Some drug categories (eg, analgesics, anticoagulants, antihypertensives, antiparkinsonian drugs, diuretics, hypoglycemic drugs, psychoactive drugs) pose special risks for elderly patients. Some, although reasonable for use in younger adults, are so risky as to be considered inappropriate for the elderly. The Beers Criteria are most commonly used to identify such inappropriate drugs (see Table 5: Drug Therapy in the Elderly: High-Risk Drugs in the Elderly (Based on the Beers Criteria)). The Zhan expert panel further categorized some inappropriate drugs from the Beers Criteria into 3 groups:

Table 5
PrintOpen table in new window
High-Risk Drugs in the Elderly (Based on the Beers Criteria) Class Drug Prescribing Concern Analgesics IndomethacinSome Trade Names INDOCIN Click for Drug Monograph * Of available NSAIDs, indomethacinSome Trade Names INDOCIN Click for Drug Monograph has the most CNS adverse effects and therefore should be avoided in the elderly. KetorolacSome Trade Names TORADOL Click for Drug Monograph Immediate- and long-term use should be avoided in the elderly because many of them have asymptomatic and undiagnosed GI disorders. MeperidineSome Trade Names DEMEROL Click for Drug Monograph † MeperidineSome Trade Names DEMEROL Click for Drug Monograph is not an effective oral analgesic and has many disadvantages compared with other opioids. It should be avoided in the elderly. Non–COX-selective NSAIDs (naproxenSome Trade Names ALEVE NAPROSYN Click for Drug Monograph , oxaprozinSome Trade Names DAYPRO Click for Drug Monograph , piroxicamSome Trade Names FELDENE Click for Drug Monograph ) Long-term use of the maximum dosage may cause GI bleeding, renal failure, hypertension, and heart failure. PentazocineSome Trade Names TALWIN Click for Drug Monograph † PentazocineSome Trade Names TALWIN Click for Drug Monograph is an opioid analgesic that has CNS adverse effects (eg, confusion, hallucinations) more commonly than other opioids; it is a mixed agonist/antagonist. For both reasons, it should usually be avoided in the elderly. PropoxypheneSome Trade Names DARVON DOLENE ‡ and combination products that contain it PropoxypheneSome Trade Names DARVON DOLENE should usually be avoided in the elderly. It has few analgesic advantages over acetaminophenSome Trade Names GENAPAP TYLENOL VALORIN Click for Drug Monograph but has the adverse effects of other opioids. Antidepressants Cyclic antidepressants (eg, amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph ,* doxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph *) Because of strong anticholinergic and sedating effects, amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph or doxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph is rarely the antidepressant of choice for the elderly. FluoxetineSome Trade Names PROZAC SARAFEM Click for Drug Monograph (taken daily) FluoxetineSome Trade Names PROZAC SARAFEM Click for Drug Monograph has a long half-life, may cause excessive CNS stimulation and sleep disturbances, and may increase agitation. Safer alternative SSRIs exist. Antihistamines ChlorpheniramineSome Trade Names CHLOR-TRIMETON Click for Drug Monograph * CyproheptadineSome Trade Names PERIACTIN Click for Drug Monograph * DexchlorpheniramineSome Trade Names No US trade name Click for Drug Monograph DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph * HydroxyzineSome Trade Names ATARAX VISTARIL Click for Drug Monograph * OrphenadrineSome Trade Names NORFLEX Click for Drug Monograph PromethazineSome Trade Names PHENERGAN Click for Drug Monograph * Tripelennamine All OTC and many prescription antihistamines have potent anticholinergic properties. Antihistamines are commonly included with other drugs in cough and cold preparations. However, many cough and cold preparations without antihistamines are available; they are safer alternatives for the elderly. Antipsychotics MesoridazineSome Trade Names SERENTIL ThioridazineSome Trade Names MELLARIL Click for Drug Monograph Risk of CNS and extrapyramidal adverse effects is increased. When used to treat dementia-related behaviors, 2nd-generation (atypical) antipsychotics may increase mortality risk. Cardiovascular drugs AmiodaroneSome Trade Names CORDARONE Click for Drug Monograph Adverse effects include QTc prolongation and risk of provoking torsades de pointes. ClonidineSome Trade Names CATAPRES Click for Drug Monograph Adverse effects include orthostatic hypotension and CNS effects. DigoxinSome Trade Names DIGITEK LANOXIN Click for Drug Monograph Because renal clearance of digoxinSome Trade Names DIGITEK LANOXIN Click for Drug Monograph is decreased in the elderly, doses should rarely exceed 0.125 mg/day, unless the patient is monitored. DipyridamoleSome Trade Names PERSANTINE Click for Drug Monograph * Immediate-release dipyridamoleSome Trade Names PERSANTINE Click for Drug Monograph frequently causes orthostatic hypotension in the elderly (the controlled-release formulation in combination products may be acceptable). The immediate-release formulation is beneficial only in patients with artificial heart valves. If possible, it should be avoided in the elderly. DisopyramideSome Trade Names NORPACE Click for Drug Monograph * Of all antiarrhythmics, disopyramideSome Trade