What medications are considered potentially inappropriate for older adults according to the Beers criteria?

Beers Criteria Medications for Older Adults

The 2019 American Geriatrics Society Beers Criteria identifies 30 individual medications or medication classes that should generally be avoided in older adults, plus over 40 additional medications requiring caution in specific diseases or conditions. 1

Core Categories of Potentially Inappropriate Medications

The Beers Criteria organizes problematic medications into five distinct categories that guide clinical decision-making 1:

1. Medications to Avoid in Most Older Adults

Central Nervous System Agents are among the highest-risk medications:

• Benzodiazepines (e.g., diazepam, lorazepam) significantly increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents 2, 3
• Nonbenzodiazepine hypnotics (Z-drugs) carry similar fall and fracture risks 1
• Antipsychotics should be avoided due to increased mortality risk, particularly in patients with dementia 1
• Tricyclic antidepressants (TCAs) cause anticholinergic effects and orthostatic hypotension 1

Anticholinergic Medications cause substantial cognitive and functional harm:

• First-generation antihistamines (diphenhydramine, hydroxyzine) 4
• Antispasmodics for bladder control 5
• These medications worsen delirium, constipation, and urinary retention 2

Cardiovascular Medications with unfavorable risk profiles:

• NSAIDs (ibuprofen, naproxen) increase gastrointestinal bleeding, acute kidney injury, and heart failure exacerbation 1, 2
• Thiazolidinediones in heart failure patients worsen fluid retention 1

Endocrine Medications:

• Sliding-scale insulin alone without basal insulin increases hypoglycemia risk without improving glycemic control 1
• Sulfonylureas (particularly long-acting) cause prolonged hypoglycemia 5

2. Disease-Specific Medications to Avoid

For patients with history of falls or fractures, avoid entirely 1:

• All benzodiazepines and nonbenzodiazepine hypnotics
• Antipsychotics
• Opioids
• SNRIs (newly added in 2019 based on fracture risk) 1
• Tricyclic antidepressants
• Three or more CNS-active drugs concurrently (antidepressants, antipsychotics, benzodiazepines, antiepileptics, opioids) 1

For patients with dementia or cognitive impairment, avoid 1:

• Anticholinergics (worsen cognition)
• Benzodiazepines (increase confusion and falls)
• Antipsychotics unless behavioral symptoms pose imminent danger

For patients with heart failure, avoid 1:

• NSAIDs (all types)
• Thiazolidinediones
• Calcium channel blockers (diltiazem, verapamil)

3. Medications Requiring Caution

Newly added or modified in 2019 1:

• Dextromethorphan/quinidine: Limited efficacy, significant drug interactions, increased fall risk 1
• Rivaroxaban in adults ≥75 years: Higher bleeding risk for venous thromboembolism or atrial fibrillation treatment 1
• Aspirin for primary prevention in adults ≥70 years (lowered from ≥80 years): Bleeding risk exceeds cardiovascular benefit 1
• Tramadol: Added to hyponatremia/SIADH risk list 1

4. Critical Drug-Drug Interactions to Avoid

Opioid combinations pose severe respiratory depression and death risk 1:

• Opioids + benzodiazepines: Avoid concurrent use entirely 1
• Opioids + gabapentinoids (gabapentin, pregabalin): Avoid unless transitioning from opioids to gabapentinoids 1

Antibiotic interactions with serious consequences 1:

• TMP-SMX + warfarin: Increases bleeding risk 1
• TMP-SMX + phenytoin: Causes phenytoin toxicity 1
• Macrolides (except azithromycin) + warfarin: Increases bleeding 1
• Ciprofloxacin + theophylline: Causes theophylline toxicity 1
• Ciprofloxacin + warfarin: Increases bleeding 1

Hyperkalemia-inducing combinations 1:

• TMP-SMX + ACEIs or ARBs in patients with reduced kidney function: Significantly increases hyperkalemia risk 1
• Expanded to include potassium-sparing diuretics, potassium supplements, and other potassium-elevating agents 1

5. Kidney Function-Based Dose Adjustments

Medications requiring avoidance or dose reduction based on creatinine clearance 1:

• Ciprofloxacin: CNS effects and tendon rupture risk increase with renal impairment 1
• TMP-SMX: Worsening renal function and hyperkalemia 1
• Dofetilide: QT prolongation and torsade de pointes risk 1
• Edoxaban: Avoid when CrCl <15 mL/min (lowered threshold from previous criteria) 1

Implementation Strategy

Apply the criteria systematically at every care transition (hospital admission, ICU transfer, discharge) to identify and deprescribe inappropriate medications 2. Prioritize removal of medications with the highest morbidity and mortality risks first: benzodiazepines, opioids, antipsychotics, and NSAIDs 2.

Use validated screening tools (Beers Criteria, STOPP/START) during comprehensive medication reviews that include all prescription drugs, over-the-counter medications, herbal products, and supplements 2.

Critical Pitfalls to Avoid

Do not apply disease-specific guidelines rigidly without considering multimorbidity burden, functional status, life expectancy, and patient-centered goals 2. Do not ignore drug-drug interactions—use systematic interaction screening tools 2. Do not rely on chronological age alone; functional and cognitive status matter more than age in years 2.

The criteria support rather than replace clinical judgment—individualization remains essential when patient-specific factors warrant exceptions 2. However, any decision to continue a Beers Criteria medication requires explicit documentation of the clinical rationale and ongoing monitoring for adverse effects 1, 2.