Instead, it is a screening and decision-support tool. A medication on the list may still be the right choice for a particular patient. The goal is to encourage a closer look at the dose, duration, medical conditions, kidney function, drug interactions, available alternatives, andmost importantlythe older adult’s own treatment goals.
What Is the Beers Criteria, Exactly?
The Beers Criteria is an evidence-based list of medications and medication-related situations that deserve special attention when treating adults age 65 and older. It is widely used by physicians, pharmacists, nurses, health systems, researchers, and other professionals involved in geriatric care.
The criteria were first developed in 1991 by geriatrician Dr. Mark Beers and colleagues. The American Geriatrics Society, commonly abbreviated as AGS, later became responsible for maintaining and updating the resource. As of 2026, the current full edition remains the 2023 AGS Beers Criteria. In 2025, the AGS also released a companion resource discussing alternatives to selected medications in the 2023 criteria.
The 2023 update was based on an extensive review of medical evidence and retained the familiar five-part framework used to evaluate potentially inappropriate medications, often shortened to PIMs.
In plain English, the Beers Criteria asks questions such as:
- Is this medicine generally riskier for older adults?
- Could it make a particular disease or condition worse?
- Should it be used cautiously rather than routinely?
- Could it interact dangerously with another medication?
- Does reduced kidney function make the usual dose unsafe?
That is much more useful than simply counting pills and declaring, “Wow, that is a crowded medicine cabinet.”
Why Do Older Adults Need Special Medication Guidelines?
Aging is not a disease, but it can change the body’s response to drugs. The kidneys may eliminate certain medications more slowly. Liver metabolism can change. Body composition shifts, including changes in muscle, water, and body fat. The nervous system may also become more sensitive to sedating or anticholinergic effects.
As a result, medications may stay in the body longer or produce stronger effects than expected. A dose that once caused mild drowsiness might later contribute to a fall. A medicine with anticholinergic effects might worsen constipation, urinary retention, dry mouth, or confusion. A medication cleared through the kidneys may accumulate when kidney function declines.
Then there is polypharmacy, a term commonly used when a person takes multiple medications, often five or more. Polypharmacy is not automatically inappropriate. Someone with diabetes, heart disease, high blood pressure, and another chronic condition may legitimately need several drugs. The problem arises when medications become unnecessary, duplicative, poorly coordinated, or harmful in combination.
Prescription medicines are not the only characters in this story. Over-the-counter products, sleep aids, allergy medicines, vitamins, and herbal supplements can also create interactions or side effects. That innocent-looking bottle from the drugstore may deserve a place in the medication review too.
The Five Main Categories of the Beers Criteria
1. Medications That Many Older Adults Should Generally Avoid
This category includes medications or drug classes for which the risks frequently outweigh the benefits in older adults, especially when safer or more effective alternatives are available.
Examples may include certain strongly anticholinergic medications, some sedative-hypnotics, skeletal muscle relaxants, and other drugs associated with problems such as confusion, falls, constipation, urinary retention, or excessive sedation.
“Avoid” still does not mean “forbidden under every imaginable circumstance.” Clinical medicine has exceptions. A healthcare professional may determine that a listed medication is appropriate because of a specific diagnosis, treatment history, or lack of suitable alternatives.
2. Medications That May Be Inappropriate With Certain Diseases or Syndromes
A drug can be reasonable for one older adult and problematic for another. This section focuses on drug-disease interactions.
For example, a medication that causes sedation or impairs balance may be especially concerning for someone with a history of falls. Drugs with strong anticholinergic properties may require particular scrutiny in a person with cognitive impairment. Other medications can worsen heart failure, Parkinsonism, urinary symptoms, or additional conditions.
This is one reason medication safety cannot be reduced to a simple list. The medical context matters enormously.
3. Medications That Should Be Used With Caution
Some medications are not broadly recommended for avoidance but deserve additional monitoring or careful consideration. The Beers Criteria places these drugs in a “use with caution” category when risks may become important under particular circumstances.
The right response may involve monitoring laboratory values, evaluating fall risk, reviewing bleeding risk, adjusting the treatment plan, or discussing whether another option would provide a better balance of benefit and harm.
