Beers Criteria - Potentially Inappropriate Medications

Question 1

1st generation antihistamines

Answer 1

Highly anticholinergic - increased risk of falls, delirium and dementia

AVOID

Question 2

ASA for primary prevention of CV disease

Answer 2

Risk of major bleeding - lack of net benefit and potential for net harm when initiated for primary prevention

AVOID for primary prevention of CV disease

Question 3

Warfarin + Rivaroxaban

For VTE, Nonvalvular AFib

Answer 3

Higher risks of major bleeding compared to other DOAC’s

Avoid in favour of safer anticoag alternatives

Rivarox could be considered if OD dosing is necessary for adherence

Question 4

Non-selective peripheral alpha-1 blockers: Doxazosin, prazosin, terazosin

For hypertension

Answer 4

High risk of orthostatic hypotension

Avoid use as antihypertensive due to better agents

Question 5

IR nifedipine

Answer 5

Potential for hypotension and risk of precipitating myocardial ischemia

AVOID

Question 6

Amiodarone

Answer 6

Greater toxicities than other antiarrythmics used in AFib

Avoid as 1st line tx for AF unless pt. has heart failure or left ventricular hypertrophy

Question 7

Dronedarone

Answer 7

Worsen outcomes in people with permanent AF, decompensated HF, or HFrEF

Avoid in these individuals

Question 8

Digoxin

For 1st line tx of AF or HF

Answer 8

Should not be used 1st line because there are safer + more effective alternatives for both conditions. Decreased renal clearance also increases risk of toxic effects

Avoid as 1st line and use low doses if required

Question 9

Antidepressants with strong anticholinergic activity

TCA’s, Paroxetine

Answer 9

Highly anticholinergic, sedating, risk of orthostatic hypotension

Avoid

Question 10

Antiparkinsonian agents with strong anticholinergic activity

Benztropine, trihexyphenidyl

Answer 10

More effective and safer agents available for tx of Parkinson’s

Avoid

Question 11

1st and 2nd gen antipsychotics

Answer 11

Increased risk of stroke
Greater rate of cognitive decline + mortality in dementia patients

Avoid except in schizophrenia, bipolar, Parkinson psychosis, MDD

Avoid for behavioural problems of dementia unless last option, or harm, Use lowest dose if necessary

Question 12

Barbiturates

Ex: Phenobarbital

Answer 12

High rate of physical dependence, intolerance to sleep benefit, greater risk of overdose

Avoid

Question 13

Benzodiazpines and Z-Drugs

Answer 13

Increased sensitivity and decreased metabolism of long-acting agents
Clinically significant physical dependence
Increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes

Avoid

May be appropriate for seizure, withdrawal syndromes, severe anxiety, anesthesia

Question 14

Androgens

Testosterone

Answer 14

Potential for cardiac problems
Potential risk in men with prostate cancer

Avoid unless confirmed hypogonadism with clinical sx’s

Question 15

Estrogens

oral; vaginal is safer

Answer 15

Evidence of carcinogenic potential
Lack of cardioprotective effect + cognitive protection in older women (60+, HRT linked to higher risk of CV disease, stroke, clots, dementia)

Do not initiate systemic estrogen - consider deprescribing for older

Question 16

Sliding scale insulin

Insulin regimens with only short/rapid acting

Answer 16

Higher risk of hypoglycemia without improvement in hyperglycemia management, regardless of care setting.

Avoid, should be used with basal/long-acting insulin

Question 17

Sulfonylureas

Answer 17

Higher risk of CV events, mortality, and hypoglycemia

Question 18

PPI’s

Answer 18

Increased risk of C.Diff, pneumonia, GI malignancy, bone loss, fracture

Avoid scheduled use for 8+ weeks, unless high-risk patient, or required for maintenance tx

Question 19

Metoclopramide

Answer 19

Can cause EPS, including tardive dyskinesia - risk may be greater in frail older adults with prolonged exposure

Avoid unless for gastroparesis

Question 20

GI antispasmodics with strong anticholinergic activity

Answer 20

Highly anticholinergic

Avoid

Question 21

Desmopressin

Answer 21

High risk of hyponatremia, safer alternative treatments for nocturia

Avoid for tx of nocturia or nocturnal polyuria

Question 22

Non-COX-2 selective NSAID (oral)

Answer 22

Increased risk of GI bleeding or peptic ulcer disease in high-risk groups. PPI reduces risk but does not eliminate risk

Avoid chronic use unless other alternatives are not effective and patient can take PPI or misoprostol
Try to avoid with corticosteroid, anticoag, or antiplatelet agents

Question 23

Skeletal muscle relaxants

Answer 23

Anticholinergic AE’s, sedation, increased risk of fractures

Avoid