Table 3.
Frequency of prescriptions containing medications that should be avoided in older adults, according to 2019 Beers criteria (n = 148).
| Classification of PIM by pharmacological group (n = 32 medications) | No. of prescriptions 148 (100.0%) | Rationale | Evidence/strength of recommendation |
| First-generation antihistamines | 4 (2.7) | Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate. | Moderate/strong |
| Dimenhydrinate | |||
| Diphenhydramine | 1 (0.7) | ||
| Meclizine | 1 (0.7) | ||
| Promethazine | 1 (0.7) | ||
| 1 (0.7) | |||
| Antispasmodics | 1 (0.7) | Strong/moderate | |
| Scopolamine | 1 (0.7) | Highly anticholinergic; uncertain effectiveness | |
| Anti-infectives | 2 (1.3) | Long-term use of nitrofurantoin can cause hepatotoxicity, pulmonary toxicity and peripheral neuropathy. Avoid in individuals with creatinine clearance <30 mL/min or for long-term suppression. Ciprofloxacin worsens renal function and increases risk of CNS effects. | Low/strong |
| Nitrofurantoin | 1 (0.7) | ||
| Ciprofloxacin | 1 (0.7) | ||
| Cardiovascular | 16 (10.9) | ||
| Doxazosin | 6 (4.0) | Risk of orthostatic hypertension; not recommended as first choice for treating hypertension. Avoid use as anti-hypertensive | Moderate/strong |
| Digoxin | 1 (0.7) | Use in atrial fibrillation: should not be used as first-line agent. May be associated with increased mortality. Use in heart failure: conflicting effects on risk of hospitalization. May be associated with increased mortality in elderly patients with heart failure; high dosages may increase risk of toxicity and death Avoid as first-line therapy | Moderate/strong |
| Low/strong | |||
| Nifedipine | 4 (2.7) | Potential for hypotension; risk of precipitating myocardial ischemia | High/strong |
| Amiodarone | 5 (3.4) | Should be avoided as first-line therapy for atrial fibrillation unless patient has heart failure or substantial left-ventricular hypertrophy | High/strong |
| Central nervous system | 69 (46.6) | High/strong | |
| Antidepressants | |||
| Amitriptyline | 33 (22.3) | Highly anticholinergic, sedating, and cause orthostatic hypotension | |
| Fluoxetine | 1 (0.7) | ||
| Imipramine | 2 (1.3) | ||
| Sertraline | 2 (1.3) | ||
| Paroxetine | 21 (14.2) | ||
| Venlafaxine | 5 (3.4) | ||
| 2 (1.3) | |||
| Antipsychotics (conventional and atypical) | 8 (5.4) | Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium, unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and older adult is threatening substantial harm to self or others. Avoid, except in schizophrenia or bipolar disorder, or for short-term use as antiemetic during chemotherapy | Moderate/strong |
| Haloperidol | |||
| Levomepromazine | 2 (1.3) | ||
| Periciazine | 5 (3.4) | ||
| 1 (0.7) | |||
| Barbiturates | 1 (0.7) | High rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages | High/strong |
| Phenobarbital | 1 (0.7) | ||
| Benzodiazepines | 27 (18.2) | Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; in general, this class increases risk of cognitive impairment, delirium, falls, fractures and motor-vehicle crashes in older adults | Moderate/strong |
| Alprazolam | 8 (5.4) | ||
| Bromazepam | 2 (1.3) | ||
| Clonazepam | 11 (7.4) | ||
| Diazepam | 4 (2.7) | ||
| Lorazepam | 2 (1.3) | ||
| Endocrine system | 16 (10.8) | Higher risk of hypoglycemia without improvement in hyperglycemia management with regimens of only short or rapid-acting insulin to control or prevent hyperglycemia, without concurrent use of basal or long-acting insulin. Oral medications can potentially cause risk of prolonged hypoglycemia in older adults | Moderate/strong |
| Insulin | 12 (8.1) | ||
| Glibenclamide | 2 (1.3) | ||
| Chlorpropamide | 2 (1.3) | ||
| Pain medications (NSAIDs) | 4 (2.7) | Increased risk of gastrointestinal bleeding or peptic ulcer disease in high-risk groups, including those >75 years or taking oral or parenteral corticosteroids, anticoagulants or antiplatelet agent. Avoid chronic use, unless other alternatives are not effective | Moderate/strong |
| Etodolac | 1 (0.7) | ||
| Ibuprofen | 1 (0.7) | ||
| Nimesulide | 2 (1.3) |
CNS = Central Nervous System, NSAIDs = nonsteroidal anti-inflammatory drugs, PIM = potentially inappropriate medications.