4. Potentially Harmful Drug-Drug Interactions
Sometimes the problem is not one medication. It is the combination.
Multiple drugs that depress the central nervous system, for instance, may increase sedation and the risk of falls or other serious complications. Combining several medications with anticholinergic effects can increase the total anticholinergic burden. Other combinations can increase bleeding, kidney injury, abnormal potassium levels, or drug toxicity.
The 2023 criteria also emphasize reviewing combinations of multiple central nervous system-active medications and other clinically significant interactions. A medicine may look reasonable by itself but become far less attractive when it joins several equally sleepy roommates in the same regimen.
5. Medications That Require Attention to Kidney Function
The kidneys help remove many medications and their metabolites from the body. Because kidney function often declines with age, some drugs may need a lower dose, closer monitoring, or complete avoidance below certain levels of renal function.
This part of the Beers Criteria is particularly important because reduced kidney clearance can allow a medication to accumulate gradually. Toxicity may not announce itself immediately with flashing lights and a marching band. It may develop as increasing sleepiness, confusion, weakness, or another seemingly vague symptom.
Common Types of Medications That May Be Flagged
The full Beers Criteria is detailed and intended primarily for clinical use, but several medication categories illustrate why the tool matters.
Strongly Anticholinergic Drugs
Anticholinergic medications block the action of acetylcholine, a chemical messenger involved in many functions throughout the body and brain. Some older adults are especially sensitive to these effects.
Certain first-generation antihistamines and other strongly anticholinergic drugs may contribute to confusion, dry mouth, constipation, blurred vision, urinary retention, or falls. This is particularly relevant because some of these products are available without a prescription. “Over the counter” does not mean “over the consequences.”
Benzodiazepines and Some Sleep Medications
Benzodiazepines may be prescribed for anxiety, insomnia, seizures, or other indications. In older adults, however, they can contribute to excessive sedation, impaired coordination, falls, fractures, and cognitive problems. Dependence and withdrawal are additional concerns.
Certain nonbenzodiazepine sleep medicines, sometimes called “Z-drugs,” also deserve caution because older adults can be more sensitive to effects such as confusion, dizziness, and falls.
These medications should not be stopped abruptly without professional guidance. Some require gradual tapering to reduce withdrawal risks.
Skeletal Muscle Relaxants
Some commonly prescribed muscle relaxants may cause grogginess, confusion, anticholinergic effects, and an increased risk of falls in older adults. Their effectiveness may also be limited for certain problems.
This creates a classic risk-benefit question: Is the potential relief worth the possibility that the patient becomes so unsteady that walking to the bathroom turns into an extreme sport?
Nonsteroidal Anti-Inflammatory Drugs
Nonsteroidal anti-inflammatory drugs, or NSAIDs, include several common prescription and over-the-counter pain relievers. Depending on the drug, dose, duration, and patient’s health, these medications can increase concerns about gastrointestinal bleeding, kidney injury, blood pressure, and other complications.
That does not mean every older adult must avoid every NSAID in every situation. It means chronic or high-risk use deserves careful evaluation, particularly when other risk factors or interacting medications are present.
Proton Pump Inhibitors
Proton pump inhibitors, or PPIs, are useful treatments for acid-related disorders and may be entirely appropriate for long-term use when a strong indication exists. The Beers Criteria has historically encouraged clinicians to reconsider unnecessary prolonged use because long-term therapy may expose some patients to avoidable risks.
The practical lesson is not “PPIs are bad.” It is “Do we still have a good reason for this PPI?” That question applies to many medications.
Certain Diabetes Medications
Some diabetes drugs can pose a greater risk of prolonged or severe hypoglycemia in older adults. Low blood sugar can be especially dangerous because it may lead to confusion, falls, loss of consciousness, or other serious complications.
Medication selection should therefore consider not only lowering glucose but also the patient’s overall health, kidney function, risk of hypoglycemia, treatment burden, and individual goals.
Aspirin and Anticoagulants
The 2023 Beers Criteria included important updates involving aspirin and anticoagulant therapy. For older adults, starting aspirin solely for primary preventionthat is, trying to prevent a first cardiovascular eventrequires different consideration from using aspirin after certain established cardiovascular events or diagnoses.
