Beers Criteria® — Medication Safety for Older Adults
Search or browse the AGS Beers Criteria® 2023. Each entry explains why the drug or class is potentially inappropriate in adults ≥ 65 and identifies the specific clinical findings nurses should monitor. Safer alternatives are included for every entry.
Beers Criteria® — Medication Safety Reference for Older Adults
American Geriatrics Society (AGS) Beers Criteria® 2023. Potentially Inappropriate Medications (PIMs) in adults ≥ 65 years. For each entry: why the drug is on the list and what nurses should monitor. Use with clinical judgment — some PIMs may be appropriate with monitoring.
Key Principle: Anticholinergic Burden is Cumulative
One low-burden agent may be tolerable. Three moderate-burden agents together can cause delirium. Always calculate total burden across all medications — including OTC products patients may not report.
Table 1 — PIMs to Avoid in Most Older Adults
Why it's on the Beers List
High anticholinergic burden. Blocks muscarinic receptors throughout the body and brain, causing delirium, cognitive impairment, and urinary retention. Frequently hidden in OTC combination sleep, allergy, and cold products — patients and families often do not recognise it as a medication.
What to Watch For (Nursing)
New or worsening confusion, agitation, or delirium; inability to void (urinary retention — check last void time); constipation; dry mucous membranes; tachycardia; daytime sedation and fall risk. Screen the medication reconciliation list carefully for any product containing diphenhydramine.
Safer Alternatives
Loratadine or cetirizine for allergies; melatonin (low dose) or CBT-I for sleep.
Why it's on the Beers List
Potent antihistamine with significant anticholinergic and CNS depressant properties. Causes sedation, cognitive impairment, and fall risk disproportionate in older adults due to age-related increased CNS sensitivity.
What to Watch For (Nursing)
Excessive sedation, over-sedation on the RASS scale, new confusion, orthostatic BP changes, fall precautions. Monitor the next morning for residual sedation.
Safer Alternatives
Buspirone for anxiety; non-pharmacologic strategies for pruritus.
Why it's on the Beers List
Among the highest anticholinergic burden of all antidepressants. Also cause cardiac arrhythmias (sodium-channel blockade → prolonged QRS/QTc), orthostatic hypotension, and sedation. Lethal in overdose.
What to Watch For (Nursing)
Orthostatic vital signs (lying → sitting → standing BP), ECG changes (wide QRS, prolonged QTc), urinary retention, constipation, confusion, falls. Hold and notify provider if QTc > 500 ms.
Safer Alternatives
SNRIs (duloxetine, venlafaxine) for depression or neuropathic pain; nortriptyline has lower anticholinergic burden if a TCA is required.
Why it's on the Beers List
The most anticholinergic SSRI. Despite being an antidepressant, it carries meaningful anticholinergic burden contributing to cognitive impairment and constipation in older adults.
What to Watch For (Nursing)
Confusion, memory complaints, urinary retention, constipation, serotonin syndrome signs if combined with other serotonergic agents. Watch for abrupt discontinuation syndrome (dizziness, electric-shock sensations, irritability).
Safer Alternatives
Sertraline or escitalopram (much lower anticholinergic burden).
Why it's on the Beers List
Immediate-release oxybutynin has the highest CNS penetration of all antimuscarinics, producing cognitive impairment and delirium in older adults. The transdermal patch has lower systemic burden.
What to Watch For (Nursing)
Acute confusion or delirium, memory decline, constipation, urinary retention (paradoxical — antimuscarinic can cause overflow incontinence), dry mouth, heat intolerance (decreased sweating).
Safer Alternatives
Mirabegron (beta-3 agonist, no anticholinergic effect); pelvic floor physical therapy.
Why it's on the Beers List
All antimuscarinics for overactive bladder carry anticholinergic burden. While lower than oxybutynin IR, the cumulative burden in patients on multiple anticholinergic agents remains clinically significant.
What to Watch For (Nursing)
Confusion, cognitive decline, constipation, urinary retention, dry mouth, tachycardia. Calculate total anticholinergic burden when patient is on multiple agents.
Safer Alternatives
Mirabegron; pelvic floor PT; bladder-training programs.
