Medications to Avoid in Older Adults According to Beers Criteria
The 2019 AGS Beers Criteria identifies 30 individual medications or medication classes that should generally be avoided in adults ≥65 years, plus 16 additional criteria for drugs to avoid in specific disease states, with strong recommendations to prevent falls, cognitive impairment, bleeding, and other serious adverse outcomes. 1
Key Categories of Medications to Avoid
Central Nervous System Medications
Benzodiazepines and sedative-hypnotics should be avoided due to increased risk of cognitive impairment, delirium, falls, and fractures 1. This includes:
- All benzodiazepines (both short and long-acting)
- Nonbenzodiazepine "Z-drugs" (zolpidem, eszopiclone, zaleplon)
First-generation antihistamines with strong anticholinergic properties should be avoided, including:
- Diphenhydramine
- Hydroxyzine
- Promethazine
- Chlorpheniramine
Antipsychotics carry increased mortality risk in older adults and should be avoided except for specific psychiatric indications 1.
Pain Medications
NSAIDs (both nonselective and COX-2 inhibitors) should be avoided due to increased risk of:
- GI bleeding and ulceration (especially with concurrent antiplatelet agents or corticosteroids)
- Acute kidney injury
- Heart failure exacerbation
- Cardiovascular events 1
This includes: indomethacin, ibuprofen, naproxen, diclofenac, meloxicam, piroxicam, ketorolac, and all others 1.
Meperidine should be avoided due to neurotoxicity risk 1.
Aspirin >325 mg/day for primary prevention should be avoided in adults ≥70 years due to bleeding risk outweighing benefit 1.
Muscle Relaxants
All skeletal muscle relaxants should be avoided due to anticholinergic effects, sedation, and fall risk 1, including:
- Cyclobenzaprine
- Carisoprodol
- Methocarbamol
- Orphenadrine
- Metaxalone
- Chlorzoxazone
Cardiovascular Medications (Disease-Specific)
In heart failure patients, avoid:
- Nondihydropyridine calcium channel blockers (diltiazem, verapamil) - risk of worsening heart failure 1
- Thiazolidinediones (pioglitazone, rosiglitazone) - fluid retention and heart failure exacerbation 1
- NSAIDs and COX-2 inhibitors - fluid retention 1
- Cilostazol and dronedarone 1
Anticholinergic Medications
Tricyclic antidepressants (TCAs) should be avoided due to strong anticholinergic effects, orthostatic hypotension, and cardiac conduction abnormalities 1.
Urinary antispasmodics with anticholinergic properties should be avoided.
Genitourinary Medications
Desmopressin should be avoided due to hyponatremia risk 1.
Alpha-1 blockers should be avoided in older adults due to orthostatic hypotension and fall risk 1.
Critical Drug-Drug Interactions to Avoid
Opioids combined with benzodiazepines - avoid due to respiratory depression and death risk 1.
Opioids combined with gabapentinoids (gabapentin, pregabalin) - avoid except when transitioning from opioids to gabapentinoids 1.
Three or more CNS-active drugs concurrently (antidepressants, antipsychotics, benzodiazepines, hypnotics, antiepileptics, opioids) - significantly increases fall risk 1.
Warfarin interactions:
- With TMP-SMX - increased bleeding risk 1
- With macrolides (excluding azithromycin) - increased bleeding risk 1
- With ciprofloxacin - increased bleeding risk 1
TMP-SMX with phenytoin - phenytoin toxicity risk 1.
Ciprofloxacin with theophylline - theophylline toxicity risk 1.
Medications increasing potassium (ACEIs, ARBs, potassium-sparing diuretics, TMP-SMX) - avoid combining due to hyperkalemia risk, especially with reduced kidney function 1.
Medications Requiring Dose Adjustment or Avoidance Based on Kidney Function
Ciprofloxacin and TMP-SMX require dose adjustment or avoidance in reduced kidney function due to:
- CNS effects and tendon rupture risk (ciprofloxacin)
- Worsening renal function and hyperkalemia (TMP-SMX) 1
Dofetilide - avoid in reduced kidney function due to QT prolongation and torsade de pointes risk 1.
Edoxaban - avoid when creatinine clearance <15 mL/min 1.
Medications Requiring Caution (Not Absolute Avoidance)
Rivaroxaban in adults ≥75 years for VTE or atrial fibrillation treatment 1.
Dabigatran in older adults requires careful monitoring 1.
Tramadol - added to hyponatremia/SIADH risk list 1.
Dextromethorphan/quinidine - limited efficacy in dementia-related behavioral symptoms with increased fall and drug interaction risk 1.
TMP-SMX with ACEIs or ARBs in reduced kidney function - hyperkalemia risk 1.
Common Pitfalls
The most critical error is assuming these criteria apply rigidly without clinical context. However, the evidence strongly supports avoiding these medications in most circumstances. The criteria specifically exclude hospice and end-of-life care where comfort takes precedence 2.
Another pitfall is continuing medications started before age 65 without reassessment - the criteria apply to all adults ≥65 regardless of when therapy was initiated 1.
The 2023 update 2 emphasizes these criteria should support, not replace, shared clinical decision-making, but the default position should be avoidance unless compelling individual circumstances justify use.