Medications on the Beers List: 12 Drugs Older Adults Should Watch Out For

As you get older, medications can start affecting you differently. You may be more sensitive to side effects. And certain side effects — such as confusion, low blood pressure, and falls — can be especially risky in older adults.

To help guide safer prescribing, the American Geriatrics Society (AGS) maintains a list of potentially inappropriate medications for older adults. It’s called the Beers Criteria — often referred to as the Beers List. If you’re 65 or older, this list can flag medications that may be riskier for you. Here’s what you should know.

Medications on the Beers List

Before diving into individual medications, here are examples of drugs and drug classes on the Beers List and the risks they pose to older adults. This list isn’t exhaustive. But it offers a snapshot of medications that often require extra caution.

Below, we cover 12 medications on the Beers List, their potential risks, and safer alternatives to consider.

1. Benadryl and older antihistamines

Antihistamines are used for various conditions, including allergies and sleep problems. But first-generation antihistamines should be avoided in older adults in many cases.

As we age, it’s harder for our bodies to properly get rid of these antihistamines. That can greatly raise your risk of side effects, including confusion. Other problematic antihistamine side effects in older adults include constipation and dry mouth.

Diphenhydramine (Benadryl) is well-known for causing side effects in the elderly. But other examples include:

• Doxylamine (Unisom)

• Chlorpheniramine (Chlor-Trimeton)

• Dimenhydrinate (Dramamine)

What’s more, these antihistamines may interact with other medications you’re taking. For example, Benadryl can interact with several medications, including metoprolol (Lopressor, Toprol XL).

Better options: Stick with newer antihistamines for allergy symptoms. Examples include fexofenadine (Allegra) and loratadine (Claritin). If you have trouble sleeping, it’s best to talk to your healthcare team about your options.

2. Sleep medications

Insomnia is often treated with prescription medications known as “Z-drugs.” These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem. But in older adults, they can cause serious problems. Delirium, falls, and cognitive problems are just a few examples.

EXPERT PICKS: WHAT TO READ NEXT

• Interactions to know about: Did you know that some drug interactions can be more dangerous as you age? Here’s a list of risky interactions for older adults.

• Common side effects: Older adults can be more sensitive to medications, increasing the risk of side effects. Learn about side effects that may be more common in this age group.

• Managing your fall risk: Falls become more common and dangerous as you age. Explore this list of medications that can increase your risk of falls.

Benzodiazepines (BZDs) should also be avoided for sleep problems. These include medications such as estazolam, triazolam (Halcion), and temazepam (Restoril). They have the same risks as Z-drugs for older people.

There are other available BZDs approved for uses beyond sleep, including alprazolam (Xanax), lorazepam (Ativan), and diazepam. You may be taking one that’s appropriate for a different health condition, such as seizures or anxiety. BZDs still carry risks for older adults in these situations, but the benefits may outweigh the risks in some cases.

Better options: Focus on nonmedication treatment of insomnia by practicing good sleep hygiene, including setting a consistent bedtime.

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3. Muscle relaxers

Muscle relaxers can be difficult for older adults to tolerate due to their side effects. In particular, they can make you feel sleepy and confused, putting you at risk of falls. They can also cause constipation and urination problems. Carisoprodol (Soma), cyclobenzaprine, and methocarbamol are a few common examples.

Better options: Try exercise and supportive treatments in place of muscle relaxers. Ask your healthcare team about alternatives that may be safer for you.

4. Antispasmodics

Spasms in your digestive tract can be quite a pain. Sometimes, they’re treated with antispasmodics, such as dicyclomine and hyoscyamine (Levsin).

But these medications may not work very well if you’re older. And they can cause side effects such as confusion, dry mouth, and constipation, too. That’s why they’re typically avoided for older people.

Better options: If you have abdominal pain, it’s best to discuss treatment options with your healthcare team. They can determine the right treatment for you, depending on what’s causing it.

5. Seroquel and other antipsychotic medications

Antipsychotic medications are used for mental health conditions such as schizophrenia and bipolar disorder. A few examples include aripiprazole (Abilify), quetiapine (Seroquel), and risperidone. Seroquel is also sometimes prescribed off-label for sleep in older adults.

Antipsychotic medications can cause a number of concerning side effects in older adults. Examples include confusion, dizziness, and low blood pressure. Uncontrollable body movements and urination problems are also possible. But, antipsychotic medications may still be used with caution for certain cases.

These medications have also been used to treat behavioral problems in older people with dementia. But, this has been shown to raise the risk of death and stroke. The FDA has issued its strictest warning to avoid them for this use in older adults.

Better options: Antipsychotic medications may be appropriate for schizophrenia and bipolar disorder. Nonmedication treatments for dementia-related behavior problems should be tried before considering an antipsychotic.

6. Tricyclic antidepressants

Tricyclic antidepressants (TCAs) aren’t just prescribed for depression. They’re also used for migraine prevention, anxiety, and insomnia. Common examples include amitriptyline, doxepin (Silenor), and nortriptyline (Pamelor).

TCAs have largely been replaced by newer antidepressants because of their side effects, which can be especially problematic in older adults. These include confusion, low blood pressure, and sedation — all of which can raise the risk of falls and other complications.

Better options: Newer antidepressants can have some of the same risks, but they’re generally lower than with TCAs. Selective serotonin reuptake inhibitors (SSRIs) are one example.

7. Barbiturates

Barbiturates, such as phenobarbital, can be used to treat epilepsy or help with sleep. Some are combined with other medications for pain or migraines, including Fioricet (butalbital / acetaminophen / caffeine) and Fiorinal (butalbital / aspirin / caffeine).

