BEERS CRITERIAPotentially Inappropriate Medication Use

in Older Adults

Medication-related problems are common, costly and often preventable in older adults and lead to poor outcomes.

Estimates in past studies in ambulatory and long-term care settings found that 27% of adverse drug events (ADE’s) in primary care and 42% of ADE’s in long-term care were preventable, with most problems occurring at the ordering and monitoring stages of care.

In a study of the 2000/2001 Medical Expenditure Panel Survey, the total estimated healthcare expenditures related to the use of PIM’s was $7.2 billion.

Explicit criteria can identify high-risk drugs using a list of PIM’s that have been identified through expert panel review as having an unfavorable balance of risks and benefits by themselves and considering the alternatives available.

A list of PIM’s was developed and published by Beers and colleagues for nursing home residents in 1991 and subsequently expanded and revised in 1997 and 2003 to include all settings of geriatric care.

The 2012 update continues to categorize the PIM’s in three categories: Medications to avoid regardless of diseases or conditions, medications considered potentially inappropriate when used in certain diseases or syndromes and medications that should be used with caution.

GROUP ONEANTICHOLINERGICS(excludes TCA’S)

Rationale

Brompheniramine Highly anticholinergic; clearance

Carbinoxamine reduced with advanced age and

Chlorpheniramine tolerance develops when used as

Clemastine hypnotic; greater risk of confusion,

Cyproheptadine dry mouth, constipation and other

Dexbrompheniramine anticholinergic effects and toxicity.

Dexchlorpheniramine Use of diphenhydramine in special

Diphenhydramine (oral) situations such as acute treatment

Doxylamine of severe allergic reaction may be

Hydroxyzine appropriate.

Promethazine

Triprolidine

ANTIPARKINSON AGENTS Rationale

Benztropine (oral) Not recommended for prevention

Trihexyphenidyl of extrapyramidal symptoms with

antipsychotics; more effective

agents available for treatment

of Parkinson disease.

ANTISPASMODICS Rationale

Belladonna alkaloids Highly anticholinergic, uncertain

Clidinium-chlordiazepoxide effectiveness.

Dicyclomine

Hyocyamine

Propantheline

Scopolamine

ANTITHROMBOTICS Rationale

Dipyridamole, oral short acting* May cause orthostatic

(does not apply to extended hypotension; more effective

Release combination with aspirin) alternatives available; intravenous

form acceptable for use in cardiac

stress testing.

Ticlopidine* Safer effective alternatives

available.

ANTI-INFECTIVES Rationale

Nitrofurantoin Potential for pulmonary toxicity;

safer alternatives available; lack

of efficacy in patients with

CrCl under 60ml/min due to

inadequate drug concentration

in the urine.

CARDIOVASCULAR Rationale

ALPHA-1 BLOCKERS: High risk of orthostatic

Doxazosin hypotension; not recommended as

Prazosin routine treatment for hypertension;

Terazosin alternative agents have superior

risk benefit profile.

ALPHA AGONISTS, CENTRAL High risk of adverse CNS effects;

Clonidine may cause bradycardia and

Guanabenz* orthostatic hypotension; not

Guanfacine* recommended as routine

Methyldopa* treatment for hypertension.

Reserpine (under 0.1 mg/d)*

CARDIOVASCULAR continued Rationale

Antiarrythmic drugs (Class Ia, IC, Data suggests that rate control

III) yields better balance of benefits

Amiodarone and harms than rhythm control for

Dofetilide most older adults.

Dronedarone Amiodarone is associated with

Flecainide multiple toxicities, including

Ibutilide thyroid disease, pulmonary

Procainamide disorders and QT interval

Propafenone prolongation.

Quinidine

Sotalol

CARDIOVASCULAR, continued Rationale

Disopyramide* Disopyramide is a potent negative

inotrope and therefore may induce

heart failure in older adults;

strongly anticholinergic; other

antiarrhythmic drugs preferred.

Dronedarone Worse outcomes have been

reported in patients taking

dronedarone with permanent

atrial fibrillation or heart failure. In

general, rate control is preferred

over rhythm control for atrial

fibrillation.

CARDIOVASCULAR, continued Rationale

Digoxin, above 0.125 mg/d In heart failure, higher doses

associated with no additional

benefit and may increase risk of

toxicity; slow renal clearance may

lead to risk of toxic effects.

Nifedipine, immediate release* Potential for hypotension; risk of

precipitating myocardial ischemia.

Spironolactone, above 25mg/d In heart failure, the risk of

hyperkalemia is higher in older

adults especially if taking

above 25mg/d or taking

concomitant NSAID, angiotensin

converting enzyme inhibitor,

angiotensin receptor blocker, or

potassium supplement.

