Beers Criteria on the NP Exam: The Drugs to Avoid in Older Adults and What to Use Instead

The American Geriatrics Society Beers Criteria, last updated in 2023, name the medications whose risks usually outweigh their benefits in adults 65 and older, and the exam tests them in one recurring shape: a vignette offers a Beers drug and a safer substitute, and the candidate must recognize both. The criteria are organized into five working tables: drugs to avoid for most older adults, drugs to avoid with specific diseases or syndromes, drugs to use with caution, drug-drug interactions to avoid, and drugs that need adjustment or avoidance by kidney function. A sixth table lists the drugs with strong anticholinergic properties, which is where most exam items come from.

What the criteria are and are not

The 2023 update applies to adults 65 and older in all settings except hospice and end-of-life care. Every entry carries a rationale, a recommendation (avoid, avoid in a defined situation, or use with caution), a quality-of-evidence rating, and a strength of recommendation. The panel removed 28 medications in 2023 because they are no longer marketed in the United States or are used by very few Medicare beneficiaries, which is why older study material still lists drugs that no longer appear.

Three framing rules apply. "Potentially inappropriate" means an alternative deserves consideration, not that the drug is contraindicated. The criteria do not replace a full medication review for duplications, omissions, and cascades. Continuing an established therapy differs from starting one: a long-term warfarin user with stable INRs may continue, while a new patient should usually receive a DOAC.

Table 2: the drugs to avoid for most older adults

The table below groups the high-yield entries by class, with the reason the panel gives and the alternative that an exam answer usually points to. Doses are standard label doses; confirm any threshold in the current criteria before applying it to a patient.

Table 3: drug-disease pairs the exam loves

These items read as "a patient with condition X is on drug Y; which should be stopped."

Tables 4 and 5: caution and interactions

Table 4 (use with caution) carries situational risks: dabigatran and prasugrel in patients 75 and older; antidepressants, antipsychotics, carbamazepine, diuretics, and tramadol for SIADH and hyponatremia, so check sodium after starting them; and, new in 2023, ticagrelor and SGLT2 inhibitors, the latter for euglycemic ketoacidosis and genitourinary infection.

Table 5 (drug-drug interactions) rewards memorization of a short list:

• Three or more CNS-active drugs together (antidepressants, antipsychotics, antiepileptics, benzodiazepines, Z-drugs, opioids, and now skeletal muscle relaxants): falls and fractures.
• Opioid plus benzodiazepine, and opioid plus gabapentinoid: respiratory depression and overdose.
• Warfarin plus amiodarone, ciprofloxacin, macrolides (except azithromycin), TMP-SMX, NSAIDs, or SSRIs (added 2023): bleeding.
• Lithium plus ACE inhibitor, ARB, ARNI (added 2023), or loop diuretic: lithium toxicity.
• RAS inhibitor plus potassium-sparing diuretic (amiloride, triamterene) in CKD 3a or worse: hyperkalemia.
• Any anticholinergic plus another anticholinergic: cumulative cognitive burden.
• Phenytoin plus TMP-SMX; theophylline plus cimetidine or ciprofloxacin: toxicity through metabolic inhibition.

Table 6: the renal thresholds

The exam often supplies an estimated creatinine clearance and expects action on it. Thresholds vary slightly by labeling; confirm in the current criteria before prescribing.

• Avoid below 30 mL/min: nitrofurantoin, NSAIDs, dabigatran, spironolactone, amiloride and triamterene, duloxetine, tramadol extended release; reduce dose for ciprofloxacin, TMP-SMX, enoxaparin, colchicine, tramadol immediate release.
• Avoid rivaroxaban below 15 mL/min; reduce edoxaban between 15 and 50 mL/min and avoid it below 15 mL/min (and, for atrial fibrillation, above 95 mL/min); follow labeled dose-reduction criteria for apixaban.
• Reduce dose below 60 mL/min: gabapentin, pregabalin. Baclofen (added 2023): avoid below 60 mL/min because of encephalopathy risk.
• Reduce famotidine below 50 mL/min, levetiracetam at 80 mL/min or below, dofetilide below 20 mL/min.

The anticholinergic burden question

The exam tests the strongly anticholinergic table in two ways: naming the anticholinergic hiding in a list (paroxetine among SSRIs, oxybutynin among incontinence drugs, cyclobenzaprine among muscle relaxants, meclizine among vertigo treatments) and recognizing the syndrome it causes (new confusion, urinary retention, constipation, dry mouth, falls). Cumulative exposure matters more than any single agent; on the Anticholinergic Cognitive Burden scale, a total of 3 or more is a prompt for review, not a diagnostic cut-off.

Substitutes: oxybutynin to mirabegron or vibegron; diphenhydramine to a second-generation antihistamine or CBT-I; amitriptyline to duloxetine; paroxetine to sertraline or escitalopram; meclizine to vestibular rehabilitation.

