Which Drugs Are Flagged in the Beers Criteria 2023?

The 2023 AGS Beers Criteria is an updated, evidence-based list of medications that are potentially inappropriate for adults aged 65 and older, published by the American Geriatrics Society. An expert panel reviewed evidence published since the previous 2019 edition and approved additions of new criteria, modifications to existing ones, and formatting changes designed to make the list easier to use in clinical practice.¹ The list is not a blanket ban on specific drugs but a practical screening tool meant to flag prescriptions that carry outsized risks for older people, helping clinicians weigh whether the benefit of a given medication truly justifies those risks.

What the Beers Criteria Actually Is

Named after geriatrician Mark Beers, who developed the original version in 1991, the Beers Criteria is a list of potentially inappropriate medications (often abbreviated PIMs) organized into several tables. These tables cover drugs to avoid regardless of condition, drugs to avoid in specific diseases, drug-drug interactions to watch for, and medications that need dose adjustments based on kidney function. The 2023 edition, like its predecessors, frames these as recommendations rather than absolute rules. A medication on the list might still be the best option for a specific patient when alternatives have failed or are unavailable. The point is to prompt a conversation rather than to override clinical judgment.

The criteria target adults 65 and older because aging changes the way the body handles drugs. Kidney and liver function decline, body composition shifts (more fat, less water), and the brain becomes more sensitive to sedating medications. These changes mean that doses appropriate for a 45-year-old can accumulate to toxic levels in an 80-year-old, or that side effects that a younger person shakes off, like dizziness or confusion, become genuinely dangerous for someone at high risk of falling.

Key Drug Classes Flagged in the 2023 Update

Several drug classes have appeared on the Beers list for years, and the 2023 update reinforced the warnings around them with newer evidence. Understanding which categories draw the most attention helps you recognize red flags in your own or a family member’s medication list.

Anticholinergic Drugs

Anticholinergics block a neurotransmitter called acetylcholine, which plays a role in memory, bladder control, and gut motility. Many common medications have anticholinergic effects, sometimes as an unintended side property. These include certain antihistamines (like diphenhydramine, the active ingredient in many over-the-counter sleep aids), bladder medications, and older antidepressants. A meta-analysis found that anticholinergic use was linked to about a 20% higher odds of developing dementia, and long-term use raised that figure to roughly 50%.² A separate systematic review and meta-analysis concluded that higher anticholinergic exposure can also increase the risk of falls and death in older adults.³

What makes anticholinergics tricky is that they hide in many medications people do not think of as brain drugs. A person taking an antihistamine for allergies, a muscle relaxant for back pain, and an overactive-bladder pill is stacking three sources of anticholinergic exposure without realizing it. The cumulative “anticholinergic burden” is what the Beers Criteria aims to flag.

Sedatives, Hypnotics, and Sleep Drugs

Benzodiazepines (like lorazepam and diazepam) and the so-called Z-drugs (like zolpidem and zopiclone) remain firmly on the list. Older adults metabolize these medications slowly, and the sedation they produce dramatically raises the risk of falls and fractures. A systematic review found that Z-drug use was tied to about a 63% increase in fracture risk, and short-term use of both benzodiazepines and Z-drugs roughly doubled the risk of hip fracture.⁴ Zolpidem in particular has been singled out: one study of adults 65 and older found that fracture and dislocation rates more than doubled in the 90 days after a new zolpidem prescription.⁵

A hip fracture in an older adult is not a minor event. It often triggers a cascade of hospitalization, surgery, immobility, and loss of independence. This is why the Beers Criteria treats these medications as high-priority targets for deprescribing, even though many patients feel attached to their sleep aids after years of use.

NSAIDs

Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen are among the most commonly used pain medications worldwide, and they are effective. But in older adults they carry elevated risks of gastrointestinal bleeding, cardiovascular events, and kidney damage.⁶ The danger compounds when an older person is also on blood thinners or has existing kidney disease. The Beers Criteria recommends avoiding chronic NSAID use in older adults and suggests alternatives like acetaminophen, topical preparations, or non-drug pain management when feasible.