CENTRAL NERVOUS SYSTEM Rationale

Tertiary TCA’s, alone or in Highly anticholinergic, sedating

combination: and cause orthostatic hypotension;

Amitriptyline safety profile of low dose doxepin

Chlordiazapoxide-amitriptyline (below 6mg/d) is comparable with

Clomipramine that of placebo.

Doxepin, above 6mg/d

Imipramine

Perhenazine-amitriptyline

Trimipramine

CENTRA NERVOUS SYSTEM , continued

Rationale

Antipsychotics, first generation (conventional):

Increased risk of cerebrovascular

Chlorpromazine accident (stroke) and mortality in

Fluphenazine persons with dementia.

Haloperidol

Loxapine

Molindone

Perphenazine

Pimozide

Promazine

Thioridazine

Thiothixene

Trifluoperazine

Triflupromazine

CENTRAL NERVOUS SYSTEM, continued

Rationale

Antipsychotics, second generation (atypical)

Same as first generation.

Aripiprazole

Asenapine

Clozapine

Iloperidone

Lurasidone

Olanzapine

Paliperidone

Quetiapine

Risperidone

Ziprasidone

CENTRAL NERVOUS SYSTEM, continued

Rationale

Thioridazine Highly anticholinergic and risk of

Mesoridazine QT interval prolongation.

Barbiturates: High rate of physical dependence;

Amobarbital* tolerance to sleep benefits; risk of

Butabarbital* overdose at low dosages.

Butalbital

Mephobarbital*

Pentobarbital*

Phenobarbital

Secobarbital*

CENTRAL NERVOUS SYSTEM, continued

Rationale

Benzodiazepines Older adults have increased

Short and intermediate acting: sensitivity to benzodiazepines and

Alprazolam slower metabolism of long acting

Estazolam agents. In general, all

Lorazepam benzodiazepines increase risk of

Oxazepam cognitive impairment, delirium,

Temazepam falls, fractures and motor vehicle

Triazolam accidents in older adults.

Long acting: May be appropriate for seizure

Clorazepate disorders, rapid eye movement

Chlordiazepoxide sleep disorders, benzodiazepine

Chlordiazepoxide-amitriptyline withdrawal, ethanol withdrawal,

Clidinium-chlordiazepoxide severe generalized anxiety

Clonazepam disorder, periprocedural

Diazepam anesthesia, end of life care.

Flurazepam

Quazepam

Chloral hydrate* Tolerance occurs within 10 days,

and risks outweigh benefits in

light of overdose with doses only

3 times the recommended dose.

Meprobamate High rate of physical dependence;

very sedating.

Nonbenzodiazepine hypnotics Benzodiazepine receptor agonists

Eszopiclone that have adverse effects similar to

Zolpidem those of benzodiazepines in older

Zaleplon adults (e.g., delirium, falls,

fractures); minimal improvement

in sleep latency and duration.

Ergot mesylates* - Isoxsuprine Lack of efficacy.

ENDOCRINE: Androgens Potential for cardiac problems and

Methyltestosterone* contraindicated in men with

Testosterone prostate cancer.

Desiccated thyroid Concerns about cardiac effects;

safer alternatives available.

ENDOCRINE RATIONALE

Estrogens with or without Evidence of carcinogenic potential

progestins (breast and endometrium); lack of

cardioprotective effect and

cognitive protection in older

women.

Evidence that vaginal estrogens

for treatment of vaginal dryness is

safe and effective in women with

breast cancer, especially at

doses of estradiol below 25 ug

twice weekly.

Growth hormone Effect on body composition is

small and associated with edema,

arthralgia, carpal tunnel syndrome,

gynecomastia, impaired fasting

glucose.

ENDOCRINE Rationale

Insulin, sliding scale Higher risk of hypoglycemia

without improvement in

hyperglycemia management

regardless of care setting.

Megestrol Minimal effect on weight;

increases risk of thrombotic

events and possibly death in older

adults.

Sulfonylureas, long duration Chlorpropamide: prolonged

Chlorpropamide half-life in older adults; can cause

Glyburide prolonged hypoglycemia; causes

syndrome of inappropriate

antidiuretic hormone secretion.

Glyburide: greater risk of severe

prolonged hypoglycemia in older

adults.

GASTROINTESTINAL RATIONALE

Metoclopramide Can cause extrapyramidal effects

including tardive dyskinesia; risk

may be even greater in frail older

adults.

Mineral oil, oral Potential for aspiration and

adverse effects; safer alternatives

available.

Trimethobenzamide One of the least effective

antiemetic drugs; can cause

extrapyramidal adverse effects.

PAIN

Meperidine Not an effective oral analgesic in

doses commonly used; may

cause neurotoxicity; safer

alternatives available.

