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Transcript
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: • 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. 1-855-272-5656 [email protected] www.remedysrxsp.ca • 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