The Beers Criteria: Which Medications Are Unsafe for Your Elderly Parent

When your parent's doctor prescribes a new medication, it is reasonable to assume someone has checked that it is safe for an older adult. In reality, that check does not always happen — at least not systematically. Prescribers focused on a single condition often reach for a familiar drug without fully accounting for how an aging body processes it differently.

That is where the Beers Criteria comes in. Understanding it is one of the most practical things you can do as a caregiver.

What Is the Beers Criteria?

The AGS Beers Criteria® (named after geriatrician Dr. Mark Beers, who created the original list in 1991) is a regularly updated clinical guideline published by the American Geriatrics Society. It identifies medications that are potentially inappropriate for older adults — drugs where the risks tend to outweigh the benefits in people aged 65 and older.

The 2023 update is the current standard. It does not mean every drug on the list is forbidden; it means each one warrants a serious conversation with the prescribing physician and, ideally, a pharmacist who specializes in geriatric care.

As a caregiver, you do not need to memorize the entire document. You need to know the high-risk categories your parent is most likely to already be taking.

Why Elderly Adults Handle Drugs Differently

Before diving into the list, it helps to understand why these medications become problematic with age. The answer comes down to basic physiology:

• Kidney function declines with age. The kidneys filter drugs out of the body. When filtration slows, drugs and their metabolites accumulate to higher concentrations than intended.
• Liver enzyme activity decreases. The liver breaks down most medications. A slower liver means drugs stay active in the system longer.
• Body composition shifts. Older adults have less total body water and more body fat relative to muscle. Fat-soluble drugs (many sedatives and sleep aids) concentrate in fatty tissue and release slowly over days, extending their effect far beyond what the label suggests.
• The brain becomes more sensitive. Drug receptors in the aging brain respond more strongly to sedating, anticholinergic, and psychoactive medications — often producing side effects that look like new medical conditions rather than drug reactions.

This physiology is why a sleeping pill that causes no problems at age 45 can cause falls, delirium, and hip fractures at age 80.

The High-Risk Categories Caregivers Need to Know

Benzodiazepines and Sleep Medications

Common drugs: Diazepam (Valium), Lorazepam (Ativan), Alprazolam (Xanax), Clonazepam (Klonopin), Zolpidem (Ambien), Eszopiclone (Lunesta)

The Beers warning: All benzodiazepines and most "Z-drug" sleep aids are listed as potentially inappropriate regardless of duration of use. Benzodiazepines are fat-soluble and accumulate in older adults, causing sedation that compounds over time.

The real-world risk: The biggest danger is falls. A sedated parent who gets up at 2 AM to use the bathroom is at serious risk for a hip fracture — and hip fractures in seniors carry a mortality rate of up to 30% within one year. Beyond falls, chronic benzodiazepine use is associated with cognitive impairment that is often mistaken for early dementia.

What to ask the doctor: Request a supervised taper plan if your parent has been on a benzodiazepine long-term. Ask about non-pharmacological alternatives for anxiety and insomnia: cognitive behavioral therapy for insomnia (CBT-I), melatonin at low doses, and sleep hygiene adjustments are all evidence-based.

Anticholinergic Medications

Common drugs: Diphenhydramine (Benadryl, Tylenol PM, ZzzQuil), Doxylamine (Unisom), Oxybutynin (Ditropan), Tolterodine (Detrol), Promethazine, Hydroxyzine (Vistaril), some antidepressants like Amitriptyline (Elavil)

The Beers warning: Anticholinergics block acetylcholine, a neurotransmitter critical for memory, bladder control, and muscle coordination. Older adults are especially vulnerable because they have fewer acetylcholine receptors to begin with.

The real-world risk: This category causes more harm through over-the-counter drugs than through prescriptions. Diphenhydramine — the active ingredient in nearly every OTC sleep aid and many allergy medications — is strongly anticholinergic. Your parent taking "just a Benadryl" to sleep is introducing a drug linked to acute confusion, urinary retention, constipation, and according to several long-term studies, accelerated cognitive decline with repeated use.

What to do right now: Check the medicine cabinet for any "PM" formulations (Tylenol PM, Advil PM, NyQuil) and any allergy medications. These are not benign over-the-counter products for an elderly adult. Replace diphenhydramine-based antihistamines with non-anticholinergic alternatives like loratadine (Claritin) or cetirizine (Zyrtec).