Applying the criteria in a visit

1. Reconcile the list, including over-the-counter sleep aids and allergy products, the usual source of unrecognized anticholinergics.
2. Flag each Beers entry and attach the reason to this patient: a benzodiazepine in a patient with two falls is a Table 3 problem, not just a Table 2 one.
3. Check kidney function, concurrent CNS-active drugs, and any Table 3 condition.
4. Decide start, continue, or taper, and document the rationale when a Beers drug is continued.
5. Plan the follow-up: 2 to 4 weeks after an antihypertensive change with orthostatic vital signs; 1 to 2 weeks after each benzodiazepine dose reduction; sodium within a few weeks of starting an SSRI; hypoglycemia review at 2 weeks and A1c at 3 months after replacing a sulfonylurea.

Teach the patient and caregiver the reason, the substitute, and the symptom to report. A patient who hears that a sleep aid causes confusion and falls accepts a taper more readily than one told only that it is "on a list."

How the exam tests this

• The hidden anticholinergic. One option is a strongly anticholinergic agent and the stem mentions age 78, mild cognitive impairment, or BPH. The trap is the familiar drug (diphenhydramine for sleep, oxybutynin for urgency).
• The "which drug should be discontinued" item. Read the Table 3 condition first, then scan the list for its pair.
• The sulfonylurea switch. A patient on glyburide or glipizide with a hypoglycemic episode; the answer is a non-hypoglycemic agent, not a different sulfonylurea.
• The anticoagulant choice. New atrial fibrillation in an 80-year-old; apixaban over warfarin, and apixaban over rivaroxaban when bleeding risk is emphasized. Long-term stable warfarin is not a reason to switch.
• The aspirin trap. Primary prevention aspirin in a 72-year-old without cardiovascular disease should be stopped, not continued; secondary prevention aspirin stays.
• The exception. Metoclopramide within 12 weeks for gastroparesis, a cholinesterase inhibitor in a patient without syncope, or quetiapine in Parkinson psychosis can be correct. If the stem includes the qualifying detail, the Beers drug is the answer.
• The renal number. The stem gives a creatinine clearance of 25 mL/min and offers nitrofurantoin for cystitis; the correct option is the culture-directed alternative.
• The prescribing cascade. Amlodipine, then ankle edema, then furosemide; the answer is to reduce or change the calcium channel blocker, not to add a diuretic.

Practice question

A 79-year-old woman with hypertension, osteoarthritis, and mild cognitive impairment presents for follow-up accompanied by her daughter, who reports that her mother has become more confused over the past month and had a near-fall in the bathroom at night. Medications: amlodipine 5 mg daily, acetaminophen 650 mg three times daily, and, started 6 weeks ago by another clinician, oxybutynin 5 mg twice daily for urinary urgency. She also takes diphenhydramine 25 mg nightly, bought over the counter, for sleep. Blood pressure is 128/74 mm Hg sitting and 122/70 mm Hg standing. Mini-Cog score is 2 of 5, down from 4 of 5 a year ago. Basic metabolic panel, TSH, and vitamin B12 are normal. Which of the following is the most appropriate next step?

• A. Increase oxybutynin to the extended-release 10 mg formulation to reduce peak anticholinergic effects.
• B. Discontinue oxybutynin and diphenhydramine, begin bladder training, and reassess cognition in 4 to 6 weeks.
• C. Start donepezil 5 mg nightly for the decline in Mini-Cog score.
• D. Replace diphenhydramine with zolpidem 5 mg at bedtime and continue oxybutynin.

Answer: B. The vignette describes a new cognitive decline and a near-fall after two strongly anticholinergic drugs were added to an older adult with baseline cognitive impairment, a Table 3 pairing (anticholinergics in dementia or cognitive impairment, and in patients with falls) and a Table 5 interaction (two anticholinergics together). The correct action is to remove both, offer a nonpharmacologic alternative for urgency, and reassess cognition after the drugs have cleared. Option A keeps the anticholinergic burden; a formulation change does not remove the central effect in a patient already showing harm. Option C treats a drug-induced decline as a neurodegenerative one before the reversible cause has been removed, and cholinesterase inhibitors are also listed to avoid in syncope. Option D swaps one Beers hypnotic for another; Z-drugs carry the same fall and cognitive risks and remain on the avoid list.

Key points

Related NPPace guides

• Dementia Screening in Primary Care: Mini-Cog, MoCA, the Reversible Causes Work-Up and Referral
• Deprescribing Benzodiazepines and Proton Pump Inhibitors: Tapers That Work and How to Monitor
• Falls Assessment in Older Adults: STEADI, Gait Tests, Medications and the Home
• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
• AANP vs ANCC: Which NP Certification Exam Should You Take?