Detail-Document #230907

−This Detail-Document accompanies the related article published in−

PHARMACIST’S LETTER / PRESCRIBER’S LETTER
September 2007 ~ Volume 23 ~ Number 230907

Potentially Harmful Drugs in the Elderly: Beers List and More

(B=Beers list drug; C=Canadian list drug)
Drug Concern Alternative Treatment
Analgesics
Ketorolac (Toradol) GI bleeding.5 Mild pain: APAP, short-acting NSAID (e.g.,
(B); long-term use (C) ibuprofen)
Meperidinea Not effective at
(Demerol) (B); long- commonly used oral Moderate or severe pain: morphine,
term use (C) doses; confusion, hydrocodone/APAP (Vicodin, etc), oxycodone
falls, factures, (OxyContin, etc), oxycodone/APAP (Percocet, etc),
dependency, fentanyl patch (Duragesic)19
withdrawal5,15
Pentazocine (Talwin) More CNS effects Topicals (neuropathic pain, arthritis): lidocaine
(B); long-term use (C) (e.g., confusion, (Lidoderm), capsaicin (Zostrix, etc)
hallucinations) than
other opioids; ceiling
to analgesic effect5
Propoxyphene (e.g., No better than
Darvon, etc) (B) acetaminophen, but
has narcotic AE5
Antidepressants
Amitriptyline (Elavil) Anticholinergic AE, Tricyclic without active metabolites (Nortriptyline
(B, C), doxepin sedation, urinary [Pamelor], desipramine [Norpramin])15
(Sinequan, etc) (B), retention or Trazodone (for insomnia)19
imipramine incontinence, SSRI15
(Tofranil)(C) constipation, Bupropion (Wellbutrin) (for cardiac patient)19
arrhythmias, falls5,15 Mirtazapine (Remeron) (for insomnia or anorexia)19
Neuropathic pain: topicals (lidocaine [Lidoderm],
capsaicin [Zostrix, etc])
Bupropion May cause seizure5 Tricyclic without active metabolites (Nortriptyline
(Wellbutrin), seizure [Pamelor], desipramine [Norpramin])15
disorder (B) Trazodone (for insomnia)19
SSRI15
Mirtazapine (Remeron) (for insomnia or anorexia)19
Fluoxetine (Prozac) Long half-life; SSRI with shorter half-life (e.g., escitalopram
used daily (B) agitation, insomnia, [Lexapro], sertraline [Zoloft])
anorexia5
Tricyclic for Fall risk; urinary SSRI, with blood pressure monitoring15
depression in patient retention; worsening
with postural glaucoma, heart
hypotension, BPH, block15
glaucoma, heart block
(C)

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 2 of 12)

Drug Concern Alternative Treatment

Antidepressants, cont.
Tricyclic in patient Urinary retention or Antidepressant with little anticholinergic or alpha-
with stress incontinence5 blocking effect (e.g., citalopram [Celexa]), bupropion
incontinence or [Wellbutrin])
bladder outflow
obstruction (B)
SSRIs in patient with May cause or worsen Tricyclic without active metabolites (Nortriptyline
SIADH (B) SIADH5 [Pamelor], desipramine [Norpramin])15
Trazodone (for insomnia)19
Bupropion (Wellbutrin) (for cardiac patient)19
Mirtazapine (Remeron) (for insomnia or weight
loss)19
SSRI in patient on Enhanced SSRI side Avoid combination. If switching from MAOI to
MAOI (C) effects15 another antidepressant, ensure a 14-day washout. If
switching from another antidepressant to an MAOI,
minimum washout is 2 weeks for drug without long
half-life and 5 weeks for drug with long half-life
(e.g., fluoxetine).30
Antihistamines
Antihistamines, anticholinergic Anticholinergic AE, Cetirizine (Zyrtec), fexofenadine (Allegra),
(B): urine retention, loratadine (Claritin), desloratadine
Chlorpheniramine (Chlor- confusion, sedation5 (Clarinex), levocetirizine (Xyzal), low-dose
Trimeton, etc), diphenhydramine19,26
Cyproheptadine (Periactin),
Dexchlorpheniramine
(Polaramine),
Diphenhydramine (Benadryl,
etc), Hydroxyzine (Vistaril,
Atarax),
Promethazine (Phenergan, etc)
Antihypertensives
Alpha-blockers Hypotension, dry mouth, Thiazide, ACE inhibitor, beta-blocker,
(doxazosin [Cardura], incontinence5 calcium channel blocker22
prazosin [Minipress],
terazosin [Hytrin])(B)
Clonidine (Catapres) Orthostatic hypotension, CNS Thiazide, ACE inhibitor, beta-blocker,
(B) AE5 calcium channel blocker22
Ethacrynic acid Hypotension; fluid, electrolyte Furosemide (Lasix), bumetanide (Bumex)
(Edecrin) (B) imbalances5
Guanethidine (B) Orthostatic hypotension, Thiazide, ACE inhibitor, beta-blocker,
depression5 calcium channel blocker22
Methyldopa Bradycardia; depression5 Thiazide, ACE inhibitor, beta-blocker,
(Aldomet) (B) calcium channel blocker22
Nifedipine, short- Hypotension, constipation5 Another calcium channel blocker or long-
acting (Procardia, acting nifedipine
Adalat) (B)

