Beers Criteria – Flashcards
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which 4 common first generation antihistamines are included in the beers criteria?
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diphenhydramine, doxylamine, hydroxyzine, promethazine
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what is the 3 rationales behind first generation antihistamines being included on the beers list?
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they have highly anticholinergic effects--greater risk of confusion, dry mouth, constipation; clearance is reduced with age; tolerance develops when used as a hypnotic
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how should first generation antihistamines be used in the elderly patient?
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avoid use
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when might diphenhydramine be appropriate to use in the elderly patient?
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acute treatment of severe allergic reaction
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which antiparkinson agent is included on the beers list?
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benztropine
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what is the rationale behind benztropine being included on the beers list? how should benztropine be used in the elderly patient?
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not recommended for extrapyramidal symptoms with antipsychotics; avoid use, there are more effective agents are available for parkinson disease
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which antithrombotic agent is included on the beers list?
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dipyridamole PO short acting
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what is the rationale behind dipyridamole SA being included on the beers list? how should dipyridamole SA be used in the elderly patient?
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may cause orthostatic hypotension; avoid use, more effective alternatives are available
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when might dipyridamole be appropriate to use in the elderly patient?
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IV forms are acceptable for use in cardiac stress testing
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which anti-infective agent is included on the beers list?
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nitrofurantoin
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what is the rationale behind nitrofurantoin being included on the beers list?
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potential for pulmonary toxicity; lack of efficacy in patients with CrCl < 60 ml/min due to inadequate drug concentration in the urine
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how should nitrofurantoin be used in the elderly patient?
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avoid use for long-term suppression; avoid use in patients with CrCl < 60 ml/min; safer alternatives available
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which three alpha-1 blockers are included on the beers list?
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doxazosin, prazosin, terazosin
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what is the rationale behind alpha-1 blockers being included on the beers list?
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high risk of orthostatic hypotension; not recommended as routine treatment for hypertension
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how should alpha-1 blockers be used in the elderly patient?
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avoid use as an antihypertensive; alternative agents have superior risk/benefit profile
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which common alpha agonist is on the beers list?
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clonidine
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what is the rationale behind clonidine being included on the beers list?
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high risk of adverse CNS effects; may cause bradycardia or orthostatic hypotension; not recommended as routine treatment for hypertension
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how should clonidine be used in the elderly patient?
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avoid clonidine as a 1st line antihypertensive
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which 2 common antiarrhythmic drugs are on the beers list?
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amiodarone, dronedarone
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what is the rationale behind antiarrhythmic drugs being included on the beers list?
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RATE control yields better balance of benefits and harms than RHYTHM control for most older adults;
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what is the rationale behind amiodarone being included on the beers list?
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multiple toxicities: thyroid disease, pulmonary disorders, QT prolongation
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how should antiarrhythmic drugs be used in the elderly patient?
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avoid antiarrhythmic drugs as first line treatment of A.Fib
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what is the rationale behind digoxin being included on the beers list?
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in HF, higher doses are not associated with additional benefits and may increase risk of toxicity; slow renal clearance may lead to risk of toxic effects
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what dose of digoxin is included on the beers list?
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> 0.125 mg/day
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how should digoxin be used in the elderly patient?
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avoid doses > 0.125 mg/day
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what is the rationale behind nifedipine IR being included on the beers list?
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potential for hypotension; risk of precipitating myocardial ischemia
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how should nifedipine IR be used in the elderly patient?
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avoid use
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what is the rationale behind spironolactone being included on the beers list?
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in HF, the risk of hyperkalemia is higher in older adults (especially if taking concomitant NSAID, ACE-I, ARB or K supplement)
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what dose of spironolactone is included on the beers list?
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> 25 mg / day
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how should spironolactone be used in the elderly patient?
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avoid in patients with HF or CrCl < 30 ml/min
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which TCAs are included on the beers list?
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all of the tertiary TCAs are, alone or in combination. amitriptyline, chlordiazepoxide, chlomipramine, doxepin, imipramine, perphenazine-amitriptyline, trimipramine
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what is the rationale behind tertiary TCAs being included on the beers list?
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highly anticholinergic effects; sedating; cause orthostatic hypotension
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why is doxepin > 6 mg/day specifically included on the beers list for tertiary TCAs?
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safety profile of low-dose doxepin < 6 mg/day is comparable with that of placebo
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how should tertiary TCAs be used in the elderly patient?
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avoid use
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which antipsychotics are included on the beers list?
