There is a list that every senior and their family should know about — and most have never heard of it. The Beers Criteria is an evidence-based list of medications that the American Geriatrics Society says are potentially inappropriate for adults aged 65 and older. It covers dozens of drugs that are still being prescribed every day — some of them among the most commonly used medications in America. The risks aren't rare side effects. They include falls, hip fractures, delirium, dementia, kidney failure, and death.
The problem isn't that these drugs are always wrong. It's that at 65 and beyond, the body processes medications differently — and many doctors, particularly those who aren't geriatric specialists, don't adjust their prescribing habits accordingly. This guide explains which medications on the Beers Criteria are most commonly encountered by seniors, exactly what the risks are at your age, and what you can ask your doctor about instead.
What this article covers:
- What the Beers Criteria is and why it matters specifically at 65, 70, 75+
- The 12 most commonly prescribed Beers Criteria medications, ranked by risk
- The safer alternatives your doctor should be offering
- An age-by-decade breakdown of medication risk changes (60–64, 65–69, 70–74, 75+)
- A printable checklist to bring to your next appointment
- How to talk to your doctor without damaging the relationship
Why Medications Work Differently After 65
Before diving into the list, it's critical to understand why age changes medication risk — because it affects every drug on this list.
1. Kidney Function Declines Progressively
Most medications are cleared from the body by the kidneys. After age 40, kidney filtration rate (eGFR) declines at roughly 1% per year. By age 70, many adults have lost 25–35% of their kidney function — not enough to feel sick, but enough that drugs stay in the body far longer than intended. A drug designed to clear your system in 6 hours may now take 10–14 hours. This causes drug accumulation, higher effective doses, and magnified side effects.
2. Liver Processing Slows
The liver metabolizes most medications through enzyme systems (primarily CYP450). These enzyme systems become less efficient with age, meaning drugs that require liver processing linger longer. Alcohol, certain foods (grapefruit), and other medications can further suppress these systems — a problem that compounds dramatically in seniors on multiple medications.
3. Body Composition Changes Drug Distribution
Fat-soluble drugs (including many sedatives, antidepressants, and pain medications) distribute into body fat. As body composition shifts after 65 — typically more fat, less lean muscle — fat-soluble drugs have a larger reservoir to accumulate in, extending their duration of action unpredictably.
4. The Brain Becomes More Drug-Sensitive
The blood-brain barrier becomes more permeable with age, and the brain itself becomes more sensitive to sedating and anticholinergic (acetylcholine-blocking) drugs. A drug that caused mild drowsiness at 45 may cause disorientation, confusion, or complete delirium at 75. This is the mechanism behind some of the most dangerous Beers Criteria medications.
Age-by-Decade Risk Increases: How Medication Danger Escalates
Not all risk increases happen at once. Here is how your medication vulnerability changes across decades — something the generic "over 65" advice ignores entirely:
| Age Group | Key Physiological Changes | Primary Medication Risks at This Stage | Most Important Actions |
|---|---|---|---|
| 60–64 | Early kidney/liver decline beginning; muscle mass starting to decrease; brain sensitivity slightly elevated | NSAIDs causing GI issues; early anticholinergic sensitivity; alcohol-drug interactions amplified | Get baseline kidney function (eGFR) test; review OTC medication habits; tell doctor all supplements you take |
| 65–69 | Medicare eligibility typically begins; polypharmacy risk increases as new specialists prescribe; kidney function meaningfully reduced for many | Sleep medications (Ambien) → falls risk. Blood pressure medications → orthostatic hypotension. Benzodiazepines → cognitive impairment. | Request comprehensive medication review at each annual wellness visit; prioritize "deprescribing" when possible |
| 70–74 | Falls become a leading cause of hospitalization; cognitive reserve declining; multiple chronic conditions requiring multiple drugs common | Muscle relaxants → very high fall risk. Anticholinergics → delirium risk. Long-acting benzodiazepines → cumulative sedation. | Ask about every medication whether it can be reduced or stopped; prioritize fall prevention; pharmacist medication review |
| 75+ | Significantly reduced kidney clearance; heightened delirium risk; frailty increasing; drug interactions multiply with each additional medication | Nearly all Beers Criteria medications carry high risk; even low doses of sedating drugs cause falls and confusion; antipsychotics carry mortality risk in dementia patients | Work with geriatrician if possible; deprescribe aggressively; any new symptom (confusion, falls, incontinence) should trigger medication review before new drugs are added |
The 12 Most Commonly Prescribed Beers Criteria Medications — Ranked by Risk
The following table ranks the medications most commonly encountered by seniors in real-world practice. Risk level is based on the 2023 AGS Beers Criteria evidence review combined with fall and hospitalization data from large-scale epidemiological studies.