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 3 of 12)

Drug Concern Alternative Treatment

Antihypertensives, cont.
Reserpine >0.25mg Depression, impotence, Thiazide, ACE inhibitor, beta-blocker,
(B, C) sedation, orthostatic calcium channel blocker22
hypotension, extrapyramidal
effects5,15

Thiazide in patient May precipitate gout attack15 ACE inhibitor, beta-blocker, calcium
with gout (C) channel blocker22

Antiplatelet Drugs
Dipyridamole, short- Ineffective for stroke For stroke prevention: low-dose aspirin, clopidogrel
acting (Persantine) prevention & (Plavix), aspirin/dipyridamole (Aggrenox)19
(B); for dementia or dementia; orthostatic
stroke (C) hypotension5,15

Ticlopidine (Ticlid) Not more effective Low dose aspirin, clopidogrel (Plavix),
(B) than aspirin, but more aspirin/dipyridamole (Aggrenox)19
toxic5
Antipsychotics
Mesoridazine CNS AE, seizures, Risperidone (Risperdal)*, haloperidol (Haldol)26
(Serentil) (B), extrapyramidal effects5
Thioridazine *Atypicals associated with increased mortality when
(Mellaril) (B) used to treat behavioral problems in elderly with
dementia31
Chlorpromazine Fall risk15 Haloperidol, with blood pressure monitoring15
(Thorazine) in patient
with history of
postural hypotension
(C)
Clozapine (Clozaril) Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26
in patient with threshold5
seizures (B) *Atypicals associated with increased mortality when
used to treat behavioral problems in elderly with
dementia31
Olanzapine (Zyprexa), Increased appetite, Risperidone (Risperdal)*, haloperidol (Haldol)26
obesity (B) weight gain
*Atypicals associated with increased mortality when
used to treat behavioral problems in elderly with
dementia31
Thiothixene Lower seizure Risperidone (Risperdal)*, haloperidol (Haldol)26
(Navane), in patient threshold5
with seizure disorder *Atypicals associated with increased mortality when
(B) used to treat behavioral problems in elderly with
dementia31

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 4 of 12)

Drug Concern Alternative Treatment

Anxiolytics
Long-acting Dependence, For anxiety: shorter acting benzodiazepines
benzodiazepines (B, depression, prolonged (appropriately dosed) (alprazolam
C): sedation, confusion, [Xanax],lorazepam [Ativan], oxazepam [Serax];
clorazepate falls, fractures, buspirone (Buspar)15,19
(Tranxene, etc), respiratory depression
chlordiazepoxide in COPD, For sleep: nondrug therapy (See our Detail-
(Librium), diazepam incontinence5,15 Document #211015 [U.S.]/#210918 [Canada]);
(Valium), quazepam temazepam (Restoril) 7.5 mg*, zolpidem (Ambien)
(Doral) 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata)
5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone
(Lunesta) 1 mg* for difficulty falling asleep, 2 mg
for difficulty staying asleep15,19,32 *Initial dose

Short-acting Falls5 For anxiety: shorter acting benzodiazepines

benzodiazepines, (appropriately dosed) (alprazolam
daily doses greater [Xanax],lorazepam [Ativan], oxazepam [Serax];
than (B): buspirone (Buspar)15,19
alprazolam (Xanax)
2 mg, lorazepam For sleep: nondrug therapy (See our Detail-
(Ativan) 3 mg, Document #211015 [U.S.]/#210918 [Canada]);
oxazepam (Serax) temazepam (Restoril) 7.5 mg*, zolpidem (Ambien)
60 mg 5 mg*, Ambien CR 6.25 mg, zaleplon (Sonata)
Meprobamate Dependence, sedation5 5 mg*, ramelteon (Rozerem) 8 mg, eszopiclone
(Miltown) (B) (Lunesta) 1 mg* for difficulty falling asleep, 2 mg
for difficulty staying asleep15,19,32
*Initial dose