Antipsychotics in Dementia

Antipsychotic medications are sometimes prescribed to manage agitation and behavioral symptoms in people with dementia, but their risks in this population are severe. A large population-based study found that current antipsychotic use in dementia patients was associated with more than double the risk of pneumonia, a 61% increase in stroke risk, and elevated odds of fracture, blood clots, heart attack, and heart failure.⁷ Mortality risk is also substantially higher: one study found a 35% increase in the adjusted risk of death among dementia patients exposed to antipsychotics.⁸ The Beers Criteria strongly recommends avoiding antipsychotics for behavioral symptoms of dementia unless the patient is a danger to themselves or others and non-drug approaches have failed.

The Rivaroxaban Addition

One of the more talked-about changes in the 2023 update is the addition of rivaroxaban to the list of medications to use with caution in older adults. Rivaroxaban is a blood thinner widely prescribed for atrial fibrillation and blood clots. The concern is that compared with other oral anticoagulants, rivaroxaban appears to carry a higher bleeding risk without offering better stroke prevention. A population-based analysis found that rivaroxaban increased bleeding risk compared to warfarin, dabigatran, and apixaban, and when compared to apixaban specifically, rivaroxaban was associated with both higher bleeding and higher stroke and embolism risk.⁹

This does not mean rivaroxaban is a bad drug. For many patients it works well, and its once-daily dosing can improve adherence. But for older adults who have other options, the criteria nudges clinicians toward apixaban or dabigatran when initiating anticoagulation, since these alternatives appear to offer a better balance of protection and safety in that age group.

Drug-Disease and Drug-Drug Interaction Tables

The Beers Criteria is not just a list of drugs. It also includes tables of drug-disease interactions and drug-drug interactions that deserve special attention in older adults.¹⁰ For example, someone with a history of falls should avoid sedating medications regardless of whether those specific drugs appear on the general avoidance list. Someone with heart failure should avoid NSAIDs because they promote fluid retention and can worsen the condition. And someone with dementia should avoid adding anticholinergic drugs to their regimen because of the cognitive effects described earlier.

A study using the 2023 criteria in heart failure patients found that roughly three-quarters of older adults with heart failure were prescribed at least one potentially inappropriate medication.¹¹ That number is striking, and it underscores how common these prescribing patterns are. The drug-disease interaction tables exist precisely for this scenario: a medication that is perfectly reasonable in a healthy 50-year-old can become genuinely harmful when a 78-year-old takes it alongside five other medications and has kidney disease and heart failure.

Does Being on a “Beers List” Drug Actually Hurt You

A fair question. The Beers Criteria flags medications as potentially inappropriate, but does exposure to these drugs actually lead to worse outcomes? The answer, at least for hospitalizations, is yes. A large study examining more than 383,000 hospitalized older adults found that exposure to potentially inappropriate medications was associated with an 18% higher odds of unplanned hospitalization, and that risk climbed with the number of flagged drugs a person was taking. About 15% of unplanned hospitalizations among exposed patients were attributed to PIM use.¹²

The evidence for other outcomes is more mixed. A systematic review found clear associations between PIM use and hospitalization in community-dwelling older adults, but no consistent link to mortality in that setting, and evidence on quality of life and costs was inconclusive.¹³ This does not mean these medications are harmless; it means the link between a flagged prescription and death is harder to isolate statistically than the link to a hospital admission. Given that hospital stays themselves carry risks for older adults (deconditioning, delirium, hospital-acquired infections), preventing unnecessary admissions is a meaningful benefit on its own.

Electronic Tools for Deprescribing

Knowing a drug is on the Beers list is one thing. Getting it safely stopped is another. Deprescribing, the planned process of reducing or stopping a medication when its risks outweigh its benefits, requires buy-in from the prescriber, the pharmacist, and the patient. Several studies have tested electronic decision support systems that automatically screen a patient’s medication list against the Beers Criteria and generate recommendations for the care team.

In one trial in long-term care facilities, using an electronic tool nearly tripled the rate of PIM deprescribing, from about 13% of residents having at least one flagged drug stopped during the control phase to about 36% during the intervention phase.¹⁴ A similar trial in acute care hospitals found that the proportion of patients with at least one PIM deprescribed at discharge rose from about 47% to 55% when clinicians had access to an electronic deprescribing tool.¹⁵ These improvements are meaningful but also reveal how deeply entrenched prescribing habits are. Even with automated alerts, many flagged medications stayed on the list.

