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Beers’ Criteria for Potentially Inappropriate By: Sheila L. Molony MS, APRN
WHY: Recently published studies confirm that inappropriate medication use remains a serious problem for the elderly.1,2,3Increased nursing awareness of high-risk medications enables attentive monitoring for adverse effects and facilitatescollaborative efforts between nurses, primary care providers and pharmacists to reduce medication-related risk.
BEST TOOL: The adapted Beers’ Criteria (HCFA Guidelines for Potentially Inappropriate Medications in the Elderly)identifies medications noted by an expert panel to have potential risks that outweigh potential benefits of the drug. Thecriteria are appropriate for persons older than 65 years of age, regardless of their level of frailty. The criteria provide arating of severity for adverse outcomes (severe vs. less severe) as well as a descriptive summary of the prescribingconcerns associated with the medication.
VALIDITY AND RELIABILITY: The criteria were developed using a modified Delphi method to achieve consensusamong 6 nationally recognized experts in geriatric care and pharmacology. The criteria have been used alone and incombination with setting-specific criteria to screen populations for possible medication-related problems. Furtherresearch is needed to validate the occurrence and severity of negative outcomes associated with high-risk medications.
STRENGTHS AND LIMITATIONS: The criteria do not identify all cases of potentially inappropriate prescribing andthey may sometimes identify appropriate prescribing as inappropriate. The criteria are designed for population-basedscreening and are not intended to substitute for professional judgment regarding the individualized needs of particularolder adults.
FOLLOW-UP: Nurses may use the criteria to increase awareness of medications that may present increased risk foradverse drug reactions. Nurses, primary care providers and pharmacists may collaborate to optimize individualizedmedication regimes and provide appropriate clinical monitoring and education. The suggested references provide furtherinformation on high-risk medications specific to patient diagnosis and prescribing practices in specific care settings.
Beers, M.H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. Archives of Internal Medicine 157:1531-1536.
Brown, N.J., Griffin, M.R., Ray, W.A., Meredith, S., Beers, M.H., Marren, J., Robles, M., Stergachis, A., Wood, A.J.J., & Avorn, J. (1998). A model for improving medication use in home health care patients. Journal of the American Pharmaceutical Association 38(6):696-702.
1Meredith, S., Feldman, P.H., Frey, D., Hall, K., Arnold, K., Brown, N.J., & Ray, W.A. (2001). Possible medication errors in home healthcare patients. Journal of the American Geriatrics Society 49:719-724 3Sloane, P. D., Zimmerman, S., Brown, L. C., Ives, T. J. & Walsh, J.F. (2002). Inappropriate medication prescribing in residential care/assisted living facilities. Journal of the American Geriatrics Society 50: 1001-1011.
2Zhan, C., Sangl, J., Bierman, A.S., Miller, M.R., Friedman, B., Wickizer, S.W., Meyer, G.S. (2001). Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel survey. Journal of the American MedicalAssociation 286:2823-2829.
Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu.
Understanding the HCFA Guidelines
for Potentially Inappropriate Medications* in the Elderly—Optimizing Prescribing in Long-Term Care
Drug Therapy with High Potential for
Drug Therapy with High Potential for
Severe Adverse Outcomes
Summary of Prescribing Concerns for the Elderly
Less Severe Adverse Outcomes
Summary of Prescribing Concerns for the Elderly
amitriptyline (Elavil), chlordiazepoxide-amitriptyline
Strong anticholinergic and sedating properties. Rarely diphenhydramine (Benadryl)
Potent anticholinergic properties. Should not be used (Limbitrol), and perphenazine-amitriptyline (Triavil)
the antidepressant of choice in the elderly. (May be as a sedative/hypnotic. To treat allergic reactions, use used for neurogenic pain if evaluation of risk vs. lowest dose possible, and with great caution. (Review not necessary if used for 7 days or less, and not morefrequently than every 3 months, for treatment of allergies.) barbiturates (all except phenobarbital)
Higher incidence of side effects than most other sedatives and hypnotics used in the elderly. Highly Frequently causes orthostatic hypotension. Use in the dipyridamole (Persantine)
Long-acting benzodiazepines-chlordiazepoxide
chlordiazepoxide, diazepam, flurazepam and other
ergot mesyloids (Hydergine), cyclandelate
Have not demonstrated effectiveness in the treatment (Librium), chlordiazepoxide-amitriptyline (Limbitrol),
long-acting benzodiazepines have a long half-life in (Cyclospasmol), (other cerebral vasodilators) clidinium-chlordiazepoxide (Librax), diazepam
the elderly. Produce prolonged sedation, increased (Valium), and flurazepam (Dalmane)