Cardiac Drugs
Amiodarone QT prolongation, Depends on type of arrhythmia; flecainide
(Cordarone, torsades de pointes, (Tambocor), sotalol (Betapace), beta-blocker,
Pacerone) (B) lack of efficacy in dofetilide (Tikosyn)27
elderly5
Beta-blockers in Worsening disease15 Alternate antihypertensive; nitrate or calcium
patient with asthma, channel blocker15
COPD, or Raynaud’s
disease (C)15
Calcium channel Worsening heart Diuretic, ACE inhibitor, appropriately titrated beta-
blocker in patient failure; blocker15
with systolic heart constipation5,15
failure (C) or chronic
constipation (B, C)
Digoxin (Lanoxin) Toxicity due to Dose reduction, with monitoring19
doses >0.125 mg/d reduced renal
except for atrial clearance5
arrhythmias (B)
Disopyramide Negative inotrope; Depends on type of arrhythmia; for atrial fibrillation,
(Norpace) (B, C) anticholinergic; digoxin, quinidine, procainamide, sotalol,
sudden death5,15 flecainide15,27
More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 5 of 12)

Drug Concern Alternative Treatment

Diabetes Drugs
Chlorpropamide Prolonged Glimepiride (Amaryl), glipizide (Glucotrol)19
(Diabinese) (B) hypoglycemia;
SIADH5 Avoid glyburide (Micronase, etc) and Glucotrol XL
due to hypoglycemia risk.33
Gastrointestinal Drugs
Antispasmodics, long- Anticholinergic AE; Diet therapy (fiber, fluids)15,23
term use (B); for IBS worsened cognition & Constipation: Psyllium, polyethylene glycol
in dementia patient behavioral problems (Miralax, etc), stool softener (e.g., docusate),
(C): belladonna in dementia; urinary lubiprostone (Amitiza)19,23
alkaloids (Donnatal), retention or Diarrhea: loperamide (Imodium, etc), aluminum
Clindinium (in incontinence; hydroxide (e.g., AlternaGel), cholestyramine
Librax), questionable (Questran, etc)15,19
Dicyclomine (Bentyl), efficacy5,15
Hyoscyamine (Levsin,
etc),
Propantheline (Pro-
Banthine)
Cimetidine (Tagamet) Confusion, other CNS Alternative H2 blocker (ranitidine [Zantac],
(B); in patient taking AE, interaction with famotidine [Pepcid], nizatidine [Axid])15
warfarin (C) warfarin5,15
Diphenoxylate Dependence, sedation, Change in diet; loperamide (Imodium, etc)15
(Lomotil, etc), long- cognitive
term use (C) impairment15
Metoclopramide Antidopaminergic Nausea: ondansetron (Zofran), granisetron (Kytril),
(Reglan) in patient effect5 dolasetron (Anzemet)19
with Parkinson’s
disease (B)
Mineral oil (B) Aspiration5 Diet therapy (fiber, fluids)15,23
Constipation: Psyllium, polyethylene glycol
(Miralax, etc), stool softener (e.g., docusate),
lubiprostone (Amitiza)19,23
Stimulant laxatives May worsen bowel Diet therapy (fiber, fluids)15,23
(e.g., bisacodyl function5 Constipation: Psyllium, polyethylene glycol
[Dulcolax, etc]), long- (Miralax, etc), stool softener (e.g., docusate),
term use, except with lubiprostone (Amitiza)19,23
opiates (B)
Trimethobenzamide Poor efficacy; Ondansetron (Zofran), granisetron (Kytril),
(Tigan) (B) extrapyramidal AE5 dolasetron (Anzemet)19

Prochlorperazine (Compazine, etc), metoclopramide

(Reglan) (avoid long-term use, and avoid in
Parkinson’s disease)26
Hormones
Estrogens (oral) Breast, endometrial Hot flashes: nondrug therapy (cool environment,
(Premarin, etc) (B) cancer; not layered clothing, cool compress), SSRIs, gabapentin,
cardioprotective5 venlafaxine24
Bone density: calcium, vitamin D, bisphosphonates,
raloxifene (Evista)
More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 6 of 12)

