1. Robyn Bryson, PharmD Kerri Hagedorn, PharmD, BCPS
Beers Criteria
Robyn Bryson, PharmD
Kerri Hagedorn, PharmD, BCPS

2. Beers Criteria Created by Dr. Mark Beers in 1991
Identified medications that could be considered inappropriate in long-term care facility patients 65 years and older
Updated in 1997, 2003, and 2012
Current list geared toward providers caring for the elderly inpatient or outpatient
Upgrade panel used expertise in geriatric medicine, nursing, pharmacy practice, research, and quality measures along with reps from CMS, NCQA, and PQA
NCQA = national committee for quality assurance
PQA = pharmacy quality alliance

3. Beers Criteria, cont
Main objective is for the provider to review this list when considering initiating medications and consider alternatives if available
Centers for Medicare and Medicaid Services are using these recommendations in assessing the quality of care rendered to elderly patients
Pharmacists participate in Medication Therapy Management Services

4. Beers Criteria 2012 Update Includes 53 medications/medication classes
Inappropriate medications and medications to avoid in elderly
Potentially inappropriate medications/classes to avoid in elderly with certain diseases and/or syndromes that could be exacerbated by the medication
Medications to be used with caution in elderly patients

5. Beers Criteria 2012 Update, cont
Update for medications to avoid
Addition of the following medications:
Megestrol (Megace)
Glyburide (DiaBeta, Glynase)
Sliding-scale Insulin
Update for medications to use with caution
Dabigatran (Pradaxa) and Prasugrel (Effient) due to increased risk of bleeding if 75yo or older

6. Beers Criteria 2012 Update, Cont
Update for PIM and classes to avoid in elderly with certain diseases/syndromes that the medication could exacerbate
Addition of the followings medications/classes
Pioglitazone (Actos) and Rosiglitazone (Avandia) in HF patients
Acetylcholinesterase inhibitors with history of syncope
SSRIs with falls/fractures
Avandia is now part of a REMS program for md and pt enrollment
New medication: Alogliptin and Pioglitazone (Oseni)
AI: aricept, exelon, razadyne

7. How could a medication be inappropriate for an elderly patient?
Adverse reactions that worsen current disease states
Adverse reactions that require treatment or hospitalization/office visit
Current trials have not proven efficacy in elderly patients
Current trials have proven increased mortality risk
Increased healthcare cost
Medications that cause orthostatic hypotension/falls/syncope which causes a fall that causes a hematoma or causes a fracture that requires surgery
All antipsychotics may increase risk of stroke and death when used to treat behavioral symptoms in demented elderly pts
Anticholinergic medications may cause unpleasant side effects and worsen dementia
Some medications may lower seizure threshold (tramadol, bupropion, thiothixene)
Some medications are not effective at higher doses in the elderly and higher doses increase the risk of adverse reactions

8. Drawbacks of Beers Criteria
Primary purpose is to be an educational tool and quality measure
PIM affected by aging were not included
Medications requiring renal dosing
Drug-Drug interactions
Therapeutic duplication
Palliative Care/Hospice patients are not included
Non-English literature was not included in review
Not for disciplinary actions
Palliative care/hospice need symptom control

9. Possible Inappropriate Medication Classes
Analgesics
Antidepressants
Antihistamines
Antihypertensives
Antiplatelet Agents/Anticoagulants
Antipsychotics
Anxiolytics
Cardiac Drugs
Central Nervous System Agents
Chemotherapy
Diabetes Drugs
Gastrointestinal Drugs
Hormones
Hypnotics
Musculoskeletal Agents
NSAIDs
Respiratory Drugs
Stimulant Drugs
Urinary Drugs

10. Analgesics Meperidine (Demerol) Pentazocine (Talwin) Tramadol (Ultram)
Neurotoxicity, Delirium, Cognitive Impairment, Poor Oral Efficacy
Pentazocine (Talwin)
Increased CNS effects (Confusion/Hallucinations); Ceiling to analgesic effect
Tramadol (Ultram)
Decreases seizure threshold

11. Is the patient allergic to any medications?
Analgesics
Safer Alternatives
Acetaminophen (Tylenol)
Short-term NSAID
Salicylates
Topical Capsaicin
Codeine
Hydrocodone/APAP (Norco/Vicodin)
Oxycodone/APAP (Percocet/Roxicet)
Is the patient allergic to any medications?

