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 |
