The document discusses pharmacotherapy and adherence to Beers criteria in the elderly. It provides an overview of medication use challenges in older adults, including age-related changes to pharmacokinetics and pharmacodynamics. It also discusses tools to evaluate inappropriate medications like Beers criteria and STOPP/START criteria. Beers criteria lists potentially inappropriate medications or classes to avoid in older adults due to risks of adverse effects. STOPP/START criteria addresses medications that should be avoided as well as those that should be considered.

1. Pharmacotherapy and
Adherence to Beers Criteria
Leonardo Rosario-Colón, Pharm.D., R.Ph.,
B.S.

2. Objectives
 Goals and Objectives: The goal of this activity
is to help providers in all settings develop a
better knowledge base on medication use in
the elderly.
 Upon completion of this activity, providers will
be able to:
 Discuss the advantages and disadvantages of
Beers criteria for guiding drug therapy in the
elderly.
 Use tools such as START/STOPP to choose the
most appropriate drug therapy in elderly patients.
2

3. MEDICATION USE IN THE
ELDERLY

4. Medication Use in the Elderly
4
 Prescribing for older patients presents unique
challenges:
 Premarketing drug trials often exclude geriatric
patients.
 Approved doses may not be appropriate for older
adults
 Special caution because of age-related changes.
 Pharmacokinetics (absorption, distribution,
metabolism, and excretion)
 Pharmacodynamics (the physiologic effects of the
drug)
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

5. Medication Use in the Elderly
(cont.)5
 Increased volume of distribution.
 Proportional increase in body fat relative to
skeletal muscle with aging.
 Diazepam
 Decreased drug clearance.
 Natural decline in renal function with age, even in
the absence of renal disease.
 Prolong drug half-lives and lead to increased
plasma drug concentrations in older people.
 Lithium
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

6. Medication Use in the Elderly
(cont.)6
 Decline in hepatic function.
 Significant variability in drug metabolism.
 May lead to adverse drug reactions (ADRs) when
polypharmacy is a factor.
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

7. Quality of Drug Prescribing
7
 Multiple factors contribute to the
appropriateness and overall quality of drug
prescribing:
 Avoidance of inappropriate medications
 Appropriate use of indicated medications
 Monitoring for side effects and drug levels
 Avoidance of drug-drug interactions
 Involvement of the patient
 Integration of patient values
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

8. Quality of Drug Prescribing
(cont.)
 Approximately 40% of patients over 60 years old
take at least 5 medications.
 Elderly patients account for about 25% of
emergency department visits due to adverse drug
events.
 Avoidable adverse drug events (ADEs) are the
serious consequences of inappropriate drug
prescribing.
 Any new symptom should be considered drug-related
until proven otherwise.
8
Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med 2004;164:305-12.
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

9. Inappropriate Medications
9
 Various criteria have been developed by
expert panels
 Assess the quality of prescribing practices and
medication use in older adult individuals.
 The most widely used criteria for inappropriate
medications are the Beers criteria.
 Other Tools:
 STOPP/START Criteria
 Drug Burden Index
 FORTA (Fit FOR The Aged) List
 Among others…
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

10. Impact of Inappropriate
Drugs10
 Several studies have identified that the use of drugs
identified as "inappropriate" is widespread in the
United States, Canada, and Europe.
 One study found that 43% of the sample used at least
one medication that would be deemed potentially
 Nonsteroidal antiinflammatory drugs (NSAIDs) being the
most common.
 Another study, using Medicare data, found that the
point prevalence in each calendar month of potentially
inappropriate medications used in adults ≥65 years
was 34.2%.
Rochon, Paula A (2016). Drug Prescribing for Older Adults. UpToDate. Available from: http://www.uptodate.com/contents/drug-prescribing-for-older-adults

11. BEERS CRITERIA

12. Beers Criteria
 Originally created by Dr. Mark Beers (Geriatrician)
 Published by the American Geriatrics Society in
1991
 last updated in 2015
 List of potentially inappropriate medications for
use in older adults (≥65 years)
 effort to decrease the risk of adverse events
 Intended for use in all ambulatory, acute, and
institutionalized settings of care
 except hospice and palliative care
12
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

13. Beers Criteria (cont.)
13
 Some notable changes in the 2015 listings:
 Removal of Loratadine from the list of medications
with strong anticholinergic properties.
 More liberal renal threshold (now creatinine clearance
<30 rather than <60 mL/min) for withholding
nitrofurantoin.
 Avoidance of long-term proton pump inhibitors
because of risk of Clostridium difficile infections and
bone loss and fractures.
 Stricter guidelines to avoid antipsychotics for
behavioral problems unless other options have failed
and the older adult is threatening harm to self or
others.American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

