Beers criteria

Introduction

Consensus criteria for safe medication use in the elderly.

Expert consensus based upon literature review.

Adopted by Centers for Medicare & Medicaid Services in July 1999 for nursing home regulation.

Beer's criteria medications account for < 4% of elderly patient emergency department visits for adverse drug events

Also see inappropriate medications in the elderly by disorder

* drug: peripheral alpha-1 blocker

• doxazosin
• prazosin
• terazosin
• concern: orthostatic hypotension

* drug: alpha agonist, centrally acting

• clonidine (Catapres) for 1st line treatment of hypertension
• guanabenz
• guanfacine
• methydopa
• reserpine (> 0.1 mg/day)
• concern: CNS effects, bradycardia, orthostatic hypotension

drug: amiodarone (Cordarone)

• concern: QT prolongation, torsades de pointes, lack of effectiveness in elderly
• severity rating: high

* drug: analeptics

• amphetamines & anorexic agents
• concern: dependence, hypertension, angina, myocardial infarction
• severity rating: high

* drug: androgen

• testosterone
• methyltestosterone (Android, Virilon, Testrad)
• concern: prostate hypertrophy, cardiovascular risk, contraindicated with prostate cancer
• severity rating: high

* drug: antiarrhythmic agent

• amiodarone
• dofetilide (removed 2015)
• dronedarone
• flecainide (removed 2015)
• ibutilide (removed 2015)
• procainamide (removed 2015)
• propafenone (removed 2015)
• quinidine (removed 2015)
• sotalol (removed 2015)
• concern: rate control results in better outcomes for most elderly patients than rhythm control

* drug: anticholinergics & antihistamines

• brompheniramine & dexbrompheniramine
• carbinoxamine
• chlorpheniramine (Chlor-Trimeton) & dexchlorpheniramine (Polaramine)
• clemastine
• cyproheptadine (Periactin)
• dimenhydrinate
• diphenhydramine (Benadryl)
• doxylamine
• hydroxyzine (Vistaril, Atarax)
• meclizine
• promethazine (Phenergan)
• tripelennamine (PBZ)
• triprolidine
• concern: anticholinergic, confusion, sedation, clearance reduced with aging,
• severity rating: high

* drug: antipsychotic (conventional & atypical)

• avoid except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy
• concern: increased risk of cerebrovascular stroke increased risk of cognitive decline & mortality in elderly with dementia

* drug: antipsychotic

• thioridazine
• mesoridazine (no longer marketed in US)
• concern: anticholinergic, QT prolongation

* drug: antispasmodic

• atropine (excludes ophthalmic)
• belladonna alkaloids
• clindium-chlordiazepoxide
• dicyclomine
• homatropine (except ophthalmic)
• hyocyamine
• methscopolamine
• propanthelene
• scopolamine
• concern: anticholinergic, uncertain effectiveness; avoid, except short term to decrease oral secretions

* drug: antithrombotic

• dipyramidole (short acting; does not apply to long-acting form used in combination with aspirin (Aggrenox)
• ticlopidine
• concern: safer, more effective alternatives available

* drug: barbiturates

• amobarbital
• butabarbital
• butalbital
• mephobarbital
• pentobarbital
• phenobarbital
• secobarbital
• concern: addiction, more adverse effects than other sedative/hypnotics in the elderly; exception is phenobarbital used to treat seizures
• severity rating: high

* drug: benzodiazepine (short-acting)

• alprazolam (Xanax) > 2 mg
• estazolam
• lorazepam (Ativan) > 3 mg
• oxazepam (Serax) > 60 mg
• temazepam (Restoril) > 15 mg
• triazolam (Halcion) > 0.25 mg
• concern: increased sensitivity to benzodiazepines in the elderly; increased risk of cognitive impairment, delirium, falls in the elderly
• severity rating: high

* drug: benzodiazepine (long-acting)

• chlorazepate (Tranxene)
• chlordiazepoxide (Librium, Limbitrol, Librax)
• clonazepam
• diazepam (Valium)
• flurazepam
• halazepam (Paxipam)
• quazepam (Doral)
• concern: long 1/2life in the elderly, prolonged sedation; short-acting benzodiazepines preferred if required
• severity rating: high

drug: chlorpropamide (Diabenese)

• concern: prolonged 1/2life in the elderly, hypoglycemia, SIADH
• severity rating: high

drug: cyclandelate (Cyclospasmol)

• concern: not effective
• severity rating: low

drug: digoxin > 0.125 mg/day (Lanoxin)

• not recommended as 1st line treatment for atrial fibrillation or heart failure
• concern: decreased renal clearance may lead to increased toxic effects; dose should NOT exceed 0.125 mg/day except when treating atrial arrhythmias
• severity rating: low

drug: dipyridamole (Persantine)

• concern: orthostatic hypotension
• severity rating: low

drug: disopyramide (Norpace)