PAIN RATIONALE

Non-COX selective NSAID’s, oral Increase risk of GI bleeding and

Aspirin (above 325 mg/d) peptic ulcer disease in high risk

Diclofenac groups, including those

Diflunisal aged above 75 or taking oral or

Etodolac parental corticosteroids,

Fenoprofen anticoagulants or antiplatelet

Ibuprofen agents. Use of proton pump

Ketoprofen inhibitor or misoprostol reduces

Meclofenamate but does not eliminate risk. Upper

Mefenamic acid GI ulcers, gross bleeding or

Meloxicam perforation caused by NSAID’s

Nabumetone occur in approximately 1% of

Naproxen patients treated for 3-6 months

Oxaprozin and in approximately 2-4% of

Piroxicam patients treated for 1 year. These

Sulindac trends continue with longer

Tolmetin duration of use.

GASTROINTESTINAL Rationale

Indomethacin Increases risk of GI bleeding and

Ketrolac, includes parental peptic ulcer disease in high risk

groups. (See above Non-COX

selective NSAID’s).

Of all the NSAID’s, indomethacin

has most adverse effects.

Pentazocine* Opiod analgesic that causes CNS

adverse effects, including

confusion and hallucinations, more

commonly than other narcotic

drugs; is also a mixed agonist and

antagonist; safer alternatives

available.

PAIN Rationale

Skeletal muscle relaxants: Most muscle relaxants are poorly

Carisoprodol tolerated by older adults because

Chlorzoxazone of anticholinergic adverse effects

Cyclobenzaprine sedation, risk of fracture,

Metaxalone effectiveness at dosages tolerated

Methocarbamol by older adults is questionable.

Orphenadrine

GROUP TWODISEASE OR SYNDROME

DRUG RATIONALE

CARDIOVASCULAR:

Heart Failure NSAID’s and COX-2 inhibitors

Potential to promote fluid retention and

Nondihydropyridine CCB’s (avoid -

exacerbate heart failure.

only for for systolic heart failure):

Diltiazem

Verapamil

Pioglitazone, rosiglitazone

Cilostazol

Dronedarone

DISEASE OR SYNDROME

DRUG RATIONALE

Syncope AChEls Increase risk of

Peripheral alpha blockers: orthostatic

Doxazosin hypotension

Prazosin or bradycardia.

Terazosin

Tertiary TCA’s

Chlorpromazine,olanzapine,

thioridazine

Chronic seizures Bupropion Lowers seizure

or epilepsy Chlorpromazine threshold; may

Clozapine be acceptable

Maprotiline in patients with

Olanzapine well controlled

Thioridazine seizures in whom

Thiothixene alternatives are

Tramadol not effective.

DISEASE OR SYNDROME

DRUG RATIONALE

Delirium All TCA’s Avoid in older adults

Anticholinergics with or at high risk of

delirium because of

Benzodiazepines inducing or worsening

Chlorpromazine delirium in older adults;

Corticosteroids if discontinuing drugs

H2-receptor antagonist

used chronically, taper to avoid withdrawal

symptoms.

Meperidine

Sedative Hypnotics

Thioridazine

DISEASE OR SYNDROME

DRUG RATIONALE

Dementia and Anticholinergics Avoid because of

cognitive Benzodiazepines adverse CNS effects.

impairment H2-receptor antagonists

Avoid antipsychotics for behavioral

Zolpidem problems of

Antipsychotics, chronic

dementia unless

and as-needed use nonpharmacological

options have failed

and patient is a threat

to themselves or others

Antipsychotics are

associated with an

increased risk of

cerebrovascular

accident (stroke) and

mortality in persons

with dementia.

DISEASE OR SYNDROME

DRUG RATIONALE

History of Anticonvulsants Ability to produce

falls or Antipsychotics ataxia, impaired

Fractures Benzodiazepines psychomotor function,

Nonbenzodiazepine hypnotics

syncope, and additional

Eszopiclone falls; shorter-acting

Zaleplon benzodiazepines are

Zolpidem not safer than long-

TCA’s and selective acting ones.

serotonin reuptake inhibitors

DISEASE OR SYNDROME

DRUG RATIONALE

Insomnia Oral decongestants: CNS stimulant effects

Pseudoephedrine

Phenylephrine

Stimulants:

Amphetamine

Methylphenidate

Pemoline

Theobromines:

Theophylline

Caffiene

DISEASE OR SYNDROME

DRUG RATIONALE

Parkinson’s All antipsychotics Dopamine receptor

disease Antiemetics: antagonists with

Metochlopramide potential to worsen

Prochlorperzaine parkinsonion symptoms.

Promethazine Quetiapine and

clozapine appear to

be less likely to

precipitate worsening

of Parkinson’s disease.

DISEASE OR SYNDROME

DRUG RATIONALE

Chronic Antimuscarinics for Can worsen

Constipation urinary incontinence constipation; agents

Darfenacin urinary incontinence:

Fesoterodine antimuscarinics overall

Oxybutynin (oral) differ in incidence of

Solifenacin constipation; response

Tolterodine variable; consider

Trospium alternative agent if

Nondihydropyridine CCB:

constipation develops.

