Geriatric Pharmacy 101: The “Beers List” Explained, Why You Must Deprescribe These 10 High-Risk Drugs in the Elderly

Older adults take more medicines than any other age group. That helps manage complex conditions, but it also raises risk. The American Geriatrics Society’s “Beers Criteria” highlights drugs that are more likely to harm than help in older adults. If you care for an older patient—or you are one—understanding this list and deprescribing high-risk drugs can reduce falls, confusion, hospitalizations, and costs. This guide explains the Beers List, why older bodies react differently to drugs, and how to safely stop or switch 10 common offenders.

Geriatric Pharmacy 101: The “Beers List” in Plain English

The Beers Criteria is a set of expert recommendations on medicines that are potentially inappropriate in most older adults. It is updated regularly and used by clinicians, pharmacists, and insurers. It groups drugs into categories:

• Avoid in most older adults. The risks outweigh benefits in the average person over 65.
• Avoid in certain diseases or syndromes. For example, antipsychotics in dementia.
• Use with caution. Higher sensitivity or dose-related issues.
• Drug–drug interactions and kidney dosing. Older adults are vulnerable to both.

It is a guide, not a ban list. Some drugs still have a place for specific patients. The point is to pause, question, and choose safer alternatives when possible.

Why Older Adults Are Different

Age changes how drugs work:

• Metabolism slows. The liver and kidneys clear drugs more slowly, so levels build up.
• More body fat, less water. Fat-soluble drugs hang around longer; water-soluble drugs hit harder.
• Brain sensitivity rises. Sedatives cause more confusion and falls.
• Polypharmacy is common. More drugs means more interactions and side effects.

Because of this, medicines that were fine at 50 can cause harm at 80—even at the same dose.

How to Deprescribe Safely

Deprescribing is a planned process of stopping or reducing medicines that no longer help or may be harmful. Done right, it improves function and quality of life.

• Clarify goals. What matters most—fewer falls, clearer thinking, comfort?
• List every medicine. Include over-the-counter and “natural” products. These often hide risks.
• Spot Beers-listed drugs. Mark the highest-risk ones first—sedatives, anticholinergics, and those causing low blood sugar.
• Prioritize. Tackle one or two at a time. Start with the drug most likely to cause harm.
• Plan the taper. Some drugs must be reduced slowly to avoid withdrawal or rebound symptoms.
• Substitute safer options. Non-drug strategies first; if needed, switch to safer medicines.
• Monitor. Set follow-up for symptoms, vitals, and labs. Adjust as needed.