Names NORPACE Click for Drug Monograph is the most potent negative inotrope and therefore may induce heart failure in the elderly. It is also strongly anticholinergic. If antiarrhythmics are needed, others should be used. DoxazosinSome Trade Names CARDURA Click for Drug Monograph Adverse effects include hypotension, dry mouth, and urinary problems. Ethacrynic acidSome Trade Names EDECRIN Click for Drug Monograph Adverse effects include hypertension and fluid imbalances. Guanethidine Guanadrel Adverse effects include orthostatic hypotension. MethyldopaSome Trade Names ALDOMET Click for Drug Monograph * MethyldopaSome Trade Names ALDOMET Click for Drug Monograph may cause bradycardia and exacerbate depression in the elderly. Alternate treatments for hypertension are generally preferred. NifedipineSome Trade Names ADALAT PROCARDIA Click for Drug Monograph (short-acting) Adverse effects include hypotension, constipation, and reflex tachycardia. ReserpineSome Trade Names SERPASIL Click for Drug Monograph * Doses > 0.25 mg pose unnecessary risks in the elderly by inducing depression, impotence, sedation, and orthostatic hypotension. Safer alternatives exist. TiclopidineSome Trade Names TICLID Click for Drug Monograph TiclopidineSome Trade Names TICLID Click for Drug Monograph is no better than aspirinSome Trade Names BUFFERIN ECOTRIN GENACOTE Click for Drug Monograph in preventing clotting and is considerably more toxic. It should be used only as a 2nd-line drug in the elderly. GI antispasmodics Belladonna alkaloids† Clidinium/chlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph DicyclomineSome Trade Names BENTYL Click for Drug Monograph † HyoscyamineSome Trade Names HYOSINE LEVSIN Click for Drug Monograph † PropanthelineSome Trade Names PRO-BANTHINE Click for Drug Monograph † GI antispasmodics are highly anticholinergic and usually cause substantial toxicity in the elderly. Efficacy at doses tolerated by the elderly is questionable. All of these drugs are best avoided in the elderly, especially for long-term use. Hypoglycemics ChlorpropamideSome Trade Names DIABINESE Click for Drug Monograph † ChlorpropamideSome Trade Names DIABINESE Click for Drug Monograph has a prolonged half-life in the elderly and can cause prolonged, serious hypoglycemia. It is the only oral hypoglycemic that causes SIADH. It should be avoided in the elderly. Laxatives (stimulant) BisacodylSome Trade Names DULCOLAX Click for Drug Monograph Cascara Neoloid except when used with opioids With long-term use, stimulant laxatives may exacerbate bowel dysfunction. Muscle relaxants CarisoprodolSome Trade Names SOMA Click for Drug Monograph ‡ ChlorzoxazoneSome Trade Names PARAFON FORTE DSC Click for Drug Monograph ‡ CyclobenzaprineSome Trade Names FLEXERIL Click for Drug Monograph ‡ MetaxaloneSome Trade Names SKELAXIN Click for Drug Monograph ‡ MethocarbamolSome Trade Names ROBAXIN Click for Drug Monograph ‡ OxybutyninSome Trade Names DITROPAN Click for Drug Monograph * Most muscle relaxants and antispasmodics are poorly tolerated by the elderly, resulting in anticholinergic effects, sedation, and weakness. Efficacy at doses tolerated by the elderly is questionable. If possible, they should not be used in the elderly. For extended-release oxybutyninSome Trade Names DITROPAN Click for Drug Monograph , the patch is better tolerated. Sedative-hypnotics AlprazolamSome Trade Names XANAX Click for Drug Monograph *, § 2 mg LorazepamSome Trade Names ATIVAN Click for Drug Monograph 3 mg OxazepamSome Trade Names SERAX Click for Drug Monograph 60 mg TemazepamSome Trade Names RESTORIL Click for Drug Monograph 15 mg TriazolamSome Trade Names HALCION Click for Drug Monograph 0.25 mg Because sensitivity to benzodiazepines is increased in the elderly, smaller doses may be effective as well as safer; total daily doses should rarely exceed those listed. Barbiturates† (except phenobarbitalSome Trade Names LUMINAL Click for Drug Monograph ) Barbiturates have more adverse effects in the elderly than most other sedative-hypnotics and are highly addictive. They should not be started as new therapy in the elderly except to control seizures. ChlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph ‡ ChlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph /amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph ClorazepateSome Trade Names TRANXENE Click for Drug Monograph Clidinium/chlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph DiazepamSome Trade Names VALIUM Click for Drug Monograph ‡ FlurazepamSome Trade Names DALMANE Click for Drug Monograph † Halazepam Nitrazepam QuazepamSome Trade Names DORAL Click for Drug Monograph These long-acting benzodiazepines have a long half-life in the elderly (often days), causing prolonged sedation and increasing risk of falls and fractures. Short- or intermediate-acting benzodiazepines are preferred if a benzodiazepine is required. DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph is potently anticholinergic and usually should not be used as a hypnotic in the elderly. When used to treat or prevent allergic reactions, it should be used in the smallest possible dose and with great caution. MeprobamateSome Trade Names EQUANIL MILTOWN Click for Drug Monograph MeprobamateSome Trade