Some drug categories (eg, analgesics, anticoagulants, antihypertensives, antiparkinsonian drugs, diuretics, hypoglycemic drugs, psychoactive drugs) pose special risks for older adults. Some drugs, although reasonable for use in younger adults, are so risky they should be considered inappropriate for older adults. The American Geriatric Society Beers Criteria® are most commonly used to identify such inappropriate drugs (see table Potentially Inappropriate Drugs in Older Adults) (1). The Beers Criteria categorize potentially inappropriate drugs into 3 groups:
Potentially inappropriate for all older adults: To be avoided if possible
Potentially inappropriate due to drug-disease and drug-syndrome interactions: To be avoided in older adults with certain diseases or syndromes
To be used with caution: Benefit may offset risk in some patients
Potentially Inappropriate Drugs in Older Adults (Based on the American Geriatrics Society 2019 Beers Criteria® Update)
Drug | Rationale and Recommendations |
|---|---|
Anticholinergics (tricyclic antidepressants are excluded) | |
Highly anticholinergic; risk of confusion, dry mouth, constipation, and other anticholinergic effects and toxicity Clearance reduced with advanced age; tolerance develops when used as hypnotics | |
Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease | |
Highly anticholinergic, uncertain effectiveness; avoid | |
Anti-infectives | |
Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy, especially with long-term use; safer alternatives available Avoid in patients with creatinine clearance < 30 mL/min (< 0.5 mL/sec) or for long-term suppression of bacteria | |
Antithrombotics | |
Possible orthostatic hypotension; more effective alternatives available; avoid, except IV form acceptable for cardiac stress testing | |
Cardiovascular drugs | |
High risk of orthostatic hypotension; alternative drugs have better risk/benefit ratio; avoid use as an antihypertensive | |
High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension Not recommended as routine treatment for hypertension | |
Effective for maintaining sinus rhythm but has greater toxicities than other antiarrhythmics used in atrial fibrillation; may be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control Avoid as first-line therapy for atrial fibrillation unless patient has heart failure or substantial left ventricular hypertrophy | |
Potent negative inotrope (may induce heart failure); strongly anticholinergic; avoid, other antiarrhythmic drugs preferred | |
Avoid in patients with permanent atrial fibrillation or severe or recently decompensated heart failure | |
Use in atrial fibrillation: Should not be used as a first-line agent, because more effective alternatives exist; avoid as first-line therapy Use in heart failure: Questionable effects on risk of hospitalization and may be associated with increased mortality in older adults with heart failure; in heart failure, higher dosages not associated with additional benefit and may increase risk of toxicity; avoid as first-line therapy | |
Risk of hypotension and myocardial ischemia; avoid | |
Central nervous system | |
Highly anticholinergic and sedating and cause orthostatic hypotension; avoid | |
Antipsychotics, 1st (conventional) and 2nd (atypical) generations | Increased risk of stroke and greater rate of cognitive decline and mortality in patients with dementia Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and older adult is threatening substantial harm to self or others Avoid, except for schizophrenia, bipolar disorder, or short-term use as antiemetic during chemotherapy |
High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages; avoid | |
Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting drugs; in general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults; avoid | |
High rate of physical dependence; sedating; avoid | |
Benzodiazepine-receptor agonists have adverse events similar to those of benzodiazepines in older adults (eg, delirium, falls, fractures); increased emergency department visits and hospitalizations; motor vehicle crashes; minimal improvement in sleep latency and duration; avoid | |
Ergot mesylates* (dehydrogenated ergot alkaloids) | Lack of efficacy; avoid |
Endocrine therapy | |
Potential for cardiac problems; contraindicated in men with prostate cancer Avoid except for confirmed hypogonadism with clinical symptoms | |
Desiccated thyroid | Possible cardiac effects; safer alternatives available; avoid |
Estrogens with or without progestins | Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women Avoid topical patch and oral Vaginal cream or tablets: Acceptable to use low-dose intravaginal estrogen for management of dyspareunia, recurrent lower urinary tract infections, and other vaginal symptoms |
Growth hormone | Little effect on body composition; associated with edema, arthralgia, carpal tunnel syndrome, gynecomastia, impaired fasting glucose Avoid except for patients diagnosed by evidence-based criteria with growth hormone deficiency due to an established etiology |
Higher risk of hypoglycemia without improvement in glucose control regardless of care setting | |
Minimal effect on weight; increases risk of thrombotic events and possibly death; avoid | |
Chlorpropamide: Prolonged half-life; can cause prolonged hypoglycemia; causes syndrome of inappropriate antidiuretic hormone secretion; avoid | |
Gastrointestinal therapy | |
Can cause extrapyramidal effects including tardive dyskinesia; risk may be greater in frail older adults; avoid unless for gastroparesis with duration of use not to exceed 12 weeks except in rare cases | |
Potential for aspiration; safer alternatives available; avoid | |
Proton-pump inhibitors | Risk of Clostridioides difficile infection and bone loss and fractures Avoid scheduled use for > 8 weeks unless for high-risk patients (eg, oral corticosteroids or chronic NSAID use), erosive esophagitis, Barrett esophagitis, pathologic hypersecretory condition, or demonstrated need for maintenance treatment (eg, due to failure of drug discontinuation trial or H2 blockers) |
