BEERS Criteria - CNS Flashcards
Which antidepressants are in the BEERS Criteria, their recommendation and why?
Antidepresants with strong anticholinergic effects
* TCAs: Amitriptyline, Amoxapine, Clomipramine, Desipramine, Doxepin >6 mg/day, Imipramine, Nortriptyline
* SSRI: Paroxetine
Recommendation: Avoid
Reasons: sedating, orthostatic hypotension
Which AntiParkinsonians drugs are in the BEERS Criteria, their recommendation and why?
AntiParkinsonians drugs with strong anticholinergic effect
* Benztropine (oral), Trihexyphenidyl
Recommendation: avoid, not recommended for tx of EPSEs due to antipsychotics
Reason: More effective alternatives available (is last line of therapy!)
Which antipsychotic drugs are in the BEERS Criteria, their recommendation and why?
All 1st and 2nd Gen Antipsychotics
* Aripiprazole, Haloperidol, Olanzapine, Quetiapine, Risperidone, Others
Recommendation: avoid except in schizophrenia, bipolar disorder, Parkinson disease psychosis, MDD or short term antiemetic
Reasons:
* ↑ risk of stroke and cognitive decline and mortality in (dementia) patients
* Avoid for behavioural problems of dementia/delirium unless non-pharmacologic options have failed or patient is threatening substantial harm to self/others
Why are barbituates in the BEERS Criteria and what is the recommendation?
Barbituates: butalbital, phenobarbital, primidone
Recommendation: avoid
Reason: High rate of physical dependence, tolerance to sleep benefits, greater risk of overdoses
Why are benzodiazepines in the BEERS Criteria and what is the recommendation?
Benzodiazepines: Alprazolam, Clonazepam, Diazepam, Lorazepam, Midazolam
Recommendation: avoid
Reason:
* Risk of misuse, abuse, addiction
* Concomitant use with opioids can result in profound sedation, respiratory depression, coma, death
* ↑ sensitivity to benzodiazepines and ↓ metabolism of long-acting agents
* ↑ risk of cognitive impairment, delirium, falls, fractures
May be appropriate in seizure disorders, REM sleep behaviour disorder, benzodiazepine withdrawal, severe generalised anxiety disorder, periprocedural anaesthesia
Why are Z-hypnotics in the BEERS Criteria and what is the recommendation?
Z-hypnotics: Eszopiclone, Zaleplon, Zolpidem
Recommendation: avoid
Reason: Risk of cognitive impairment, delirium, falls, fracture, hospitalisations
Which drugs have the potential of inducing/ worsening delirium?
Anticholinergics, Benzodiazepines, H2-receptor antagonists, Z-hypnotics → Avoid in high risk of delirium
Others mentioned in BEERS Criteria: corticosteroids, opioids
Why are corticosteroids in the BEERS Criteria and what is the recommendation?
Recommendation: avoid, use lowest possible dose for the shortest duration
Reason:
* ↑ cortisols released in the body → delirium
* Monitor for delirium
Why are opioids in the BEERS Criteria and what is the recommendation?
Recommendation: minimise use, use pain assessment tools and non-drug approaches
Reason:
* Associated with delirium
* Esp pethidine in poor renal function
Which drugs should be avoided in dementia / cognitive impairment?
Anticholinergics, Benzodiazepines, Z-hypnotics Antipsychotics
Avoid for behavioural problems/delirium
Which drugs should be avoided in patients with history of falls/ fractures, and why?
Anticholinergics, Antidepressants (SSRI, SNRI, TCAs), Antiepileptics, Antipsychotics, Benzodiazepines, Z-hypnotics
Recommendation: avoid unless no other alternatives
Reason: May cause ataxia, impaired psychomotor function, syncope, additional falls
Implement other measures to reduce fall risk
Which 2 drugs should be avoided in Parkinson’s Disease, and why?
Antiemetics (Metoclopramide, Prochlorperazine, Promethazine), Antipsychotics (except clozapine, quetiapine, pimavanserin)
Recommendation: avoid (because antidopaminergic agents)
Reason: Potential to worsen PD symptoms
Which CNS drugs listed in the BEERS Criteria require lower doses in reduced kidney function? Include recommendations and reasons why.
Duloxetine
* Avoid when CrCl < 30 mL/min
* Increased GI adverse effects (e.g. nausea, diarrhoea)
Levetiracetam
* Dose reduction when CrCl ≤ 80 mL/min
* CNS adverse effects
List the risk rationale and recommendations for these 5 DDIs:
* Opioids + Benzodiazepines
* Anticholinergics + Anticholinergics
* Combination of ≥3 selective CNS drugs
* Lithium + ACEis/ ARBs/ ARNIs/ Loop diuretics
* Phenytoin + Bactrim
Refer to formularies table
List anticholinergic CNS drugs
- Antidepressants: amitriptyline, amoxapine, clomipramine, desipramine, doxepin (> 6 mg/day), imipramine, nortriptyline, paroxetine
- Antiparkinsonians: benztropine, trihexyphenidyl
- Antipsychotics: chlorpromazine, clozapine, olanzapine, perphenazine
AD drugs can cause ________ in syncope patients
Bradycardia
AD drugs: Donepezil, Rivastigmine, Galantamine (AChEIs)
