The Beers List is a medically established guide that identifies medications considered potentially unsafe for adults over the age of 65. Formally known as the AGS Beers Criteria, it was developed by geriatrician Dr. Mark Beers in 1991 and is now maintained by the American Geriatrics Society, which updates it every three years. The most recent version, published in May 2023, flags 134 medications or drug classes that carry elevated risks for older adults — risks that become even more serious for people living with dementia.
For a family caregiver managing a parent with Alzheimer’s, for instance, knowing that something as common as Benadryl appears on this list can be the difference between preserving cognition and accelerating decline. For dementia patients specifically, the Beers List matters because two major categories of flagged drugs — antipsychotics and anticholinergics — are still routinely prescribed despite strong evidence of harm. Antipsychotics carry an FDA black box warning for dementia patients that has been in place since 2005. Anticholinergics, which include everyday medications sold over the counter, directly deplete the same brain chemical that Alzheimer’s disease already erodes. This article covers what the list includes, why dementia patients face heightened danger from these drugs, what the 2023 update changed, and what caregivers and patients can do with this information.
Table of Contents
- What Is the Beers List and How Does It Apply to Dementia Patients?
- Why Antipsychotics Are Flagged — and Why They’re Still Prescribed
- Anticholinergics and Why They’re Particularly Dangerous for Alzheimer’s Patients
- What Caregivers and Families Can Do With This Information
- The Over-the-Counter Problem
- How the Beers Criteria Is Evolving
- The Broader Shift Toward Non-Drug Dementia Care
- Conclusion
- Frequently Asked Questions
What Is the Beers List and How Does It Apply to Dementia Patients?
The Beers Criteria began as a practical tool for nursing home physicians trying to identify which drugs were doing more harm than good in elderly patients. Over more than three decades, it has expanded into a comprehensive reference used by geriatricians, pharmacists, and primary care physicians across the country. The 2023 AGS Beers Criteria covers 134 medications or drug classes, and a 2026 update is currently in progress that will expand kidney dosing guidance to cover every drug cleared by the kidneys — a significant gap, since the current version addresses only about 68 percent of those drugs. The list exists because aging bodies process medication differently. As people get older, the kidneys and liver slow down their ability to metabolize and eliminate drugs, meaning standard doses can accumulate to toxic levels. More than 90 percent of adults age 65 and older take at least one prescription medication, and more than 66 percent take more than three prescriptions per month.
That level of drug exposure, combined with age-related changes in physiology, means one in six adults over 65 will experience at least one adverse drug event. For people with dementia, whose neurological vulnerability is already profound, the stakes are considerably higher. It is worth noting that the Beers List is not a legal prohibition. Physicians can and sometimes do prescribe these medications with appropriate justification. The list functions as a clinical decision-making tool, not a mandate. That distinction matters because caregivers who see a flagged drug on a loved one’s prescription list should raise the concern with the prescribing doctor rather than assume the medication is simply wrong in every situation.
Why Antipsychotics Are Flagged — and Why They’re Still Prescribed
Antipsychotics are among the most controversial drugs on the Beers List when it comes to dementia care. Medications like haloperidol and quetiapine are sometimes prescribed to manage behavioral symptoms in dementia patients — agitation, aggression, sleep disturbances — because these symptoms can be genuinely difficult to manage and distressing for both patient and caregiver. However, the 2023 update to the Beers Criteria strengthened its existing warnings against this practice, citing evidence that antipsychotic use in dementia and delirium patients increases the rate of cognitive decline, raises stroke risk, and is associated with increased mortality. The FDA had already weighed in forcefully. In 2005, it issued its strongest category of warning — a black box warning — against prescribing antipsychotics to elderly dementia patients. The agency found that these drugs can disrupt heart, lung, and muscle function in ways that can be fatal.
Despite this, prescribing of antipsychotics in dementia care settings continued, which is part of why the 2023 Beers Criteria felt it necessary to expand and reinforce the warning language. The tension here is real. Families and care staff dealing with a dementia patient who is severely agitated or physically combative are often desperate for solutions. The problem is that reaching for antipsychotics in that situation carries documented risks of shortening life and worsening the very cognitive symptoms caregivers are trying to manage. The 2023 Criteria explicitly promotes the DICE approach — an acronym for Describe, Investigate, Create, and Evaluate — as a structured method for addressing dementia behavioral symptoms through non-drug strategies before turning to medication. This is a meaningful shift in the official guidance: the preference is now clearly for behavioral and environmental interventions first.
