Beers Criteria: potentially inappropriate medications in older adults

The AGS Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) for adults 65 and older. It applies in all ambulatory, acute, and institutional settings except hospice and end-of-life care. There are five categories: drugs to avoid for most older adults, drugs to avoid with certain diseases or syndromes, drugs to use with caution, risky drug-drug interactions, and drugs that need a renal dose adjustment. Use it to support shared decision-making and deprescribing, not as a punitive rule, and review total anticholinergic burden at each medication reconciliation.

Avoid these for most older adults because of falls, fractures, delirium, sedation, and anticholinergic burden: benzodiazepines, the Z-drug hypnotics zolpidem, eszopiclone, and zaleplon, barbiturates, first-generation antihistamines such as diphenhydramine, hydroxyzine, promethazine, and meclizine, strongly anticholinergic antidepressants including the tricyclics amitriptyline and imipramine plus paroxetine, and skeletal muscle relaxants such as cyclobenzaprine, methocarbamol, and carisoprodol. Low-dose doxepin at 6 mg/day or less is an exception and is acceptable. Also avoid antipsychotics for the behavioral symptoms of dementia or delirium unless nonpharmacologic options have failed and the person is a substantial threat to self or others, given the higher risk of stroke, cognitive decline, and death.

Also avoid for most older adults: all sulfonylureas, including glyburide and glimepiride, and sliding-scale-only insulin, both because of hypoglycemia. Avoid scheduled proton pump inhibitors past 8 weeks without a clear indication, given the risk of C. difficile, pneumonia, bone loss, and fractures. Avoid chronic oral nonselective NSAIDs because of GI bleeding, kidney injury, and heart failure. Avoid digoxin as a first-line drug for atrial fibrillation or heart failure, and avoid any dose above 0.125 mg/day. Avoid nitrofurantoin when CrCl is under 30 mL/min or for long-term suppression. Avoid the peripheral alpha-1 blockers doxazosin, prazosin, and terazosin as blood-pressure drugs because of orthostatic hypotension. Avoid systemic estrogens with or without progestins, and avoid megestrol.

Antithrombotics, with the notable 2023 changes. Do not start aspirin for the primary prevention of cardiovascular disease, though it still has a role in secondary prevention for established disease. Prefer a DOAC over warfarin as initial therapy for nonvalvular atrial fibrillation or VTE, while a long-term warfarin patient with well-controlled INRs can reasonably stay on it. Avoid rivaroxaban for the long-term treatment of nonvalvular AF or VTE because it carries more bleeding than other DOACs, and apixaban is preferred. The 2023 update also widened the sulfonylurea criterion to the whole class, added anticholinergics to the drugs to avoid in anyone with a history of falls or fractures, moved SGLT2 inhibitors into use-with-caution, and added dextromethorphan with quinidine to the drugs to avoid in heart failure.

The 2023 update is the current version and the seventh overall. The American Geriatrics Society hosts the full tables, a pocket card, and a mobile app at GeriatricsCareOnline.org. A 2025 companion, the Beers Criteria Alternatives List, suggests evidence-based drug and non-drug alternatives for common targets such as insomnia, anxiety, and chronic pain. Confirm the full criterion, its rationale, and any exceptions at the source before you act on it.