Older people should generally avoid these barbiturates. Besides causing confusion, they can be habit-forming and pose a risk for overdose.

Better options: Alternatives for epilepsy include lacosamide (Vimpat), lamotrigine (Lamictal), and levetiracetam (Keppra). It’s best to discuss your options with your healthcare team. And instead of taking butalbital for pain, ask them about safer alternatives.

8. NSAIDs such as indomethacin and ketorolac

NSAIDs are commonly used to treat pain. Indomethacin is a prescription NSAID for arthritis pain and gout. Ketorolac is also a prescription NSAID for pain. But it’s only used for up to 5 days due to a risk of serious side effects.

Compared with other NSAIDs, indomethacin may be more likely to cause side effects, especially in older adults. These include confusion, kidney damage, and gastrointestinal ulcers or bleeding. Ketorolac also has significant kidney, ulcer, and bleeding risks.

Other NSAIDs, such as ibuprofen (Advil, Motrin) are still risky for older adults. But you may not have to avoid them. It’s best to take the lowest effective dose for the shortest time possible. Your healthcare team can determine if an NSAID is OK for you and how long you can take it.

Better options: If you need longer-term relief, talk to your healthcare team about your options. They may recommend a non-NSAID medication to help manage your symptoms.

9. Opioids

Opioid pain medications can pose added risks for older adults. They commonly cause drowsiness and confusion, which may lead to falls. Other side effects include constipation, difficulty urinating, and slowed breathing.

Meperidine is one opioid that’s especially risky for this age group. It’s more likely to cause confusion and offers limited benefits for pain relief in older adults, so it’s best avoided.

Whenever possible, opioid use should be minimized. And combining opioids with other medications — such as BZDs, gabapentin (Neurontin), or pregabalin (Lyrica) — should be avoided unless absolutely necessary. These combinations can increase the risk of dangerous side effects, such as respiratory depression and death.

Better options: Your healthcare team may recommend non-opioid treatments first. But for some people, an opioid may be necessary. Your prescriber can help you figure out which treatment is right for you and how to safely manage these risks.

10. Alpha blockers

Alpha blockers such as doxazosin (Cardura), terazosin, and prazosin are sometimes prescribed to treat high blood pressure. But for older adults, they come with added risks.

One key concern is orthostatic hypotension, which is a sudden drop in blood pressure when moving from sitting to standing. This can lead to dizziness, fainting, and falls. Because of this, alpha blockers are generally avoided for treating high blood pressure in older adults.

Better options: There are many blood pressure medications that are safer for older adults. Examples include thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers. Your healthcare team can help find the best option based on your overall health and the other medications you take.

11. Long-acting sulfonylureas

Glimepiride (Amaryl) or glyburide are used to treat Type 2 diabetes. They both belong to a medication class called sulfonylureas. But they tend to stick around in your body longer than other sulfonylureas.

The most common side effect of sulfonylureas is hypoglycemia. This risk may be more severe and last longer with glimepiride and glyburide. If left untreated, hypoglycemia can be life-threatening.

Better options: Glipizide (Glucotrol XL) is a shorter-acting sulfonylurea that may be a better option for older adults. There are also other medications with minimal hypoglycemia risks, too. Examples include metformin and glucagon-like peptide-1 (GLP-1) receptor agonists.

12. Certain anticoagulants

Warfarin and rivaroxaban are anticoagulants that prevent blood clots and lower the risk of stroke, especially in people with health conditions such as atrial fibrillation. But for older adults, these medications can raise the risk of serious bleeding.

Warfarin requires frequent blood tests to make sure the dose is right, and it interacts with many foods and medications. This can make it challenging for older adults to manage safely. Rivaroxaban doesn’t require as much monitoring. But compared with similar medications, it can have a higher risk of major bleeding in older adults.

There may still be situations where these medications are appropriate. For example, warfarin may be used if you can’t take other anticoagulants or have been taking it long term without issues. Rivaroxaban may be useful if its once-daily dosage helps you stay on track, compared with alternatives taken twice daily.

Better options: All anticoagulants should be used with caution in older adults. But certain options, such as apixaban (Eliquis), can be safer than others. Your healthcare team can consider your bleeding risk, kidney health, and other factors when selecting the best option for you.

Choosing a safer alternative medication

In some cases, there may be safer options for older adults. For example, alternatives to Benadryl include newer antihistamines, such as Claritin.

There are also many antidepressant, blood pressure, and epilepsy medications that are less risky for this age group. Your healthcare team can help you find out which medication is best for your situation.

If you’re concerned about taking a medication on this list, talk to your healthcare team. It’s possible that the medication’s benefits outweigh the risks for you. If this is the case, you and your prescriber may need to watch your health more closely. Don’t stop taking a medication without letting them know first.

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Written by:

Brian Leonard, PharmD, BCACP, BCGP

Brian Leonard earned his doctorate in pharmacy from the University of Florida College of Pharmacy and is board certified in Ambulatory Care and Geriatric Pharmacy.

Edited by:

Alyssa Billingsley, PharmD

Alyssa Billingsley, PharmD, is the director of pharmacy content for GoodRx. She has over a decade of experience as a pharmacist and has worked in clinical, academic, and administrative roles.

Reviewed by:

Christina Aungst, PharmD

Christina Aungst, PharmD, is a pharmacy editor for GoodRx. She began writing for GoodRx Health in 2019, transitioning from freelance writer to editor in 2021.

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