12. Antidepressants Bupropion (Wellbutrin) Paroxetine (Paxil)
Decreases seizure threshold
Paroxetine (Paxil)
Cause/Worsen Delirium, Worsen Constipation/Urinary Retention/Cognitive Impairment
Mirtazapine (Remeron)
SIADH
SSRIs
SIADH, Psychomotor Impairment
Tricyclic Antidepressant
Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin, Imipramine (Tofranil) Trimipramine (Surmontil)
Anticholinergic effects, Delirium, Sedation, Orthostatic Hypotension, Cognitive Impairment, SIADH
Syndrome of inappropriate antidiuretic hormone secretion causes euvolemic hyponatremia (correct with lasix and hypertonic saline IV)

13. Antihistamines Anticholinergic Antihistamines Loratadine (Claritin)
Brompheniramine, Carbinoxamine, Chlorpheniramine, Clemastine, Cyproheptadine, Dexbrompheniramine, Dexchlorpheniramine, Diphenhydramine oral, Doxylamine, Hydroxyzine, Promethazine, Triprolidine
Loratadine (Claritin)
May worsen delirium, cognitive impairment, constipation, or urinary retention

14. Antihistamines Safer Alternatives Cetirizine (Zyrtec)
Fexofenadine (Allegra)
Desloratadine (Clarinex)
Levocetirizine (Xyzal)

15. Antihypertensives
Doxazosin (Cardura), Prazosin (Minipress), Terazosin (Hytrin)
Could cause orthostatic hypotension, urinary incontinence
Clonidine (Catapres), Guanabenz, Guanfacine, Methyldopa, Reserpine
Could cause orthostatic hypotension, bradycardia, CNS adverse effects
Short-acting Nifedipine
Hypotension, Myocardial Ischemia
Triamterene
Kidney injury
Vasodilators
Increased syncope

16. Antiplatelet Agents & Anticoagulants
Aspirin
Caution in patients >= 80yo
Dabigatron (Pradaxa)
Increased bleeding risk in patients >= 75yo
Decreased efficacy in renal impairment
Prasugrel (Effient)
Increased bleeding risk
Ticlopidine (Ticlid)
Dipyridamole short-acting (Persantine)
Orthostatic Hypotension

17. Antipsychotics
All antipsychotics increase the risk of stroke, death, and SIADH in demented elderly patients requiring behavioral treatment
Chlorpromazine, Clozapine, Fluphenazine, Olanzapine (Zyprexa), Perphenazine, Thioridazine, Thiothixene (Navane), Trifluoperazine
May cause/worsen delirium, worsen constipation, worsen cognitive impairment, worsen urinary retention
Clozapine requires close monitoring of WBC and ANC due to agranulocytosis

18. Antipsychotics
Quetiapine (Seroquel) or Clozapine (Clozaril) are better options for Parkinson’s disease
Less Anticholinergic Options:
Aripiprazole (Abilify)
Asenapine (Saphris)
Haloperidol
Iloperidone
Lurasidone (Latuda)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Atypical antipsychotics carry unwanted side effects (weight gain, diabetes, etc)

19. Anxiolytics
Benzodiazepines should be used with caution when used for agitation/delirium or in patients with dementia/cognitive impairment
Meprobamate may cause dependence or sedation
Benzos are okay for severe anxiety, seizures, REM sleep d/o, benzo/ETOH withdrawal, EOL or perioperative anesthesia
Alternative: SSRI, SNRI, Buspirone

20. Cardiac Medications Amiodarone Antiarrhythmics Dronedarone (Multaq)
QT prolongation, Pulmonary toxicity, hypo- or hyperthyroidism
Antiarrhythmics
Dofetilide, Flecainide, Ibutilide, Procainamide, Propafenone, Quinidine, Sotalol
Prefer rate control over rhythm control for Afib
Dronedarone (Multaq)
Shown to produce worse outcome in AFib/HF
Disopyramide (Norpace)
Anticholinergic SE
Diltiazem & Verapamil
Could worsen systolic HF or constipation
Digoxin
Doses >0.125 mg/day have shown to provide no additional efficacy
Cilostazol (Pletal)
Could worsen HF
Spironolactone
Hyperkalemia, caution if CrCl <30 ml/min
Dig-monitor for renal impairment
HF-recommend using ACEI, ARB, Diuretic, BB (titrated)

21. CNS Agents Acetylcholinesterase Inhibitors Anticonvulsants
Donepezil (Aricept)
Orthostatic hypotension, bradycardia
Anticonvulsants
Unsteady gait, psychomotor impairment, syncope, falls
Carbamazepine
SIADH
Dimenhydrinate & Meclizine
Cause/worsen delirium, worsen constipation/urinary retention, cognitive impairment