Names EQUANIL MILTOWN Click for Drug Monograph is a highly addictive and sedating anxiolytic. It should be avoided in the elderly. Elderly patients who take it for long periods may become addicted, and the drug may need to be withdrawn slowly. Other Amphetamines Anorexics These drugs may cause dependence, hypertension, angina, and MI. Amphetamines have CNS stimulant adverse effects (methylphenidateSome Trade Names CONCERTA RITALIN Click for Drug Monograph may be useful for certain elderly patients). CimetidineSome Trade Names TAGAMET Click for Drug Monograph CimetidineSome Trade Names TAGAMET Click for Drug Monograph has CNS adverse effects, including confusion. Cyclandelate Ergot mesylates These drugs in the doses studied have not been shown to be effective for treatment of dementia or any other disorder. Desiccated thyroid Cardiac effects are a concern. Safer alternatives exist. EstrogensSome Trade Names PREMARIN Click for Drug Monograph only (oral) Evidence suggests that estrogensSome Trade Names PREMARIN Click for Drug Monograph increase risk of breast and endometrial cancer and may increase risk of pulmonary embolism, stroke, and coronary artery disease in older women. Ferrous sulfateSome Trade Names FEOSOL FER-GEN-SOL FER-IN-SOL Click for Drug Monograph Doses > 325 mg/day do not substantially increase total absorption and are more likely to cause constipation. IsoxsuprineSome Trade Names VASODILAN Click for Drug Monograph IsoxsuprineSome Trade Names VASODILAN Click for Drug Monograph is not effective in the elderly. MethyltestosteroneSome Trade Names ORETON Click for Drug Monograph Adverse effects include benign prostatic hypertrophy and cardiac problems. Mineral oil Mineral oil may result in aspiration. NitrofurantoinSome Trade Names FURADANTIN MACROBID MACRODANTIN Click for Drug Monograph NitrofurantoinSome Trade Names FURADANTIN MACROBID MACRODANTIN Click for Drug Monograph is ineffective in patients with moderate to severe renal insufficiency; metabolites may cause peripheral neuropathy. Long-term use for UTI prevention can cause pulmonary fibrosis. TrimethobenzamideSome Trade Names TIGAN Click for Drug Monograph † TrimethobenzamideSome Trade Names TIGAN Click for Drug Monograph is one of the least effective antiemetics and can have extrapyramidal adverse effects. When possible, it should be avoided in the elderly. *Sometimes indicated but often misused according to the Zhan panel. †Always to be avoided according to the Zhan panel. ‡Rarely appropriate according to the Zhan panel. §Doses of alprazolamSome Trade Names XANAX Click for Drug Monograph may be higher when used to treat panic disorders. COX = cyclooxygenase; SIADH = syndrome of inappropriate antidiuretic hormone secretion. Adapted from Fick DM, Cooper JW, Wade WE, et al: Updating the Beers criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine 163:2716–2724, 2003. High-Risk Drugs in the Elderly (Based on the Beers Criteria) Class Drug Prescribing Concern Analgesics IndomethacinSome Trade Names INDOCIN Click for Drug Monograph * Of available NSAIDs, indomethacinSome Trade Names INDOCIN Click for Drug Monograph has the most CNS adverse effects and therefore should be avoided in the elderly. KetorolacSome Trade Names TORADOL Click for Drug Monograph Immediate- and long-term use should be avoided in the elderly because many of them have asymptomatic and undiagnosed GI disorders. MeperidineSome Trade Names DEMEROL Click for Drug Monograph † MeperidineSome Trade Names DEMEROL Click for Drug Monograph is not an effective oral analgesic and has many disadvantages compared with other opioids. It should be avoided in the elderly. Non–COX-selective NSAIDs (naproxenSome Trade Names ALEVE NAPROSYN Click for Drug Monograph , oxaprozinSome Trade Names DAYPRO Click for Drug Monograph , piroxicamSome Trade Names FELDENE Click for Drug Monograph ) Long-term use of the maximum dosage may cause GI bleeding, renal failure, hypertension, and heart failure. PentazocineSome Trade Names TALWIN Click for Drug Monograph † PentazocineSome Trade Names TALWIN Click for Drug Monograph is an opioid analgesic that has CNS adverse effects (eg, confusion, hallucinations) more commonly than other opioids; it is a mixed agonist/antagonist. For both reasons, it should usually be avoided in the elderly. PropoxypheneSome Trade Names DARVON DOLENE ‡ and combination products that contain it PropoxypheneSome Trade Names DARVON DOLENE should usually be avoided in the elderly. It has few analgesic advantages over acetaminophenSome Trade Names GENAPAP TYLENOL VALORIN Click for Drug Monograph but has the adverse effects of other opioids. Antidepressants Cyclic antidepressants (eg, amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph ,* doxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph *) Because of strong anticholinergic and sedating effects, amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph or doxepinSome Trade Names SINEQUAN ZONALON Click for Drug Monograph is rarely the antidepressant of choice for the elderly. FluoxetineSome Trade Names PROZAC SARAFEM Click for Drug Monograph (taken daily) FluoxetineSome Trade Names PROZAC SARAFEM Click for Drug Monograph has a long half-life, may cause excessive CNS stimulation and sleep