Beers Criteria (PIMs)

Benzodiazepines (all)

Fall/fracture, cognitive impairment, oversedation — all older adults

Non-BZD hypnotics (Z-drugs)

Eszopiclone, zaleplon, zolpidem — same risks as BZDs; Beers 2023 updates to "Avoid"

Antipsychotics (1st & 2nd gen)

Avoid unless schizophrenia/bipolar/BPSD with safety risk; increased mortality in dementia

Meprobamate

High risk sedation and dependence

First-gen antihistamines (diphenhydramine, chlorphenamine)

Cognitive impairment, delirium, sedation, falls

TCAs (amitriptyline, imipramine)

Highly anticholinergic, orthostatic hypotension, falls

Oxybutynin (oral)

Highly anticholinergic; prefer mirabegron or solifenacin

Belladonna alkaloids, dicyclomine

Highly anticholinergic; safer alternatives exist

Digoxin > 0.125 mg/day

Toxicity risk; renal clearance reduced with age

Nifedipine (short-acting)

Hypotension; reflex tachycardia; myocardial infarction risk

Alpha-1 blockers for hypertension (doxazosin, prazosin, terazosin)

Orthostatic hypotension; prefer other antihypertensives

Amiodarone

Pulmonary toxicity, thyroid disease, QTc prolongation; use only if AF with no alternatives

Systemic NSAIDs (non-selective)

GI bleed, peptic ulcer, AKI, HF exacerbation; avoid long-term use

Indomethacin

Highest NSAID risk for CNS adverse effects in older adults

Ketorolac (systemic or intranasal)

All routes — increased GI bleed and AKI risk

Meperidine (pethidine)

Normeperidine accumulation — neurotoxic; avoid in all older adults

Skeletal muscle relaxants (cyclobenzaprine, methocarbamol)

Poorly tolerated: sedation, anticholinergic effects, fractures

Long-acting sulfonylureas (glibenclamide, chlorpropamide)

Prolonged hypoglycaemia; prefer shorter-acting agents

Sliding-scale insulin regimens

Hypoglycaemia risk; no evidence of benefit over fixed dosing

Megestrol acetate

Minimal appetite stimulation; DVT, adrenal suppression risk

Systemic oestrogens (oral)

Increased risk of breast cancer and cardiovascular disease in older women

Metoclopramide

Tardive dyskinesia risk, especially with prolonged use

Mineral oil (oral)

Aspiration pneumonitis risk