Medications Older Adults Should Avoid or Use with Caution:
The American Geriatrics Society Beers Criteria (2023 Update)

Today we’re covering a touchstone resource for geriatricians: the “Beers List” of medications that older adults should avoid or use with caution.

(Technically, it’s called “The AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.” I personally think of it as the list of “risky medications” for older adults.)

If you want to know which medications older adults should be careful about, this is the list!

This list gets updated every few years, so the Beers Criteria published in May 2023 is about as up-to-date as you can get for this type of guideline document. 

You should know that experts in geriatrics and in medication safety go through a very careful process of reviewing the research on medications, and of updating this list of medications that older adults should avoid or use with caution.

So in this article, here’s what I’ll be sharing with you:

• What is the Beers Criteria?
• What’s in the 2023 Beers Criteria?
• How experts decide what to include in the Beers Criteria
• How should health providers be using the Beers Criteria
• Risky medications that I particularly pay attention to
• What you can do, to be proactive about medication safety in aging

I also recommend listening to this podcast episode featuring geriatrician Dr. Michael Steinman, who is part of the expert panel that worked on the most recent update to the AGS Beers Criteria:

088– Interview: Avoiding Inappropriate Prescribing in Aging & What to Know About the Beers Criteria

The story of the Beers Criteria

If you spend enough time with geriatricians and other experts in aging health, you’ll notice pretty soon that we spend a lot of time reviewing medications, and considering whether to deprescribe them.

Medications are, of course, a mainstay of modern medicine. They are often key to how we manage a variety of health conditions, whether that’s by relieving a distressing symptom, reducing the risk of a future serious health event, or even helping the body correct a life-threatening illness.

But medications also come with risks and side-effects.

Aging makes people more susceptible to these downsides of all medications.  And, over the years, geriatricians have noticed that some medications, in particular, are more likely to cause problems or create extra risks.

These types of observation led a geriatrician named Mark Beers to publish a scholarly paper in 1991, identifying several categories of medication that seemed to be especially risky for nursing home residents.

Dr. Beers worked with various colleagues and organizations over the years to refine his list, which soon expanded its scope to consider which medications are potentially inappropriate for older adults who aren’t necessarily frail enough to be in nursing homes.

Dr. Beers died in 2009, but his “Beers Criteria” lives on. Since 2011, the process of reviewing and updating the list has been overseen by the American Geriatrics Society (AGS), which published updates in 2012, 2015, 2019, and most recently, in May of 2023.

What’s in the Beers Criteria

Technically, it’s “The AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.” The 2023 update is here.

This is essentially an extensive list of “potentially inappropriate medications” that should be avoided or used with caution, when it comes to the health care of adults aged 65 and older.

About “potentially inappropriate” medications in older adults

“Potentially inappropriate” means that in most older adults, the likely risks of using the medication outweigh the likely benefits, especially when compared with other available treatment options.

It’s important to know that just because a medication is “potentially inappropriate,” this does not mean that it’s always “wrong” to prescribe it to an older person.

But, since these are riskier medications for older adults, it’s important to

• Take extra care before prescribing them,
• Make sure that safer alternatives have been considered
• Confirm that for a specific patient, the likely benefits of the medication outweigh the likely risks

Ideally, the risks of the medication would also be discussed with the older person and with family (when family is closely involved).

Research has repeatedly confirmed that these riskier medications are often prescribed to older adults, and that in many cases, it’s not clear that the risks were explained to the patients or that safer alternatives were offered.

What’s in the 2023 Beers Criteria

Recent versions of the Beers Criteria have organized potentially inappropriate medications into categories. The 2023 update’s categories include:

• Medications that are potentially inappropriate in most older adults (Table 2)
  • These are grouped by therapeutic category (meaning, they name what organ or type of condition the medication is used for), and include a rationale for why the medication may be inappropriate.
  • The recommendation for most medications in this long list is “avoid”.
• Medications that are potentially inappropriate in older adults with certain conditions (Table 3)
  • The conditions listed include syndromes more common in older adults (e.g. history of falls, delirium, dementia or cognitive impairment) and also specific health diagnoses (e.g. Parkinson’s disease, kidney disease, heart failure).
• Medications to be used “with caution” in older adults (Table 4)
  • This list identifies drugs for which there is some cause for concern, but for which the evidence is not yet sufficient to merit inclusion in the main “medications that are potentially inappropriate” list.
• Clinically important drug-drug interactions to be avoided in older adults  (Table 5)
  • This list highlights combinations of medications that are especially common among older adults, and can be particularly risky.
• Medications to be avoided or used in reduced dosage, for older adults with reduced kidney function (Table 6)
  • Since reduced kidney function is common among older adults (many of whom may not realize they are affected by this), this list specifies medications to avoid, or use in reduced dosage.
• A list of “Drugs with Strong Anticholinergic Properties” (Table 7)
  • Since “anticholinergics” as a group are referenced in several different tables within the Beers Criteria, Table 7 provides a list of specific medications to avoid or use with caution.

The 2023 Beers Criteria also include additional tables, summarizing changes relative to the prior 2019 update of the Beers Criteria.

How experts decide what to include in the Beers Criteria 

To review, revise, and update the Beers Criteria, the American Geriatrics Society convenes an expert panel which includes physicians, pharmacists, and nurses, all with special expertise in geriatrics and in reviewing scientific literature.

This review process is very careful and takes 18-24 months to complete.

During this time, the experts review the available scientific research, and decide on what changes to make to the Beers Criteria. They also consider how to organize and present the material, to be most useful to the clinicians who are the primary intended users of the Beers Criteria.

In short, this is a very careful, thoughtful, and evidence-based process.

How health providers (and others) should use the Beers Criteria

The Beers Criteria is a terrific resource, when used appropriately.

To provide guidance on how to use the Beers Criteria, in 2019 the AGS released a companion editorial, authored by two members of the expert panel: Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. (Free online to all.)

This editorial outlines these seven key principles to help clinicians and others appropriately use the Beers Criteria:

1. Medications in the AGS Beers Criteria® are potentially inappropriate, not definitely inappropriate.
2. Read the rationale and recommendations statements for each criterion. The caveats and guidance listed there are important.
3. Understand why medications are included in the AGS Beers Criteria®, and adjust your approach to those medications accordingly.
4. Optimal application of the AGS Beers Criteria® involves identifying potentially inappropriate medications and where appropriate offering safer nonpharmacologic and pharmacologic therapies.
5. The AGS Beers Criteria® should be a starting point for a comprehensive process of identifying and improving medication appropriateness and safety.
6. Access to medications included in the AGS Beers Criteria® should not be excessively restricted by prior authorization and/or health plan coverage policies.
7. The AGS Beers Criteria® are not equally applicable to all countries.

In general, this editorial fall short of instructing clinicians on how to prescribe safely to older adults, or how to use the Beers criteria. As the authors note, the Beers Criteria is not meant to be the definitive word on prescribing, but rather is an important resource that fits into a “larger picture of improving prescribing for older adults.”

But, the gist is this: they suggest health providers take extra care when prescribing these medications to older adults, and also be vigilant for side effects, since older adults have a higher risk of experiencing these or being harmed by them.

Risky medications that I pay particular attention to

Everything in the Beers List is important, but in truth, some medications on the list feel much more relevant to me than others.

That’s because some of these medications are widely used by lots of older adults, most of whom have no idea they are taking a potentially inappropriate medication. Whereas other medications, such as barbituates, are on the list but are hardly ever used anymore.

So, without copying too much out of the Beers Criteria, here’s a brief list of the risky medications that I consider especially relevant to most older adults:

• The 4 types of medications that affect brain function. These are listed in depth in my article on this topic, and are also included in the 2023 AGS Beers Criteria’s Table 3, in the list of medications to avoid in people with dementia or cognitive impairment. They should also be avoided when older people have delirium. They are:
  • Anticholinergics
  • Benzodiazepines
  • Non-benzodiazepine sedatives
  • Antipsychotics
• Non-steroidal anti-inflammatory drugs (NSAIDs).
  • These include common over-the-counter painkillers such as ibuprofen and naproxen (brand names Advil and Alleve), as well as prescription-strength NSAIDs, which are often prescribed for arthritis and other pain. I explain the risks of these medications in this article.
• Aspirin for prevention (in adults age 70+ who have NOT had a heart attack, stroke, or other cardiovascular event).
  • Concordant with the recent American College of Cardiology guidelines, aspirin for primary prevention of cardiovascular disease is no longer recommended.
• Proton-pump inhibitors.
  • These are medications that reduce stomach acid, such as omeprazole (Prilosec).  They are not recommended for chronic use of more than 8 weeks, unless there are compelling reasons to continue.
• Medications to avoid or use with caution if there is a history of falls or fractures.
  • This is an important list since falls are really common in older adults.
  • The AGS 2023 Beers Criteria list for this includes:
    • Anticholinergics
    • Antiepileptics (also known as anticonvulsants; these are sometimes used off-label for difficult dementia behaviors, see here.)
    • Antipsychotics
    • Benzodiazepines
    • Non-benzodiazepine sedatives
    • Antidepressants
    • Opioids
  • Note: in my own list of medications to review for fall prevention, I also include medications related to blood pressure (recommended by the CDC guidelines) and blood sugar (common sense; low blood sugar is common in older people on diabetes medications and is definitely associated with falls). For more, see here.