| # | Drug / Drug Class | Common Brand Names | Risk Level | Primary Risks After 65 | Safer Alternative |
|---|---|---|---|---|---|
| 1 | Diphenhydramine (antihistamine/sleep aid) | Benadryl, ZzzQuil, Unisom, Tylenol PM, Advil PM, Nyquil | VERY HIGH | Confusion, delirium, falls, urinary retention, constipation; linked to dementia with long-term use | Melatonin 0.5–1mg for sleep; loratadine (Claritin) for allergies; CBT-I for chronic insomnia |
| 2 | Benzodiazepines (especially long-acting) | Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam) | VERY HIGH | Falls and hip fractures, cognitive impairment, delirium, overdose risk especially with opioids, dependence | CBT for anxiety; SSRI antidepressants; buspirone; if benzo absolutely needed, use shortest-acting at lowest dose with plan to taper |
| 3 | Z-drugs (sleep medications) | Ambien (zolpidem), Lunesta (eszopiclone), Sonata (zaleplon) | VERY HIGH | Falls (especially nighttime), next-day cognitive impairment, complex sleep behaviors (sleepwalking, sleep-driving), dependence | CBT-I (Cognitive Behavioral Therapy for Insomnia) — superior to medications in long-term trials; melatonin low-dose; doxepin 3–6mg if medication needed |
| 4 | Oral NSAIDs (long-term use) | Advil, Motrin (ibuprofen), Aleve (naproxen), Naprosyn, Mobic (meloxicam) | HIGH | GI bleeding (2–5x higher risk after 65), acute kidney injury, heart attack, stroke, fluid retention worsening heart failure | Topical diclofenac (Voltaren Gel) — same anti-inflammatory effect, minimal systemic absorption; acetaminophen for mild pain; physical therapy |
| 5 | Muscle relaxants | Flexeril (cyclobenzaprine), Soma (carisoprodol), Robaxin (methocarbamol), Skelaxin (metaxalone) | HIGH | Sedation, falls, anticholinergic effects (confusion, urinary retention), limited evidence of benefit beyond 2–3 weeks | Physical therapy; topical diclofenac; heat/cold therapy; short-term acetaminophen for muscle pain |
| 6 | Tricyclic antidepressants | Elavil (amitriptyline), Pamelor (nortriptyline), Sinequan (doxepin at high doses) | HIGH | Strongly anticholinergic; cardiac arrhythmias, orthostatic hypotension (dizzy on standing → falls), sedation, confusion | SSRIs (sertraline, escitalopram) or SNRIs for depression/anxiety; Note: low-dose doxepin 3–6mg for insomnia IS on the safe list |
| 7 | Anticholinergic bladder medications | Ditropan (oxybutynin), Detrol (tolterodine), Enablex (darifenacin) | HIGH | Cognitive impairment, confusion, delirium; urinary retention; dry mouth and eyes; constipation; worsens existing cognitive decline | Bladder training and pelvic floor exercises (as effective as medication in trials); mirabegron (Myrbetriq) — non-anticholinergic bladder medication on the safer list |
| 8 | Glyburide (sulfonylurea diabetes drug) | DiaBeta, Glynase, Micronase | MODERATE-HIGH | Severe, prolonged hypoglycemia (blood sugar crashes); at higher risk in seniors due to slower kidney clearance; hospitalizations and falls from hypoglycemia | Shorter-acting sulfonylureas like glipizide; or metformin (if kidney function allows); or newer agents (GLP-1 agonists, SGLT2 inhibitors) with geriatrician guidance |
| 9 | Alpha-blockers for blood pressure | Cardura (doxazosin), Hytrin (terazosin), Minipress (prazosin) | MODERATE-HIGH | Orthostatic hypotension (blood pressure drops on standing), causing dizziness and falls; generally not recommended as first-line BP medication after 65 | For blood pressure: ACE inhibitors, ARBs, or thiazide diuretics; for prostate symptoms (BPH): tamsulosin at lowest effective dose with monitoring |