Anticoagulants present another excellent example of why the criteria cannot replace individualized care. These medications can prevent devastating strokes and other complications, but they also carry bleeding risks. The choice of drug depends on the indication, kidney function, previous treatment, interactions, adherence, affordability, and other patient-specific factors.
Does a Beers Criteria Medication Have to Be Stopped?
No. Finding a medication on the Beers list is a reason to review it, not a reason to throw the bottle dramatically into the nearest trash can.
A potentially inappropriate medication may still be clinically appropriate when:
- The benefit clearly outweighs the risk.
- Safer alternatives have failed or are unsuitable.
- The medication is being used for a specific accepted indication.
- The dose and duration have been carefully selected.
- The patient is being appropriately monitored.
- The patient’s goals and preferences support continuing treatment.
Stopping medications can also cause harm. Abrupt withdrawal from certain sedatives, antidepressants, blood pressure medications, corticosteroids, and other drugs may lead to serious problems. Deprescribing is a clinical process, not a medicine-cabinet cleanup challenge.
How Healthcare Professionals Use the Beers Criteria
The Beers Criteria can be used during routine medication reviews, hospital admissions and discharges, pharmacy consultations, annual wellness visits, and other transitions of care.
A clinician or pharmacist may examine questions such as:
- Why was this medication originally prescribed?
- Is that reason still present?
- Is the drug producing a meaningful benefit?
- Could a current symptom actually be a medication side effect?
- Are two medications treating the same problem unnecessarily?
- Could one medicine be causing a side effect that led to another prescription?
- Has kidney function changed?
- Is there a safer alternative?
That last-but-one scenario is known as a prescribing cascade. For example, a medication causes a new symptom, the symptom is mistaken for a new disease, and another drug is prescribed to treat it. Soon the medication list begins reproducing like rabbits.
Good medication review tries to identify the original cause before automatically adding another prescription.
Important Limitations of the Beers Criteria
The Beers Criteria is valuable, but it is not a complete medication safety system.
First, it focuses primarily on potentially inappropriate medication use in older adults. It does not identify every possible prescribing problem. A medication absent from the list can still be inappropriate because of an allergy, an incorrect dose, a new interaction, poor adherence, duplication, or another patient-specific issue.
Second, a medication on the list may still be appropriate. The criteria are designed to inform professional judgment rather than replace it.
Third, the framework generally applies to adults age 65 and older outside certain end-of-life settings such as hospice and palliative care, where treatment goals may be very different. A medication choice intended to maximize long-term prevention may make little sense when the primary goal is immediate comfort, and vice versa.
Finally, older adults are not one homogeneous group. A healthy 66-year-old marathon runner and a frail 96-year-old with advanced dementia may technically occupy the same “65 and older” category while having dramatically different needs.
What Older Adults and Caregivers Can Do
The most useful response to the Beers Criteria is not fear. It is a better conversation.
Keep an updated list of every prescription medication, over-the-counter drug, vitamin, supplement, and herbal product. Include the dose, how often it is taken, why it is used, and who recommended it. Bring the list to medical appointments and pharmacy consultations.
Useful questions include:
- Why am I taking this medication?
- Is it still necessary?
- Could it be causing my dizziness, sleepiness, confusion, or falls?
- Does my kidney function affect the dose?
- Does it interact with anything else I take?
- Is there a safer medication or non-drug alternative?
- If we stop it, does it need to be tapered?
A pharmacist can be especially valuable when several prescribers are involved. Medication reconciliation after hospitalization is also important because transitions between care settings can create duplication, omissions, and confusion.
Real-World Experiences and Practical Lessons From Beers Criteria Reviews
The following scenarios are illustrative composites based on common medication-safety patterns. They are not descriptions of specific patients and should not be interpreted as personal medical advice.
Experience 1: The “Harmless” Nighttime Allergy Pill
Imagine an older adult who starts taking an over-the-counter antihistamine every evening. It helps with allergies and makes falling asleep easier. Two problems solved with one little tabletor so it seems.
Months later, the person complains of dry mouth, constipation, daytime grogginess, and occasional confusion. Nobody initially thinks of the allergy medicine because it was purchased without a prescription. It is simply sitting in the medicine cabinet looking innocent.
