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Potentially Inappropriate
Medications in the Elderly*
Medication
Prescribing Concern
Possible Alternatives
Anticholinergics (excludes TCAs)First-generation antihistamines • Clearance reduced with advanced age • Use the smallest dose possible if using • Highly anticholinergic; increased risk first generation antihistamine for acute treatment of severe allergic reaction of confusion, dry mouth, constipation, and other anticholinergic effects/ • If using for sleep, consider trazadone Dexchlorpheniramine Diphenhydramine (oral) Doxylamine Hydroxyzine Promethazine Triprolidine *Medications listed are included in The AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012 Potentially Inappropriate Medications in the Elderly
Medication
Prescribing Concern
Possible Alternatives
effect). Elderly may require dosage reductions based on renal function levodopa, pramipexole, selegiline, bromocriptine or ropinirole AntithromboticsDipyridamole, oral short-acting • May cause orthostatic hypotension • Consider alternative antiplatelet agents (does not apply to the extended- • More effective alternatives available release combination with aspirin) • IV form acceptable for use in cardiac • Consider alternative antiplatelet agents • Not much better than aspirin in clot • Safer, more effective alternatives available • Lack of efficacy in patients with CrCl • Potential for pulmonary toxicity• Safer alternatives available • Consider an alternative treatment for hypertension (a diuretic, beta-blocker or • May cause bradycardia and orthostatic • Not recommended as routine treatment • When appropriate, other antiarrhythmic • Avoid doses greater than 0.125 mg/day associated with no additional benefit and may increase risk of toxicity • Decreased renal clearance may increase • Risk of precipitating myocardial ischemia Medication
Prescribing Concern
Possible Alternatives
Central nervous systemTertiary TCAs, alone or in • Highly anticholinergic, sedating, and • Consider an antidepressant agent with • The safety profile of low-dose doxepin Clomipramine Doxepin >6 mg/day Imipramine Perphenazine-amitriptyline TrimipramineAnti-psychotics, first-generation • Highly anticholinergic and greater risk of • Consider second generation Thioridazine • Avoid use in the elderly, except when Mephobarbital • Tolerance to sleep benefits • Greater risk of overdose at low dosages • Low dose trazodone (25-50mg); may be • Avoid use in the elderly; if using for • If used for prolonged periods of time, the Nonbenzodiazepine hypnotics Eszopiclone (Lunesta) • Low dose trazodone (25-50mg); may be Zolpidem (Ambien, Ambien CR) • Benzodiazepine-receptor agonists that used intermittently. Evidence suggests trazodone does not affect REM sleep have adverse events similar to those of benzodiazepines in older adults (e.g., • Minimal improvement in sleep latency • Avoid use in the elderly; if using ergot mesylates for Alzheimer’s, consider donepezil • Consider levothyroxine as an alternative Medication
Prescribing Concern
Possible Alternatives
Endocrine continuedEstrogens with or without • For vasomotor symptoms, consider use • For vaginal symptoms, consider local • Topical vaginal cream: Acceptable to urinary tract infections, and other vaginal Tier 4 – Non-Preferred Brands: treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 mcg twice weekly • Increases risk of thrombotic events and • One of the least effective antiemetic drugs • Consider safer alternatives: • Can cause extrapyramidal adverse effects prochlorperazine, ondansetron, granisetron Pain medicationsNon-COX-selective NSAIDs • Increases risk of GI bleeding/peptic ulcer • Avoid use in the elderly; safer alternatives • Avoid chronic use unless other alternatives are not effective. Use with gastroprotective • Avoid use in the elderly; morphine is the • May cause neurotoxicity• Safer alternatives available adverse effects, including confusion and Skeletal muscle relaxants (as a single agent or as part of a combination product)Carisoprodol Metaxalone anticholinergic adverse effects, sedation • Effectiveness at dosages tolerated by

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