Table 4   . 2002 Criteria for potentially inappropriate medication use in older adults: independent of diagnoses or conditions

Propoxyphene (Darvon) and combination products (Darvon with ASA, Darvon-N, and Darvocet-N)

Offers few analgesic advantages over acetaminophen, yet has the adverse effects of other narcotic drugs .

Low

Indomethacin (Indocin and Indocin SR)

Of all available nonsteroidal anti-inflammatory drugs , this drug produces the most CNS adverse effects.

High

Pentazocine (Talwin)

Narcotic analgesic that causes more CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs . Additionally, it is a mixed agonist and antagonist.

High

Trimethobenzamide (Tigan)

One of the least effective antiemetic drugs , yet it can cause extrapyramidal adverse effects.

High

Muscle relaxants and antispasmodics: methocarbamol (Robaxin), carisoprodol (Soma), chlorzoxazone (Paraflex), metaxalone (Skelaxin), cyclobenzaprine (Flexeril), and oxybutynin (Ditropan). Do not consider the extended-release Ditropan XL

Most muscle relaxants and antispasmodic drugs are poorly tolerated by elderly patients, since these cause anticholinergic adverse effects, sedation, and weakness. Additionally, their effectiveness at doses tolerated by elderly patients is questionable.

High

Flurazepam (Dalmane)

This benzodiazepine hypnotic has an extremely long half-life in elderly patients (often days), producing prolonged sedation and increasing the incidence of falls and fracture. Medium-or short-acting benzodiazepines are preferable.

High

Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol), and perphenazine-amitriptyline (Triavil)

Because of its strong anticholinergic and sedation properties, amitriptyline is rarely the antidepressant of choice for elderly patients.

High

Doxepin (Sinequan)

Because of its strong anticholinergic and sedating properties, doxepin is rarely the antidepressant of choice for elderly patients.

High

Meprobamate (Miltown and Equanil)

This is a highly addictive and sedating anxiolytic. Those using meprobamate for prolonged periods may become addicted and may need to be withdrawn slowly.

High

Doses of short-acting benzodiazepines: doses greater than lorazepam (Ativan), 3 mg; oxazepam (Serax), 60 mg; alprazolam (Xanax), 2 mg; temazepam (Restoril), 15 mg; and triazolam (Halcion), 0.25 mg

Because of increased sensitivity to benzoadiazepines in elderly patients, smaller doses may be effective as well as safer. Total daily doses should rarely exceed the suggested maximums.

High

Long-acting benzodiazepines: chlordiazepoxide (Librium), chlordiazepoxide-amitriptyline (Limbitrol) clidinium-chlordiazepoxide (Librax), diazepam (Valium), quazepam (Doral), halazepam (Paxipam), and chlorazepate (Tranxene)

These drugs have a long half-life in elderly patients (often several days), producing prolonged sedation and increasing the risk of falls and fractures. Short- and intermediate-acting benzodiazepines are preferred if a benzodiazepine is required.

High

Disopyramide (Norpace and Norpace CR)

Of all antiarrhythmic drugs , this is the most potent negative inotrape and therefore may induce heart failure in elderly patients. It is also strongly anticholinergic. Other antiarrhythmic drugs should be used.

High

Digoxin (Lanoxin) (should not exceed >0.125 mg/d except when treating atrial arrhythmias)

Decreased renal clearance may lead to increased risk of toxic effects.

Low

Short-acting dipyridamole (Persantine). Do not consider the long-acting dipyridamole (which has better properties than the short-acting in older adults) except with patients with artificial heart valves

May cause orthostatic hypotension.

Low

Methyldopa (Aldomet) and methyldopa-hydrochlorothiazide (Aldoril)

May cause bradycardia and exacerbate depression in elderly patients.

High

Reserpine at doses >0.25 mg

May induce depression, impotence, sedation, and orthostatic hypotension.

Low

Chlorpropamide (Diabinese)

It has a prolonged half-life in elderly patients and could cause prolonged hypoglycemia. Additionally, it is the only oral hypoglycemic agent that causes SIADH.

High

Gastrointestinal antispasmodic drugs : dicyclomine (Bentyl), hyoscyamine (Levsin and Levsinex), propantheline (Pro-Banthine), belladonna alkaloids (Donnatal and others), and clidinium-chlordiazepoxide (Librax)

GI antispasmodic drugs are highly anticholinergic and have uncertain effectiveness. These drugs should be avoided (especially for long-term use).