Why it's on the Beers List
Strong anticholinergic and dopamine-antagonist activity. In older adults, causes excessive sedation, delirium, urinary retention, and risk of extrapyramidal symptoms.
What to Watch For (Nursing)
Sedation level, confusion, urinary retention, involuntary movements (akathisia, dystonia), orthostatic hypotension, respiratory depression (especially if combined with opioids).
Safer Alternatives
Ondansetron (4 mg) for nausea; prochlorperazine used with extreme caution (also dopamine antagonist).
Why it's on the Beers List
First-generation antihistamines readily cross the blood-brain barrier and carry significant anticholinergic burden. Meclizine is frequently prescribed for dizziness but contributes to falls and cognitive impairment.
What to Watch For (Nursing)
Confusion, sedation, falls, urinary retention, constipation. Meclizine: assess whether 'dizziness' could be orthostatic hypotension requiring a different workup.
Safer Alternatives
Second-generation antihistamines (loratadine, cetirizine); vestibular rehabilitation for dizziness.
Why it's on the Beers List
Used for drug-induced extrapyramidal symptoms (EPS), but the anticholinergic burden causes significant cognitive impairment and delirium in older adults.
What to Watch For (Nursing)
Confusion, delirium, urinary retention, constipation, tachycardia, blurred vision, dry mouth. Monitor for paradoxical worsening of movement control.
Safer Alternatives
Amantadine for EPS; dose reduction or switch of offending antipsychotic.
Why it's on the Beers List
All benzodiazepines — regardless of half-life — increase fall risk, fractures, motor vehicle accidents, over-sedation, cognitive impairment, and delirium in older adults. Age-related CNS sensitisation means effects are unpredictable and prolonged. Long-acting agents (diazepam, clonazepam) accumulate in lipophilic tissues due to increased fat-to-water ratio.
What to Watch For (Nursing)
RASS level (target range per order), respiratory rate and O2 saturation (especially with concurrent opioids — black box warning dual CNS depressant), fall risk assessment, paradoxical agitation (more common in older adults), functional decline, signs of dependence or withdrawal if discontinued abruptly (seizures, tremor, diaphoresis, hypertension). Taper never stop abruptly.
Safer Alternatives
CBT-I for insomnia; SSRIs/SNRIs for anxiety; buspirone for generalised anxiety.
Why it's on the Beers List
Despite being marketed as 'safer' than benzodiazepines, Z-drugs produce the same adverse effects in older adults: falls (especially nocturnal), fractures, parasomnias (sleepwalking, sleep-eating, sleep-driving), cognitive impairment, and rebound insomnia on discontinuation.
What to Watch For (Nursing)
Nocturnal falls (check incident reports), complex sleep behaviors (sleepwalking, eating while asleep), morning sedation residue, confusion, driving or operating hazards in community-dwelling patients. Instruct patient/family about parasomnias.
Safer Alternatives
Melatonin (low dose, 0.5–1 mg); CBT-I; doxepin ≤6 mg (FDA approved at this dose for sleep maintenance).
Why it's on the Beers List
All antipsychotics carry a black box warning for increased mortality in older adults with dementia (primarily cerebrovascular events and pneumonia). Additional risks include extrapyramidal symptoms (EPS), tardive dyskinesia, QTc prolongation, metabolic syndrome, orthostatic hypotension, sedation, and falls. Quetiapine and risperidone are frequently used off-label for BPSD — risk remains despite widespread use.
What to Watch For (Nursing)
QTc interval on ECG (obtain baseline and follow up; hold and notify if > 500 ms), orthostatic BP, fall risk, involuntary movements (use AIMS, BARS, SAS scales), metabolic panel (glucose, lipids), sedation level, respiratory status in patients prone to aspiration, documentation of indication and informed consent (especially dementia patients).
Safer Alternatives
Non-pharmacologic behavioral interventions for BPSD (structured routine, therapeutic activity, caregiver coaching); treat underlying delirium cause.