disturbances, and may increase agitation. Safer alternative SSRIs exist. Antihistamines ChlorpheniramineSome Trade Names CHLOR-TRIMETON Click for Drug Monograph * CyproheptadineSome Trade Names PERIACTIN Click for Drug Monograph * DexchlorpheniramineSome Trade Names No US trade name Click for Drug Monograph DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph * HydroxyzineSome Trade Names ATARAX VISTARIL Click for Drug Monograph * OrphenadrineSome Trade Names NORFLEX Click for Drug Monograph PromethazineSome Trade Names PHENERGAN Click for Drug Monograph * Tripelennamine All OTC and many prescription antihistamines have potent anticholinergic properties. Antihistamines are commonly included with other drugs in cough and cold preparations. However, many cough and cold preparations without antihistamines are available; they are safer alternatives for the elderly. Antipsychotics MesoridazineSome Trade Names SERENTIL ThioridazineSome Trade Names MELLARIL Click for Drug Monograph Risk of CNS and extrapyramidal adverse effects is increased. When used to treat dementia-related behaviors, 2nd-generation (atypical) antipsychotics may increase mortality risk. Cardiovascular drugs AmiodaroneSome Trade Names CORDARONE Click for Drug Monograph Adverse effects include QTc prolongation and risk of provoking torsades de pointes. ClonidineSome Trade Names CATAPRES Click for Drug Monograph Adverse effects include orthostatic hypotension and CNS effects. DigoxinSome Trade Names DIGITEK LANOXIN Click for Drug Monograph Because renal clearance of digoxinSome Trade Names DIGITEK LANOXIN Click for Drug Monograph is decreased in the elderly, doses should rarely exceed 0.125 mg/day, unless the patient is monitored. DipyridamoleSome Trade Names PERSANTINE Click for Drug Monograph * Immediate-release dipyridamoleSome Trade Names PERSANTINE Click for Drug Monograph frequently causes orthostatic hypotension in the elderly (the controlled-release formulation in combination products may be acceptable). The immediate-release formulation is beneficial only in patients with artificial heart valves. If possible, it should be avoided in the elderly. DisopyramideSome Trade Names NORPACE Click for Drug Monograph * Of all antiarrhythmics, disopyramideSome Trade Names NORPACE Click for Drug Monograph is the most potent negative inotrope and therefore may induce heart failure in the elderly. It is also strongly anticholinergic. If antiarrhythmics are needed, others should be used. DoxazosinSome Trade Names CARDURA Click for Drug Monograph Adverse effects include hypotension, dry mouth, and urinary problems. Ethacrynic acidSome Trade Names EDECRIN Click for Drug Monograph Adverse effects include hypertension and fluid imbalances. Guanethidine Guanadrel Adverse effects include orthostatic hypotension. MethyldopaSome Trade Names ALDOMET Click for Drug Monograph * MethyldopaSome Trade Names ALDOMET Click for Drug Monograph may cause bradycardia and exacerbate depression in the elderly. Alternate treatments for hypertension are generally preferred. NifedipineSome Trade Names ADALAT PROCARDIA Click for Drug Monograph (short-acting) Adverse effects include hypotension, constipation, and reflex tachycardia. ReserpineSome Trade Names SERPASIL Click for Drug Monograph * Doses > 0.25 mg pose unnecessary risks in the elderly by inducing depression, impotence, sedation, and orthostatic hypotension. Safer alternatives exist. TiclopidineSome Trade Names TICLID Click for Drug Monograph TiclopidineSome Trade Names TICLID Click for Drug Monograph is no better than aspirinSome Trade Names BUFFERIN ECOTRIN GENACOTE Click for Drug Monograph in preventing clotting and is considerably more toxic. It should be used only as a 2nd-line drug in the elderly. GI antispasmodics Belladonna alkaloids† Clidinium/chlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph DicyclomineSome Trade Names BENTYL Click for Drug Monograph † HyoscyamineSome Trade Names HYOSINE LEVSIN Click for Drug Monograph † PropanthelineSome Trade Names PRO-BANTHINE Click for Drug Monograph † GI antispasmodics are highly anticholinergic and usually cause substantial toxicity in the elderly. Efficacy at doses tolerated by the elderly is questionable. All of these drugs are best avoided in the elderly, especially for long-term use. Hypoglycemics ChlorpropamideSome Trade Names DIABINESE Click for Drug Monograph † ChlorpropamideSome Trade Names DIABINESE Click for Drug Monograph has a prolonged half-life in the elderly and can cause prolonged, serious hypoglycemia. It is the only oral hypoglycemic that causes SIADH. It should be avoided in the elderly. Laxatives (stimulant) BisacodylSome Trade Names DULCOLAX Click for Drug Monograph Cascara Neoloid except when used with opioids With long-term use, stimulant laxatives may exacerbate bowel dysfunction. Muscle relaxants CarisoprodolSome Trade Names SOMA Click for Drug Monograph ‡ ChlorzoxazoneSome Trade Names PARAFON FORTE DSC Click for Drug Monograph ‡ CyclobenzaprineSome Trade Names FLEXERIL Click for Drug Monograph ‡ MetaxaloneSome Trade Names SKELAXIN Click for Drug Monograph ‡ MethocarbamolSome Trade Names ROBAXIN Click for Drug Monograph ‡ OxybutyninSome Trade Names DITROPAN Click for Drug Monograph * Most muscle relaxants and