Drug Concern Alternative Treatment

Hormones, cont.
Methyltestosterone Prostatic hyperplasia, None
(Android, etc) (B) cardiac AE5
Thyroid, desiccated (B) Cardiac AE5 Levothyroxine (Levoxyl, Synthroid, etc)
Hypnotics
Barbiturates, except Dependence; higher Nondrug therapy (See our Detail-Document #211015
phenobarbital for risk of AE (falls, [U.S.]/#210918 [Canada]); temazepam (Restoril)
seizures (B); long- fractures, confusion, 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR
term for insomnia (C) cognitive impairment) 6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon
than other (Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for
hypnotics5,15 difficulty falling asleep, 2 mg for difficulty staying
asleep 15,19,32 *Initial dose
Long-acting See entry under See entry under Anxiolytics.
benzodiazepines (B, Anxiolytics.
C) (See entry under
Anxiolytics)
Diphenhydramine Confusion, sedation, Nondrug therapy (See our Detail-Document #211015
(Benadryl, etc) (B) anticholinergic [U.S.]/#210918 [Canada]); temazepam (Restoril)
effects5 7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR
6.25 mg, zaleplon (Sonata) 5 mg,* ramelteon
(Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for
difficulty falling asleep, 2 mg for difficulty staying
asleep 15,19,32 *Initial dose
Flurazepam Sedation, falls, Nondrug therapy (See our Detail-Document #211015
(Dalmane) (B) accumulation5 [U.S.]/#210918 [Canada]); temazepam (Restoril)
7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR
6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon
(Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for
difficulty falling asleep, 2 mg for difficulty staying
asleep 15,19,32 *Initial dose
Triazolam (Halcion) Cognitive/behavioral Nondrug therapy (See our Detail-Document #211015
(C) disturbances15 [U.S.]/#210918 [Canada]); temazepam (Restoril)
7.5 mg*, zolpidem (Ambien) 5 mg*, Ambien CR
6.25 mg, zaleplon (Sonata) 5 mg*, ramelteon
(Rozerem) 8 mg, eszopiclone (Lunesta) 1 mg* for
difficulty falling asleep, 2 mg for difficulty staying
asleep15,19,32 *Initial dose
Muscle Relaxants
Muscle relaxants (B): Anticholinergic Physiotherapy; correct seating & footwear15,19
Carisoprodol (Soma), effects, sedation, For spasticity, use antispasmodics (e.g, baclofen,
Chlorzoxazone, cognitive impairment, tizanidine [Zanaflex]) or nerve blocks; treat problems
Cyclobenzaprine weakness, urine that may worsen condition19
(Flexeril) (C), retention;
Metaxalone questionable efficacy
(Skelaxin), at lower doses5
Methocarbamol
(Robaxin) (C),
Orphenadrine
(Norflex)
More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 7 of 12)

Drug Concern Alternative Treatment

NSAIDs
Aspirin for pain in Bleeding15 Acetaminophen15
patient on warfarin
(C)
NSAIDs, longer half- GI bleeding, renal Ibuprofen (Motrin, Advil, etc), acetaminophen,
life, full dose, long failure, hypertension, topical agents (e.g., lidocaine patch [Lidoderm],
duration (B): heart failure5 capsaicin [Zostrix, etc]), choline magnesium
Naproxen (Aleve, trisalicylate (Trilisate); start with lowest dose and
Naprosyn, etc), increase slowly19
Oxaprozin (Daypro), *See Detail-Document #221003, “Cardiovascular
Piroxicam (Feldene) Risks of NSAIDs and COX-2 inhibitors”
(C)
Indomethacin CNS AE, GI effects, Ibuprofen (Motrin, Advil, etc), acetaminophen,
(Indocin) (B); long- fluid retention5,15 topical agents (e.g., lidocaine patch [Lidoderm],
term use (C) capsaicin [Zostrix, etc]), choline magnesium
trisalicylate (Trilisate); start with lowest dose and
increase slowly19

