Beers Criteria 2023: Smarter Meds for Aging Well

You know that moment when you're standing in the kitchen, holding your mom's pill organizer, and suddenly pausejust for a secondwondering if all these little colored capsules are really helping her? Maybe she's a bit more forgetful lately. Or she's started stumbling on the carpet. Maybe she just seems off.

It's not in your head. And you're far from alone.

Every year, thousands of older adults face side effectsnot from their illnesses, but from the very medications meant to help them. That's why the Beers Criteria 2023 update matters so much. It's not about fear or stopping medicine. It's about getting smartermaking sure every pill has a purpose, and not a hidden cost.

Think of it like spring cleaning for your medicine cabinet, but with real medical guidance behind it. The American Geriatrics Society (AGS) just refreshed their gold-standard list of medications that can be riskier than helpful for adults over 65. And this time, they didn't just shuffle things aroundthey listened. They looked at what doctors are actually prescribing and what patients are really taking.

So whether you're managing your own prescriptions or helping someone you love, let's walk through this update togetherno white coat required.

What's New

First, let's get one thing straight: the Beers Criteria aren't rules carved in stone. They're more like guardrailswise advice from a team of geriatric experts who've reviewed over 1,500 studies since the last update. They're designed to help doctors and patients alike ask better questions.

And the big shift in 2023? Real-world relevance.

For the first time, the AGS checked which medications are actually being used by older adultswith help from Medicare data. If a drug hadn't been prescribed to at least 4,000 seniors, it was moved out of the main list. Why keep warning about something nobody's using, right?

This cleanup makes the guidelines sharper, more practical, and honestlymore trustworthy. It shows they're not just academics in a lab; they're paying attention to what's happening in real clinics and homes.

New Alerts

Some drugs have made their way into the spotlight this yearnot because they're new, but because we're starting to see their risks more clearly.

Medication	Why It's Flagged
Dapagliflozin, Empagliflozin (SGLT2 inhibitors)	These diabetes meds can increase the risk of serious genital infections and a rare but dangerous condition called ketoacidosisespecially if someone is frail, dehydrated, or not eating well.
Dextromethorphan/quinidine	Used for pseudobulbar affect (emotional outbursts), but quinidine can mess with heart rhythm. High risk if someone already has heart failure.
Prasugrel (antiplatelet)	Blood thinner used after stents, but bleeds more easily in older adults. The 2023 update says: if you're over 75, cut the dose to 5 mg.
Ticagrelor	Another antiplatelet now flagged for cautionespecially because it can cause bleeding and shortness of breath.

I'll be honestthese warnings hit close to home. Just last month, a neighbor's dad, 81 and sharp as a tack, started feeling weak and confused after starting an SGLT2 inhibitor. Turns out, he was slightly dehydrated, and the med tipped the scale. His doctor switched him to a safer option, and within days, he was back to beating everyone at Scrabble.

Moral of the story? Context matters. A drug isn't "bad"it's about whether it's right for you.

Familiar Names, Fresh Warnings

Some meds we thought we knew are getting a second look. These updates reflect how geriatric care is evolvingfrom simply treating conditions to protecting quality of life.

Drug	What Changed
Aspirin	No longer "use with caution"now says avoid starting if you're using it to prevent heart disease but haven't had one yet. That matches advice from the US Preventive Services Task Force (USPSTF), especially for people over 60.
Warfarin	Directs doctors to strongly consider DOACs (like apixaban or rivaroxaban) insteadunless you've been stable on warfarin for years. Easier to manage, fewer diet restrictions.
NSAIDs (ibuprofen, naproxen)	Even short-term use is now discouraged when combined with blood thinnersbecause the risk of internal bleeding goes way up.
PPIs (like omeprazole)	Long-term use now linked to pneumonia and even stomach cancernot just bone loss or C. diff infections.
Sulfonylureas	Glipizide and others now all flagged for high risk of low blood sugar, which can lead to falls, heart attackseven strokes.

Look, I get it. Some of these meds have been staples for decades. But just because something's been around a long time doesn't mean it's still the best choice today. Medicine evolves. And so should our conversations with doctors.

Gone But Not Forgotten

Not everything stays on the list forever. Some medslike dexbrompheniramine and disopyramidewere removed from the main criteria because they're hardly used anymore. That doesn't mean they're safe. It just means they've faded into history.

Still, if your loved one is taking something you've never heard of, trust your gut. A quick conversation with the pharmacist can go a long way.

Condition Matters

Here's a truth we don't talk about enough: The same med can be safe for one person and dangerous for anotherjust based on their health.

That's why the 2023 update emphasizes disease-specific warnings. What's fine in general may be risky if you have certain conditions.

Condition	Avoid These Medications
Heart Failure	Dextromethorphan/quinidine, NSAIDs, certain antipsychotics
Delirium or Dementia	Benzodiazepines, anticholinergic drugs, opioids
History of Falls/Fractures	Anticholinergics, sedatives, muscle relaxants
Kidney Impairment (eGFR <30)	Metformin, gabapentin, baclofen, NSAIDs

One small but huge change? Opioids are now explicitly linked to worsening deliriuman issue that's often missed but can make someone seem "out of it" overnight.

