Beers Criteria

Question 1

What are the Classes/Medications that are in the beers list?

Answer 1

Anticholinergic
Dicyclomine
Nitrofurantoin
Peripheral alpha-1 blockers
Clinidine
Dig
Nifedipine (IR)
Amiodarone
Antidepressants
Antipsychotics
Benzos
Non-benzo benzo receptor agonist hypontics
Estrogen w/ or w/o progestins
Insulin, sliding scale
Megestrol
Sulfonylureas, long duration
PPIs
Meperidine
Non-cyclooxygenase-selective NSAIDs
Indomethacin/ketorolax
Skeletal muscle relaxants

Question 2

What is the rationale for anticholinergics being on the beers list?

Answer 2

Clearance reduced with advanced age, risk of confusion, constipation, etc.
Tolerance develops when used as hypnotic

Question 3

What is the rationale for dicyclomine being on the beers list?

Answer 3

Highly anticholinergic

Question 4

What is the rationale for nitrofurantoin being on the beers list?

Answer 4

Risk pulmonary toxicity, hepatitis, peripheral neuropathy especially with long term use. Safer alternatives available

Question 5

What is the rationale for peripheral alpha-1 blockers being on the beers list?

Answer 5

High risk of orthostatic hypotension, not recommended as routine treatment for HTN; alternative agents have superior risk-benefit profile

Question 6

What is the rationale for clonidine being on the beers list?

Answer 6

High risk of ADR CNS effects

May cause bradycardia and orthostatic hypotension

Question 7

What is the rationale for digoxin being on the beers list?

Answer 7

May be associated with increased mortality
Questionable effects of risk on hospitalization in those with HF, may be associated with increased mortality. Higher doses not associated with more benefit - may increase toxicity
Decreased renal clearance = toxicity

Question 8

What is the rationale for nifedipine being on the beers list?

Answer 8

Risk for hypotension and myocardial ischemia

Question 9

What is the rationale for antidepressants being on the beers list?

Answer 9

Highly anticholinergic, sedation, risk of orthostatic hypotension

Question 10

What is the rationale for amiodarone being on the beers list?

Answer 10

Effective, but toxicities are higher than for other antiarrhythmics

Question 11

What is the rationale for antipsychotics being on the beers list?

Answer 11

Increased risk of stroke and greater cognitive decline and mortality in those with dementia

Question 12

What is the rationale for benzos being on the beers list?

Answer 12

Increased sensitivity, decreased metabolism of long-acting agents; in general all BZDs increase risk of cognitive impairment, delirium, falls, fractures, and MVA in older adults
May be appropriate for seizure disorders, rapid eye movement sleep disorders, BZD, or EtOH withdrawal, severe GAD, and periprocedurally

Question 13

What is the rationale for non-benzo benzo being on the beers list?

Answer 13

Similar risk to benzos

Minimal improvement in sleep latency and duration

Question 14

What are non-benzo benzos?

Answer 14

Ambien
Lunesta
Zaleplon

Question 15

What is the rationale for estrogen w/ or w/o progestin being on the beers list?

Answer 15

carcinogenic (breast, endometrial), lack of cardiac/cognitive protection in older women
Vaginal estrogens are for vaginal dryness are safe and effective

Question 16

What is the rationale for sliding scale insulin being on the beers list?

Answer 16

High risk of hypoglycemia w/o improvement in hyperglycemia management regardless of care setting

Question 17

What is the rationale for megestrol being on the beers list?

Answer 17

Minimal effect on weight, increased risk of thrombotic events and possibly death

Question 18

What is the rationale for sulfonylureas being on the beers list?

Answer 18

Hypoglycemia

Question 19

What is the rationale for PPIs being on the beers list?

Answer 19

Risk of C diff infection and bone loss/fractures

Question 20

What is the rationale for meperidine being on the beers list?

Answer 20

Not effective in doses commonly used, may have higher neurotoxicity risk
Safer alternatives available

Question 21

What is the rationale for non-COX-selective NSAIDs being on the beers list?

Answer 21

Increased risk of GI bleed or PUD in those aged > 75 years or taking corticosteroids, anticoagulants, or antiplatelet agents
Use of PPI or misoprostol reduces risk
Upper GI ulcers, bleeding, or perforation
Risk increases with duration of use

Question 22

What is the rationale for Indomethacin/ketoralac being on the beers list?

Answer 22

More likely than other NSAIDs to have CNS effects

Higher risk of bleeding and AKI in older adults

Question 23

What is the rationale for skeletal muscle relaxant being on the beers list?

Answer 23

Most poorly tolerated d/t anticholinergic ADRs, sedation, increased risk of fractures
Effectiveness at dosages tolerated by older adults questionable

Question 24

Which of the beers list medications are recommended to be avoided regardless?

Answer 24

Anticholinergics
Dicyclomine
Antidepressants
Benzos
Nonbenzo benzo
Insulin
Sulfonylurea
Indomethacin/ketoralac
Skeletal muscle relaxant

Question 25

When should elderly avoid nitrofurantoin?

Answer 25

CrCl < 30

Question 26

When should elderly avoid peripheral alpha-1 blockers

Answer 26

As hypertensive

Question 27

When should elderly avoid clonidine?

Answer 27

Routine treatment for HTN

Question 28

When should elderly avoid dig?

Answer 28

1st line for AF 1st line for HF If used, avoid doses > 0.125 mg/d

Question 29

When can amiodarone be used in elderly?

Answer 29

as 1st line for those with AF and HF or LVH if rhythm control is preferred over rate control

Question 30

When should elderly avoid antipsychotics?

Answer 30

For behavioral problems of dementia or delirium unless non-pharmacologic options have failed or are not possible AND the older adult is threatening substantial harm to self or others For schizophrenia, bipolar disorder, short term use as an antiemetic during chemotherapy is reasonable

Question 31

When should elderly avoid Estrogen w/ or w/o progestins

Answer 31

Oral and topical patch | Vaginal creams and tablets acceptable to use low dose

Question 32

When should elderly avoid PPIs?

Answer 32

Avoid scheduled use for > 8 weeks unless high risk patient (oral corticosteroids/chronic NSAID use), erosive esophagitis, Barrett's esophagus, pathological hypersecretory condition, or demonstrated need for maintenance treatment

Question 33

When should elderly avoid meperidine?

Answer 33

Generally but especially those with CKD

Question 34

When should elderly avoid Non-COX-selective NSAIDs?

Answer 34

Avoid chronic use, unless other alternatives are not effective and patient can take gastroprotective agent (PPI or misoprostol)