High

Anticholinergics and antihistamines: chlorpheniramine (Chlor-Trimeton), diphenhydramine (Benadryl), hydroxyzine (Vistaril and Atarax), cyproheptadine (Periactin), promethazine (Phenergan), tripelennamine, dexchlorpheniramine (Polaramine)

All nonprescription and many prescription antihistamines may have potent anticholinergic properties. Nonanticholinergic antihistamines are preferred in elderly patients when treating allergic reactions.

High

Diphenhydramine (Benadryl)

May cause confusion and sedation. Should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.

High

Ergot mesyloids (Hydergine) and cyclandelate (Cyclospasmol)

Have not been shown to be effective in the doses studied.

Low

Ferrous sulfate >325 mg/d

Doses >325 mg/d do not dramatically increase the amount absorbed but greatly increase the incidence of constipation.

Low

All barbiturates (except phenobarbital) except when used to control seizures

Are highly addictive and cause more adverse effects than most sedative or hypnotic drugs in elderly patients.

High

Meperidine (Demerol)

Not an effective oral analgesic in doses commonly used. May cause confusion and has many disadvantages to other narcotic drugs .

High

Ticlopidine (Ticlid)

Has been shown to be no better than aspirin in preventing clotting and may be considerably more toxic. Safer, more effective alternatives exist.

High

Ketorolac (Toradol)

Immediate and long-term use should be avoided in older persons, since a significant number have asymptomatic GI pathologic conditions.

High

Amphetamines and anorexic agents

These drugs have potential for causing dependence, hypertension, angina, and myocardial infarction.

High

Long-term use of full-dosage, longer half-life, non-COX-selective NSAIDs: naproxen (Naprosyn, Avaprox, and Aleve), oxaprozin (Daypro), and piroxicam (Feldene)

Have the potential to produce GI bleeding, renal failure, high blood pressure, and heart failure.

High

Daily fluoxetine (Prozac)

Long half-life of drug and risk of producing excessive CNS stimulation, sleep disturbances, and increasing agitation. Safer alternatives exist.

High

Long-term use of stimulant laxatives: bisacodyl (Dulcolax), cascara sagrada, and Neoloid except in the presence of opiate analgesic use

May exacerbate bowel dysfunction.

High

Amiodarone (Cordarone)

Associated with QT interval problems and risk of provoking torsades de pointes. Lack of efficacy in older adults.

High

Orphenadrine (Norflex)

Causes more sedation and anticholinergic adverse effects than safer alternatives.

High

Guanethidine (Ismelin)

May cause orthostatic hypotension. Safer alternatives exist.

High

Guanadrel (Hylorel)

May cause orthostatic hypotension.

High

Cyclandelate (Cyclospasmol)

Lack of efficacy.

Low

Isoxsurpine (Vasodilan)

Lack of efficacy.

Low

Nitrofurantoin (Macrodantin)

Potential for renal impairment. Safer alternatives available.

High

Doxazosin (Cardura)

Potential for hypotension, dry mouth, and urinary problems.

Low

Methyltestosterone (Android, Virilon, and Testrad)

Potential for prostatic hypertrophy and cardiac problems.

High

Thioridazine (Mellaril)

Greater potential for CNS and extrapyramidal adverse effects.

High

Mesoridazine (Serentil)

CNS and extrapyramidal adverse effects.

High

Short acting nifedipine (Procardia and Adalat)

Potential for hypotension and constipation.

High

Clonidine (Catapres)

Potential for orthostatic hypotension and CNS adverse effects.

Low

Mineral oil

Potential for aspiration and adverse effects. Safer alternatives available.

High

Cimetidine (Tagamet)

CNS adverse effects including confusion.

Low

Ethacrynic acid (Edecrin)

Potential for hypertension and fluid imbalances. Safer alternatives available.

Low

Desiccated thyroid

Concerns about cardiac effects. Safer alternatives available.

High

Amphetamines (excluding methylphenidate hydrochloride and anorexics)

CNS stimulant adverse effects.

High

Estrogens only (oral)

Evidence of the carcinogenic (breast and endometrial cancer) potential of these agents and lack of cardioprotective effect in older women.

Low

Fick DM, Cooper JW, Wade WE, et al. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Results of a US Consensus Panel of Experts. Arch Intern Med 2003;163:2719-20; permission.