Kidney Adjustments

Let's talk about kidneys. As we age, they don't filter meds as well. That means even a normal dose can build up in the body and cause side effects.

The 2023 guidelines now give clearer advice on when to reduce doses based on kidney function.

Drug	When to Adjust
Baclofen	New in 2023: Dose down if eGFR is under 80 mL/min
Levetiracetam	Reduce if creatinine clearance 80 mL/min
Enoxaparin (Lovenox)	Lower dose if CrCl <30 mL/min
Rivaroxaban (Xarelto)	Avoid if CrCl <30; reduce dose if 3049
NSAIDs	Chronic use not advised if CrCl <60

Here's a pro tip: ask your doctor, "Is this drug cleared by the kidneys?" A simple blood test (creatinine and eGFR) can tell you a lot. It's like checking the oil in your carprevents breakdowns before they happen.

Dangerous Combos

This section? It's kind of like looking at a fireworks warning label. One spark is fine. But mix the wrong ingredients, and things get dangerous fast.

Risk	Avoid or Monitor This Combination
Serotonin Syndrome	SSRIs + tramadol, fentanyl, or MAOIs can overstimulate the nervous systemcausing agitation, fever, and rapid heart rate.
Bleeding	Warfarin + NSAIDs or SSRIs increases bleeding risk more than either drug alone.
Lithium Toxicity	Lithium + NSAIDs, ARBs, or ARNIs (like Entresto) can cause lithium levels to spikeleading to tremors, confusion, or kidney damage.
High Potassium	ARNI (sacubitril/valsartan) + trimethoprim/sulfa antibiotics can dangerously raise potassiumrisking heart rhythm problems.
Multiple CNS Depressants	Using more than three of: benzodiazepines, antipsychotics, opioids, or muscle relaxants increases fall and confusion risk. Seriouslyless is more.

One study found that adding even one sedative to a senior's med list increases fall risk by 50%. Add two or more? It's like walking a tightrope blindfolded.

Better Choices

Okay, so we've talked a lot about what to avoid. But here's the real question: What do you use instead?

Good newsthe AGS released a companion paper titled Alternative Treatments to Selected Medications in the 2023 Beers Criteria in the Journal of the American Geriatrics Society. It's not about leaving problems untreated. It's about treating them more safely.

What's Being Avoided	Safer Alternatives
Benzodiazepines	Cognitive Behavioral Therapy (CBT) for insomnia, low-dose melatonin, or sometimes mirtazapine (with caution).
Diphenhydramine (Benadryl)	Loratadine or low-dose cetirizinemuch less likely to cause confusion or falls.
Long-acting opioids	Physical therapy, topical pain creams, or short-term NSAIDs (if safe).
PPIs for chronic heartburn	H2 blockers (like famotidine), dietary changes, or testing for H. pylori bacteria.
Sulfonylureas for diabetes	Metformin (if kidneys allow), SGLT2 inhibitors, or GLP-1 agonistsmany of which also help with weight and heart protection.

Take Mrs. Lee, for example. 78, sharp mind, but started falling at night. She'd been taking diphenhydramine for years to help her sleep. Sounds harmless, right? But that one pill was clouding her brain, slowing her reflexes. Her doctor switched her to a sleep hygiene plan and a tiny dose of trazodone. No more falls. No more midnight confusion.

And here's a gentle reminder: Never stop a medication cold. Deprescribing should be slow, supported, and monitored. Taper down. Watch for changes. Your body's used to that drugit needs time to adjust.

Use It Right

Let's address the elephant in the room. Some nursing homes or insurance companies have misused the Beers Criteria to deny care or pressure doctors into inappropriate changes. That's not what this is for.

The American Geriatrics Society is crystal clear: The Beers Criteria support clinical judgmentit doesn't replace it.

Sometimes, a "potentially inappropriate" medication is still the best choice. For example:

• If someone has severe schizophrenia, an antipsychotic may be neededeven if it's on the list.
• In hospice or palliative care, comfort is the goal. The criteria don't apply.
• If safer options have failed, and the benefit outweighs the riska medication can stay, as long as it's discussed and documented.

The golden rule? Talk with your doctor. If you see a med on the list, don't panic. Ask: "Is this still the safest option for me? Could we try something else? What happens if we slowly reduce it?"

Final Thoughts

The Beers Criteria 2023 isn't about fear. It's about respectrespect for older adults who deserve care that honors their dignity, their goals, and their safety.

It gives us allpatients, families, doctorsa shared language to have better conversations. Not "more medicine," but better medicine. Fewer side effects. Fewer falls. Fewer trips to the ER. More good days at the dinner table, in the garden, or laughing with grandkids.

Medicine isn't one-size-fits-all. And aging doesn't have to mean surviving on a handful of pills that leave you groggy or unsteady. There's a better way.

So the next time you're reviewing a medication listyours or a loved one'slet the 2023 AGS Beers Criteria be your guide, not your judge. Ask questions. Partner with your care team. And remember: the goal isn't just to live longer. It's to live well.

For more on geriatric prescribing guidelines and patient-friendly resources, visit GeriatricsCareOnline.org or explore tools at HealthinAging.org.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.