Diltiazem

Verapamil

DISEASE OR SYNDROME

DRUG RATIONALE

Chronic constipation, First-generation antihistamines as

continued single agent or part of

combination products:

Brompheniramine

Carbinoxamine

Chlorpheniramine

Clemastine

Cyproheptadine

Dexbropheniramine

Dexchlorpheniramine

Diphenhydramine

Doxylamine

Hydroxyzine

Promethazine

Triprolidine

DISEASE OR SYNDROME

DRUG RATIONALE

Chronic constipation, Anticholinergics and

continued Antispasmotics:

Antipsychotics

Belladonna alkaloids

Clidinium- chlordiazepoxide

Dicyclomine

Hyoscyamine

Propantheline

Scopolamine

Tertiary TCA’s:

Amitriptyline

Clomipramine

Doxepin

Imipramine

Trimipramine

DISEASE OR SYNDROME

DRUG RATIONALE

Chronic constipation, Anticholinergics and

continued Antispasmotics:

Antipsychotics

Belladonna alkaloids

Clidinium- chlordiazepoxide

Dicylcomine

Hyoscyamine

Propantheline

Scopolamine

Tertiary TCA’s:

Amitriptyline, Clomipramine,

Doxepin, Imipramine,

Trimipramine

DISEASE OR SYNDROME

DRUG RATIONALE

History of gastric Aspirin (above 325 mg)

May exacerbate

or duodenal ulcers Non-COX2 selective NSAID’s

existing ulcers or cause

new or additional

ulcers.

Chronic kidney NSAID’s May increase risk of

disease, Stages IV or V

Triamterene (alone or kidney injury.

in combination)

Urinary Estrogen oral and Aggravation of

Incontinence transdermal (excludes incontinence.

(all types) intravaginal estrogen)

in women

GROUP THREE

DRUG RATIONALE RECOMMENDATION

Aspirin Lack of evidence of Use with caution in

for primary prevention

benefit versus risk in adults over 80.

of cardiac events individuals over 80

Dabigatran Greater risk of Use with caution in

bleeding than with adults aged above 75

warfarin in adults aged

or if CrCl below

above 75; lack of 30mL/min.

evidence for efficacy

and safety in

individuals with CrCl

Below 30 mL/min

Pasugrel Greater risk of Use with caution in

bleeding in older adults above 75.

adults; risk may be

offset by benefit in

highest risk older adults

(e.g., with prior

myocardial infarction

or diabetes mellitus

DIEASE OR SYNDROME

DRUG RATIONALE

Lower urinary tract symptoms,

Inhaled anicholinergic agents

May decrease urinary flow and cause

benign prostatic hyperplasia

Strongly anitcholinergic drugs

urinary retention.

except antimusscarinics for

urinary incontinence

Stress or mixed Alpha blockers: Aggravation of

urinary incontinence Doxazosin incontinence.

Prazosin

Terazosin

GROUP THREEDRUG RATIONALE RECOMMENDATION

Aspirin, for primary prevention

Lack of evidence of benefit versus risk in

Use with caution in adults over age 80.

of cardiac events individuals over age 80

Dabigatran Greater risk of Use with caution in

bleeding than with adults over age 75 or

warfarin in adults aged

If CrCl less than 30mL

above 75; lack of /min.

evidence for efficacy

and safety in

individuals with CrCl less than 30mL/min

Prasugrel Greater risk of Use with caution in

bleeding (may benefit adults above age 75.

higher risk adults with

prior myocardial injury or diabetes mellitus

DRUG RATIONALE RECOMMENDATION

Antipsychotics May exacerbate or Use with caution.

Carbamazepine cause syndrome of

Carboplatin inappropriate

Cisplatin antidiuretic hormone

Mirtazapine secretion or

Serotonin-norepinephrine

hyponatremia;need to

reuptake inhibitor monitor sodium level

Selective serotonin closely when starting

reuptake inhibitor or changing dosages

Tricyclic antidepressants

in older adults due to increased risk

Vincristine

Vasodilators May exacerbate Use with caution.

episodes of syncope

in individuals

with history of syncope

Previously, as many as 40% of older adults received one or more of the medications on this list, depending on the care setting.

These criteria have some limitations: Older adults are often underrepresented in drug trials, The criteria does not address other types of PIM’s that are not unique to aging and Hospice and palliative care patients needs (symptom control being paramount) are not completely addressed.

Finally, these criteria are not meant to supersede clinical judgment or an individual’s values and needs. Prescribing and managing disease conditions should be individualized and involve shared decision making.

REFERENCE

The American Geriatric Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. JAGS 2012:1-16.

Victor J. Sobolewski, III, D.O.Visiting Physicians

West Allis, WI262-949-1893