antispasmodics are poorly tolerated by the elderly, resulting in anticholinergic effects, sedation, and weakness. Efficacy at doses tolerated by the elderly is questionable. If possible, they should not be used in the elderly. For extended-release oxybutyninSome Trade Names DITROPAN Click for Drug Monograph , the patch is better tolerated. Sedative-hypnotics AlprazolamSome Trade Names XANAX Click for Drug Monograph *, § 2 mg LorazepamSome Trade Names ATIVAN Click for Drug Monograph 3 mg OxazepamSome Trade Names SERAX Click for Drug Monograph 60 mg TemazepamSome Trade Names RESTORIL Click for Drug Monograph 15 mg TriazolamSome Trade Names HALCION Click for Drug Monograph 0.25 mg Because sensitivity to benzodiazepines is increased in the elderly, smaller doses may be effective as well as safer; total daily doses should rarely exceed those listed. Barbiturates† (except phenobarbitalSome Trade Names LUMINAL Click for Drug Monograph ) Barbiturates have more adverse effects in the elderly than most other sedative-hypnotics and are highly addictive. They should not be started as new therapy in the elderly except to control seizures. ChlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph ‡ ChlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph /amitriptylineSome Trade Names ELAVIL ENDEP Click for Drug Monograph ClorazepateSome Trade Names TRANXENE Click for Drug Monograph Clidinium/chlordiazepoxideSome Trade Names LIBRIUM Click for Drug Monograph DiazepamSome Trade Names VALIUM Click for Drug Monograph ‡ FlurazepamSome Trade Names DALMANE Click for Drug Monograph † Halazepam Nitrazepam QuazepamSome Trade Names DORAL Click for Drug Monograph These long-acting benzodiazepines have a long half-life in the elderly (often days), causing prolonged sedation and increasing risk of falls and fractures. Short- or intermediate-acting benzodiazepines are preferred if a benzodiazepine is required. DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph DiphenhydramineSome Trade Names BENADRYL NYTOL Click for Drug Monograph is potently anticholinergic and usually should not be used as a hypnotic in the elderly. When used to treat or prevent allergic reactions, it should be used in the smallest possible dose and with great caution. MeprobamateSome Trade Names EQUANIL MILTOWN Click for Drug Monograph MeprobamateSome Trade Names EQUANIL MILTOWN Click for Drug Monograph is a highly addictive and sedating anxiolytic. It should be avoided in the elderly. Elderly patients who take it for long periods may become addicted, and the drug may need to be withdrawn slowly. Other Amphetamines Anorexics These drugs may cause dependence, hypertension, angina, and MI. Amphetamines have CNS stimulant adverse effects (methylphenidateSome Trade Names CONCERTA RITALIN Click for Drug Monograph may be useful for certain elderly patients). CimetidineSome Trade Names TAGAMET Click for Drug Monograph CimetidineSome Trade Names TAGAMET Click for Drug Monograph has CNS adverse effects, including confusion. Cyclandelate Ergot mesylates These drugs in the doses studied have not been shown to be effective for treatment of dementia or any other disorder. Desiccated thyroid Cardiac effects are a concern. Safer alternatives exist. EstrogensSome Trade Names PREMARIN Click for Drug Monograph only (oral) Evidence suggests that estrogensSome Trade Names PREMARIN Click for Drug Monograph increase risk of breast and endometrial cancer and may increase risk of pulmonary embolism, stroke, and coronary artery disease in older women. Ferrous sulfateSome Trade Names FEOSOL FER-GEN-SOL FER-IN-SOL Click for Drug Monograph Doses > 325 mg/day do not substantially increase total absorption and are more likely to cause constipation. IsoxsuprineSome Trade Names VASODILAN Click for Drug Monograph IsoxsuprineSome Trade Names VASODILAN Click for Drug Monograph is not effective in the elderly. MethyltestosteroneSome Trade Names ORETON Click for Drug Monograph Adverse effects include benign prostatic hypertrophy and cardiac problems. Mineral oil Mineral oil may result in aspiration. NitrofurantoinSome Trade Names FURADANTIN MACROBID MACRODANTIN Click for Drug Monograph NitrofurantoinSome Trade Names FURADANTIN MACROBID MACRODANTIN Click for Drug Monograph is ineffective in patients with moderate to severe renal insufficiency; metabolites may cause peripheral neuropathy. Long-term use for UTI prevention can cause pulmonary fibrosis. TrimethobenzamideSome Trade Names TIGAN Click for Drug Monograph † TrimethobenzamideSome Trade Names TIGAN Click for Drug Monograph is one of the least effective antiemetics and can have extrapyramidal adverse effects. When possible, it should be avoided in the elderly. *Sometimes indicated but often misused according to the Zhan panel. †Always to be avoided according to the Zhan panel. ‡Rarely appropriate according to the Zhan panel. §Doses of alprazolamSome Trade Names XANAX Click for Drug Monograph may be higher when used to treat panic disorders. COX = cyclooxygenase; SIADH = syndrome of inappropriate antidiuretic hormone secretion. Adapted from Fick DM, Cooper JW, Wade WE, et al: Updating the Beers criteria for potentially inappropriate medication use in older adults. Archives of Internal Medicine 163:2716–2724, 2003.