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

Common drugs: Ibuprofen (Advil, Motrin), Naproxen (Aleve), Indomethacin, Meloxicam, Ketorolac

The Beers warning: Oral NSAIDs should be avoided in elderly patients unless no other alternative exists and a proton pump inhibitor is taken simultaneously. Even then, use should be minimized.

The real-world risk: NSAIDs erode the stomach lining, increasing the risk of gastrointestinal bleeding — a risk that grows sharply when combined with blood thinners (Warfarin, Eliquis, Xarelto), aspirin, or corticosteroids. NSAIDs also constrict blood vessels in the kidneys, worsening kidney function. In patients with heart failure or chronic kidney disease, they can trigger acute decompensation.

Safer alternatives: Acetaminophen (Tylenol) up to 3,000mg per day is the preferred oral pain reliever for elderly adults. Topical diclofenac gel (Voltaren) delivers anti-inflammatory effect locally with minimal systemic absorption — a much safer option for localized arthritis pain.

Muscle Relaxants

Common drugs: Cyclobenzaprine (Flexeril), Carisoprodol (Soma), Methocarbamol (Robaxin), Baclofen

The Beers warning: All muscle relaxants are listed as potentially inappropriate for older adults. The evidence that they relieve musculoskeletal pain beyond what acetaminophen achieves is weak; meanwhile, the sedation risk is high.

The real-world risk: Muscle relaxants cause sedation and impaired coordination — again, the dominant downstream risk is falls. They also carry significant anticholinergic burden and can cause urinary retention in men with prostate enlargement.

Certain Diabetes Medications

Common drugs: Glyburide (Diabeta), Glipizide (in high doses), Chlorpropamide

The Beers warning: Long-acting sulfonylureas are flagged because they can cause prolonged, severe hypoglycemia (low blood sugar) in older adults, particularly those skipping meals or with reduced kidney function.

The real-world risk: A hypoglycemic episode in an elderly diabetic can present as confusion, weakness, or sudden unconsciousness. It is often mistaken for a neurological event. The longer the drug stays active in the body, the harder it is to reverse once the blood sugar drops.

Digoxin at High Doses

Common drugs: Digoxin (Lanoxin)

The Beers warning: Digoxin used for atrial fibrillation should not exceed 0.125mg/day in older adults. The drug has an extremely narrow therapeutic window — the difference between a therapeutic dose and a toxic one is small, and that window narrows further as kidney function declines.

The real-world risk: Signs of digoxin toxicity — nausea, loss of appetite, visual disturbances (seeing halos or yellow-green tints), and irregular heartbeat — are easily attributed to other causes. If your parent is on digoxin, ask the doctor how often blood levels are being monitored.

How to Use This Information Without Alarming the Doctor

When a medication on the Beers list is prescribed, the correct response is not to refuse the prescription or demand it be stopped immediately. It is to open a conversation. A few scripts that work well:

• "I read that this medication is on the Beers Criteria list for older adults. Can you help me understand why it's the right choice for Mom at this stage, and what side effects to watch for?"
• "Are there alternatives to this drug that carry less sedation risk for someone her age?"
• "How often will we revisit whether she still needs this medication?"

A good geriatrician or geriatric pharmacist will welcome these questions. If a prescriber is dismissive, that is itself useful information.

Building a Medication Safety System

Knowing the Beers Criteria is only useful if you have an accurate, complete list of everything your parent is taking — prescriptions, over-the-counter drugs, vitamins, and supplements. That single source of truth is the starting point for every safety conversation.

The Medication Management Kit was built specifically for this kind of systematic approach. It includes a printable Master Medication Record, a drug interaction reference sheet, a brown bag review checklist, and a complete set of tools for organizing complex regimens. Cross-referencing your parent's full medication list against the Beers Criteria takes about 20 minutes when you have the right documentation in front of you — and it can prevent the kind of adverse event that puts a senior in the hospital.

Get the Medication Management Kit →

The Bottom Line

The Beers Criteria is not a list of drugs that will inevitably harm your parent. It is a list of drugs that require an extra layer of scrutiny in older adults — scrutiny that does not always happen automatically in a busy clinical setting. Your job as a caregiver is to bring that scrutiny.

Check the medicine cabinet. Cross-reference the list. Ask the questions. The side effects of these medications are frequently mistaken for normal aging or the progression of disease — when in fact they are drug reactions that can be reversed once the medication is adjusted or stopped.