Beers Criteria: psychiatric medications in older adults

The main Beers-listed psychiatric medications

Why paroxetine keeps showing up on this list

Among SSRIs, paroxetine has the strongest anticholinergic activity, a shorter half-life that produces prominent discontinuation syndrome, and sedation that compounds fall risk. It's also a strong CYP2D6 inhibitor, which matters more in older adults on polypharmacy. When you see a 78-year-old on paroxetine, atenolol, and oxybutynin, you've got three overlapping problems.

Sertraline is the usual first-line SSRI in older adults. It's clean on drug interactions, well tolerated, and has the most safety data in geriatric depression trials. Escitalopram is fine, though watch QT prolongation in patients on other QT-prolonging drugs, and the max dose is 10 mg after age 60 per FDA labeling.

Benzodiazepines: the exceptions people ask about

Beers says avoid all benzos. In practice, there are a handful of situations where a benzo in an older adult is defensible:

1. Alcohol withdrawal. Short-course lorazepam (glucuronidated, no active metabolites) with a clear taper.
2. Status epilepticus, acute agitation with clear danger. Emergency use, not chronic.
3. REM sleep behavior disorder. Low-dose clonazepam is standard, though melatonin is often tried first now.
4. Long-standing use on a patient nobody wants to destabilize. A 78-year-old on 0.5 mg alprazolam nightly for 20 years might not be a good taper candidate. The judgment call is real, and there's evidence that abrupt discontinuation causes as much harm as continuation in some patients.

What's not defensible: starting a benzo for generalized anxiety or insomnia in an older adult who hasn't tried CBT, an SSRI, or basic sleep hygiene. The number needed to harm on falls, fractures, and MVAs is small.

Z-drugs are not the safer benzo

When zolpidem, zaleplon, and eszopiclone launched, they were positioned as cleaner than benzodiazepines because of receptor subtype selectivity. Twenty-five years of data haven't backed that up. Fall risk, fracture risk, complex sleep behaviors (sleep-driving, sleep-eating), and cognitive effects are all present. The FDA added a boxed warning for complex sleep behaviors in 2019.

For insomnia in older adults:

• CBT for insomnia (CBT-I). First-line. Real evidence, no side effects.
• Sleep hygiene. Caffeine, alcohol, late naps, screen exposure, evening exercise.
• Melatonin 1 to 3 mg. Modest effect, low harm.
• Ramelteon. Melatonin receptor agonist, works modestly, safe.
• Doxepin 3 to 6 mg. The Beers exception. At this dose, it's selectively H1-antagonist and non-anticholinergic.
• Low-dose trazodone (25 to 50 mg). Evidence is thin but risk is low. See below.

Antipsychotics in behavioral symptoms of dementia

This is the toughest area because the alternatives often aren't enough. The current consensus is:

1. Nonpharmacologic first. Rule out and treat pain, constipation, infection (UTI, pneumonia), medication side effects, environmental triggers. Caregiver training and behavioral approaches work better than most people give them credit for.
2. If pharmacologic is needed, define the target symptom. Aggression, psychosis, agitation, and sundowning don't respond identically. Delusions and hallucinations respond better to antipsychotics than pure agitation does.
3. Choose an agent with the least bad profile.
   • Risperidone low dose (0.25 to 1 mg) has the most evidence for psychosis and aggression. EPS and stroke signal.
   • Quetiapine low dose (12.5 to 50 mg) for sedation and agitation. Less EPS, more sedation and orthostasis.
   • Olanzapine low dose. Weight and metabolic effects less relevant in advanced dementia.
   • Aripiprazole less sedation, potential akathisia.
   • Brexpiprazole FDA-approved (2023) for agitation in Alzheimer dementia. Evidence base is modest and mortality signal is present.
   • Haloperidol for acute delirium, short courses. Not for chronic BPSD.
4. Time-limit and reassess. Every 3 months at minimum. A large portion of nursing home antipsychotic use continues years after the original indication has faded.
5. Document boxed warning discussion. The mortality signal (roughly 1.6 to 1.7x, mostly cardiovascular and infectious) is real. Consent should be documented with family.

Anticholinergic burden

The additive anticholinergic load in older adults is worth quantifying, and there are validated tools (Anticholinergic Cognitive Burden scale, Anticholinergic Risk Scale). The clinical picture: dry mouth, constipation, urinary retention, blurred vision, tachycardia, confusion, sometimes frank delirium.

Common psychiatric offenders:

• Tertiary TCAs
• Paroxetine
• Doxepin (at antidepressant doses)
• Diphenhydramine, hydroxyzine, chlorpheniramine
• Quetiapine (moderate)
• Clozapine (high)
• Olanzapine (moderate)
• Cyproheptadine

Common non-psych offenders that stack: oxybutynin, tolterodine, benztropine, trihexyphenidyl, dicyclomine, ranitidine (still around in some regions), scopolamine.

The rule of thumb: if a patient's cognition is deteriorating and they're on three or more anticholinergic drugs, deprescribing before adding a cognitive enhancer is the right first move.

Trazodone for sleep in older adults

Trazodone at 25 to 100 mg is one of the most commonly prescribed sleep aids in geriatric psychiatry. The evidence is thinner than practice would suggest. A few points:

• Orthostatic hypotension is the main safety concern, especially at doses above 50 mg.
• Priapism risk is low but real (male patients should be warned).
• Serotonin syndrome risk exists if stacked with SSRIs at meaningful doses.
• It's on Beers as "use with caution" rather than "avoid," which reflects the pragmatic reality that alternatives are limited.

For a 75-year-old with sleep-onset insomnia who has tried sleep hygiene and melatonin, trazodone 25 mg at bedtime is a reasonable trial. Reassess at 4 to 6 weeks. If it's not helping, don't just keep it going.