14. Designations of Quality of
Evidence and Strength of
Recommendations14
 Quality of Evidence
 High - evidence includes consistent results
 Moderate - evidence is sufficient to determine risks
 Low - evidence is insufficient to assess harms or
risks
 Strength of Recommendation
 Strong - benefits clearly outweigh harms
 Weak - benefits may not outweigh harms
 Insufficient - evidence inadequate to determine net
harmsAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

15. Potentially Inappropriate Medications
(PIM)
15
Drugs Rationale Recommendation
Anticholinergics
(1st Generation)
Diphenhydramine
Hydroxyzine
Promethazine
Risk of confusion, dry
mouth and constipation
Avoid
Antiparkinson
Benztropine
Trihexyphenidyl
Not recommended for
prevention of
extrapyramidal symptoms
with antipsychotics
Avoid
Antispasmodics
Dicyclomine
Highly anticholinergic Avoid
Anti-infective
Nitrofurantoin
Potential for pulmonary
toxicity, hepatotoxicity and
peripheral neuropathy
Avoid when CrCl <
30mL/min or long term use
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

16. PIM - Cardiovascular
16
Drugs Rationale Recommendation
Peripheral alpha-1
blockers
Terazosin
High risk of orthostatic
hypotension
Avoid use as
antihypertensive
Central alpha blockers
Clonidine
Methyldopa
High risk of adverse CNS
effects, bradycardia and
orthostatic hypotension
Avoid Clonidine as 1st line
Avoid others
Digoxin Use in atrial fibrillation:
may increase mortality
Use in heart failure: higher
doses not associated with
additional benefit and may
increase toxicity
Renal patients: adjust dose
in stage 4-5 CKD
Avoid as 1st line
Avoid as 1st line
Avoid dosages >
0.125mg/dAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

17. PIM – Cardiovascular cont.
17
Drugs Rationale Recommendation
Amiodarone Higher toxicities than other
antiarrhythmics
Avoid as 1st line for atrial
fibrillation unless patient
has heart failure or
substantial left ventricular
hypertrophy
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

18. PIM – Central Nervous
System18
Drugs Rationale Recommendation
Antidepressants (alone or
in combination)
Amitriptyline
Doxepin > 6 mg/d
Imipramine
Nortriptyline
Paroxetine
Highly anticholinergic,
sedating and cause
orthostatic hypotension
Avoid
Antipsychotics
Conventional and Atypical
(see Mental Health PDL)
Increase risk of
cerebrovascular accident
and greater rate of
cognitive decline and
mortality in persons with
dementia
Avoid except for
schizophrenia, bipolar
disorder, or short-term use
as antiemetic during
chemotherapy
Barbiturates
Butalbital
Phenobarbital
High rate of dependence,
tolerance to sleep benefits,
and greater risk of
Avoid
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

19. PIM – CNS cont.
19
Drugs Rationale Recommendation
Benzodiazepines – Short
/ Intermediate Acting
Lorazepam
Temazepam
Increase risk of cognitive
impairment, delirium, falls,
fractures, and motor
vehicle crashes
Avoid
Benzodiazepine – Long
Acting
Clonazepam
Diazepam
Flurazepam
Increase risk of cognitive
impairment, delirium, falls,
fractures, and motor
vehicle crashes
May be appropriate for
seizure disorders, rapid
eye movement sleep
disorder, severe
generalized anxiety
disorder, and
periprocedural anesthesia
Non-benzodiazepine
Hypnotics
Zolpidem
Increase risk of delirium,
falls, and fractures.
Minimal improvement in
sleep latency and duration.
Avoid
Ergoloid mesylate Lack of efficacy AvoidAmerican Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

20. PIM - Endocrine
20
Drugs Rationale Recommendation
Androgens
Testosterone
Potential for cardiac
problems, contraindicated
in prostate cancer
Avoid, unless indicated for
confirmed hypogonadism
with clinical symptoms
Estrogens with or
without progestins
Estradiol
Estradiol - Norethindrone
Estropipate
Carcinogenic potential,
lack of cardioprotective
effect and cognitive
protection
Avoid oral and topical
patch
Vaginal use: acceptable at
low dosages
Growth hormone
Somatropin
Impact on body
composition is small and
associated with edema,
arthralgia, carpal tunnel
syndrome, impaired fasting
glucose
Avoid, except as hormone
replacement after pituitary
gland removal
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

21. PIM – Endocrine cont.
21
Drugs Rationale Recommendation
Insulin sliding scale Higher risk of
hypoglycemia without
improvement in
hyperglycemia
management regardless of
care setting
Avoid
Megestrol Minimal effect on weight;
increases risk of
thrombotic events and
possibly death in older
adults
Avoid
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

22. PIM - Gastrointestinal
22
Drugs Rationale Recommendation
Metoclopramide Can cause extrapyramidal
effects, including tardive
dyskinesia; risk may be
greater in frail older adults
Avoid, unless for
gastroparesis
Proton-pump inhibitors
Omeprazole
Risk if Clostridium difficile
infection and bone loss
and fractures
Avoid scheduled use for >
8 weeks unless for high-
risk patients
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

