BEERS Criteria and Fall Risk in the Older Adult
Updated: 3/6/25
Essential Points:
The 2023 AGS BEERS Criteria identifies potentially inappropriate medications (PIMs) for older adults, incorporating the latest research on medication risks, including fall-related concerns.
Medications such as benzodiazepines, antidepressants, and antipsychotics remain flagged for their potential to impair balance and increase fall risk, with updated cautions on anticoagulants and pain medications.
Polypharmacy and drug interactions are critical factors in fall prevention, as medication adjustments can significantly impact balance and safety.
Healthcare providers should conduct regular medication reviews, explore safer alternatives, and educate patients on fall risk mitigation.
Medications play a crucial role in managing health conditions, but they can also pose serious risks, especially when it comes to balance and fall prevention. Older adults experience physiological changes that alter how drugs are metabolized, making them more susceptible to adverse effects like dizziness, sedation, and impaired coordination.
The 2023 update to the BEERS Criteria, a widely used guide by the American Geriatrics Society (AGS), helps healthcare providers identify medications that may do more harm than good in adults aged 65 and older. (1, 2) While not an absolute rulebook, the BEERS Criteria serves as a red-flag system, prompting clinicians to weigh risks versus benefits when prescribing medications. In this article, we will delve into the criteria and the most recent update from 2023.
How Aging Affects Medication-Related Fall Risk
Several age-related physiological changes contribute to increased medication sensitivity and fall risk:
Slower Drug Metabolism – Reduced liver and kidney function prolong drug clearance, leading to prolonged effects and higher toxicity risk. (3)
Increased Sensitivity to CNS Depressants – Older adults experience greater sedation, dizziness, and cognitive slowing with medications affecting the central nervous system. (4)
Orthostatic Hypotension – Blood pressure regulation becomes less efficient, making sudden drops in blood pressure (and resulting falls) more common. (5)
Even medications that once worked well for an individual may become problematic over time. That’s why medication reviews are essential.
Key Medications That Increase Fall Risk (1, 2)
1. Benzodiazepines & Nonbenzodiazepine Hypnotics
Examples: Diazepam (Valium), Lorazepam (Ativan), Alprazolam (Xanax), Zolpidem (Ambien)
Why They’re Risky:
Increased sedation, slower reaction times, and cognitive impairment
Higher likelihood of falls and fractures, particularly with prolonged use
2023 Update: Reaffirmed high risk, with stronger warnings against long-term use due to potential for dependence and withdrawal complications
2. Antidepressants (TCAs & SSRIs)
Examples: Amitriptyline, Paroxetine, Sertraline, Fluoxetine
Why They’re Risky:
Cause dizziness, orthostatic hypotension, and sedation
Higher risk of falls, particularly in frail individuals
2023 Update: No major changes, but increased emphasis on using safer alternatives for depression in older adults
3. Antipsychotics (First & Second Generation)
Examples: Haloperidol, Quetiapine, Risperidone
Why They’re Risky:
Can cause sedation, dizziness, and movement disorders
Increased mortality risk in dementia patients
2023 Update: Reinforced caution, with added emphasis on avoiding use in dementia patients unless absolutely necessary
4. Antiepileptics
Examples: Gabapentin, Carbamazepine, Phenytoin
Why They’re Risky:
Impair coordination and balance, increasing fall risk
2023 Update: Added caution on gabapentinoids, which are increasingly prescribed for neuropathic pain but still carry a fall risk similar to benzodiazepines
5. Opioids & Pain Medications
Examples: Oxycodone, Morphine, Tramadol
Why They’re Risky:
Sedation, dizziness, and respiratory depression
Increased risk of falls, fractures, and overdose
2023 Update: Stronger recommendation against long-term opioid use for chronic pain, with emphasis on alternative pain management strategies
6. Cardiovascular Medications
Examples: Warfarin, Rivaroxaban, Alpha-blockers, Diuretics
Why They’re Risky:
Blood thinners increase injury severity if a fall occurs
Diuretics and alpha-blockers can cause dehydration and orthostatic hypotension
2023 Update: Added warnings on warfarin and rivaroxaban due to bleeding risks, and stronger cautions on blood pressure medications that contribute to dizziness
Polypharmacy: A Hidden Risk Factor
Polypharmacy, the use of multiple medications, can amplify fall risk especially when CNS-active drugs are combined. Older adults should have their medication lists reviewed at least annually to reduce unnecessary prescriptions and dangerous combinations. I recommend having your doctor and pharmacist review the medications to ensure both expertise can weigh in on need of the medications and potential side-effects from combinations.
What Healthcare Providers and Caregivers Can Do
1. Conduct Routine Medication Reviews
Check for BEERS Criteria medications
Identify unnecessary prescriptions or high-risk combinations
Discuss safer alternatives with prescribing doctors
2. Consider Safer Medication Alternatives
Use non-pharmacological approaches for pain and sleep disorders (e.g., physical therapy, cognitive behavioral therapy)
Opt for lower-risk antidepressants when able
3. Educate Patients and Caregivers
Encourage medication awareness and self-advocacy
Provide resources on drug interactions and fall prevention
Reinforce the importance of mobility and strength exercises
Resources for Safer Medication Management
Final Thoughts: Always have BEERs on Hand
Falls are one of the leading causes of injury in older adults, and medication use is a majorly often overlooked contributor. While the BEERS Criteria is not a rigid rulebook, it provides valuable guidance on reducing medication-related fall risks.
As healthcare providers, we must remain proactive in reviewing medications, exploring safer alternatives, and educating patients. Even small adjustments, such as switching medications or reducing dosages, can make a significant difference in preventing falls and preserving independence.
If you work with older adults, take the time to review their medication list. It could be the key to preventing their next fall.
References
THE AMERICAN GERIATRICS SOCIETY, Beers M. A POCKET GUIDE TO THE 2023 AGS BEERS CRITERIA.; 2023. https://gwep.usc.edu/wp-content/uploads/2023/11/AGS-2023-BEERS-Pocket-PRINTABLE.pdf
Jordan Samuel M, Beers M. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.; 2023. doi:10.1111/jgs.18372
Mangoni AA, Jackson SHD. Age‐related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology. 2003;57(1):6-14. doi:10.1046/j.1365-2125.2003.02007.x
Gronich N. Central Nervous System Medications: Pharmacokinetic and pharmacodynamic considerations for older adults. Drugs & Aging. 2024;41(6):507-519. doi:10.1007/s40266-024-01117-w
Dani M, Dirksen A, Taraborrelli P, et al. Orthostatic hypotension in older people: considerations, diagnosis and management. Clinical Medicine. 2021;21(3):e275-e282. doi:10.7861/clinmed.2020-1044