Anticholinergics and Why They’re Particularly Dangerous for Alzheimer’s Patients
Anticholinergic drugs work by blocking acetylcholine, a neurotransmitter that plays a central role in memory and cognitive function. The problem for dementia patients — and for Alzheimer’s patients in particular — is that the disease already causes a significant depletion of acetylcholine in the brain. Taking a drug that further suppresses that chemical is, in effect, compounding the neurological damage the disease is already doing. The Beers Criteria explicitly flags anticholinergics as drugs to avoid altogether in dementia patients. The list of common anticholinergics that fall into this category is broader than many people realize. Diphenhydramine, sold under the brand name Benadryl and found in a wide range of over-the-counter sleep aids and allergy medications, is one of the most widely used anticholinergics in the country.
Oxybutynin, prescribed for overactive bladder, is another. Several older antidepressants — including amitriptyline and doxepin — also carry strong anticholinergic activity. For a family who notices their loved one seems more confused or delirious after starting a new medication, an anticholinergic effect is one of the first things worth investigating. The 2023 update added specific language about cumulative anticholinergic burden — the idea that the danger isn’t limited to any single drug but compounds when a patient is taking multiple anticholinergic medications simultaneously. An older adult taking Benadryl for sleep, oxybutynin for bladder urgency, and an older antidepressant could be experiencing a combined anticholinergic load that significantly impairs cognition, even if each drug individually seemed like a reasonable choice. This concept of cumulative burden makes medication review more complicated but also more important.
What Caregivers and Families Can Do With This Information
Knowing about the Beers List is most useful when it leads to a specific conversation with a prescribing physician or pharmacist. If a person with dementia is taking a medication that appears on the list, the appropriate response is to bring it up at the next appointment — not to stop the medication abruptly, which can cause its own serious problems, but to ask whether the drug is still necessary, whether a safer alternative exists, and whether the prescriber is aware of the risks for dementia patients. A medication review by a pharmacist or geriatrician who is familiar with the Beers Criteria can be particularly valuable. These reviews, sometimes called comprehensive medication reviews or medication therapy management sessions, are designed specifically to catch this kind of problem. In a review, a clinician looks at the full picture — every prescription, every over-the-counter drug, every supplement — to identify dangerous combinations and flagged medications.
Given that more than 66 percent of adults over 65 take more than three prescriptions a month, the odds of an unexamined interaction or inappropriate drug being present are not trivial. There is an important tradeoff to acknowledge here. Deprescribing — the deliberate process of tapering and stopping medications that are no longer appropriate — requires care. Stopping some drugs abruptly can cause withdrawal or rebound symptoms that are themselves dangerous. The goal is not to eliminate medications wholesale but to ensure that each drug a dementia patient takes has a clear, current justification and that safer alternatives have been genuinely considered. Families should approach these conversations as partners in a clinical decision, not as adversaries demanding a prescription be cancelled.
The Over-the-Counter Problem
One of the underappreciated dangers the Beers List highlights is that not all risky medications require a prescription. Diphenhydramine, the anticholinergic flagged for its effects on dementia patients, is the active ingredient in products like Benadryl, ZzzQuil, Unisom SleepTabs, and dozens of other common cold, allergy, and sleep remedies sold in grocery stores and pharmacies without a prescription. A caregiver or family member who carefully monitors prescription medications may never think twice about giving a loved one a nighttime cold tablet, not realizing it contains a drug that could worsen their dementia symptoms. This blind spot extends to the clinical setting. Physicians who carefully prescribe dementia-appropriate medications may not know that a patient is also taking OTC sleep aids or antihistamines.
Unless someone asks directly and the patient or caregiver thinks to mention it, these drugs often go undisclosed during medical appointments. The 2023 Beers Criteria’s expanded discussion of anticholinergic burden makes this problem more visible, but awareness alone doesn’t close the gap without a deliberate effort to account for every drug entering the patient’s system. The warning here for caregivers is specific: before giving any over-the-counter medication to a person with dementia — including products marketed for sleep, colds, allergies, or nausea — check whether the active ingredient appears on the Beers List or carries anticholinergic activity. Many pharmacists will answer this question directly if asked, and several online tools exist to check a drug’s anticholinergic rating. When in doubt, ask before administering.