Gout, chronic treatment: allopurinol15

Gout, acute: alternative NSAID, short-term
indomethacin15,19
NSAID, long-term for GI bleeding, renal Acetaminophen,15 capsaicin [Zostrix, etc]
osteoarthritis (C) failure, hypertension,
heart failure15
NSAID for Bleeding risk15 Acetaminophen; NSAID with gastroprotective agent
osteoarthritis patient (e.g., proton pump inhibitor; misoprostol
receiving warfarin (C) [Cytotec]),15 capsaicin [Zostrix, etc]
NSAID in patient New ulcers; bleeding Acetaminophen; NSAID with gastroprotective agent
with history of peptic risk5,15 (e.g., proton pump inhibitor; misoprostol [Cytotec])15
ulcer (B, C)
NSAID, long-term in Worsening Acetaminophen15
patient with hypertension15
hypertension (C)
Respiratory Drugs
Corticosteroids, oral, Worsening glucose Inhaled corticosteroid and bronchodilator15
long-term for COPD, control15
patient with diabetes
(C)
Pseudoephedrine in Increased blood Saline nasal spray, nasal steroid25
patient with pressure; incontinence5
hypertension or
bladder outflow
obstruction(B)
Theophylline, patient May contribute to Inhaled corticosteroid and bronchodilator
with insomnia (B) insomnia5

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 8 of 12)

Drug Concern Alternative Treatment

Stimulant Drugs
Amphetamines, Dependence, For weight control: Diet and lifestyle modification;
anorexics (B) hypertension,
myocardial ischemia, For depression:
CNS stimulation Tricyclic without active metabolites (Nortriptyline
(agitation, insomnia)5 [Pamelor], desipramine [Norpramin])15
Trazodone19
SSRI15
Bupropion (Wellbutrin) (for cardiac patient)19
Mirtazapine (Remeron) (for insomnia or anorexia)19

Any stimulant in Appetite suppression5 For depression:

patient with Tricyclic without active metabolites (Nortriptyline
anorexia/malnutrition [Pamelor], desipramine [Norpramin])15
(B) Trazodone (for insomnia)19
SSRI15
Mirtazapine (Remeron) (for insomnia or anorexia)19
Methylphenidate for CNS stimulation, Tricyclic without active metabolites (Nortriptyline
depression (C) agitation, seizures15 [Pamelor], desipramine [Norpramin])15
Trazodone19
SSRI15
Bupropion (Wellbutrin) (for cardiac patient)19
Mirtazapine (Remeron) (for insomnia or anorexia)19

Urinary Drugs
Nitrofurantoin Nephrotoxicity5 Depends on infection
(Macrodantin, etc)
(B)
Oxybutyninb Urine retention, For urge incontinence: Behavioral therapy (e.g.,
(Ditropan), in patient confusion, urge suppression, bladder retraining)28
with bladder outflow hallucinations,
obstruction (B) sedation5,34 For BPH: 5-alpha-reductase inhibitor (finasteride
[Proscar], dutasteride [Avodart])
Tolterodineb (Detrol) Urinary retention, For urge incontinence: Behavioral therapy (e.g.,
in patient with confusion, urge suppression, bladder retraining)28
bladder outflow hallucinations,
obstruction (B) sedation5,34 For BPH: 5-alpha-reductase inhibitor (finasteride
[Proscar], dutasteride [Avodart])
Miscellaneous
Anticholinergic (e.g., Agitation, delirium, Decrease antipsychotic dose or discontinue;15
trihexyphenidyl) to cognitive impairment15 atypical antipsychotic
manage antipsychotic
extrapyramidal effects
(C)
Ergot mesylates Unproven efficacy5 Donepezil (Aricept), rivastigmine (Exelon), etc.
(Hydergine) (B)

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 9 of 12)

Drug Concern Alternative Treatment

Miscellaneous, cont.
Ferrous sulfate Constipation, without None
>325 mg per day (B) increased iron
absorption5
Isoxsuprine Lack of efficacy5 Exercise (for peripheral arterial disease)
(Vasodilan) (B)
Sodium containing Worsening heart Various, depending on drug & indication
drugs in heart failure failure5
(B)

ACE – angiotensin converting enzyme, AE – adverse effects, APAP – acetaminophen, B – Beers list
drug, BPH – benign prostatic hyperplasia, C – Canadian list drug, CNS – central nervous system, COX –
cyclooxygenase, GI – gastrointestinal, IBS – irritable bowel syndrome, MAOI – monoamine oxidase
inhibitor, NSAID – nonsteroidal antiinflammatory drug, SIADH – syndrome of inappropriate diuretic
hormone secretion, SSRI – selective serotonin reuptake inhibitor

a. Meperidine: while not mentioned specifically in Beers/Canadian listings, meperidine should be used
cautiously in all elderly patients due to increased risk of seizures with renal impairment.26
b. Since the Beers list was last published, newer agents for overactive bladder (OAB) have been
developed. All OAB drugs should be avoided in patients with bladder outlet obstruction. For a listing of
these agents see Detail-Documents #210209 (U.S.) and #220616 (Canada).