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first generation (conventional): chlorpromazine, fluphenazine, haloperidol, loxapine, molindone, perphenazine, pimozide, promazine, thioridazine, thiothixene, trifluoperazine, triflupromazine. second generation( atypical): aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone
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what is the rationale behind antipsychotics being included on the beers list?
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increased risk of cerebrovascular accident (stroke); mortality in person with dementia
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how should antipsychotics be used in the elderly patient?
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avoid use for behavioral problems of dementia unless nonpharm options have failed and patient is a threat to self or others
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which benzodiazepines are included on the beers list?
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SA/Intermediate: alprazolam, estazolam, lorazepam, oxazepam, temazepam, triazolam LA: chlorazepate, chlordiazepoxide, clonazepam, diazepam, flurazepam, quazepam
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what is the rationale behind including benzodiazepines on the beers list?
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older adults have increased sensitivity to benzodiazepines; slower metabolism of long-acting agents; all benzos increase risk of: cognitive impairment, delirium, falls, fractures, motor vehicle accidents;
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how should benzodiazepines be used in the elderly patient?
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avoid for treatment of insomnia, agitation, or delirium; may be appropriate to use for seizure disorders, rapid eye movement sleep disorders, benzo withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end-of-life care
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which common non-benzo hypnotic is included on the beers list?
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zolpidem
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what is the rationale behind including zolpidem on the beers list?
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benzo receptor agonists that have AEs similar to benzos; risks: delirium, falls, fractures; minimal improvement in sleep latency and duration
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how should zolpidem be used in the elderly patient?
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avoid chronic use > 90 days
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which estrogens are included on the beers list?
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with or without progestins
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what is the rationale behind including estrogens on the beers list?
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evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in elderly women;
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how should estrogens be used in the elderly patient?
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avoid PO and topical patch; topical cream is acceptable to use at low-doses for management of dysparenia, lower UTIs; vacinal estrogens for tmt of vaginal dryness is safe and effective in women with breast cancer, espically at dosages of < 25 micrograms of estradiol twice weekly
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what is the rationale behind insulin SLIDING SCALE being included on the beers list?
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higher risk of hypoglycemia without improvement in hyperglycemic management regardless of care setting
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how should insulin SLIDING SCALE be used in elderly patients?
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avoid use
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what is the rationale behind megestrol being included on the beers list?
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minimal effect on weight; increases risk of thrombotic events and possibly death
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how should megestrol be used in the elderly patient?
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avoid use
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what long acting sulfonylureas are included on the beers list?
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chlorpropamide, glyburide
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what is the rationale behind including LA sulfonylureas (glyburide) on the beers list?
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greater risk of severe prolonged hypoglycemia
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what is the rationale behind including LA sulfonylureas (chlorpropamide) on the beers list?
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prolonged half life in older adults; can cause prolonged hypoglycemia; causes syndrome of inappropriate ADH secretion (SIADH)
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how should long acting sulfonylureas be used in the elderly patient?
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avoid use
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which GI mobility agent is included on the beers list?
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metoclopramide
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what is the rationale behind including metoclopramide on the beers list?
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can cause extrapyramidal effects including tardive dyskinesia; risk may be even greater in frail older adults
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how should metoclopramide be used in the elderly patient?
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avoid use, unless for gastroparesis
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which IV pain management drug included on the beers list?
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meperidine
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what is the rationale behind including meperidine on the beers list?
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not as effective as PO analgesic in dosages commonly used; may cause neurotoxicity; safer alternatives available
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how should meperidine be used in the elderly patient?
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avoid use; safer alternatives available
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which NSAIDs are included on the beers list?
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non-cox selective, oral: all of them
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what is the rationale behind including non-selective NSAIDs on the beers list?
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increases risk of GI bleeding and peptic ulcer disease in high-risk groups (age > 75, PO or IV corticosteroids, anticoagulants, antiplatelet agents);
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what can be done to reduce the risk of GI bleeding with non-selective NSAIDs in the elderly patients?
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use of PPIs or misoprostol reduces but does not eliminate risk
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in patients treated with NSAIDs for 3-6 months, what AEs are associated?
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GI ulcers, gross bleeding, perforation
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how should NSAIDs be used in the elderly population?
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avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agents (PPIs or misoprostol)
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which skeletal muscle relaxants are included on the beers list?
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carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine
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what is the rationale behind including skeletal muscle relaxants on the beers list?
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most muscle relaxants are poorly tolerated because of anticholinergic AEs, sedation and risk of fracture; effectiveness at dosages tolerated by older adults is questionable
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how should skeletal muscle relaxants be used in elderly patients?
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avoid use
