Understanding the Beers Criteria
First published in 1991 by Dr. Mark Beers, the Beers Criteria was created to identify medications that pose risks outweighing their benefits in older adults. Maintained and updated regularly by the American Geriatrics Society (AGS) since 2011, this evidence-based tool is a cornerstone of geriatric medicine, designed to improve prescribing practices and patient outcomes. It is not a rigid prohibition list but a guide for clinicians, patients, and caregivers to facilitate informed decisions about medication use. The criteria are especially important given that age-related physiological changes affect how drugs are absorbed, metabolized, and eliminated, increasing vulnerability to adverse effects.
The 2025 Beers Criteria Updates
While the American Geriatrics Society (AGS) last fully updated the official Beers Criteria in 2023, a significant 2025 development is the release of the AGS Beers Criteria Alternatives List. This new resource moves beyond identifying risky medications by offering evidence-based, curated lists of safer, and equally effective alternatives. An interdisciplinary panel of experts developed this resource to help clinicians navigate challenging prescribing scenarios and promote shared decision-making with patients. This shift reflects a move toward more personalized healthcare, providing actionable solutions rather than just warnings.
Key Components of the Beers Criteria
The criteria are organized into several lists to provide comprehensive guidance on potentially inappropriate medication (PIM) use in older adults.
- Medications to Avoid: Drugs that are potentially inappropriate for most older adults, with specific rationale and recommended alternatives.
- Medications to Avoid with Specific Diseases or Conditions: Drugs that can exacerbate certain conditions, such as using tricyclic antidepressants in patients with dementia or delirium.
- Medications to Be Used with Caution: Drugs that may be harmful but may also be the best option, requiring careful monitoring.
- Potentially Clinically Important Drug-Drug Interactions: High-risk medication combinations that should be avoided.
- Medications to Be Avoided or Dosed Differently with Impaired Kidney Function: Specific dosing guidance for drugs eliminated by the kidneys.
The Risks of Potentially Inappropriate Medications (PIMs)
Ignoring the Beers Criteria can lead to several dangerous health outcomes for older adults. As people age, changes in kidney and liver function can alter drug metabolism, causing medications to stay in the body longer and increasing the risk of adverse effects. Polypharmacy, the use of multiple medications, is a major risk factor for adverse drug events, falls, and hospitalization. For instance, a common antihistamine like diphenhydramine (Benadryl) can cause significant confusion and sedation in seniors due to its strong anticholinergic properties.
How to Apply the Beers Criteria in Practice
Applying the Beers Criteria requires a patient-centered approach. Clinicians and caregivers should not use it as a substitute for clinical judgment but as a conversation starter. A key strategy is deprescribing, the process of systematically reviewing a patient's medication list to reduce or discontinue drugs that may no longer be necessary or beneficial.
Comparison of Common PIMs and Safer Alternatives (2025 Guidance)
| Medication Category | Potentially Inappropriate Medication | Risks in Older Adults | Safer or Non-Pharmacological Alternatives (2025 Guidance) |
|---|---|---|---|
| First-Generation Antihistamines | Diphenhydramine (Benadryl), Hydroxyzine | Confusion, sedation, urinary retention, increased fall risk due to anticholinergic effects. | Second-generation antihistamines like Loratadine (Claritin), Cetirizine (Zyrtec), or saline nasal rinses. |
| Benzodiazepines & "Z-Drugs" | Diazepam (Valium), Alprazolam (Xanax), Zolpidem (Ambien) | Increased risk of falls, fractures, cognitive impairment, and dependence. | Cognitive Behavioral Therapy for Insomnia (CBT-I), improved sleep hygiene, or other non-pharmacologic interventions. |
| Skeletal Muscle Relaxants | Cyclobenzaprine (Flexeril), Methocarbamol (Robaxin) | Anticholinergic effects, sedation, increased fall risk. | Physical therapy, acetaminophen, or topical analgesics like diclofenac gel. |
| Proton Pump Inhibitors (PPIs) | Omeprazole (Prilosec), Pantoprazole (Protonix) for long-term use | Increased risk of C. difficile infection, bone loss, and fracture when used long-term. | Lifestyle changes (e.g., diet modification, hydration), or deprescribing with a healthcare provider's guidance. |
| NSAIDs | Indomethacin, Long-term use of Ibuprofen or Naproxen | Gastrointestinal bleeding, peptic ulcers, and increased cardiovascular risk. | Physical therapy, acetaminophen, topical NSAIDs, or other topical agents. |
The Evolution of the Beers Criteria
The American Geriatrics Society regularly updates the Beers Criteria to incorporate new evidence and address changing clinical needs. The 2025 publication of the Alternatives List complements the 2023 core criteria, which saw changes such as the cautionary recommendation for SGLT2 inhibitors in older adults due to risks of urogenital infections and dehydration. These regular updates ensure the guidelines remain relevant and effective for promoting safer geriatric care.
Conclusion: Looking Ahead with the Beers Criteria 2025
The Beers Criteria remains an essential tool for promoting medication safety in older adults, and the 2025 Alternatives List reinforces a critical step forward. By moving beyond simply identifying risky drugs to providing actionable, evidence-based alternatives, the AGS empowers clinicians and patients to make better, more personalized decisions. Healthcare professionals must leverage this tool in conjunction with clinical judgment and open communication with patients and their families. For older adults, being proactive and discussing the Beers Criteria with your doctor is a vital step toward ensuring a safe and effective medication plan.
How to Discuss PIMs with Your Healthcare Provider
- Bring an up-to-date medication list. Include all prescriptions, over-the-counter drugs, and supplements.
- Ask about side effects. Be aware of what to look for and report any adverse reactions promptly.
- Consider deprescribing. Ask if any medications can be reduced or stopped.
- Explore alternatives. Discuss non-pharmacologic options or safer alternatives identified by the Beers Criteria.
- Review all medications regularly. Periodically reassess the medication list to ensure it remains safe and effective.