23. PIM – Pain Medication
23
Drugs Rationale Recommendation
Meperidine May have higher risk of
neurotoxicity, including
delirium, than other opioids
Avoid, especially in
individuals with CKD
Non-cyclooxygenase-
selective NSAIDS, oral:
Aspirin > 325 mg/d
Diclofenac
Ibuprofen
Nabumetone
Naproxen
Sulindac
Increased risk of
gastrointestinal bleeding
for peptic ulcer disease in
high risk groups
Avoid chronic use, unless
other alternatives are not
effective and patient can
take gastroprotective agent
(PPI or Misoprostol)
Indomethacin
Ketorolac
More likely to have CNS
and kidney adverse effects
Avoid
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

24. PIM – Pain Medications cont.
24
Drugs Rationale Recommendation
Skeletal Muscle
Relaxants –
Cyclobenzaprine
Most are poorly tolerated
by older adults, sedation,
anticholinergic effects, and
increase risk of fractures
Avoid
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

25. PIM - Genitourinary
25
Drugs Rationale Recommendation
Desmopressin High risk of hyponatremia Avoid for treatment of
nocturia or nocturnal
polyuria
American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46

26. STOPP/ START CRITERIA

27. STOPPing/STARTing Medications in the
Elderly
 Beers Criteria does not address some
medications that should be avoided in the
elderly, drug interactions, duplications, and
underprescribing
 STOPP (Screening Tool of Older Persons’
potentially inappropriate Prescritptions)
 START (Screening Tool to Alert doctors to
Right Treatment)
27
PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

28. Select Safer Alternatives
PL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.
28
STOPP START
Colchicine Allopurinol
Systemic corticosteroids DMARD (Rheumatoid Arthritis)
Acetaminophen, topicals (Osteoarthritis)
Inhaled corticosteroids and/or bronchodilator
(COPD)
Opioids Acetaminophen or NSAID (Mild/Moderate pain)
Non-selective Beta Blockers
(COPD)
Atenolol (Cardioselective Beta Blockers)
Benzodiazepines Anxiety – low doseshorter acting (Lorazepam),
SSRI or SNRI
Sleep – Low dose Temazepam or Zolpidem
Glyburide Glimepiride or Glipizide

29. Consider STARTing…
29
 Cardiovascular:
 Metformin – patients with Type 2 Diabetes
 ACEI or ARB – heart failure, post-MI, diabetic
neuropathy
 Aspirin – prevention in diabetes with at least one
major cardiovascular risk factor
 Statin – patients with cardiovascular,
cerebrovascular, or peripheral vascular disease,
and diabetes plus additional cardiovascular risk
factor
 Calcium and Vitamin D – patients with
osteoporosisPL Detail-Document, STARTing and STOPPing Medications in the Elderly. Pharmacist’s Letter/Prescriber’s Letter. September 2011.

30. Summary and
Recommendations30
 Various criteria sets exist for identifying
medications that should not be prescribed, or
should be prescribed with caution, in older
adults.
 ADEs result in four times as many
hospitalizations in older, compared with
younger, adults.
 NSAIDS, atypical antipsychotic medications
and Warfarin are the most common drugs
involved in ADEs in the elderly.

31. Summary and Recommendations
(cont.)31
 A stepwise approach to prescribing for older
adults should include:
 Periodic review of current drug therapy
 Discontinuing unnecessary medications
 Considering nonpharmacologic alternative
strategies
 Considering safer alternative medications
 Using the lowest possible effective dose
 Including all necessary beneficial medications.

32. QUESTIONS?

33. Pre- and Post- Test
1. According to Beers criteria, which of the
following is not a concern with using Proton
Pump Inhibitors ?
a. Risk of Clostridium difficile infection.
b. Risk of neurotoxicity.
c. Risk of bone fractures.
d. Risk of bone loss.

34. Pre- and Post- Test
1. According to Beers criteria, which of the
following is not a concern with using Proton
Pump Inhibitors ?
b. Risk of neurotoxicity.

35. Pre- and Post- Test
2. A 66 y/o man who has a history of Type 2
Diabetes, smoker and hypertension. Based
on given information and assuming no
contraindications, what medications regimen
will be best for this patient?
a. Glyburide, Aspirin and ACEI.
b. Metformin, Statin and Clonidine.
c. Glyburide, Aspirin and Doxazosin.
d. Metformin, Statin, Aspirin, and ACEI.

36. Pre- and Post- Test
2. A 66 y/o man who has a history of Type 2
Diabetes, smoker and hypertension. Based
on given information and assuming no
contraindications, what medications regimen
will be best for this patient?
d. Metformin, Statin, Aspirin, and ACEI.