| 10 | First-generation antihistamines (non-sleep) | Chlorpheniramine (in many cold medicines), promethazine (Phenergan), hydroxyzine (Vistaril) | MODERATE | Anticholinergic sedation, confusion, urinary retention; found in countless OTC cold, allergy, and cough medications where seniors may not realize they're taking them | Loratadine (Claritin) or cetirizine (Zyrtec) for allergies — second-generation antihistamines with far less anticholinergic activity |
| 11 | High-dose PPIs (proton pump inhibitors, long-term) | Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole) | MODERATE | Vitamin B12 and magnesium deficiency (B12 deficiency mimics dementia); increased C. difficile infection risk; hip fracture risk with long-term use. Note: short-term use is fine and often necessary. | Use at the lowest effective dose for the shortest time needed; H2 blockers (famotidine/Pepcid) for milder acid issues; lifestyle modifications; regular B12 monitoring if on long-term PPIs |
| 12 | Digoxin (at doses >0.125mg/day) | Lanoxin, Digitek | MODERATE | Narrow therapeutic window with steep toxicity curve; kidney clearance decline in older adults makes blood levels unpredictable; toxicity causes nausea, arrhythmias, visual disturbances | Modern heart failure and rate control medications (beta-blockers, calcium channel blockers) are generally preferred; if digoxin is necessary, monitor blood levels closely and maintain dose ≤0.125mg/day |
The Hidden Danger: OTC Medications on the Beers List
One of the most important — and least discussed — aspects of the Beers Criteria is that it includes many over-the-counter medications. These are drugs anyone can buy without a prescription, often in products specifically marketed for sleep, cold relief, allergy, and pain.
The most dangerous OTC category for seniors is diphenhydramine, which appears under many brand names and in combination products. When a senior reaches for "PM" versions of common pain relievers or popular nighttime sleep aids at the drugstore, they're often buying a Beers Criteria medication without realizing it. The anticholinergic effects accumulate overnight — and the morning-after cognitive impairment, confusion, and fall risk can be significant.
The Polypharmacy Problem: When Multiple Beers Drugs Combine
A 68-year-old man with high blood pressure, anxiety, insomnia, and mild arthritis might be prescribed: a benzodiazepine for anxiety, Ambien for sleep, a muscle relaxant for back pain, and an alpha-blocker for blood pressure. He also takes Benadryl PM because he read it was "natural." That's four to five Beers Criteria medications at once — each multiplying the risk of the others.
This is not a hypothetical. A 2023 study in the Journal of the American Geriatrics Society found that 1 in 5 adults over 65 filled prescriptions for at least 3 Beers Criteria medications in a single year. The compounding of anticholinergic burden alone — from the benzodiazepine, the Ambien, the muscle relaxant, and the Benadryl — can push an otherwise cognitively intact older adult into acute delirium during a hospitalization, or cause a serious fall at 3am when they get up to use the bathroom.