Mirtazapine's niche

Mirtazapine is often the depression-plus-insomnia-plus-poor-appetite pick in older adults. Low-dose (7.5 to 15 mg) is more sedating and appetite-stimulating than higher doses (30 to 45 mg), which is counterintuitive but useful. It's not on the Beers list to avoid, has minimal anticholinergic activity, low fall risk compared to TCAs, and low drug interactions. Weight gain and sedation are the main issues.

The safer picks for common presentations in older adults

Depression: Sertraline first-line. Escitalopram (max 10 mg over age 60). Mirtazapine if sleep and appetite are also issues. Bupropion if energy is the problem and there's no seizure risk. Venlafaxine if SSRIs fail. Duloxetine if there's comorbid pain, with BP monitoring.

Anxiety: SSRI first-line (sertraline, escitalopram). Buspirone as adjunct. CBT if the patient can engage. Avoid benzos and hydroxyzine as chronic strategies.

Insomnia: CBT-I first. Sleep hygiene. Melatonin 1 to 3 mg. Ramelteon. Doxepin 3 to 6 mg. Low-dose trazodone. Avoid benzos, Z-drugs, diphenhydramine.

Behavioral symptoms of dementia: Nonpharmacologic first (workup for pain, infection, environment). If pharm needed: low-dose risperidone, quetiapine, olanzapine, or brexpiprazole with documented consent and time-limited trials.

Bipolar disorder: Lithium remains reasonable (target lower levels 0.4 to 0.6, watch renal function). Valproate is used but hepatic and thrombocytopenia risks matter. Lamotrigine for depressive phase. Aripiprazole or quetiapine adjuncts. Avoid carbamazepine if possible.

Psychosis (not dementia-related): Risperidone, aripiprazole, or olanzapine at lower doses than younger adults. Watch metabolic and EPS.

STOPP/START v3 psychiatric additions

The STOPP/START criteria are the European counterpart to Beers, and v3 (2023) expanded the psychiatric section modestly. Key STOPP additions worth noting:

• Long-term (above 4 weeks) benzodiazepines or Z-drugs for insomnia or anxiety.
• Antipsychotics as long-term hypnotics (excluding sub-therapeutic doxepin and modest trazodone).
• SSRI use in patients with current or recent hyponatremia without close monitoring.
• Any anticholinergic drug in patients with a diagnosis of dementia or cognitive impairment.

START additions (things that should be prescribed but often aren't):

• SSRI or SNRI in moderate to severe depression lasting more than 3 months.
• Cholinesterase inhibitor in mild to moderate Alzheimer disease when tolerated.

Common questions

What's actually wrong with paroxetine in older adults?

Three things stacked. It's the most anticholinergic SSRI, which drives dry mouth, constipation, urinary retention, and cognitive fog in older patients. It has a shorter half-life than other SSRIs and produces a rough discontinuation syndrome when missed. It's a strong CYP2D6 inhibitor, which matters more in older adults on other 2D6 substrates like beta-blockers, opioids (codeine, tramadol), and antipsychotics. Sertraline or escitalopram get you the same class benefit without the baggage.

Is trazodone for sleep okay for a 75-year-old?

Yes, at low dose (25 to 50 mg), with the caveats that orthostasis is real and should be watched, and the evidence for efficacy in chronic insomnia is thinner than the prescribing patterns suggest. It's a defensible choice after sleep hygiene, CBT-I, and melatonin have been tried, and it's safer than benzos, Z-drugs, or diphenhydramine. Reassess at 4 to 6 weeks and don't just let it ride if it isn't helping.

Can I ever use a benzo in someone 65 or older?

Yes, but the situations are narrow. Alcohol withdrawal (short course, lorazepam-based). REM sleep behavior disorder (low-dose clonazepam, though melatonin is tried first). Acute agitation with danger. Long-standing stable use where a taper would destabilize the patient. Starting a benzo for chronic anxiety or insomnia in an older adult who hasn't tried CBT and an SSRI is hard to defend, and the fall, fracture, and MVA data are convincing.

Why is diphenhydramine on the list?

Strong anticholinergic activity. In older adults it causes dry mouth, urinary retention, constipation, tachycardia, and confusion, and it's a well-documented precipitant of delirium. It also causes next-day sedation and fall risk when used for sleep. Same story for hydroxyzine and chlorpheniramine. Second-generation antihistamines (loratadine, cetirizine, fexofenadine) don't cross the blood-brain barrier meaningfully and are fine for allergy. For sleep, doxepin 3 to 6 mg or low-dose trazodone are better picks.

What antipsychotic is safest for behavioral symptoms of dementia?

There's no truly safe answer. All second-generation antipsychotics carry a boxed mortality warning in dementia, roughly 1.6 to 1.7x, mostly cardiovascular and infectious deaths. Among the options, low-dose risperidone (0.25 to 1 mg) has the most efficacy data for psychosis and aggression. Quetiapine (12.5 to 50 mg) is often chosen for sedation and less EPS, though the efficacy signal is weaker. Brexpiprazole was FDA-approved for Alzheimer agitation in 2023, though the effect size is modest. Whatever you pick, nonpharmacologic approaches should come first, targets should be defined, families should be counseled about the mortality signal, and reassessment should happen at least every 3 months.

Sources

• American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (JAGS, 2023).
• STOPP/START criteria version 3 (2023).
• APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia.
• FDA labeling for brexpiprazole (Rexulti) Alzheimer agitation indication (2023).
• Cochrane reviews on antipsychotics for BPSD, benzodiazepines in older adults, and CBT-I.
• Stahl's Essential Psychopharmacology, 5th edition.

Reviewed against current guidelines as of June 8, 2026. This is not medical advice.