• concern: most potent negative inotrope of antiarrhythmics anticholinergic, may induce heart failure
• severity rating: high

drug: doxepin (Sinequan)

• concern: anticholinergic, sedative
• severity rating: high

drug: doxazosin (Cardura)

• concern: hypotension, dry mouth, urinary retention
• severity rating: low

drug: dronedarone

• concern: worse outcomes in patients with permanent atrial fibrillation or heart failure; rate control better than rhythm control in elderly

* drug: ergot mesyloids (ergoloid mesylates) (Hydergine)

• isoxsuprine
• concern: not effective
• severity rating: low

drug: estrogen only (oral)

• concern: endometrial cancer, breast cancer, lack of cardioprotective effect
• severity rating: low

drug: ethacrynic acid (Edecrin)

• concern: hypertension, fluid imbalance
• severity rating: low

drug: flurazepam (Dalmane)

• concern: long 1/2life in elderly
• severity rating: high

* drug: gastrointestinal antispasmodic agent

• dicyclomine (Bentyl)
• hyoscyamine (Levsin, Levsinex)
• propatheline (Pro-Banthine)
• belladonna alkaloids (Donnatal, others)
• clindinium-chlordiazepoxide (Librax)
• concern: anticholinergic, uncertain effectiveness
• severity rating: high

drug: growth hormone

• concern: edema, arthralgia, carpal tunnel syndrome, gynecomastia, hyperglycemia

drug: desmopressin

• avoid for treatment of nocturia
• concern: hyponatremia

* drug: NSAIDs (non-selective)

• aspirin >325 mg/d
• diclofenac
• diflunisal
• etodolac
• fenoprofen
• ibuprofen
• ketoprofen
• meclofenamate
• mefenamic acid
• meloxicam
• nabumetone
• naproxen (Naprosyn, Avaprox, Aleve)
• oxaprozin (Daypro) - piroxicam
• piroxicam (Feldene)
• sulindac
• tolmetin
• concern: GI bleeding or peptic ulcer disease
• severity rating: high
• avoid full dosage & longer 1/2life

* COX2 inhibitors apparently not on Beers list

drug: indomethacin (Indocin)

• concern: more CNS effects than other NSAIDs
• severity rating: high

drug: ketorolac (Toradol), includes parenteral

• concern: GI bleeding, peptic ulcer disease, acute kidney injury
• severity rating: high

drug: pentazocine

• concern: confusion, hallucinations
• severity rating: high

drug: insulin sliding scale

• concern: risk of hypoglycemia without improvement in overall glycemic control

drug: isoxsurpine (Vasodilan)

• concern: not effective
• severity rating: low

drug: megestrol

• concern: minimal effect on weight; thrombosis, death

drug: meperidine (Demerol)

• concern: confusion, effectiveness in question; toradol works better
• severity rating: high

drug: meprobamate (Miltown, Equanil)

• concern: sedative, addiction, withdrawals
• severity rating: high

drug: methyldopa (Aldomet)

• concern: bradycardia, depression
• severity rating: high

drug: metoclopramide

• concern: extrapyramidal effects
• avoid unless for gastroparesis

drug: mineral oil

• concern: aspiration, other adverse effects
• severity rating: high

drug: proton pump inhibitor

• concern: C difficile colitis, osteopenia, fractures avoid scheduled use for > 8 weeks unless high risk
• severity rating: high

* drug: muscle relaxants & antispasmodics

• carisoprodol (Soma),
• chlorzoxazone (Paraflex)
• cyclobenzaprine (Flexeril)
• metaxalone (Skelaxin),
• methocarbamol (Robaxin)
• orphenadrine
• oxybutynin (Ditropan) (not listed in ref)
• concern: anticholinergic effects, sedation, weakness effectiveness at tolerated dosages in question
• severity rating: high

drug: nifedipine, short-acting (Procardia, Adalat)

• concern: hypotension, constipation
• severity rating: high

drug: nitrofurantoin (Macrodantin)

• concern: renal impairment, pulmonary toxicity, hepatotoxicity, peripheral neuropathy
• severity rating: high
• avoid in elderly with creatinine clearance < 30 mL/min

drug: orphenadrine (Norflex)

• concern: anticholinergic, sedation
• severity rating: high

* drug: Parkinsonian agent

• benztropine
• trihexyphenidyl
• concern: more effective agents available

drug: pentozocine (Talwin)

• concern: CNS adverse effects, more so than other narcotics
  • confusion, hallucinations, mixed agonist/antagonist, thus not particularly effective
• severity rating: high

drug: reserpine (Serpasil) > 0.25 mg/day

• concern: depression, impotence, sedation, orthostatic hypotension
• severity rating: low

* drug: sedative/hypnotic (Z-drug)

