It’s a fact of life for most adults: The older you get, the more health conditions you acquire. Treating those health conditions often requires an arsenal of medications, all of which come with their own set of directions and potential side effects.
It gets even more complicated when certain medications become less safe to take as you age, while others carry warnings about drug interactions. Aging can make some medication levels in your body get out of whack based on changes in the way your body processes them—and can put you at increased risk for adverse events.
Given the number of medications that many seniors take each day, it can feel daunting to keep track of what you’re on and figure out if it’s safe for you. Thankfully, the American Geriatrics Society (AGS) maintains a list called the Beers Criteria, an evidence-based collection of medications that seniors may want to avoid, or at least use with caution under the supervision of a health professional.
Read on for more about what’s included in the list and how you can use it to medicate safely.
What is the Beers Criteria?
The Beers Criteria is a set of guidelines for clinicians to refer to when prescribing or recommending medications to seniors. It was adopted by the AGS in 2011 and last updated in 2019; the organization typically re-evaluates the criteria every three years.
The list includes all potentially inappropriate medications for older adults, generally defined as people over 65. There are nearly 100 drugs on the list as of 2019. The purpose of the AGS Beers Criteria is to ensure that all geriatric patients are prescribed safe and appropriate medications for their overall health, taking into consideration three main factors:
Older people with certain prior medical conditions should always be evaluated using the Beers Criteria, but the list applies to any adult over 65—regardless of their health status.
Why? Because our bodies’ ability to metabolize some medications changes as we age, says Jeffrey Fudin, Pharm.D., owner and managing editor of paindr.com: “Some drugs are cleared through the kidneys and the older you get, the worse your kidney function is.”
Some drugs are on the list because they can cause dangerous side effects in seniors. Blood pressure drugs, for example, may cause orthostatic hypotension (a sudden drop in blood pressure, usually when going from sitting or laying down to standing quickly). This may catch an older patient off guard, putting them at a higher risk of falling and seriously injuring themselves.
2. Other medications
Drug interactions happen more often than you think, and your risk of taking a drug that interacts with another is higher if you’re taking several different medications. This is known as polypharmacy, and it’s very common in the elderly.
“Older people are often prescribed multiple medications or [even given] inappropriate medications to manage their multiple chronic conditions,” says Scott Kaiser, MD, director of geriatric cognitive health for the Pacific Neuroscience Institute at Providence Saint John’s Health Center.
Ideally, all of your medical information would be stored in one database so all of your healthcare providers could keep up-to-date with your current prescriptions. But this wouldn’t solve every problem, says Dr. Kaiser, who warns that many people don’t think to mention non-prescription drugs like over-the-counter (OTC) medications and supplements to their doctors.
For example, diphenhydramine, or Benadryl, is included on the Beers Criteria for its anticholinergic effects on the nervous system, such as dizziness and confusion—but it’s an OTC drug, not a prescription one, and can be easily overlooked.
“If someone gives you a list of all the meds they’re taking but leaves out that they’re taking something with diphenhydramine in it every night for sleep, you’re missing out on a huge piece of the puzzle,” Dr. Kaiser explains.
3. Existing health conditions
The chances of having one or more medical conditions only goes up the older you get, but whether these are official diagnoses—like Type 2 diabetes or hypertension—or not, you may still be managing multiple symptoms across multiple conditions.
“You might have symptomatic complaints like sleep issues, mental health concerns, or UTIs, and you might be [participating in] multiple medical solutions, including taking OTC drugs, going to your PCP, and seeing specialists,” Dr. Kaiser says.
Any complex health scenario leaves you vulnerable to ending up on a medication that’s inappropriate for use because of your age or health status.
Which medications are on the Beers list?
Dr. Fudin finds it useful to group the medications in the Beers Criteria by pharmacology, or what the drugs are often used for. Classes of medications are grouped into broad categories including:
- Those that are potentially inappropriate in most older adults
- Those that are potentially inappropriate in older adults with certain conditions
- Those that should be used with caution
Each class of medication is assigned a strength of quality within that category based on a review of available literature: high, moderate, or low quality of evidence. Still, very few medications are outright contraindicated in all cases—meaning there is almost always a benefit versus risk assessment needed.
