Understanding the Beers Criteria
For older adults, medication management becomes a nuanced and crucial aspect of healthcare. As the body changes with age, the way it processes and eliminates drugs also shifts. Many medications that were safe and effective for younger individuals can become risky for those over 65, potentially causing serious side effects such as falls, confusion, and other health complications. To address this, the American Geriatrics Society (AGS) maintains the Beers Criteria, a widely recognized guideline listing potentially inappropriate medications (PIMs) for older adults. The Beers Criteria is a critical tool for healthcare providers, patients, and caregivers to ensure safer prescribing and medication management.
The criteria categorize medications that should be avoided in most older adults, those to be used with caution, those to avoid with specific diseases or syndromes, and those with potentially harmful drug-drug interactions. It is important to note that the Beers Criteria are guidelines and not absolute rules; a healthcare provider’s clinical judgment, based on a patient’s individual health, goals, and preferences, is still essential. However, being aware of these recommendations is the first step toward informed decision-making.
Key Medication Categories to Avoid
Several classes of drugs are frequently flagged by the Beers Criteria due to their high-risk profile in older adults. These include both prescription and common over-the-counter (OTC) medications. Understanding these groups is vital for all seniors and their caregivers.
Anticholinergic Medications
Anticholinergics block the neurotransmitter acetylcholine, affecting many bodily functions. For seniors, these medications can increase the risk of confusion, drowsiness, dry mouth, constipation, and blurred vision, which can lead to falls and injuries. The risk is cumulative, meaning taking multiple anticholinergic medications increases the total 'anticholinergic burden' and risk of harm. Potent anticholinergic medications include:
- Certain antihistamines: Diphenhydramine (found in Benadryl, Tylenol PM, Advil PM, and many cold remedies) and chlorpheniramine are strongly advised against for routine use.
- Some antidepressants: Older tricyclic antidepressants like amitriptyline and imipramine are highly anticholinergic and should generally be avoided.
- Overactive bladder medications: Drugs like oxybutynin can cause significant anticholinergic side effects.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Long-term or high-dose use of NSAIDs, such as ibuprofen and naproxen, is not recommended for older adults. These drugs can increase the risk of stomach ulcers, bleeding, kidney problems, and can worsen heart failure. For pain relief, alternatives like acetaminophen may be safer, but should still be used with caution and at recommended doses.
Benzodiazepines and Z-Drugs
Benzodiazepines (e.g., alprazolam, diazepam, lorazepam) and non-benzodiazepine hypnotics, often called Z-drugs (e.g., zolpidem, eszopiclone), are used for anxiety and insomnia. However, they are highly associated with increased risk of falls, fractures, cognitive impairment, and dependence in older adults. Safer, non-pharmacological alternatives for sleep and anxiety are often recommended first.
Muscle Relaxants
Skeletal muscle relaxants, including carisoprodol and cyclobenzaprine, are generally not recommended for seniors. These medications can cause sedation, fatigue, and have anticholinergic effects, which elevate the risk of falls. Their efficacy in older adults is also often questionable.
Other Potentially Inappropriate Medications
- Certain diabetes drugs: Long-acting sulfonylureas like glyburide can cause dangerously low blood sugar (hypoglycemia).
- Certain antipsychotics: Antipsychotics should be avoided for behavioral problems associated with dementia due to an increased risk of stroke, cognitive decline, and mortality, unless non-pharmacological options have failed.
- Meperidine: This opioid pain reliever is not recommended for older adults due to risks of neurotoxicity and confusion.
- Proton-Pump Inhibitors (PPIs): Long-term use (more than 8 weeks) of PPIs like omeprazole is linked to increased risk of bone loss, fractures, and C. difficile infection.
Medication Alternatives and Safer Practices
It's crucial to explore safer alternatives and practices with a healthcare provider to minimize risks associated with certain medications. This requires a proactive, collaborative approach to care.
Comparison of Potentially Inappropriate Medications vs. Safer Alternatives
| Condition | Meds to Avoid (Examples) | Risks | Safer Alternatives / Practices |
|---|---|---|---|
| Allergies/Insomnia | Diphenhydramine (Benadryl, Tylenol PM) | High anticholinergic effects, confusion, falls, constipation, dry mouth | Second-generation antihistamines (e.g., cetirizine, fexofenadine), sleep hygiene practices |
| Pain/Inflammation | NSAIDs (Ibuprofen, Naproxen) | GI bleeding, kidney problems, heart failure exacerbation | Acetaminophen, topical pain relievers, non-drug methods like physical therapy |
| Anxiety/Insomnia | Benzodiazepines (Diazepam, Lorazepam), Z-drugs (Zolpidem) | Cognitive impairment, delirium, falls, fractures, dependency | CBT for insomnia, relaxation techniques, antidepressants (e.g., SSRIs) for anxiety |
| Overactive Bladder | Oxybutynin | High anticholinergic effects, confusion, constipation | Pelvic exercises, timed voiding, some newer medications with lower anticholinergic burden |
How to Reduce Risks and Optimize Medication Use
To ensure safer medication use in your later years, follow these actionable steps:
- Medication Review: Regularly review your full medication list with a doctor or pharmacist. This includes all prescriptions, OTC drugs, and supplements. Ask about each medication's necessity, dosage, potential side effects, and risks, especially concerning drug-drug interactions.
- Deprescribing: In consultation with your healthcare provider, consider a process of deprescribing, which involves reducing or discontinuing a medication when its risks outweigh its benefits. This is a guided process and should never be done without medical supervision.
- Non-Drug Strategies: Before turning to medication for conditions like insomnia or pain, explore non-pharmacological approaches. Cognitive Behavioral Therapy (CBT), improved sleep hygiene, exercise, and physical therapy are effective alternatives with fewer risks.
- Awareness of Anticholinergic Burden: Discuss your total anticholinergic burden with your provider. For example, using an overactive bladder medication and a nighttime antihistamine together can dramatically increase side effects. The ACB Calculator is a tool that can help identify and quantify this risk.
- Stay Informed: Keep up-to-date on changes to medication guidelines. Organizations like the AGS periodically update their Beers Criteria based on new evidence. A useful resource for information is the Health in Aging Foundation, run by the American Geriatrics Society, which provides patient-friendly resources on medication safety, available at: https://www.healthinaging.org.
Conclusion
While many medications are critical for managing health conditions, seniors must be vigilant about the potential risks. What medication is not recommended for patients over 65 is not a simple question with a single answer but involves a personalized risk-benefit assessment for each individual. By understanding key problematic drug classes, adhering to expert guidelines like the Beers Criteria, and maintaining an open dialogue with healthcare providers, older adults can significantly reduce their risk of adverse drug events. Regular medication reviews, exploring non-pharmacological treatments, and focusing on deprescribing when appropriate are all crucial steps toward safer, healthier aging. Empowering yourself with knowledge is the best defense against medication-related harm.