• Always to be avoided
• Rarely appropriate
• Sometimes indicated but often misused

Analgesics: NSAIDs are used by > 30% of people aged 65 to 89, and half of all NSAID prescriptions are for people > 60. Several NSAIDs are available without prescription.

The elderly may be prone to adverse effects of these drugs, and adverse effects may be more severe because of the following:

• NSAIDs are highly soluble in lipids, and because adipose tissue increases with age, distribution of the drugs is extensive.
• Plasma protein is often decreased, resulting in higher levels of unbound drug and exaggerated pharmacologic effects.
• Renal function is reduced in many of the elderly, resulting in decreased renal clearance and higher drug levels.

Serious adverse effects include peptic ulceration and upper GI bleeding; risk is increased when an NSAID is begun and when dose is increased. Risk of upper GI bleeding increases when NSAIDs are given with warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
, aspirinSome Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
, or other antiplatelet drugs (eg, clopidogrelSome Trade Names
PLAVIX
Click for Drug Monograph
). NSAIDs may increase risk of cardiovascular events and can cause fluid retention and, rarely, nephropathy.

NSAIDs can also increase BP; this effect may be unrecognized and lead to intensification of antihypertensive treatment (a prescribing cascade). Thus, clinicians should keep this effect in mind when BP increases in elderly patients and ask them about their use of NSAIDs, particularly OTC NSAIDs.

Selective COX-2 (cyclooxygenase-2) inhibitors (coxibs) cause less GI irritation and platelet inhibition than other NSAIDs. Nonetheless, coxibs have a risk of GI bleeding, especially for patients taking warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
or aspirinSome Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
(even at a low dose) and for those who have had GI events. Coxibs, as a class, appear to increase risk of cardiovascular events, but risk may vary by drug; they should be used cautiously. Coxibs have renal effects comparable to those of other NSAIDs.

Lower-risk alternatives (eg, acetaminophenSome Trade Names
GENAPAP
TYLENOL
VALORIN
Click for Drug Monograph
) should be used when possible. If NSAIDs are used in the elderly, the lowest effective dose should be used, and continued need should be reviewed frequently. If NSAIDs are used long-term, serum creatinine and BP should be monitored closely, especially in patients with other risk factors (eg, heart failure, renal impairment, cirrhosis with ascites, volume depletion, diuretic use).

Anticoagulants: Aging may increase sensitivity to the anticoagulant effect of warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
. Careful dosing and scrupulous monitoring can largely overcome the increased risk of bleeding in elderly patients taking warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
. Also, because drug interactions with warfarinSome Trade Names
COUMADIN
Click for Drug Monograph
are common, closer monitoring is necessary when new drugs are added or old ones are stopped; computer drug interaction programs should be consulted if patients take multiple drugs.

