If you’re over 65 and taking multiple medications, there’s a reasonable chance that at least one of them appears on a list your physician may never have mentioned, a list that exists specifically because that medication carries risks in older adults that it doesn’t carry in younger ones.
That list is called the Beers Criteria. It’s one of the most important tools in geriatric medicine, and it’s almost entirely unknown to the patients it’s designed to protect.
Where It Comes From
The Beers Criteria was first developed in 1991 by Dr. Mark Beers, a geriatrician who identified a set of medications that were commonly prescribed to older adults despite evidence that they were unsafe or ineffective for this population. The list has been updated regularly since then by the American Geriatrics Society, most recently incorporating the latest evidence on drug risks, interactions, and outcomes in adults over 65.
It’s not a list of bad medications in general. Most of the drugs on it are appropriate and effective in younger adults. What the Beers Criteria identifies is a specific mismatch, medications whose risk-benefit profile changes meaningfully with age, because of how aging affects the body’s ability to process and respond to them.
Why Aging Changes the Equation
The body’s relationship with medications changes in several important ways after 65. Kidney function declines gradually, and since most medications are cleared through the kidneys, this means drugs stay in the body longer and reach higher concentrations than intended at doses that were once appropriate. Liver metabolism slows similarly, affecting how drugs are broken down and activated.
Body composition shifts, less muscle, more fat, which changes how medications distribute through the body. The brain becomes more sensitive to sedating drugs, meaning a dose of a sleep aid or antihistamine that produced mild drowsiness at 50 may produce significant confusion and impaired coordination at 75. The cardiovascular system is less able to compensate for blood pressure drops caused by certain medications.
These changes don’t happen overnight, and they don’t happen at the same rate in everyone. But they are consistent enough across the population of older adults that certain medication classes warrant specific caution, which is exactly what the Beers Criteria formalizes.
What’s Actually on the List
The Beers Criteria covers several categories of medications, and understanding the major ones is useful for any older adult reviewing their own medication list.
Benzodiazepines and sleep medications. Drugs like diazepam, lorazepam, alprazolam, and the so-called Z-drugs, zolpidem, eszopiclone, appear on the list because older adults metabolize them more slowly, leading to accumulation and prolonged sedation. The risks include cognitive impairment, falls, and motor vehicle accidents. These drugs are among the most commonly prescribed in older adults and among the most commonly flagged in medication management reviews.
Anticholinergic medications. This is a broad category that includes certain antihistamines like diphenhydramine, found in many over-the-counter sleep aids and allergy medications, as well as some antidepressants, bladder medications, and gastrointestinal drugs. Anticholinergics block a neurotransmitter called acetylcholine, and in older adults this produces a recognizable constellation of effects: confusion, memory impairment, constipation, urinary retention, and dry mouth. The cumulative anticholinergic burden, the combined effect of multiple medications each with some anticholinergic activity, is a significant and underappreciated driver of cognitive problems in older adults. Whether a medication is contributing to memory or cognitive changes is often a question that points back to anticholinergic effects.
NSAIDs. Over-the-counter pain relievers like ibuprofen and naproxen are on the list because chronic use in older adults carries elevated risks of gastrointestinal bleeding, kidney injury, and fluid retention that can worsen heart failure and hypertension. They also blunt the effectiveness of blood pressure medications, which is a common and underrecognized drug interaction.
Certain antidepressants. Tricyclic antidepressants like amitriptyline and doxepin appear on the list because of their strong anticholinergic and sedating effects. They’re sometimes prescribed at low doses for pain or sleep, uses that aren’t well supported by evidence in older adults and that carry real risks.
Muscle relaxants. Cyclobenzaprine, carisoprodol, and similar drugs are flagged because their sedating effects are poorly tolerated in older adults and their effectiveness for musculoskeletal conditions is limited.
First-generation antihistamines. Diphenhydramine, found in Benadryl and many combination cold and allergy products, crosses the blood-brain barrier readily in older adults and produces significant anticholinergic effects. It’s one of the most commonly used over-the-counter medications and one of the most problematic for older adults, particularly because patients often don’t mention it to physicians because they don’t consider it a real medication.
Certain cardiovascular drugs. Some older antihypertensive medications and antiarrhythmics appear on the list because of specific risks in older adults, digoxin at higher doses, for example, or alpha-blockers that cause significant orthostatic hypotension and fall risk. The effects of blood pressure medications on fall risk and balance in older adults are significant enough that a balance assessment is often worthwhile for patients on multiple antihypertensives.
Why These Medications Stay on the List, and on the Prescription
If these drugs are on a list of potentially inappropriate medications for older adults, why are so many older adults still taking them?
Several reasons. Many were prescribed years ago, when the patient was younger and the risk profile was different, and nobody has revisited whether they’re still appropriate. Prescribing habits change slowly, and not every physician applies the Beers Criteria consistently. Some medications, particularly sleep aids and anxiolytics, are difficult to stop once started because of physiological dependence and the genuine distress of stopping them without support.
There’s also the issue of fragmented care. If a primary care physician, a specialist, and a psychiatrist are each prescribing medications without full visibility into what the others have added, the cumulative anticholinergic burden or sedation risk may not be visible to any one of them.
What to Do With This Information
The Beers Criteria isn’t a directive, it’s a framework for clinical judgment. A medication on the list isn’t automatically wrong for every patient. There are situations where the benefit outweighs the risk, and the decision to continue, reduce, or stop any medication should always be made with medical guidance.
What the list is useful for is prompting the conversation. If you’re over 65 and taking a medication that you’ve been on for years without anyone reviewing it, it’s worth asking whether it’s still the right choice. If you’re taking something for sleep or allergies that you’ve never mentioned to your physician because you consider it over-the-counter, it’s worth mentioning. If you’ve noticed cognitive changes, increased falls, or other symptoms that could be medication-related, a formal medication management review that uses tools like the Beers Criteria is exactly the right starting point.
The Right Medications for Where You Are Now
At Prime MD Plus in Coppell, TX, Dr. Divya Javvaji provides comprehensive medication management for patients across the Dallas-Fort Worth area, including systematic review of medications against current evidence, identification of drugs that may no longer be appropriate, and careful, supported transitions when changes are warranted. Reach out to schedule an appointment.