Antihistamines such as: single and combination Potent anticholinergic properties. Use cough-and-cold preparations containing chlorpheniramine (Chlor-
substitutes without antihistamines. (Review not chlorpropamide (Diabinese)
Prolonged half-life in the elderly, which can cause Trimeton), diphenhydramine (Benadryl), hydroxyzine
necessary if diphenhydramine is used for 7 days or prolonged hypoglycemia. Also causes SIADH.† (Vistaril, Atarax), PERIACTIN® (cyproheptadine HCI),
less, and not more frequently than every 3 months, for promethazine (Phenergan), tripelennamine (PBZ),
dicyclomine (Bentyl), hyoscyamine (Levsin, Levsinex),
GI antispasmodics are highly anticholinergic and and dexchlorpheniramine (Polarmine)
propantheline (Pro-Banthine), belladonna alkaloids
generally produce substantial toxic effects in the (Donnatal and others), and clidinium-
elderly. Effectiveness at doses tolerated by the elderly INDOCIN® (indomethacin), INDOCIN SR®
More CNS† side effects than other NSAIDs† and, chlordiazepoxide (Librax)
is questionable. Best avoided in the elderly, especially (indomethacin)
therefore, should not be used in the elderly. (Short- for long term use. (Use for 7 days or less, and not term use, e.g. 1 week, is acceptable for treatment of more frequently than every 3 months, does not methocarbamol (Robaxin), carisoprodol (Soma),
Most muscle relaxants are poorly tolerated by the
digoxin (Lanoxin) >0.125 mg/day
Because of decreased renal clearance in the elderly, chlorzoxazone (Paraflex), metaxalone (Skelaxin),
elderly, leading to anticholinergic side effects, sedation and avoid doses >0.125mg, except when treating atrial FLEXERIL® (cyclobenzaprine), dantrolene
weakness. The effectiveness at doses tolerated by the (Dantirum), and orphenadrine (Norflex, Norgesic)
elderly is questionable. (Review not necessary if used for7 days or less, and not more frequently than every 3 disopyramide (Norpace, Norpace CR)
Negative inotrope that may induce heart failure.
months, for symptoms of an acute, self-limiting condition.) phenylbutazone (Butazolidin)
May produce serious hematological side effects (blood doxepin (Sinequan)
Strong anticholinergic and sedating properties. Rarely disorders) and should not be used in the elderly.
the antidepressant of choice in the elderly.
reserpine (Serpasil), resperpine combination products
May cause depression; sedation, and orthostatic meperidine (Demerol)
hypotension. Safer alternatives exist.
meprobamate (Miltown, Equanil)
Highly addictive and sedating anxiolytic. Avoid in trimethobenzamide (Tigan)
Can cause extrapyramidal side effects. Low effectiveness as an antiemetic drug.
ALDOMET® (methyldopa), ALDORIL®
May cause bradycardia and exacerbate depression in (methyldopa/hydrochlorothiazide)
the elderly. Alternate antihypertensives are preferred.
ALDOMET, ALDORIL, INDOCIN, INDOCIN SR, FLEXERIL and PERIACTIN are registered trademarks of Merck & Co., Inc. All other brandslisted are trademarks of their respective owners and not of Merck & Co., Inc. pentazocine (Talwin)
Narcotic analgesic causing more CNS† side effectsthan other narcotic drugs, including confusion and * It is important to note that most package circulars produced by drug manufacturers do not include language identical to the statements hallucinations. Mixed agonist and antagonist.
presented here. Although the adverse effects that these drugs can produce are generally listed in the package circulars, these as well as warnings and contraindications must be approved by regulatory agencies and in general are not based on consensus or surveys. ticlopidine (Ticlid)
No better than aspirin in preventing clotting and Before prescribing ALDOMET, ALDORIL, INDOCIN, INDOCIN SR, FLEXERIL, and PERIACTIN, please read the accompanying
considerably more toxic. Avoid in the elderly. (Review full Prescribing Information.
† CNS indicates central nervous system; NSAIDs indicates nonsteroidal anti-inflammatory drugs. SIADH indicates syndrome of not necessary if used in patients who have had a stroke or have evidence of stroke precursors [transientischemic attacks], and cannot tolerate aspirin.) Source: Adapted from: Beers MH. Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly. An Update.
Arch Intern Med. 1997;157:1531-1536. Reprinted with permision.
* It is important to note that most package circulars produced by manufacturers do not include language identical to the statements presented here. Although the adverse effects that these drugs can produce are generally listed in the package circulars, these as well as warnings and contraindications must be approved by regulatory agencies and in general are not based on consensus or surveys. † CNS indicates central nervous system; NSAIDs indicates nonsteroidal anti-inflammatory drugs. SIADH indicates syndrome of The Hartford Institute for Geriatric Nursing www.hartfordign.org
1999, Merck & Co., Inc. All rights reserved.

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