Users of this document are cautioned to use their own professional judgment and consult any other necessary or
appropriate sources prior to making clinical judgments based on the content of this document. Our editors have
researched the information with input from experts, government agencies, and national organizations. Information
and Internet links in this article were current as of the date of publication.

More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208
Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 10 of 12)

Preventing Adverse Drug Events in the Elderly: the Role of the Beers List
Another Round of Beers healthcare outcomes. Most have been
In 1991, Dr. Mark Beers published a methods retrospective cohort studies. A systematic review
paper describing the development of a consensus of these studies revealed an association between
list of medicines considered to be inappropriate use of Beers list medications and hospitalization
for long-term care facility residents.4 The Beers in community-dwelling elderly. However, there
criteria or “Beers list” is now in its third was no association with mortality or other
permutation.5,6 Some medications are of concern healthcare use. Evidence for an impact on quality
in all elderly patients, but others are of concern of life or cost was inconclusive. In nursing
only in certain situations (e.g., bupropion in homes, there was no evidence of association with
patient with seizure disorder).5 mortality. Association with hospitalization was
The Beers list was originally constructed inconclusive. For hospitalized elderly, evidence
specifically for long-term care, but it has been was insufficient to make any associations.14
revised for use in hospital, outpatient, managed Clearly, prospective studies are needed to see if
care, and other settings. The Beers list has been these criteria make a difference in patient
used to evaluate clinical drug use, to study the outcomes.
effect of intervention on reducing adverse drug
effects in older patients, and to analyze The Bottom Line
computerized administrative data sets.7-13 Adverse drug effects may go unrecognized in
The Beers list is increasingly being used as a the elderly because they are nonspecific (e.g.,
quality measure. The Centers for Medicare & confusion, lethargy, falls). Many of the drugs on
Medicaid Services (CMS) has adopted the Beers the Beers and Canadian lists are included because
list to regulate long-term care facilities. In 2006, of sedative and anticholinergic adverse effects.
the Health Plan Employer Data and Information CNS depressants can cause sedation and cognitive
Set (HEDIS) used Beers list to create a list of impairment in the elderly, resulting in difficulty
medications used to assess quality of managed with self-care and falls. Anticholinergics (e.g.,
care plans. They plan to expand this in 2007.14 diphenhydramine, amitriptyline) cause cognitive
There is also a “Canadian criteria” list. These problems by adding to the age-related decrease in
criteria for inappropriate prescribing practices in cholinergic transmission.2 Anticholinergics can
elderly people were developed by a national also cause constipation and urinary retention.2,18
consensus panel in Canada.15 The Canadian The chart above lists medicines that should be
criteria give more consideration to indication, avoided in elderly patients based on the Beers list
comorbidities, and duration of therapy than the and Canadian criteria. Drugs on this list are not
Beers list. On the Beers list many drugs are contraindicated, but should be used cautiously,
considered potentially inappropriate regardless of with consideration of alternatives. For example,
diagnosis or indication. For example, low-dose amitriptyline (Elavil) may be helpful for
indomethacin is inappropriate per Beers, but per peripheral neuropathy.13 And although using
the Canadian criteria is okay short-term for acute propoxyphene (Darvon) is not “wrong,” better
gout.5,15 analgesics are available. Make decisions based on
Valid concerns about using a “hit list” the whole patient, taking into account their
approach to inappropriate prescribing have been medical, social, and psychological conditions,
raised. Concerns include paucity of evidence, lack prognosis, and quality of life [Evidence level C;
of allowance for exceptions (e.g., palliative care), consensus].16
and misuse resulting in patient harm.16 Also, The Beers list is only one tool for reducing
research that provides a complete picture of adverse drug events in the elderly. Drugs not on
diagnoses, drug dose and duration, as well as the Beers list can also cause trouble in the
potential drug interactions and adverse drug geriatric population (e.g., glyburide [Micronase]-
effects, is lacking.17,18 induced hypoglycemia).20 Consider
Several studies have examined the association recommendations from pharmacists and
between use of drugs on the Beers list and computerized alerts, periodic medication review,
More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 11 of 12)