Pain management | |
Not an effective oral analgesic in common dosages; may cause neurotoxicity; safer alternatives available; avoid | |
Increased risk of gastrointestinal bleeding and peptic ulcer disease in high-risk groups, including those aged > 75 or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents Upper gastrointestinal ulcers, gross bleeding, or perforation occur in about 1% of patients treated for 3 to 6 months and in about 2 to 4% of patients treated for 1 year; these trends continue with longer duration of use | |
Increased risk of gastrointestinal bleeding/peptic ulcer disease and acute kidney injury in older adults; avoid | |
Poorly tolerated because of anticholinergic effects; sedation; risk of fracture; effectiveness at dosages tolerated by older adults is questionable; avoid | |
Genitourinary | |
High risk of hyponatremia; safer alternative treatments; avoid for treatment of nocturia or nocturnal polyuria | |
* These drugs are used infrequently. | |
CNS = central nervous system; NSAID = nonsteroidal anti-inflammatory drug. | |
Adapted from The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767 | |
Drugs to Be Used With Caution in Older Adults (Based on the American Geriatrics Society 2019 Beers Criteria® Update)
Drug | Reason for Caution |
|---|---|
Use with caution in patients ≥ 70 years | |
Use with caution for treatment if venous thromboembolism (VTE) or atrial fibrillation in patients ≥ 75 years | |
Use with caution in patients ≥ 75 years. Increased risk of bleeding; benefit may offset risk in highest-risk older adults (eg, those with previous myocardial infarction or diabetes mellitus) | |
Antipsychotics Diuretics Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCAs) | May worsen or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia Monitor sodium level closely when starting or changing dosages |
Limited efficacy in patients with behavioral symptoms of dementia (does not apply to treatment of pseudobulbar affect) May increase risk of falls and concerns with clinically significant drug interactions | |
Adapted from The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767 | |
Analgesics
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are used by > 30% of people aged 65 to 89, and half of all NSAID prescriptions are for people > 60. Several NSAIDs are available without prescription.
Older adults may be prone to adverse effects of these drugs, and adverse effects may be more severe because of the following:
NSAIDs are highly lipid-soluble, and because adipose tissue usually increases with age, distribution of the drugs is more extensive.
Plasma protein is often decreased, resulting in higher levels of unbound drug and exaggerated pharmacologic effects for drugs that are highly protein-bound.
Renal function is reduced in many older adults, resulting in decreased renal clearance and higher drug levels.
NSAIDs can also increase blood pressure; this effect may be unrecognized and lead to intensification of antihypertensive treatment (a prescribing cascade). Thus, clinicians should keep this effect in mind when blood pressure increases in older adults and ask them about their use of NSAIDs, particularly over-the-counter NSAIDs.
Anticoagulants
Antidepressants
Antihyperglycemics
Doses of antihyperglycemics should be titrated carefully in patients with diabetes mellitus. Risk of hypoglycemia due to sulfonylureas may increase with age. As described in the table Potentially Inappropriate Drugs in Older Adults
insulin and can be effective given alone or with sulfonylureas. Risk of lactic acidosis, a rare but serious complication, increases with degree of renal impairment and with patient age. Symptomatic heart failure is a contraindication.
Antihypertensives
Antiparkinsonian drugs
Antipsychotics
Antipsychotics should be used only for psychosis. In nonpsychotic, agitated patients, antipsychotics control symptoms only marginally better than placebo and can have severe adverse effects. In people with dementia, studies showed antipsychotics increased mortality and risk of stroke, leading the U.S. Food and Drug Administration (FDA) to issue a black box warning on their use in such patients. Generally, dementia-related behavior problems (eg, wandering, yelling, uncooperativeness) do not respond to antipsychotics. Antipsychotics should not be used merely because a behavioral problem (eg, yelling, repeating phrases) is annoying to people other than the patient.
When an antipsychotic is used, the starting dose should be about one quarter the usual starting adult dose and should be increased gradually with frequent monitoring for response and adverse effects. Once the patient responds, the dose should be titrated down, if possible, to the lowest effective dose. The drug needs to be stopped if it is ineffective. Clinical trial data relating to dosing, efficacy, and safety of these drugs in older adults are limited.
Antipsychotics can reduce paranoia but may worsen confusion (see also Antipsychotic Drugs: Conventional antipsychotics). Older adults, especially women, are at increased risk of tardive dyskinesia, which is often irreversible. Sedation, orthostatic hypotension, anticholinergic effects, and akathisia (subjective motor restlessness) can occur in up to 20% of older adults taking an antipsychotic, and drug-induced parkinsonism can persist for up to 6 to 9 months after the drug is stopped.
Anxiolytics and hypnotics
Treatable causes of insomnia should be sought and managed before using hypnotics
Duration of anxiolytic or hypnotic therapy should be limited if possible because tolerance and dependence may develop; withdrawal may lead to rebound anxiety or insomnia.
Digoxin
≤>≥® suggest avoiding doses > 0.125 mg/day (1
Diuretics
Reference
1. The American Geriatrics Society 2019 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 67(4):674-694, 2019. doi:10.1111/jgs.15767