Quality of evidence
Here are some of the major categories of drugs included on the list with moderate to high quality of evidence to place them on the Beers List:
|Drug class||Why it’s on the list||Specific drug names|
|First generation antihistamines||Anticholinergic; may cause dry mouth, constipation, dry eyes, dizziness, confusion||Diphenhydramine, doxylamine|
|Alpha blockers||May cause sudden drops in blood pressure (orthostatic hypotension)||Doxazosin, terazosin|
|Tricyclic antidepressants||Anticholinergic; may be extremely sedating||Amitriptyline, nortriptyline|
|Barbiturates||Higher risk of dependence and overdose||Butalbital, phenobarbital|
|Androgens||Increased risk of heart problems||Testosterone|
|Benzodiazepines||Increased risk of cognitive impairment and falls||Lorazepam, diazepam|
|Proton-pump inhibitors||Increased risk of infection, bone loss, and fractures||Esomeprazole, omeprazole|
Many medications included on the Beers list may be safe for use in some patients, but require physician’s supervision; they may or may not be safe for you, depending on your other medications, existing conditions, or overall health. These include:
|Drug class||Why it’s on the list||Specific drug names|
|NSAIDs||Increased risk of GI bleeds; may increase risk of kidney injury||Ibuprofen, naproxen|
|Antipsychotics||May increase symptoms of Parkinson’s disease, increased risk of cognitive impairment and falls||Clozapine, olanzapine|
|Oral decongestants||May increase insomnia, blood pressure, or have other stimulating effects||Pseudoephedrine, phenylephrine|
|Vasodilators||Risk of serious electrolyte abnormalities due to drug interactions||Lisinopril, Benazepril|
|Anticoagulants||Risk of several drug interaction resulting in increased risk of bleeding||Warfarin|
|Antiemetics||May increase symptoms of Parkinson’s disease||Metoclopramide|
|Anticonvulsants||May increase risk of falls, fainting, loss of coordination||Topiramate, clonazepam|
This is not a full list of medications on the Beers list, which contains nearly 100 drugs; a complete listing of the drugs included in the 2019 update can be found here.
How to make sure your medications are safe
If you’re feeling overwhelmed by the thought of potentially inappropriate medication use or simply keeping track of everything you’re prescribed, don’t stress: There are several ways you can manage your complex medication needs without putting yourself at risk.
1. Say “yes” to pharmacist counseling
If you always dismiss the pharmacy’s offer of medication counseling when you fill a new prescription, you’re missing out on an opportunity to receive a free consultation about your medication usage.
“You should never ever refuse counseling,” says Dr. Fudin. “When you’re handed a bag with instructions, it’s important for you or your caregivers to understand what you’re being given.”
Not only could you be overlooking common issues or contraindications with that drug, you could be paying too much attention to things that happen only rarely and aren’t a major concern. Your pharmacist can help you focus on the prescription information you actually need.
2. Be proactive
In a perfect world, you could count on every person on your medical team to know everything about each one of your medications. But the reality is that you need to be the captain of your ship: you need a reliable system to keep track of every medication or supplement you put in your body every day, says Dr. Kaiser, whether it’s by maintaining an updated list in your smartphone or simply bringing all your pill bottles with you to your appointments.
And don’t be afraid to get informed about the Beers Criteria yourself; although it was developed as a tool for clinicians, you may need to review it and call attention to any concerns you have.
“If you have multiple conditions, it’s important to be the CEO of your own health,” advises Dr. Kaiser. “Get informed and educated, review your own list of medications, and use [that knowledge] to drive meaningful conversations with your healthcare team.”
3. Re-evaluate your prescriptions regularly
Just because you’ve been taking a drug or dose for a long period of time doesn’t mean it’s still working for your now-older body. It’s important, says Dr. Fudin, to renew your familiarity with the medications you’re on by reading the pamphlet that comes with your prescription every three to four months.
“Let’s say you’ve been on Ambien (zolpidem) for five years and you’re used to taking it every night at bedtime—but one of the things Ambien can cause is sleepwalking, and the older you get the more common that is,” explains Dr. Fudin.
Not reading up on the side effects of a drug like Ambien could put you in a dangerous situation and you may not even realize the cause. A familiar drug could create different side effects now that you’re older than it did when you first started taking it.
4. Notify your healthcare provider of changes
Going on a new diet? Taking a new vitamin? Talk to your healthcare provider or pharmacist! Dr. Fudin says many natural products, like supplements, block or rev up the enzymes responsible for metabolizing certain drugs, so taking some supplements and medications together can increase side effects or make your medications less effective—a very broad spectrum of potential problems.
There’s also another reason to be cautious with supplements, Dr. Kaiser says: “There’s less regulation and it can be unclear what’s in there, plus we have a more limited understanding of how they could potentially interact with what you’re taking as well as their potential adverse effects.”
5. Be open to communication
As much as some people view the Beers Criteria as a list of drugs seniors should avoid, Dr. Kaiser says no drug on the list is truly off-limits. Instead, the list gives you and your physician the guidance to think about possible interactions or concerns and to talk through a risk versus benefit analysis of potential side effects.
Dr. Kaiser explains: “The Beers Criteria is an invitation for people to look at the meds they’re on and ask questions: When was this prescribed, by whom, and why? What is its purpose, and is it having its intended effect?”
The goal, in other words, is to assess a drug’s appropriateness for you, personally—the Beers Criteria is meant as a starting point for meaningful conversations with your healthcare provider, but it doesn’t replace those conversations (or the expertise and experience of your medical team).