By Kelly Wesselman, PharmD
Potentially Inappropriate Medication Use in Older Adults with Chronic Diseases
The American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication (PIM) Use in Older Adults is a resource for physicians and pharmacists to make careful clinical decisions for their patients. Updated in 2019, using the AGS Beers Criteria® improves medication selection, educates clinicians and patients, reduces adverse drug events, and is valuable for evaluating quality of care, cost, and drug-use patterns in older adults. The safety and clinical efficacy of certain medications are of greater concern in those ages 65 and older. PharmD Live® regards the AGS Beers Criteria as an invaluable resource to provide the safest recommendations to patients and their providers.
In addition to providing medical practices oversight of patient medication, the benefits of applying AGS Beers Criteria through PharmD Live’s Chronic Care Management and Remote Patient Monitoring solutions are as follows:
Safety and Efficacy
- Our clinical pharmacists identify inappropriate medication use by carefully evaluating the indication, dosage, and duration of each medication the patient is taking. If use is warranted, we will proceed with caution and follow labs to determine safety and efficacy for continuing. If necessary, dosage adjustments will be made according to the most recent lab values and vitals.
Highlights Adverse Drug Potential
- The pharmacist will work with the patient to identify any adverse effects, drug-drug interactions, and all other medication concerns the patient may have.
Pharmacist-Patient Monthly Appointments
- A clinical pharmacist closely monitors and meets monthly with the patient.
Physician-Pharmacist Review and Planning
- Our pharmacists present recommendations to the patient’s physician for further review and the patient receives a collaborative care plan.
| Potentially Inappropriate Medication Use in Older Adults | Rationale and Recommendation |
|---|---|
| Antidepressants: Alone or in combination Amitriptyline Amoxapine Clomipramine Desipramine Doxepin > 6 mg/day Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine | Highly anticholinergic, sedating, and cause orthostatic hypotension May cause ataxia, impaired psychomotor function, syncope, additional falls If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures Tertiary TCAs increase the risk of orthostatic hypotension or bradycardia Data is mixed but no compelling evidence that certain antidepressants confer less fall risk than others Safety profile of low-dose doxepin (≤ 6 mg/day) comparable to that of placebo |
| Antiemetics: Metoclopramide Prochlorperazine Promethazine All antipsychotics except: Quetiapine Clozapine Pimavanserin | Metoclopramide: Can cause extrapyramidal effects, including tardive dyskinesia; may be greater in frail older adults with prolonged exposure Dopamine-receptor antagonists potentially worsen parkinsonian symptoms Exceptions: Pimavanserin and clozapine appear to be less likely to precipitate worsening of Parkinson disease. Quetiapine has only been studied in low-quality clinical trials with efficacy comparable to that of placebo in five trials and to that of clozapine in two others. |
| Antipsychotics: First (conventional) and Second (atypical) generation | Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia May cause ataxia, impaired psychomotor function, syncope, additional falls If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures Avoid antipsychotics for behavioral problems of dementia or delirium unless non pharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others Avoid use except in schizophrenia or bipolar disorder, or for short-term use as antiemetic during chemotherapy or in the case of Parkinson’s disease it is acceptable to use pimavanserin, clozapine, or quetiapine. |
| Benzodiazepines Short and intermediate acting: Alprazolam Estazolam Lorazepam Oxazepam Temazepam Triazolam Long acting: Chlordiazepoxide (alone or in combo with amitriptyline or clidinium) Clorazepate Diazepam Flurazepam Quazepam | Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. All benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, ataxia, syncope, and motor vehicle crashes in older adults. Avoid use because of adverse CNS effects If one of the drugs must be used, consider reducing use of other CNS-active medications that increase risk of falls and fractures May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, and periprocedural anesthesia. |
| Central alpha-agonists Clonidine for first-line treatment of hypertension Guanabenz Guanfacine Methyldopa Reserpine (>0.1 mg/day) | High risk of adverse CNS effects May cause bradycardia and orthostatic hypotension Not recommended as routine treatment for hypertension |
| Desiccated thyroid | Concerns about cardiac effects; safer alternatives available (e.g., levothyroxine) |
| Desmopressin | High risk for hyponatremia Safer alternative treatments Avoid use for treatment of nocturia or nocturnal polyuria |
| Dextromethorphan/quinidine (Nuedexta) | Limited efficacy in patients with behavioral symptoms of dementia (does not apply to treatment of pseudobulbar affect (PBA)). May increase risk of falls and concerns with clinically significant drug interactions. Does not apply to PBA. |
| Direct Oral Anticoagulants (DOACs) Rivaroxaban (Xarelto) Dabigatran (Pradaxa) | Increased risk of GI bleeding compared with warfarin and reported rates with other DOACs when used for long-term of VTE or atrial fibrillation in adults ≥ 75 years Use with caution for treatment of VTE or atrial fibrillation in adults ≥75 years of age |
