In 1991, geriatrician Mark Beers published a landmark paper identifying medications that should be used with caution or avoided in older adults. The document, now maintained by the American Geriatrics Society and updated every three years, is known as the Beers Criteria, or informally, "the Beers List."
It exists because adults over 65 have physiological changes that make certain medications significantly more dangerous for them than for younger adults. The drugs on the list are not necessarily bad drugs, many have legitimate uses at any age, but their risk to benefit ratio shifts meaningfully as we age.
The most recent version (2023) of the Beers Criteria includes 35 categories of medications. Here are the ones most frequently encountered at community pharmacies.
Diphenhydramine (Benadryl) and Similar Antihistamines
This is perhaps the most commonly encountered Beers List issue in community pharmacy. Diphenhydramine is the active ingredient in Benadryl, but it also appears as the "PM" ingredient in dozens of widely used products: Tylenol PM, Advil PM, ZzzQuil, Unisom SleepTabs, and many store brand nighttime cold and allergy medications.
In older adults, diphenhydramine causes:
- Significant sedation and next day grogginess
- Increased fall risk, the number one medication related injury concern in seniors
- Confusion and delirium (particularly in patients with any degree of dementia)
- Urinary retention
- Constipation
- Dry mouth and dry eyes
For pain relief with sleep, acetaminophen alone is safer. For allergy symptoms, loratadine, cetirizine, or fexofenadine are better choices. For insomnia, a conversation with a physician about non pharmacological approaches or safer medications is warranted.
Benzodiazepines (Xanax, Valium, Ativan, Klonopin, Restoril)
The Beers Criteria explicitly recommends avoiding benzodiazepines in older adults for insomnia, agitation, or anxiety due to:
- Increased risk of cognitive impairment, delirium, falls, and fractures
- Motor vehicle accidents
- Respiratory depression risk when combined with other CNS depressants
Benzodiazepines are highly habit forming, and what began as short term use often becomes long term dependence. In older adults, the drug is eliminated more slowly, leading to accumulation and prolonged sedation.
The same concerns apply to sleep medications in the "Z drug" class: zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata), which also appear on the Beers List.
Muscle Relaxants (Flexeril, Soma, Robaxin)
Cyclobenzaprine (Flexeril), carisoprodol (Soma), methocarbamol (Robaxin), and similar muscle relaxants are Beers Listed because:
- They are poorly tolerated in older adults
- The anticholinergic effects increase fall risk and cause confusion
- Evidence for their effectiveness in older adults is limited
- Safer alternatives for musculoskeletal pain exist
Nonsteroidal anti inflammatories (NSAIDs) also appear on the Beers List for extended use in seniors, not because they should never be used, but because GI bleeding risk, cardiovascular risk, and kidney toxicity are all elevated in older adults, making long term regular NSAID use problematic.
Digoxin (Above 0.125 mg/day)
Digoxin is used for heart failure and atrial fibrillation. At higher doses, it has a narrow therapeutic window and toxicity risk increases with age due to reduced kidney clearance. The Beers Criteria recommends doses above 0.125 mg/day be avoided in older adults.
Sliding Scale Insulin
Long term sliding scale insulin regimens without a basal insulin component are associated with excessive hypoglycemia episodes in older adults. Tighter insulin management approaches are preferred.
Common OTC Medications on the List
Seniors often assume OTC means safe. Not always. Beers List OTC medications to use cautiously or avoid:
How to Use This Information
The Beers Criteria is a clinical tool, not an absolute prohibition list. "Potentially inappropriate" does not mean "never appropriate", it means the prescriber and pharmacist should review whether the drug is still the best option given the patient's current situation.
If a medication on your list appears on the Beers Criteria:
- Do not stop it on your own, some of these have serious withdrawal or discontinuation effects
- Raise the concern with your prescriber at your next appointment
- Ask your pharmacist whether alternatives are available
- Ask whether the original reason for the medication still applies
A comprehensive medication review with a pharmacist is the right structure for this conversation.
This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.