10 High-Risk Drugs You Should Strongly Consider Deprescribing

• 1) First-generation antihistamines (diphenhydramine, chlorpheniramine)
  • Why risky: Strong anticholinergic effects cause confusion, dry mouth, constipation, urinary retention, and blurred vision. They worsen memory and raise fall risk.
  • What to do: Stop for sleep or allergies. No taper needed. Expect 1–2 weeks for anticholinergic fog to lift.
  • Safer choices: For allergies—cetirizine, loratadine. For sleep—sleep hygiene, low-dose melatonin (1–3 mg), cognitive behavioral therapy for insomnia.
• 2) Benzodiazepines and “Z-drugs” (diazepam, lorazepam, alprazolam; zolpidem, zaleplon)
  • Why risky: Sedation, delirium, memory problems, falls, fractures, and dependence. Long-acting agents linger for days.
  • What to do: Taper slowly to avoid withdrawal. Reduce dose by 10–25% every 2–4 weeks. Go slower at low doses or after long-term use. Combine with CBT-I for insomnia or CBT for anxiety.
  • Safer choices: For anxiety—SSRI/SNRI (start low, go slow), buspirone, psychotherapy. For sleep—CBT-I, melatonin, sleep hygiene.
• 3) Antipsychotics for dementia behaviors (quetiapine, risperidone, olanzapine)
  • Why risky: Higher risk of stroke, death, sedation, and falls. Often used for behaviors better managed by environment and routines.
  • What to do: Use only for severe danger or distress after non-drug measures. If already on, reassess monthly. Taper 25–50% every 1–2 weeks while intensifying non-drug supports.
  • Safer choices: Identify triggers (pain, constipation, infection, sleep disruption). Use caregiver training, routine, lighting, hearing/vision optimization.
• 4) Strong anticholinergic antidepressants (amitriptyline, doxepin >6 mg, paroxetine)
  • Why risky: Anticholinergic burden causes confusion, constipation, urinary retention; TCAs also cause orthostatic hypotension and heart rhythm issues.
  • What to do: Taper 10–25% every 1–2 weeks to avoid withdrawal. Check for drug interactions and ECG risks with alternatives.
  • Safer choices: For depression—sertraline, escitalopram (monitor sodium, QT in citalopram). For neuropathic pain—duloxetine or gabapentin (start low).
• 5) Skeletal muscle relaxants (cyclobenzaprine, carisoprodol, methocarbamol)
  • Why risky: Sedation, dizziness, anticholinergic effects with minimal long-term benefit. Carisoprodol is dependence-forming.
  • What to do: Usually stop without taper (except carisoprodol—reduce over 1–2 weeks). Reassess pain sources.
  • Safer choices: Physical therapy, heat/ice, gentle stretching, topical NSAIDs or lidocaine. For spasticity, specialist-guided options.
• 6) Chronic oral NSAIDs (ibuprofen, naproxen, diclofenac, meloxicam)
  • Why risky: GI bleeding, kidney injury, higher blood pressure, and heart failure exacerbations. Risk climbs with age, anticoagulants, or steroids.
  • What to do: Stop or use the lowest dose for the shortest time. If essential, add a PPI for GI protection and check blood pressure, kidneys, and hemoglobin.
  • Safer choices: Acetaminophen within safe limits, topical NSAIDs for osteoarthritis, duloxetine for knee/hip OA, physical therapy, bracing, injections when appropriate.
• 7) Sulfonylureas—especially glyburide and glimepiride
  • Why risky: Prolonged hypoglycemia that leads to falls, confusion, and ER visits. Glyburide is the worst offender.
  • What to do: If A1c is at goal or hypoglycemia has occurred, reduce dose or stop. Consider higher A1c targets (often 7.5–8.5%) in frail adults. Monitor glucose closely during changes.
  • Safer choices: DPP‑4 inhibitors, SGLT2 inhibitors or GLP‑1 receptor agonists if kidney function and cost allow, low-dose basal insulin (with careful monitoring).
• 8) Sliding-scale insulin alone (reactive insulin without basal)
  • Why risky: Chasing highs causes wide swings and hypoglycemia without improving control.
  • What to do: Transition to a simple basal regimen (e.g., low-dose long-acting insulin) and reduce or stop sliding scale. Review meals, sick-day rules, and hypoglycemia prevention.
  • Safer choices: Basal insulin plus oral agents with low hypoglycemia risk; simplified targets that fit the patient’s life and comorbidities.
• 9) Proton pump inhibitors long-term without a strong indication (omeprazole, esomeprazole)
  • Why risky: With long-term use, higher risk of C. difficile infection, fractures, low magnesium, and B12 deficiency. Many were started for short-term reflux and never stopped.
  • What to do: If no ongoing indication (like severe esophagitis or chronic NSAID use), taper over 2–4 weeks to prevent rebound acid: lower the dose, then every-other-day, then stop.
  • Safer choices: On-demand use, H2 blockers (e.g., famotidine), antacids, weight loss, smaller meals, avoiding late-night eating.
• 10) Peripheral alpha‑1 blockers for hypertension (doxazosin, terazosin)
  • Why risky: Orthostatic hypotension and falls, especially at night. Not first-line for blood pressure control in older adults.
  • What to do: If used only for hypertension, switch to better options. If used for BPH, consider uroselective tamsulosin and monitor for dizziness.
  • Safer choices: Thiazide diuretics, ACE inhibitors, or ARBs as appropriate. Check orthostatic vitals during and after the switch.

Real-World Examples

• Falls and sleep meds: An 82-year-old with two falls at night uses zolpidem “as needed.” Stopping zolpidem over 4 weeks while starting CBT-I and a 2 mg melatonin routine reduces awakenings and eliminates falls.
• Recurrent confusion: A 78-year-old with delirium episodes takes diphenhydramine nightly. After stopping and switching to cetirizine for allergies, her cognition improves and constipation resolves.
• Hypoglycemia: An 85-year-old on glyburide has morning dizziness. A1c is 6.6%. Glyburide is stopped, and A1c goal reset to 7.5–8%. No further lows; energy improves.

Monitoring After Deprescribing

• Agree on what to watch. Sleep quality, number of falls, bowel habits, mood, pain, blood sugars, blood pressure.
• Plan check-ins. Usually 2–4 weeks after each change, sooner for high-risk drugs like benzodiazepines or insulin.
• Expect rebound and withdrawal. Reflux after PPI taper, anxiety after benzodiazepine reductions. Reassure, go slower, and use non-drug strategies.
• Track wins and harms. Document fewer side effects and any symptom return to guide future choices.

A Quick Deprescribing Checklist

• List all medicines and reasons they were started. Remove duplicates and outdated therapies.
• Identify Beers-list drugs and those without a current indication.
• Rank by harm potential and patient priorities (falls, cognition, comfort).
• Plan one change at a time with a clear taper and a follow-up date.
• Substitute safer options and non-drug approaches first.
• Monitor and adjust. Slow down if withdrawal or rebound occurs.

The Beers List is a practical tool to make medication regimens safer for older adults. Deprescribing is not about stopping everything—it’s about matching each drug to the patient’s current goals and biology. Start with the ten high-risk drugs above, go slowly, and measure what matters. Most patients feel better with fewer, safer medicines.

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com