| Estrogens with or without progestins | Evidence of carcinogenic potential (breast and endometrium) Lack of cardioprotective effect and cognitive protection in older women Vaginal estrogens for the treatment of vaginal dryness are safe and effective Women with a history of breast cancer who do not respond to non hormonal therapies are advised to discuss the risks and benefits of low-dose vaginal estrogen (dosages of estradiol <25 mcg twice weekly) with their healthcare provider Avoid systemic estrogen (oral and topical patch) Vaginal cream or tablets are acceptable to use at low dose intravaginally (estrogen) for the management of dyspareunia, recurrent lower UTIs and other vaginal symptoms |
| Gabapentinoids Pregabalin (Lyrica) Gabapentin (Neurontin) | Risk of falls and ataxia Should be avoided in combination with opioids due to sedation, respiratory depression, and death |
| Growth hormone | Impact on body composition is small and associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose Avoid use except for patients with rigorously diagnosed evidence-based criteria for growth hormone deficiency due to established etiology |
| Insulin – sliding scale | Avoid regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting |
| Megestrol | Minimal effect on weight Increase risk of thrombotic event and possible death in older adults |
| Meperidine | Oral analgesic not effective in doses commonly used May have higher risk of neurotoxicity including delirium than other opioids Safer alternatives available; avoid use |
| Meprobamate | High rate of physical dependence; sedating Avoid use |
| Mineral oil | Given orally, potential for aspiration and adverse effects Safer alternatives available |
| Nonbenzodiazepine (benzodiazepine receptor agonist hypnotics, i.e., “Z-drugs”) Eszopiclone Zaleplon Zolpidem | Adverse effects are like those of benzodiazepines in older adults (e.g., delirium, falls, fractures) Increased ED room visits/hospitalizations; motor vehicle crashes Minimal improvement in sleep latency and duration |
| Non-cyclooxygenase-selective NSAIDs: Aspirin > 325 mg/day Diclofenac Diflunisal Etodolac Fenoprofen Ibuprofen Ketoprofen Meclofenamate Mefenamic acid Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Sulindac Tolmetin Indomethacin Ketorolac (including parenteral) | Increased risk of gastrointestinal bleeding/peptic ulcer disease and acute kidney injury in older adults Risk is higher when > 75 years of age or if taking an oral or parenteral corticosteroid, anticoagulant, or antiplatelet agent Risks are dose related Risk of major bleeding from aspirin increases markedly in older age. When used for primary prevention in older adults with cardiovascular risk factors, studies suggest lack of net-benefit. Aspirin may exacerbate existing ulcers or cause new/additional ulcers at doses > 325 mg/day Avoid chronic use unless other alternatives are not effective, and patient can take a gastroprotective agent such as a proton-pump inhibitor or misoprostol Indomethacin is more likely than other NSAIDs to have adverse CNS effects |
| Non-dihydropyridine Calcium Channel Blockers Diltiazem (Cardizem) Verapamil (Calan) | When used in older adults with heart failure, there is a potential to promote fluid retention and/or exacerbate heart failure Potential to increase mortality This class of medication should be avoided; if indication is required, proceed with caution |
| Non-selective (peripheral) alpha-1 blockers Doxazosin (Cardura) Prazosin (Minipress, Prazin) Terazosin (Hytrin) | Can cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension Can aggravate incontinence, avoid use in women |
| Prasugrel (Effient) | Increased risk of bleeding in older adults Benefit for use may offset risk when used in highest-risk older adults (e.g., those with prior MI or diabetes mellitus) for its indication of acute coronary syndrome to be managed with percutaneous coronary intervention (PCI) |
| Proton-pump inhibitors | Risk of Clostridium difficile infection, bone loss and fractures Avoid scheduled use for > 8 weeks unless for high-risk patients (e.g., oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett esophagitis, pathological hypersecretory condition, or demonstrated need for maintenance treatment (e.g., failure of drug discontinuation trial or H2-receptor antagonists) |
| Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Venlafaxine (Effexor) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima) | May exacerbate or cause SIADH or hyponatremia; monitor sodium level closely when starting or changing dosages in older adults May cause ataxia, impaired psychomotor function, syncope, additional falls |
| Sulfonylureas: Long acting Chlorpropamide Glimepiride Glyburide (a.k.a. glibenclamide) | Chlorpropamide has a prolonged half-life in older adults – can cause prolonged hypoglycemia Chlorpropamide causes SIADH Glimepiride and glyburide have higher risk of severe prolonged hypoglycemia in older adults |
The clinical pharmacists at PharmD Live have extensive backgrounds and knowledge. They evaluate: drug-drug and drug-disease interactions and therapeutic interchanges for optimal medication therapy, inappropriate medication use, and optimize patient care.
PharmD Live’s pharmacists are a nationwide network dedicated to providing the best value-based care. We believe it is imperative as healthcare professionals that AGS’ Beers Criteria be applied to screen for inappropriate use of certain medications. The criteria applied to our clinical decisions ensure that we provide our older adult patients the most effective care plan.
Additional reading regarding Beers Criteria:
