Potentially Inappropriate Drugs in Older Adults (Based on the American Geriatrics Society 2019 Beers Criteria^® Update)

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