Researchers have developed a scoring system called the Anticholinergic Cognitive Burden (ACB) Scale that assigns point values to drugs based on their anticholinergic potency. Studies show that ACB scores above 3 are associated with meaningful cognitive decline in older adults — and many seniors unknowingly accumulate ACB scores of 6, 8, or higher.
If you're concerned about this, a pharmacist-led medication review is one of the most practical and underused resources available to seniors. Many Medicare plans cover an annual Comprehensive Medication Review (CMR) at no cost. Your pharmacist — who specializes in exactly this kind of drug-drug interaction analysis — can calculate your anticholinergic burden and flag interactions your primary care doctor may not have noticed.
Watch: Why Muscle Health After 40 Matters More Than You Think
Maintaining muscle strength after 60 is one of the most powerful ways to reduce fall risk — especially important when medications increase fall risk.
When Fall Risk Becomes Life-or-Death: The Medication-Fall Connection
Falls are the leading cause of injury-related death in adults over 65. Each year in the United States, approximately 36 million falls occur in this age group, resulting in 3 million emergency department visits and nearly 32,000 deaths. What is less commonly discussed: medications are a modifiable risk factor in up to 40% of senior falls.
The mechanisms are multiple. Sedating medications (benzodiazepines, Z-drugs, antihistamines, muscle relaxants, tricyclics) impair balance, coordination, and reaction time — particularly at night when seniors get up to use the bathroom. Blood pressure medications that cause orthostatic hypotension (a sudden BP drop when standing) cause dizziness the moment the person stands up. Anticholinergic medications cause confusion that prevents a person from recognizing they're unsafe to walk.
A hip fracture in a 75-year-old adult has a 20–30% mortality rate within one year — often not from the fracture itself, but from the cascade of post-surgical complications, immobility, and decline that follows. Preventing the fall by reviewing and reducing Beers Criteria medications is, literally, life-saving intervention.
If you or a loved one is currently on any of the medications in our table above, this is worth a direct conversation with your doctor at your next visit. See the printable checklist below.
Deprescribing: The Medical Art of Safely Stopping Medications
"Deprescribing" is the medically supervised process of tapering or stopping medications that are no longer needed, are causing harm, or where risks outweigh benefits. It's an emerging discipline that geriatricians practice routinely — and that primary care physicians are increasingly being trained in.
The critical point: most Beers Criteria medications cannot be stopped abruptly. Benzodiazepines and Z-drugs, in particular, cause physical dependence and require slow tapering over weeks or months to avoid withdrawal symptoms including rebound anxiety and, in severe cases, seizures. Stopping these medications is a medical process — not something to do on your own after reading this article.
What you can and should do:
- Bring your complete medication list (prescription and OTC) to your next appointment
- Ask specifically: "Are any of these on the Beers Criteria for seniors?"
- Ask: "Is there a safer alternative, or can any of these be reduced or stopped?"
- Request a referral to a geriatrician or clinical pharmacist for a full medication review if you're on 5+ medications
- Request your eGFR (kidney function) number — it directly affects how safely you can take many drugs
The American Geriatrics Society notes that even brief interventions — a single pharmacist review, a single geriatrician consultation — can meaningfully reduce Beers Criteria medication use and improve outcomes. Studies on deprescribing show reductions in falls, hospitalizations, and cognitive decline when Beers Criteria medications are removed under medical supervision.
Protecting Muscle Strength While Reducing Medications
One underappreciated consequence of reducing sedating and pain medications is that seniors may experience a temporary increase in discomfort, anxiety, or difficulty sleeping as safer alternatives are initiated. This is where protecting muscle strength and physical resilience becomes especially important — because stronger muscles mean better balance, reduced fall risk even if some medication-related impairment persists during the transition, and better overall health outcomes.