and patient education [Evidence level B; 2. Kim J, Cooper A. Geriatric drug use. In:
systematic review].21 These methods have been Koda-Kimble MA, Young LY, Kradjan WA,
Guglielma BJ, eds. Applied therapeutics: the
shown to improve prescribing in the elderly; clinical use of drugs. 8 ed.
th
Lippincott
however, keep in mind they have not been shown Williams & Wilkins; 2005.
to decrease adverse events.21 See our Detail- 3. Goulding MR. Inappropriate medication
Document #221211, “Emergency Department prescribing for elderly ambulatory care
patients. Arch Intern Med 2004;164:305-12.
Visits Due to Adverse Drug Events,” and Detail- 4. Beers MH, Ouslander JG, Rollingher I, et al.
Document #190822, “Drugs to Avoid in Patients Explicit criteria for determining inappropriate
with Dementia” for more tips. medication use in nursing home residents.
UCLA Division of Geriatric Medicine. Arch
Intern Med 1991;151:1825-32.
5. Fick DM, Cooper JW, Wade WE, et al.
Users of this document are cautioned to use their own Updating the Beers criteria for potentially
professional judgment and consult any other necessary inappropriate medication use in older adults:
or appropriate sources prior to making clinical results of a US consensus panel of experts.
judgments based on the content of this document. Our Arch Intern Med 2003;163:2716-24.
editors have researched the information with input 6. Beers MH. Explicit criteria for determining
from experts, government agencies, and national potentially inappropriate medication use by the
elderly. An update. Arch Intern Med
organizations. Information and Internet links in this
1997;157:1531-6.
article were current as of the date of publication. 7. Fick DM, Waller JL, Maclean JR, et al.
Potentially inappropriate medication use in a
Medicare managed care population:
Levels of Evidence association with Yeser costs and utilization. J
In accordance with the trend towards Evidence-Based Managed Care Pharm 2001;7:407-413.
Medicine, we are citing the LEVEL OF EVIDENCE 8. Onder G, Landi F, Cesari M, et al.
Inappropriate medication use among
for the statements we publish.
hospitalized older adults in Italy: results from
Level Definition the Italian Group of Pharmacoepidemiology in
A High-quality randomized controlled trial (RCT) the Elderly. Eur J Clin Pharmacol
High-quality meta-analysis (quantitative 2003;59:157-62.
systematic review) 9. Hanlon JT, Fillenbaum GG, Kuchibhatla M, et
B Nonrandomized clinical trial al. Impact of inappropriate drug use on
Nonquantitative systematic review mortality and functional status in
Lower quality RCT representative community dwelling elders.
Clinical cohort study Med Care 2002;40:166-76.
Case-control study 10. Mort JR, Aparasu RR. Prescribing potentially
Historical control inappropriate psychotropic medications to the
Epidemiologic study ambulatory elderly. Arch Intern Med
C Consensus 2000;160:2825-31.
Expert opinion 11. Doucet J, Chassagne P, Trivalle C, et al.
D Anecdotal evidence Drug-drug interactions related to hospital
In vitro or animal study admissions in older adults: a prospective study
Adapted from Siwek J, et al. How to write an evidence-based of 1000 patients. J Am Geriatr Soc 1996; 44:
clinical review article. Am Fam Physician 2002;65:251-8. 944-8.
12. Golden AG, Preston RA, Barnett SD, et al.
Inappropriate medication prescribing in
homebound older adults. J Am Geriatr Soc
Project Leader in preparation of this Detail- 1999;47:948-53.
Document: Gayle Nicholas Scott, Pharm.D., 13. Zhan C, Sangl J, Bierman AS, et al.
BCPS. ELS, Assistant Editor, Melanie Cupp, Potentially inappropriate medication use in the
Pharm.D., BCPS community -dwelling elderly: findings from the
1996 Medical Expenditure Panel Survey.
JAMA 2001;286:2823-9.
14. Jano E, Aparasu RR. Healthcare outcomes
associated with Beers’ criteria: a systematic
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More. . .
Copyright © 2007 by Therapeutic Research Center
Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.pharmacistsletter.com ~ www.prescribersletter.com
 (Detail-Document #230907: Page 12 of 12)

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Cite this Detail-Document as follows: Potentially harmful drugs in the elderly: Beers list and more.
Pharmacist’s Letter/Prescriber’s Letter 2007;23(9):230907.

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