22. Diabetes Medications Chlorpropamide (Diabinese)
Extended half-life, prolonged hypoglycemia, SIADH
Glyburide (Diabeta, Glynase)
Prolonged hypoglycemia
Sliding Scale Insulin
Poor efficacy, hypoglycemia
Pioglitazone (Actos)
Caution in HF due to edema
Avoid Glucotrol XL
Use basal insulin, rapid-acting mealtime insulin, premixed insulin 1-2X/day

23. GI Medications Antispasmodics H2 Blocker Metoclopramide (Reglan)
Belladonna alkaloids, Clidinium, Dicyclomine, Hyoscyamine, Propantheline, Scopolamine
Anticholinergic SE, delirium
H2 Blocker
Cause/worsen delirium, Worsen cognitive impairment
Metoclopramide (Reglan)
Extrapyramidal SE, Tardive dyskinesia
Mineral Oil
Aspiration
Prochlorperazine
Cause/worsen delirium, Worsen constipation, Cognitive impairment, Worsen Parkinson’s Dz
Promethazine
Anticholinergic SE, Delirium, Cognitive impairment, Worsen Parkinson’s Dz, Reduced clearance in elderly
Trimethobenzamide (Tigan)
Extrapyramidal SE, Poor efficacy

24. Hormones Corticosteroids Estrogen Growth Hormone Megestrol
Cause/worsen delirium
Estrogen
Breast/Endometrial cancer, Worsen incontinence, No cardioprotective properties, No cognitive protection
Growth Hormone
Edema, Arthralgia, Carpal tunnel, Gynecomastia, Insulin resistance
Megestrol
Thrombosis, Death, Lack of efficacy for weight gain
Testosterone/Methyltestosterone
Prostatic hyperplasia, Cardiac events
Desiccated Thyroid
Cardiac SE

25. Hypnotics Barbiturates Benzodiazepines Chloral Hydrate
Dependence, Tolerance, Delirium, Possible overdose
Benzodiazepines
Cognitive impairment, Delirium, Unsteady gait, Syncope, Falls, Accidents, Fractures
Chloral Hydrate
Tolerance, Delirium, Possible overdose
Eszopiclone (Lunesta), Zaleplon (Sonata), Zolpidem (Ambien)
Cognitive impairment, Delirium, Unsteady gait, Syncope, Falls, MVA, Fractures, Little benefit

26. Musculoskeletal Medications
Muscle Relaxants
Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, Orphenadrine
Anticholinergic SE, Sedation, Fractures, Delirium, Cognitive impairment
Benztropine, Tizanidine (Zanaflex), Trihexyphenidyl
Delirium, Worsen cognitive impairment, Worsen constipation, Worsen urinary retention

27. NSAIDs Cause GI bleeding or peptic ulcer
Cause renal injury in advanced renal disease
Caution in CHF due to edema SE
Indomethacin
Causes more SE than other NSAIDs
Aspirin
Max daily dose of 325 mg
Recommend—hydrocodone/APAP, oxycodone/APAP, codeine, celecoxib (except in HF), duloxetine, venlafaxine, pregabalin, gabapentin, topical analgesics, lidocaine patches
Avoid ketorolac and indomethacin
If NSAIDs are used then recommend to use a GI protectant (misoprostol/PPI)

28. Respiratory & Miscellaneous Medications
Inhaled Anticholinergic
Tiotropium (Spiriva), Ipratropium
Urinary retention
Phenylepherine, Pseudoephedrine, Theophylline
CNS stimulant
Atropine or Homatropine
Anticholinergic SE, Delirium, Worsen constipation, Worsen cognitive impairment
Amphetamine & Methylphenidate
CNS stimulation

29. Urinary Medications Nitrofurantoin Urinary Antimuscarinics
Pulmonary toxicity, Minimal efficacy if CrCl <60 ml/min
Urinary Antimuscarinics
Darifenacin (Enablex), Oxybutynin (Ditropan), Trospium (Sanctura), Tolterodine (Detrol)
Cause/worsen delirium, Worsen constipation, Cognitive impairment

30. STARTing and STOPPing Criteria

31. START and STOPP STOPP START
Screening Tool of Older Persons’ potentially inappropriate Prescriptions
START
Screening Tool to Alert doctors to Right Treatment

32. START and STOPP Organized by organ system
Provides the “START” options initially
Example: START ACEI or ARB for HF, post-MI, or in diabetic nephropathy
Then provides the “STOPP” treatments
Example: STOPP beta-blockers in COPD or diabetic patients
BB in COPD: bronchospasm
BB in DM: masks hypoglycemia

33. References
American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc Apr;60(4):
PL Detail-Document, Potentially Harmful Drugs in the Elderly: Beers List. Pharmacist’s Letter/Prescriber’s Letter. June 2012.
PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.