Creatine supplementation has been studied specifically in older adults as a strategy for maintaining and building muscle — the research in this age group is among the strongest in the creatine literature. A 2021 meta-analysis in Nutrients found that creatine combined with resistance exercise produced significantly greater lean mass and strength gains in adults 55+ compared to exercise alone. Stronger muscles act as shock absorbers and balance stabilizers — directly reducing the fall risk that Beers Criteria medications increase.
If you're working with your doctor to reduce fall-risk medications, building a consistent exercise routine (including resistance training) during this period can meaningfully bridge the gap. It's the kind of practical, evidence-based strategy that rarely makes it into the standard medical conversation — but makes a real difference for active, engaged older adults. You can learn more in our guide to energy and fatigue after 60 and our article on bone density and fall risk.
🔑 Key Takeaway
The Beers Criteria is not a list of medications that are always wrong. It's a list of medications that carry specific, documented higher risk for adults 65+ — and that often have safer alternatives that work just as well. The goal isn't to avoid all medication. It's to make sure every medication you take is the right choice for a body that is processing drugs differently than it was at 50. Ask the question. Start the conversation.
Printable Medication Review Checklist
📋 Bring This to Your Next Doctor Appointment
- Write down every medication you take — prescription AND over-the-counter (include supplements)
- Check each OTC product's ingredient label for "diphenhydramine" — common in PM products and sleep aids
- Ask: "Are any of these on the Beers Criteria list for adults over 65?"
- Ask: "Is there a safer alternative to [specific medication] for someone my age?"
- Ask: "Can we reduce the dose of any of these given my current kidney function?"
- Ask: "Can any of these be stopped or tapered safely?"
- Request your eGFR (kidney function) number if you don't know it
- Ask for a referral to a pharmacist-led Comprehensive Medication Review (CMR) — often free under Medicare
- If on 5+ medications, consider requesting a geriatric consultation
- If on any benzodiazepine or sleep medication, ask about a supervised tapering plan
What the 2023 and 2025 Updates Added
The Beers Criteria is updated approximately every three years. The 2023 update refined guidance on several categories, and a 2025 supplementary alternatives guide was released by the American Geriatrics Society to help prescribers identify appropriate substitutions. Key additions and clarifications from recent updates include:
- Stronger language on anticholinergic burden: The 2023 version more explicitly addressed cumulative anticholinergic risk rather than individual drugs in isolation
- Bladder medications: Oxybutynin oral formulation received stronger "avoid" language; mirabegron (Myrbetriq) was noted as a preferred alternative
- GLP-1 agonists: The 2025 alternatives guide noted that while not traditional Beers medications, these drugs require special monitoring in seniors regarding hypoglycemia risk and muscle loss — worth discussing with your doctor if you are on Ozempic or similar drugs. (Read more in our comprehensive GLP-1 guide for seniors.)
- PPIs (proton pump inhibitors): Long-term use continues to carry caution status, particularly regarding B12 deficiency — a condition that mimics dementia symptoms and is frequently missed in older adults
- Sleep medications: All Z-drugs remain on the list; the updated alternatives document emphasizes CBT-I as the first-line recommendation for chronic insomnia at any age
For adults who are currently managing multiple chronic conditions with multiple medications — a very common situation after 65 — an annual medication review isn't just recommended. It may be the single most important health action you can take. Not to add new medications, but to thoughtfully reduce the ones that are no longer serving you well. For related reading on managing medications safely, see our guide to medications that hit differently after 60.
Frequently Asked Questions
What is the Beers Criteria?
The Beers Criteria (formally the AGS Beers Criteria®) is a list of medications that are potentially inappropriate for adults aged 65 and older. First developed in 1991 by geriatrician Dr. Mark Beers, it is now maintained by the American Geriatrics Society and updated every few years — with 2023 being the current version and a supplementary alternatives guide released in 2025. The list is intended to guide prescribers but every senior should know which drugs are on it so they can ask informed questions at their appointments.
Is Benadryl (diphenhydramine) dangerous for seniors?