• eszopiclone (Lunesta)
• zalepan
• zolpidem
• concern: risk exceeds benefit; adverse rffects similar to benzodiazepines; cognitive impairment, delirium, falls in the elderly

drug: spironolactone > 25 mg/day

• concern: hyperkalemia;
• avoid if creatinine clearance < 30 ml/min

* drug: sulfonylurea

• chloropramide
• glimeperide
• glyburide
• concern: prolonged hypoglycemia

drug: thioridazine (Mellaril)

• concern: CNS effects, extrapyramidal effects
• severity rating: high

drug: thyroid, dessicated

• concern: cardiac effects
• severity rating: high

drug: desmopression

• concern: hyponatremia
• avoid for treatment of nocturia or nocturnal polyuria

drug: ticlopidine (Ticlid)

• concern: no better than aspirin, but more hazardous
• severity rating: high

* drug: tricyclic antidepressant

• amitriptyline (Elavil, Limbitrol, Triavil)
• amoxapine
• clomipramine
• desipramine
• doxepin >6 mg/day
• imipramine
• nortriptyline
• protriptyline
• trimipramine
• concern: anticholinergic, sedative
• severity rating: high

drug: fluoxetine (Prozac)

• concern: long 1/2life, excessive CNS stimulation, sleep disturbance, agitation
• severity rating: high

drug: paroxetine

• concern: anticholinergic, sedative
• severity rating: high

disease/syndrome: heart failure

• avoid: cilastazol
• avoid: verapamil, diltiazem with LV systolic dysfunction
• avoid: NSAIDs, COX2-inhibitors
• avoid: thiazolidinediones

disease/syndrome: syncope

• avoid: acetylcholinesterase inhibitors
• concern: bradycardia
• avoid: alpha-1 blockers (doxazosin, prazosin, terazosin)
• concern: orthostatic hypotension
• avoid: tricyclic antidepressant
• concern: orthostatic hypotension & bradycardia
• avoid: antipsychotics (chlorpromazine, thiorididine, olanzapine)
• concern: orthostatic hypotension & bradycardia

disease/syndrome: delirium

• avoid: anticholinergic agents
• avoid: benzodiazepines
• avoid: glucocorticoids
• avoid: H2 receptor antagonists
• avoid: meperidine
• avoid: hypnotics (eszopiclone, zaleplon, zolpidem)
• concern: worsening of delrium
• avoid: antipsychotics
• concern: increased risk of stroke & mortality in patients with dementia

disease/syndrome: dementia

• avoid: anticholinergic agents
• avoid: benzodiazepines
• avoid: hypnotics (eszopiclone, zaleplon, zolpidem)
• concern: precipitation or worsening of delrium
• avoid: antipsychotics
• concern: increased risk of stroke & mortality

disease/syndrome: falls in the elderly, osteoporosis

• avoid: anticonvulsants
• avoid: antipsychotics
• avoid: benzodiazepines
• avoid: antidepressants (TCA, SSRI. SNRI)
• avoid: hypnotics (eszopiclone, zaleplon, zolpidem)
• avoid: opiates
• concern: ataxia, worsening psychomotor function, syncope, falls

disease/syndrome: Parkinson's disease

• avoid: antiemetics (metoclopramide, prochlorperazine, promethazine)
• avoid: antipsychotics (except: quetiapine, clozpeine, pimaveserin)
• concern: worsening of parkinsonism

disease/syndrome: history of peptic ulcer

• avoid: aspirin > 325 mg/day
• avoid: NSAIDS (non COX2 inhibitors)
• concern: precipitation or exacerbation of peptic ulcer

disease/syndrome: chronic renal failure, stte 4 & 5

• avoid: NSAIDS (COX1 & COX2 inhibitors)
• concern: may increase risk of acute kidney injury

disease/syndrome: urinary incontinence (women)

• avoid: oral & transdermal estrogen, intravaginal estrogen ok
• concern: lack of efficacy
• avoid: alpha-1 blockers (doxazosin, prazosin, terazosin)
• concern: aggravation of urinary incontinence

aspirin for primary prevention of cardiovascular disease or colorectal cancer

• avoid: caution in adults > 70 years
• concern: increased risk for major bleeding

dabigatran & rivaroxaban

• avoid: caution in adults > 75 years
• concern: increased risk for major bleeding compared with warfarin, apixaban

pasugrel

• avoid: caution in adults > 75 years
• concern: increased risk for major bleeding

drugs associated with hyponatremia

• drugs:
  • antipsychotics
  • anticonvusants: carbamazepine, oxcarbazepine
  • antidepressants: SSRI,SNRI, tricyclic antidepressants, mirtazapine
  • diuretics
  • tramadol
• concern: SIADH

dextromethorphan/quinidine

• avoid: caution
• concern: limited efficacy for psychosis & agitation in the elderly

trimethoprim/sulfamethoxazole (Bactrim)

• avoid: caution in patients on ACE inhibitor or ARB & renal insufficiency
• concern: hyperkalemia

More general terms

• criteria

Additional terms

• inappropriate medications in the elderly (by disorder)