Antidepressants: Tricyclic antidepressants are effective but should rarely be used in the elderly. SSRIs and mixed serotonin/dopamineSome Trade Names
INTROPIN
Click for Drug Monograph
reuptake inhibitors are as effective as tricyclic antidepressants and cause less toxicity; however, there are some concerns about some of these drugs:

• FluoxetineSome Trade Names
  PROZAC
  SARAFEM
  Click for Drug Monograph
  : A possible disadvantage is the long elimination half-life, especially of its active metabolite.
• ParoxetineSome Trade Names
  PAXIL
  Click for Drug Monograph
  : This drug is more sedating than other SSRIs, has anticholinergic effects, and, like some other SSRIs, can inhibit hepatic cytochrome P-450 2D6 enzyme activity, possibly impairing the metabolism of several drugs, including some antipsychotics, antiarrhythmics, and tricyclic antidepressants.
• SertralineSome Trade Names
  ZOLOFT
  Click for Drug Monograph
  : This drug is more activating; diarrhea is a common adverse effect.

Doses of these drugs should be reduced by up to 50%. Many SSRIs are available, but data on their use in the elderly are sparse.

Antihyperglycemics: Doses of antihyperglycemics should be titrated carefully in patients with diabetes mellitus. Risk of hypoglycemia due to sulfonylureas may increase with age. ChlorpropamideSome Trade Names
DIABINESE
Click for Drug Monograph
is not recommended because elderly patients are at increased risk of hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and because the drug's long duration of action is dangerous if adverse effects or hypoglycemia occurs. Risk of hypoglycemia is greater with glyburideSome Trade Names
DIABETA
GLYNASE
MICRONASE
Click for Drug Monograph
than with other oral antihyperglycemics because like chlorpropamideSome Trade Names
DIABINESE
Click for Drug Monograph
, it is eliminated by the kidneys, and clearance can be reduced when renal function is impaired.

MetforminSome Trade Names
GLUCOPHAGE
Click for Drug Monograph
, a biguanide excreted by the kidneys, increases peripheral tissue sensitivity to insulin and can be effective given alone or with sulfonylureas. Risk of lactic acidosis, a rare but serious complication, increases with degree of renal impairment and with patient age. Heart failure is a contraindication.

Antihypertensives: In many elderly patients, lower starting doses of antihypertensives may be necessary to reduce risk of adverse effects; however, for most elderly patients with hypertension, achieving BP goals requires standard doses and multidrug therapy. Initially, a thiazide-type diuretic is usually given alone or with one of the other classes shown to be beneficial (ACE inhibitors, angiotensin II receptor blockers, β-blockers, Ca channel blockers). Short-acting dihydropyridines (eg, nifedipineSome Trade Names
ADALAT
PROCARDIA
Click for Drug Monograph
) may increase mortality risk and should not be used. Sitting and standing BP can be monitored, particularly when multiple antihypertensives are used, to check for orthostatic hypotension, which may increase risk of falls and fractures.

Antiparkinsonian drugs: Levodopa clearance is reduced in elderly patients, who are also more susceptible to the drug's adverse effects, particularly orthostatic hypotension and confusion. Therefore, elderly patients should be given a lower starting dose of levodopa and carefully monitored for adverse effects (see Movement and Cerebellar Disorders: Levodopa). Patients who become confused while taking levodopa may also not tolerate newer dopamineSome Trade Names
INTROPIN
Click for Drug Monograph
agonists (eg, pramipexoleSome Trade Names
MIRAPEX
Click for Drug Monograph
, ropiniroleSome Trade Names
REQUIP
Click for Drug Monograph
). Because elderly patients with parkinsonism may be cognitively impaired, anticholinergic drugs should be avoided.

Antipsychotics: In nonpsychotic, agitated patients, antipsychotics control symptoms only marginally better than placebos and can have severe adverse effects. Antipsychotics should be reserved for psychosis.

When an antipsychotic is used, the starting dose should be about one quarter the usual starting adult dose and should be increased gradually. Clinical trial data relating to dosing, efficacy, and safety of these drugs in the elderly are limited.

Antipsychotics can reduce paranoia but may worsen confusion (see also Schizophrenia and Related Disorders: Conventional antipsychotics). Elderly patients, especially women, are at increased risk of tardive dyskinesia, which is often irreversible. Sedation, orthostatic hypotension, anticholinergic effects, and akathisia (subjective motor restlessness) can occur in up to 20% of elderly patients taking an antipsychotic, and drug-induced parkinsonism can persist for up to 6 to 9 mo after the drug is stopped.