Why it's on the Beers List
Opioids in older adults cause falls and fractures, delirium, respiratory depression, constipation (opioid-induced constipation — OIC), urinary retention, nausea, and physical dependence. The combination of opioids + benzodiazepines dramatically increases overdose and death risk (dual CNS depressant black box). Tramadol additionally lowers seizure threshold and has serotonergic activity. Meperidine (Demerol) accumulates normeperidine — a toxic metabolite that causes CNS excitability, tremors, and seizures.
What to Watch For (Nursing)
Sedation level (RASS, assess before each dose), respiratory rate (hold if < 12/min in most protocols), O2 saturation, bowel movement frequency and consistency (OIC often requires scheduled bowel regimen), voiding (urinary retention), pain reassessment, concurrent benzodiazepine or CNS depressant orders (alert prescriber), naloxone availability at bedside per policy.
Safer Alternatives
Acetaminophen as baseline analgesic; topical agents for localised pain; SNRIs for neuropathic pain; lowest effective opioid dose with scheduled bowel regimen if opioids are necessary. Avoid meperidine — no clinical advantage, high toxicity.
Why it's on the Beers List
Alpha-1 blockers cause significant orthostatic hypotension and fall risk in older adults. Superior antihypertensive agents are available. Note: tamsulosin (Flomax) is used for BPH — more uroselectivity, but still increases fall risk and orthostatic hypotension.
What to Watch For (Nursing)
Orthostatic vital signs (lying, sitting, standing — document each; ≥20 mmHg systolic or ≥10 mmHg diastolic drop = positive orthostatic hypotension), dizziness on standing, syncopal episodes, falls (especially shortly after dose administration or in the morning).
Safer Alternatives
ACE inhibitors, ARBs, thiazide diuretics, or calcium channel blockers for hypertension.
Why it's on the Beers List
Digoxin has a narrow therapeutic index. In older adults, reduced renal clearance (↓ GFR) leads to drug accumulation and toxicity even at 'normal' doses. Toxicity risk is amplified by hypokalemia, hypomagnesemia, and hypothyroidism.
What to Watch For (Nursing)
Heart rate before administration (hold if < 60 bpm per protocol or provider order), digoxin serum level (therapeutic 0.5–0.9 ng/mL for HF; toxicity > 2 ng/mL), potassium and magnesium levels, signs of toxicity: bradycardia, AV block, nausea/vomiting, anorexia, visual disturbances (yellow-green halos, blurred vision), confusion or fatigue.
Safer Alternatives
Rate control with beta-blockers or calcium channel blockers in AF; digoxin at ≤0.125 mg/day with close monitoring if required.
Why it's on the Beers List
Immediate-release nifedipine causes rapid, unpredictable drops in blood pressure and reflex tachycardia, increasing risk of myocardial infarction and stroke. Older adults are at particular risk of hypoperfusion injury due to impaired baroreceptor function.
What to Watch For (Nursing)
Rapid BP reduction after administration, new chest pain, tachycardia, syncope or presyncope, signs of ischemia. Do not use for hypertensive urgency/emergency.
Safer Alternatives
Extended-release nifedipine or amlodipine for ongoing BP management.
Why it's on the Beers List
At doses above 25 mg/day, spironolactone significantly increases hyperkalemia risk — especially when combined with ACE inhibitors, ARBs, or NSAIDs, or when GFR is reduced. Cardiac arrhythmias can result from severe hyperkalemia.
What to Watch For (Nursing)
Potassium levels (frequency per prescriber order — ideally within 1 week of initiation and after dose increases), renal function (creatinine, GFR), concurrent medications (ACEi + ARB + spironolactone = triple combination, very high hyperkalemia risk), signs of hyperkalemia: muscle weakness, paresthesias, palpitations, bradycardia, wide QRS on ECG.
Safer Alternatives
Lowest effective dose (≤25 mg/day) with monitoring; eplerenone; furosemide if diuresis is the primary goal.
Why it's on the Beers List
Associated with worse outcomes (increased mortality, HF hospitalisation, stroke) in older adults with permanent atrial fibrillation and heart failure.
What to Watch For (Nursing)
Fluid retention, worsening dyspnea, weight gain (HF exacerbation), bradycardia, QTc prolongation, hepatotoxicity (LFTs), pulmonary toxicity.
Safer Alternatives
Rate control strategy with beta-blockers or calcium channel blockers for permanent AF.
