Medications

Beers Criteria

Older adults are typically at greater risk for adverse reaction to prescription drugs due to altered pharmacokinetics, increased exposure to multiple concomitant medications, and co-morbid conditions. Mark Beers, MD, and colleagues published criteria listing “potentially inappropriate medications” for older patients. Beers criteria is used to provide a guideline for safer use of medications in older adults. The criteria should not serve as a substitute for professional judgment nor should it dictate prescribing for specific patients. The information presented in the criteria should serve only as a guide, with care tailored to each patient’s needs.

Medications to Avoid Regardless of Condition

Drug or drug class Rationale
First-generation antihistamines Highly anticholinergic; greater risk of confusion, dry mouth, and other anticholinergic adverse events
Antispasmodics Highly anticholinergic; questionable effectiveness
Short-acting, oral dipyridamole May cause orthostatic hypotension
Ticlopidine Safer alternatives available
Nitrofurantoin Pulmonary toxicity may occur; lack of efficacy data in those with a CrCl < 60 mL/min
Alpha-1 blockers May cause orthostatic hypotension; do not use as an antihypertensive
Alpha agonists (e.g., clonidine, guanabenz, methyldopa) High risk for CNS adverse events
Class Ia, Ic, and III antiarrhythmics Evidence suggest that rate control yields more benefits than rhythm control in older adults; specific agents associated with numerous
toxicities
Digoxin > 0.125 mg/d Higher doses do not result in additional benefit and risk of toxicity high especially in those with reduced renal function
Immediate-release nifedipine Hypotension and potential risk of precipitating MI
Tertiary TCAs Highly anticholinergic
Antipsychotics, both first and second generation Increased risk of stroke and mortality in those with dementia
Barbiturates High rate of physical dependence; overdose a concern
Benzodiazepines Older adults more sensitive to effects; increases risk of cognitive impairment, delirium, falls, and fractures
Nonbenzodiazepine hypnotics (e.g., zolpidem) Adverse events similar to those observed with benzodiazepines
Estrogens Evidence of carcinogenic potential and lack of cardiovascular or cognitive benefits
Sliding scale insulin Higher risk of hypoglycemia without improving hyperglycemia
Megestrol Minimal effect on weight with accompanying adverse events
Long-acting sulfonylureas (i.e., chlorpropamide, glyburide) Greater risk of prolonged hypoglycemia
Metoclopramide Associated with extrapyramidal adverse events
Meperidine Not effective for pain control and associated with neurotoxic effects
Non-COX selective oral NSAIDs Increased risk of GI bleed and peptic ulcer disease in high-risk groups
Pentazocine CNS adverse events
Skeletal muscle relaxants Poorly tolerated because of anticholinergic effects

Medications to Approach With Caution

Drug or drug class Recommendation Rationale
Aspirin for primary prevention of cardiac events Use with caution in patients ≥ 80 years of age Lack of benefit vs. risk in patients ≥ 80 years of age
Dabigatran (Pradaxa—Boehringer Ingelheim) Use with caution in patients ≥ 75 years of age or in those with CrCl < 30 mL/min Greater risk of bleeding in older adults; lack of evidence for efficacy and safety in those with CrCl < 30 mL/min
Prasugrel (Effient—Daiichi Sankyo, Eli Liily) Use with caution in patients ≥ 75 years of age Greater risk of bleeding in older adults
Antipsychotics, carbamazepine, mirtazapine, SNRIs, SSRIs, TCAs, carboplatin, cisplatin, vincristine) Use with caution May exacerbate syndrome of inappropriate antidiuretic hormone secretion or
hyponatremia
Vasodilators Use with caution May exacerbate episodes of syncope in those with a history of syncope