Yes — diphenhydramine is one of the highest-risk Beers Criteria medications for older adults. It is powerfully anticholinergic, blocking acetylcholine receptors in the brain and body. In adults 65+, this causes acute confusion, next-day cognitive impairment, urinary retention, constipation, and significantly increased fall risk. Long-term use has been associated with higher dementia risk in observational studies. Safer alternatives for sleep include low-dose melatonin (0.5–1mg), CBT-I therapy, and — if medication is needed — doxepin 3–6mg (not the higher antidepressant doses). For allergies, loratadine (Claritin) or cetirizine (Zyrtec) are substantially safer options.
Should seniors take Ambien (zolpidem) for sleep?
The Beers Criteria recommends avoiding zolpidem and other Z-drugs in older adults. They cause the same risks as benzodiazepines — impaired balance, falls, next-day cognitive fog — and the FDA has mandated lower doses for women and older adults (5mg instead of 10mg). Many seniors are still prescribed 10mg. The gold standard for chronic insomnia at any age is Cognitive Behavioral Therapy for Insomnia (CBT-I), which outperforms sleep medications in long-term trials and has no side effects. CBT-I is available through therapists, apps, and some Medicare-covered programs.
What muscle relaxants are dangerous for seniors?
Most oral muscle relaxants are on the Beers Criteria: cyclobenzaprine (Flexeril), carisoprodol (Soma), methocarbamol (Robaxin), and metaxalone (Skelaxin). They are anticholinergic and sedating, significantly increasing fall risk. There's also limited evidence they work beyond 2–3 weeks. Safer approaches for muscle pain and spasm in older adults include physical therapy, topical diclofenac (Voltaren Gel), heat and cold therapy, and acetaminophen for short-term pain management.
How do I bring up the Beers Criteria with my doctor?
Simply say: "I've read about the Beers Criteria — the list the American Geriatrics Society recommends for prescribing safety after 65. I'm currently taking [medication name]. Is this on the Beers list, and is there a safer alternative for me?" Most physicians respond positively to this question. You can also ask your pharmacist to conduct a medication review — pharmacists are trained to identify Beers Criteria medications and drug interactions, and many Medicare plans cover annual Comprehensive Medication Reviews (CMR) at no cost.
What is polypharmacy and why does it matter after 65?
Polypharmacy means taking 5 or more prescription medications simultaneously. It affects approximately 40% of adults over 65 in the US. The danger isn't just individual drug risks — it's unpredictable drug-drug interactions in a body with slower kidney and liver function. Studies consistently link polypharmacy with higher rates of falls, hospitalization, cognitive decline, and mortality in older adults. A periodic medication review with your pharmacist or a geriatrician is one of the highest-value health actions any senior over 65 can take.
References & Sources
- American Geriatrics Society. (2023). "American Geriatrics Society 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults." Journal of the American Geriatrics Society, 71(7), 2052–2081. PubMed
- American Geriatrics Society. (2025). "Alternatives for Medications Listed in the AGS Beers Criteria®." HealthInAging.org. healthinaging.org
- Masnoon N, et al. (2017). "What is polypharmacy? A systematic review of definitions." BMC Geriatrics, 17(1), 230. PubMed
- Richardson K, et al. (2018). "Anticholinergic drugs and risk of dementia: case-control study." BMJ, 361. PubMed
- Candow DG, et al. (2021). "Creatine supplementation for older adults: focus on sarcopenia, osteoporosis, frailty and Alzheimer's disease." Nutrients, 13(6), 2013. PubMed
- Centers for Disease Control and Prevention. (2024). "Falls Data and Statistics: Older Adult Falls." cdc.gov
- Qato DM, et al. (2023). "Prevalence of Beers Criteria medications among U.S. older adults." JAMA Internal Medicine. PubMed
- Schuling J, et al. (2012). "Deprescribing medication in very elderly patients: a systematic review." Drugs & Aging, 29(5), 337–354. PubMed