Why it's on the Beers List
NSAIDs inhibit prostaglandins that protect the gastric mucosa and maintain renal blood flow. In older adults: (1) GI bleeding and peptic ulcer risk is significantly elevated; (2) renal blood flow reduction can precipitate acute kidney injury; (3) sodium/water retention worsens hypertension and heart failure; (4) cardiovascular event risk is elevated. Indomethacin has the highest CNS toxicity of all NSAIDs (confusion, headache). Ketorolac: parenteral NSAID with high GI and renal toxicity — avoid beyond 5 days.
What to Watch For (Nursing)
GI: black or tarry stools (melena), coffee-ground emesis, abdominal pain, epigastric discomfort. Renal: urine output, creatinine/BUN trends, weight gain, edema. Cardiovascular: BP elevation, leg edema, dyspnea, weight gain. CNS (especially indomethacin): confusion, headache. Electrolytes: sodium and potassium changes with fluid retention.
Safer Alternatives
Acetaminophen (up to 2–3 g/day; reduce to 2 g/day with liver disease or heavy alcohol use); topical diclofenac gel for localised joint pain; physical therapy and non-pharmacologic modalities.
Why it's on the Beers List
Glyburide has active metabolites that accumulate with reduced GFR — common in older adults — causing prolonged, severe, and life-threatening hypoglycemia. Duration of hypoglycemia can last 12–24 hours despite treatment.
What to Watch For (Nursing)
Blood glucose before meals and at bedtime. Signs of hypoglycemia: diaphoresis, tremulousness, tachycardia, confusion, agitation, pallor, hunger. In older adults, hypoglycemia frequently presents atypically as confusion or falls WITHOUT classic sympathetic signs. Assess food intake at every meal — hold or reduce dose if patient is not eating. Document GFR and report declining renal function.
Safer Alternatives
Glipizide (shorter acting, no active metabolites); metformin if GFR allows (hold if GFR < 30); GLP-1 receptor agonists; SGLT-2 inhibitors (with renal dosing adjustments).
Why it's on the Beers List
SSI alone is reactive management — it corrects hyperglycemia after it occurs rather than preventing glucose excursions. This approach leads to hypoglycemia (administering doses when oral intake is reduced) and wide glucose swings without achieving glycemic targets.
What to Watch For (Nursing)
Blood glucose before insulin administration and 1–2 hours after. Meal intake documentation before coverage doses. Signs of hypoglycemia (see glyburide entry). Hold coverage insulin if patient is NPO or has significantly reduced PO intake — notify provider.
Safer Alternatives
Basal insulin with correction factor; consistent carbohydrate diet; consult endocrinology or diabetes nurse educator.
Why it's on the Beers List
Used for appetite stimulation, but in older adults causes thromboembolism, adrenal insufficiency (via suppression of the HPA axis), minimal meaningful improvement in lean body mass (weight gain is primarily fat and fluid, not muscle), and may worsen hypogonadism.
What to Watch For (Nursing)
Signs of DVT/PE (leg pain, swelling, dyspnea, pleuritic chest pain), adrenal insufficiency if stopped abruptly (hypotension, fatigue, nausea), fluid retention, glucose elevation (due to glucocorticoid-like effects).
Safer Alternatives
Mirtazapine (appetite stimulation plus antidepressant effect); address underlying cause of anorexia; nutritional counseling.
Why it's on the Beers List
Muscle relaxants cause significant sedation, cognitive impairment, and anticholinergic effects (cyclobenzaprine has a TCA-like structure). Evidence for efficacy in musculoskeletal pain in older adults is weak. Carisoprodol is metabolised to meprobamate — a controlled substance with abuse potential. Baclofen accumulates with reduced GFR causing encephalopathy.
What to Watch For (Nursing)
Sedation, RASS level, falls, confusion, voiding difficulty (urinary retention from anticholinergic burden — especially cyclobenzaprine). Baclofen: monitor for encephalopathy, confusion, myoclonus in patients with renal impairment.
Safer Alternatives
Physical therapy, heat/cold therapy, topical analgesics, acetaminophen, low-dose TCA for neuropathic component.