During a complete medication review, the clinician notices that the product has strong anticholinergic effects. The discussion shifts from “What new disease is causing these symptoms?” to “Could an existing medicine be contributing?”
The important experience here is not that every antihistamine is dangerous. It is that OTC medications belong in the medication history. A thorough Beers Criteria review often works best when every pill, liquid, patch, supplement, and occasional sleep remedy gets invited to the meeting.
Experience 2: A Fall That Is Really a Medication Clue
Consider someone taking several central nervous system-active medications: perhaps a drug for anxiety, another for sleep, and another for chronic pain. Each prescription may have been started for a legitimate reason by a different healthcare professional.
Individually, the medications may seem manageable. Together, they can create a larger burden of sedation, slowed reaction time, and impaired balance. The person begins feeling unsteady in the morning and eventually falls.
A poor medication review might focus only on adding a cane or ordering more tests. A better review also asks whether the medication combination is contributing to the problem.
This is one of the biggest practical lessons behind the Beers Criteria: symptoms in older adults are sometimes medication effects until proven otherwise. New dizziness, confusion, fatigue, constipation, or instability should prompt a review of recent medication changes and combinations.
Experience 3: The Prescribing Cascade
Now picture an older adult who starts a medication and develops ankle swelling. The swelling is treated with another drug. That second medicine changes laboratory values, creating another problem that leads to yet another prescription.
No single clinician has done anything obviously reckless. The difficulty is that care has become fragmented. Each new symptom has been treated as an independent problem rather than as a possible consequence of the existing regimen.
During a structured medication review, the team steps backward through the timeline. What changed first? Which symptom appeared after which medication? Is every drug still needed?
This experience shows why deprescribing is not simply “taking away medicines.” Done properly, it is careful detective work. Sometimes the best treatment for a drug side effect is not another drug.
Experience 4: The Medication That Outlasted Its Original Purpose
Another familiar situation involves a medication started years earlier during a hospitalization. The immediate problem resolved, but the drug remained on the list through refill after refill. Eventually, nobody is quite sure why it is still there.
The patient assumes the doctor wants it. The doctor assumes another specialist wants it. The specialist assumes primary care is monitoring it. The medication, meanwhile, enjoys remarkable job security.
The Beers Criteria encourages clinicians to ask whether the original indication remains valid. This is especially useful for medicines that may become less favorable when used longer than necessary or when a person’s health status changes.
The practical lesson is simple: every long-term medicine should still have a current job description.
Experience 5: Kidney Function Changes the Equation
A medication dose may have been entirely appropriate five years ago. Then kidney function gradually declines. The prescription stays the same, but the body’s ability to eliminate the drug does not.
The person may develop increasing sedation, weakness, confusion, or another adverse effect that appears unrelated to the original treatment. Reviewing kidney function alongside the medication list can reveal that the dose now needs adjustment or that another medication would be safer.
This scenario highlights a core truth of geriatric medication management: a good prescription is not necessarily good forever. Medication safety is a moving target because bodies, diseases, priorities, and treatment options change.
Across all of these experiences, the Beers Criteria works best as a conversation starter. It gives clinicians a structured way to notice risks that might otherwise hide inside a long medication list. For patients and caregivers, it offers a useful question to bring to an appointment: “Are any of these medications potentially inappropriate for me now, and should we review the risks, benefits, and alternatives?”
Conclusion: The Beers Criteria Is a Safety Check, Not a Ban List
The Beers Criteria is one of the most important tools for improving medication safety in adults age 65 and older. It identifies potentially inappropriate medications, risky drug-disease combinations, medications that should be used cautiously, important drug-drug interactions, and drugs that require special attention when kidney function is reduced.
Its greatest value lies in prompting better decisions. A medication should not be continued merely because “we have always done it this way,” nor should it be stopped simply because its name appears on a list.
The safest approach is individualized care: review the reason for each medication, weigh benefits against risks, consider alternatives, account for kidney function and interactions, and include the older adult’s own goals and preferences.
In other words, the Beers Criteria does not tell clinicians to prescribe fewer medications at all costs. It encourages them to prescribe more thoughtfully. And when a medicine cabinet begins to resemble a small pharmacy, thoughtful is a very good place to start.
