Download July 2013

The Remedy’sRx Press
The Beers List of Potentially Inappropriate Medications in the Elderly
The Beers List was developed in 1991 by Dr. Mark Beers and colleagues as a strategy to try to reduce adverse effects and other
medication-related problems in older adults. It was first developed for nursing homes, but has since been expanded to include all
adults 65 years and older and has recently been updated (October 2012). Here are some of the highlights.
1. ANTICHOLINERGICS (medications that block the neurotransmitter acetylcholine)
Many medications have an anticholinergic effect and these effects are ADDITIVE, which can lead to a toxicity syndrome.
Common possible anticholinergic side effects are:
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Sedation
•
Dry mouth
•
Constipation
•
Confusion (especially in the elderly with dementia)
•
Urinary retention
•
Blurred vision
Remember the Beers List is
intended as a guideline
•
Dry eyes
and is not a substitute for
professional judgement.
•
Tachycardia
Ask your Remedy’sRx Pharmacist
Is that enough for you? – for
because
are more!
more there
information.
•
Double vision
Medications with severe anticholinergic side effects include:
o S
copolamine, atropine, glycopyrrolate, incontinence drugs
(oxybutynin, tolterodine, solifenacin, darifenacin)
o Older
antihistamines (diphenhydramine, chlorpheniramine,
hydroxyzine)
o Antinauseants (dimenhydrinate, more)
o Tricyclic antidepressants (amitriptyline, imipramine, more)
o Paroxetine
o Older antipsychotics (chlorpromazine, loxapine, more)
o Clozapine
o Olanzapine
o Muscle relaxants (cyclobenzaprine, methocarbamol)
As well, there are many more medications with milder
anticholinergic side effects, and let’s not forget the side
effects are additive.
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•
ecreased sweating (increased body temperature,
D
hot and flushed skin)
•
Disorientation
•
Dizziness
•
Hallucinations
•
Delirium
•
Dysphagia
•
Impaired gastrointestinal motility
2. BENZODIAZEPINES (for example: lorazepam, diazepam)
Older adults are more sensitive to these medications and metabolize them more slowly. All benzodiazepines increase the risk for cognitive
impairment, delirium, unsteady gait, syncope, falls, and fractures. They can cause dependence, and a tolerance can develop to their
effects. If these medications are used, try to use them for the shortest amount of time possible.
•
lternative treatments for insomnia include non-drug measures (dark, quiet/white noise, no napping during midday and moderate
A
exercise after supper), low-dose trazodone, low-dose doxepin, and low-dose mirtazapine (especially if an anti-depressant effect is
desired).
nd if you think the “Z” Drugs – like zopiclone – are the alternative to using benzodiazepines, think again. It turns out their side effects
A
can be just as undesirable. They also produce cognitive impairment, fall, and dependency risks. They have been found to deliver minimal
benefit and are fine for short-term use, but are not to be used for more than 90 days.
3. ANTIPSYCHOTICS (we know, we know)
Not to be used for dementia-related behaviour problems unless non-drug options have failed and the older adult is a danger to self or
others. All antipsychotics are associated with an increased stroke and mortality risk when used to treat behavioural problems in the
elderly with dementia. There are many other side effects, including Parkinson-like effects, increased falls, drowsiness, and cognitive
decline. Evidence shows that the only symptoms that benefit from antipsychotic treatment are agitation, aggression, psychosis, and
hallucinations/delusions – NOT calling out, sexual disinhibition, wandering, resistiveness, repetitive behaviours, hoarding, nocturnal
restlessness, or paranoid behaviours. The need for antipsychotic drugs should be re-assessed because behaviours usually stabilize
naturally. To stop an antipsychotic drug, taper dose by 25% every 1-2 weeks, unless treating acute delirium, then it’s fine to stop the
drug upon resolution of the symptoms.
4. Diltiazem and Verapamil
They can worsen chronic constipation.
5. Amiodarone
It has many drug interactions and multiple toxicities, including thyroid and pulmonary. Have you ever noticed that many people who have
been on amiodarone for a long time are also on thyroid medications?
6. Digoxin >0.125mg daily
No additional benefit from higher doses, but increased risk of toxicity.
7. Nitrofurantoin
Avoid in reduced kidney function (<60mL/min – inadequate amounts get into urine) and for chronic use (potential for pulmonary toxicity).
8. Sliding Scale Insulin
Higher risk of hypoglycemia and poor efficacy, not to mention the amount of finger-poking involved!
There is much more to see. The Beers List is available on the AGS (American Geriatrics Society) website and as a smartphone app.
It is intended as a guideline and is not a set of hard and fast rules. Keep in mind that all medications must be individualized.
*Ask your Remedy’sRx Pharmacist for more information
on The Beers List and for your pocket guide copy of the
AGS Beers Criteria.
Courtesy of: Lanai Vek, RPh, CGP
1-855-272-5656
[email protected]
www.remedysrxsp.ca