How the Beers Criteria Is Evolving
The Beers Criteria is not a static document. The American Geriatrics Society updates it on a three-year cycle to reflect new evidence, and the upcoming 2026 revision signals an important expansion. Currently, the Criteria provides kidney dosing guidance for approximately 68 percent of drugs that are cleared by the kidneys.
The 2026 update is designed to extend that coverage to every such drug — a significant improvement for clinicians managing dementia patients who also have kidney disease, a common co-occurrence in older adults. This evolution matters because the kidney dosing question is not academic. A drug that is safe at a standard dose can accumulate to toxic levels in a patient with impaired kidney function, causing side effects that may be mistaken for dementia symptoms worsening when in fact they are medication-related. Closing the kidney dosing gap in the next update would give clinicians a more complete tool for protecting elderly patients from preventable harm.
The Broader Shift Toward Non-Drug Dementia Care
The inclusion of the DICE approach in the 2023 Beers Criteria reflects a broader movement in dementia care away from medication-first responses to behavioral symptoms. The evidence base for non-pharmacological interventions — structured activity, environmental modification, caregiver communication strategies, music and sensory therapies — has grown substantially, and clinical guidelines are beginning to reflect that. The Beers Criteria’s formal endorsement of this framework sends a signal to prescribers that reaching for a prescription pad in response to dementia behavioral symptoms is increasingly out of step with the evidence.
For families and care providers, this shift is both encouraging and demanding. It asks more of caregivers, who must learn and implement behavioral strategies rather than relying on a pill to manage difficult symptoms. But it also opens a path toward managing dementia that doesn’t carry the stroke, mortality, and cognitive decline risks associated with antipsychotics. As the 2026 update approaches and the research base continues to develop, the Beers Criteria will likely continue pushing in this direction — prioritizing the quality and safety of life over the convenience of pharmaceutical management.
Conclusion
The Beers List is one of the most practical tools available for anyone responsible for the medical care of a person with dementia. It identifies 134 medications that pose elevated risks for adults over 65, with particular urgency around anticholinergics and antipsychotics — two drug categories that directly threaten cognitive function and survival in dementia patients. Knowing that diphenhydramine is in the nightly cold tablet, that haloperidol carries an FDA black box warning for dementia, and that multiple anticholinergic drugs taken together compound their harm: this is information that can change clinical decisions and, in some cases, outcomes. The most immediate next step for caregivers is a medication review.
Bring the complete list of every drug, prescription and over-the-counter, to a physician or pharmacist familiar with geriatric prescribing. Ask which drugs are on the Beers List, whether each one is still necessary, and whether non-drug approaches have been explored for managing behavioral symptoms. The 2023 AGS Beers Criteria is publicly available, and the American Geriatrics Society publishes accessible summaries for non-clinicians. This is not information that should stay inside the doctor’s office.
Frequently Asked Questions
Is the Beers List legally binding — can a doctor still prescribe these medications?
The Beers List is a clinical guidance tool, not a legal prohibition. Physicians can still prescribe medications on the list if they determine the clinical benefit outweighs the risk for a specific patient. The list is meant to prompt careful consideration, not eliminate prescriber judgment.
How do I find out if a medication my loved one takes is on the Beers List?
The American Geriatrics Society publishes the criteria, and the Cleveland Clinic maintains an accessible summary online. A pharmacist or geriatrician familiar with the list can review a patient’s full medication regimen and flag any concerns.
Is Benadryl really dangerous for dementia patients?
Yes. Diphenhydramine, the active ingredient in Benadryl and many OTC sleep and allergy products, is an anticholinergic drug that blocks acetylcholine — the same brain chemical depleted by Alzheimer’s disease. The Beers Criteria explicitly flags anticholinergics as drugs to avoid in dementia patients.
What is the DICE approach mentioned in the 2023 Beers Criteria?
DICE stands for Describe, Investigate, Create, and Evaluate. It is a structured framework for managing behavioral symptoms in dementia patients — such as agitation or aggression — through non-drug strategies before resorting to medication. The 2023 Beers Criteria formally endorses this approach as the preferred first step.
What is cumulative anticholinergic burden?
This refers to the combined anticholinergic effect of taking multiple drugs with anticholinergic properties at the same time. Even if each individual drug seems manageable, their effects add up and can significantly impair cognition, especially in dementia patients. The 2023 update added explicit language warning about this risk.
When is the next Beers Criteria update expected?
A 2026 update is currently in progress. It is expected to expand kidney dosing guidance to cover every drug cleared by the kidneys, up from the current coverage of approximately 68 percent.