There are more medications in the 2023 AGS Beers Criteria to be mindful of, to be sure.  But the drugs above are the ones that I most commonly encounter and work on deprescribing when possible.

What you can do about medication safety in aging

So if you’re an older adult, or if you’re involved in the medical care of an aging relative, what can you do?

Dr. Steinman’s advice, which he shared in the podcast episode, is to be proactive.

Although we do have a lot of information available regarding which medications are risky for older adults, and how to manage medications more safely, it’s still very common for older adults to experience inappropriate prescribing and also harms from their medications.

Most health providers are well-intentioned and caring. But they’re also often lacking the time, resources, and supportive systems they need to be more careful about medications.

So for now, if you want to improve your chances of using medication carefully, here are some suggestions:

• Review your medications, and try to find out if any are listed in the Beers Criteria. Pharmacists can be a good resource, if you want help spotting these medications.
  • If you are taking a Beers list medication, HealthinAging.org offers a helpful resource here: What To Do And What To Ask If A Medication You Take Is Listed In The AGS Beers Criteria® For Potentially Inappropriate Medication Use In Older Adults.
• Always ask questions when a new medication is being prescribed, to make sure you understand why a medication is being prescribed and to confirm that it makes sense to proceed with this medication. Good questions for older adults to consider asking include:
  • Could this medication affect my balance or my thinking?
  • Is this medication listed in the Beers Criteria?
  • Can you please review with me what is the expected benefit of this medication, and what are the likely risks?
  • Are there any safer or non-drug approaches to treatment that I should be aware of?
  • Are there any particular side-effects I should look out for?
• Ask to review medications after hospital discharge or a move from one healthcare location to another. Many medications prescribed during hospitalization may not need to be continued long-term.
  • Your usual health provider will be more likely to carefully review your post-discharge medications if you request this.
  • If you don’t have a usual health provider, you can still request an appointment with a doctor, nurse, or pharmacist, to carefully review medications and discuss whether each is still likely to be beneficial.
• Ask to schedule regular medication reviews with your health provider. Most experts recommend regular medication reviews for older adults.
  • I suggest yearly medication reviews, especially for older adults who are taking any medications listed in the Beers Criteria, or who take more than 5 medications.
  • I share a five-step process to help you prepare for a useful medication review here.
• Regularly ask about deprescribing. Remember that when it comes to older adults and medications, less is often more. Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm, to maintain or improve quality of life.
  • For more on deprescribing, see this article, which includes links to a series of excellent consumer guides to help older adults discuss deprescribing of benzodiazepines, NSAIDs, proton-pump inhibitors, antipsychotics and more.
  • Deprescribing is much more likely to happen when older adults and families ask about it. So ask!

I know it can seem a bit daunting to start asking a lot of questions about your medications, or your older parents’ medications.

I also know that although many health providers will welcome your questions and be glad to see you participating in your care, others might give you a hard time, because they’re busy or maybe they just aren’t used to having to think over what they are prescribing.

Nonetheless, I want to encourage you to do it anyway! Yes, it can be a little extra work, but it’s your health and safety at stake. (Plus there’s your wallet, paying all those co-pays.)

Many older adults do need to be on medication. And, many of them are on more medication than is truly necessary.

You don’t have to be one of them.

You now know about the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. You know that every few years, an ace team of experts is reviewing the medical literature and coming up with a carefully chosen list of medications that older adults should avoid, or use with caution.

Even if you don’t get a copy of the most recent AGS Beers Criteria, you can follow the suggestions listed above.

Find out if any of your medications are listed in the Beers Criteria. Ask about alternatives. Review medications regularly. Get medications deprescribed when possible.

With just a little bit of effort, I know that you will vastly improve the odds that whatever medications you — or your older relative — are taking are truly serving your health, and not exposing you to unnecessary risk.