The FDA has issued a warning regarding the use of 2nd-generation (atypical) antipsychotics, once thought to be safer, in the treatment of behavioral disorders in elderly patients with dementia; a review of placebo-controlled studies has shown a higher mortality rate associated with their use. Extrapyramidal dysfunction can develop when 2nd-generation antipsychotics (eg, olanzapineSome Trade Names
ZYPREXA
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, quetiapineSome Trade Names
SEROQUEL
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, risperidoneSome Trade Names
RISPERDAL
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) are used, especially at higher doses. Risks and benefits of using an antipsychotic should be discussed with the patient or the person responsible for the patient's care.

Anxiolytics and hypnotics: Treatable causes of insomnia should be sought and managed before using hypnotics (see also Sleep and Wakefulness Disorders: Hypnotics). Nonpharmacologic measures and sleep hygiene (eg, avoiding caffeinated beverages, limiting daytime napping, modifying bedtime) should be tried first. If they are ineffective, nonbenzodiazepine hypnotics (eg, the imidazopyridines, alpidem and zolpidemSome Trade Names
AMBIEN
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) are options. These drugs bind mainly to a benzodiazepine receptor subtype. Imidazopyridines disturb the sleep pattern less than benzodiazepines and have a more rapid onset, fewer rebound effects, fewer next-day effects, and less potential for dependence. Short- or intermediate-acting benzodiazepines with half-lives of < 24 h (eg, alprazolamSome Trade Names
XANAX
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, lorazepamSome Trade Names
ATIVAN
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, oxazepamSome Trade Names
SERAX
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, temazepamSome Trade Names
RESTORIL
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) are preferable to long-acting benzodiazepines but may have adverse effects, including those that lead to falls and fractures.

Longer-acting benzodiazepines (eg, clonazepamSome Trade Names
KLONOPIN
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, diazepamSome Trade Names
VALIUM
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, flurazepamSome Trade Names
DALMANE
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) should be avoided because they have active metabolites, are likely to accumulate, and have adverse effects (eg, drowsiness, impaired memory, impaired balance leading to falls and fractures).

Duration of anxiolytic or hypnotic therapy should be limited if possible because tolerance and dependence may develop; withdrawal may lead to rebound anxiety or insomnia.

Antihistamines (eg, diphenhydramineSome Trade Names
BENADRYL
NYTOL
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, hydroxyzineSome Trade Names
ATARAX
VISTARIL
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) are not recommended as anxiolytics or hypnotics because they have anticholinergic effects.

BuspironeSome Trade Names
BUSPAR
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, a partial serotonin agonist, can be effective for general anxiety disorder; elderly patients tolerate doses up to 30 mg/day well. The slow onset of anxiolytic action (up to 2 to 3 wk) can be a disadvantage in urgent cases.

Digoxin: DigoxinSome Trade Names
DIGITEK
LANOXIN
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, a cardiac glycoside, is used to increase the force of myocardial contractions and to treat supraventricular arrhythmias. However, it must be used with caution in patients with heart failure. In men with heart failure and a left ventricular ejection fraction of ≤ 45%, serum digoxinSome Trade Names
DIGITEK
LANOXIN
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levels > 0.8 ng/mL are associated with increased mortality risk. Adverse effects are typically related to its narrow therapeutic index. One study found digoxinSome Trade Names
DIGITEK
LANOXIN
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to be beneficial in women when serum levels were 0.5 to 0.9 ng/mL but possibly harmful when levels were ≥ 1.2 ng/mL. A number of factors increase the likelihood of digoxinSome Trade Names
DIGITEK
LANOXIN
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toxicity in the elderly. Renal impairment, temporary dehydration, and NSAID use (all common among the elderly) can reduce renal clearance of digoxinSome Trade Names
DIGITEK
LANOXIN
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. Furthermore, digoxinSome Trade Names
DIGITEK
LANOXIN
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clearance decreases an average of 50% in elderly patients with normal serum creatinine levels. Also, if lean body mass is reduced, as may occur with aging, volume of distribution for digoxinSome Trade Names
DIGITEK
LANOXIN
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is reduced. Therefore, starting doses should be low (0.125 mg/day) and adjusted according to response and serum digoxinSome Trade Names
DIGITEK
LANOXIN
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levels (normal range 0.8 to 2.0 ng/mL). However, serum digoxinSome Trade Names
DIGITEK
LANOXIN
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level does not always correlate with likelihood of toxicity.

Diuretics: Lower doses of thiazide diuretics (eg, hydrochlorothiazideSome Trade Names
ESIDRIX
HYDRODIURIL
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or chlorthalidoneSome Trade Names
HYGROTON
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12.5 to 25 mg) can effectively control hypertension in many elderly patients and have less risk of hypokalemia and hyperglycemia than other diuretics (see also Hypertension: Diuretics). Thus, K supplements may be required less often.

K-sparing diuretics should be used with caution in the elderly; the K level must be carefully monitored, particularly when these diuretics are given with ACE inhibitors.

Last full review/revision September 2009 by J. Mark Ruscin, PharmD

Content last modified February 2012