How the Beers Criteria Compares to STOPP

The Beers Criteria is not the only screening tool for inappropriate prescribing in older adults. The STOPP criteria (Screening Tool of Older Persons’ Prescriptions), developed in Europe, takes a somewhat different approach. A comparative study in heart failure patients found that the Beers Criteria flagged PIMs in about 76% of patients, while STOPP version 3 identified them in about 29%.¹⁶ That difference does not mean one is better. The Beers Criteria casts a wider net and includes drugs to “use with caution,” while STOPP focuses more narrowly on prescriptions tied to specific clinical scenarios. Their overlap is surprisingly modest, which is why some geriatrics experts advocate using both.

If you are outside the United States, you are more likely to encounter STOPP, which was designed with European formularies in mind. Inside the U.S., the Beers Criteria dominates clinical practice and quality metrics. Medicare quality measures, for instance, track PIM prescribing rates using the Beers list.

Over-the-Counter Medications That Slip Through

A blind spot in how the Beers Criteria gets applied is that many flagged ingredients are available without a prescription. A study examining Chinese over-the-counter products found that 71 OTC medications contained ingredients listed in the Beers Criteria, with compound cold medications accounting for nearly half.¹⁷ This applies broadly, not just in China. Diphenhydramine, the antihistamine in many nighttime cold formulas and over-the-counter sleep aids sold in the U.S., is one of the most commonly flagged anticholinergic drugs. An older adult whose physician carefully avoids prescribing Beers-listed medications may still be taking them nightly from a drug-store sleep aid that nobody asked about.

This gap highlights the importance of medication reconciliation that includes everything a person actually takes, not just what shows up in the pharmacy computer. Herbal products and supplements can introduce their own interactions, but the OTC drug problem is more straightforward: these are well-known active ingredients with well-documented risks, and they simply are not being captured in many clinical encounters.

Racial and Ethnic Disparities in PIM Exposure

An unexpected finding in the research around the Beers Criteria is that potentially inappropriate medication use is not distributed evenly across racial and ethnic groups. A large analysis of Medicare beneficiaries found that White patients had the highest rates of PIM use. Black beneficiaries had high-risk medication use rates roughly 3.4 percentage points lower, and Asian or Pacific Islander beneficiaries about 1.7 points lower, compared to White beneficiaries. For drug-disease interactions in patients with dementia, the gap was even wider: Black beneficiaries had rates about 11 percentage points lower than White beneficiaries.¹⁸

These numbers do not mean that minority populations receive better prescribing. Lower PIM rates could reflect less access to specialists, fewer prescribed medications overall, or different patterns of care-seeking. A separate study of dementia patients with access to dementia experts still found significant racial and ethnic disparities in PIM exposure, suggesting the differences may be even wider in the broader community where access is less consistent.¹⁹ The relationship between medication access, prescribing quality, and health equity in older adults is complicated, and the Beers Criteria alone cannot untangle it.

What Older Adults Themselves Want

Deprescribing only works if the patient is willing to stop a medication. Surveys across 14 countries found that about 46% of older adults who wanted to reduce their medications cited side effects as the main reason, followed by disliking taking medications (24%) and inconvenience (22%).²⁰ In practice, most older adults are receptive. A study in Ethiopia found that about 81% of respondents agreed they would stop one or more regular medications if their physician said it was possible, even though roughly half were satisfied with their current regimen.²¹

The disconnect is not usually patient reluctance. It is that the conversation never happens. Prescribing a new medication takes one clinic visit. Reviewing whether old medications are still appropriate takes time that many appointments do not allow. The Beers Criteria gives clinicians a structured reason to open that discussion, and for patients and caregivers, knowing the list exists is its own form of empowerment. If you are managing medications for an older family member, asking a pharmacist to run the list against the Beers Criteria is a reasonable starting point. It does not replace a physician’s judgment, but it can surface questions that might otherwise go unasked for years.