Table I.
Norwegian General Practice Nursing Home (NORGEP-NH) criteria for potentially inappropriate medication use in elderly (> 70 years) nursing home residents.
| A: Single substance criteria | Comments, adverse effects |
| Regular use should be avoided | |
| 1. Combination analgesic codeine/paracetamol | Poor long-term effects. Constipation, sedation, falls |
| 2. Tricyclic antidepressants (TCAs)1 | Anticholinergic effects, cardiotoxicity |
| 3. Non-steroid anti-inflammatory drugs (NSAIDs) | High risk of side effects and interactions |
| 4. First-generation antihistamines2 | Anticholinergic effects, prolonged sedation |
| 5. Diazepam | Over-sedation, falls, fractures |
| 6. Oxazepam: Dosage > 30 mg/day | Over-sedation, falls, fractures |
| 7. Zopiklone: Dosage > 5 mg/day | Over-sedation |
| 8. Nitrazepam | Over-sedation, falls, fractures |
| 9. Flunitrazepam | Over-sedation, falls, fractures, addiction |
| 10. Chlometiazole | Poor safety record. Risk of cardiopulmonary death |
| 11. Regular use of hypnotics | Over-sedation, falls, fractures |
| B: Combination criteria | |
| Combinations to avoid | |
| 12. Warfarin + NSAIDs | Increased risk of bleeding |
| 13. Warfarin + SSRIs/SNRIs3 | Increased risk of bleeding |
| 14. Warfarin + ciprofloxacin/ofloxacin/erythromycin/clarithromycin | Increased risk of bleeding |
| 15. NSAIDs/coxibs4 + ACE-inhibitors5/AT2-antagonists6 | Increased risk of kidney failure |
| 16. NSAIDs/coxibs + diuretics | Reduced effect of diuretics, risk of heart and kidney failure |
| 17. NSAIDs/coxibs + glucocorticoids | Increased risk of bleeding, fluid retention |
| 18. NSAIDs/coxibs + SSRI/SNRIs | Increased risk of bleeding |
| 19. ACE-inhibitors/AT2-antagonists + potassium or potassium-sparing diuretics | Increased risk of hyperkalaemia |
| 20. Beta blocking agents + cardioselective calcium antagonists | Increased risk of atrioventricular block, myocardial depression, hypotension, orthostatism |
| 21. Erythromycin/clarithromycin + statins | Increased risk of adverse effects of statins |
| 22. Bisphosphonate + proton pump inhibitors | Increased risk of fractures |
| 23. Concomitant use of 3 or more psychotropics7 | Increased risk of falls, impaired memory |
| 24. Tramadol + SSRIs | Risk of serotonin syndrome |
| 25. Metoprolol + paroxetine/fluoxetine/bupropion | Hypotension, orthostatism |
| 26. Metformin + ACE-inhibitor AT2-antagonists + diuretics | Risk of impaired renal function and metformin-induced lactacidosis, especially in dehydration |
| C: Deprescribing criteria. Need for continued use should be reassessed8 | |
| 27. Anti-psychotics (incl. “atypical” substances9) | Frequent, serious side effects. Avoid long-term use for BPSD10 |
| 28. Anti-depressants | Limited effect on depression in dementia |
| 29. Urologic spasmolytics | Limited effect for urinary incontinence in old age Risk of anticholinergic side effects |
| 30. Anticholinesterase inhibitors | Temporary symptomatic benefits only. Frequent side effects |
| 31. Drugs lowering blood pressure | Hypotension, orthostatism, falls |
| 32. Bisphosphonates | Assess risk–benefit in relation to life expectancy |
| 33. Statins | Assess risk–benefit in relation to life expectancy |
| 34. Any preventive medicine | Assess risk–benefit in relation to life expectancy |
Notes: 1Amitriptyline, doxepine, chlomipramine, trimipramine, nortryptiline; 2dexchlorfeniramine, promethazine, hydroxyzine, alimemazine (trimeprazine); 3selective serotonin reuptake inhibitors/selective norepinephrine reuptake inhibitors; 4cyclooxygenase-2-selective inhibitors; 5angiotensin-converting enzyme inhibitors; 6angiotensin II receptor antagonists; 7from the groups centrally acting analgesics, antipsychotics, antidepressants, and/or benzodiazepines; 8this should be undertaken at regular intervals. For criteria 27–29, a safe strategy for re-evaluation is first to taper dosage, then stop the drug while monitoring clinical condition; 9risperidone, olanzapine, quetiapine, aripiprazole; 10behavioural and psychological symptoms in dementia.