The following medications should be avoided or used very cautiously in persons aged 65 years and over, independent of their health conditions and diagnoses.
| Drug Name or Class | Comments |
Severity |
|
Long-acting benzodiazepines:
|
These agents have very long half-lives, cause prolonged
sedation and increase the risk of falls and fractures. If benzodiazepine therapy is unavoidable, use short-acting agents. |
High |
|
Short-acting benzodiazepines should rarely exceed the doses shown below.
|
With rare exceptions, the agents should be used only in persons who are physically dependent or who are being treated with short-course therapy for an acute condition. |
High |
|
Meprobamate (Miltown and Equanil) |
This anxiolytic is highly sedating and addictive. All use should be avoided except in individuals who are already physically dependent. |
High |
|
Barbiturates except Phenobarbital for seizures |
All use should be avoided except in individuals who are
physically dependent or for seizure disorder management. There are safer sedative-hypnotics available. |
High |
| Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol), Amitriptyline-perphenazine (Triavil), doxepin (Sinequan) | Because amitriptyline and doxepin are very sedating and anticholinergic, their use should be avoided. |
High |
| Methyldopa (Aldomet) Methyldopa-hydrochlorothiazide (Aldoril) |
All use should be avoided. Methyldopa causes bradycardia and can exacerbate depression in the elderly. Safer antihypertensives are available. |
High |
| Reserpine at doses >0.25mg | All use should be avoided. Safer antihypertensives are available. |
Low |
| Indomethacin (Indocin and Indocin SR) | All use should be avoided. Other NSAIDs cause CNS toxic reactions less often. |
High |
| Chlorpropamide (Diabinese) | All use should be avoided. Other oral hypoglycemics have shorter half-lives and do not cause SIADH. |
High |
| Propoxyphene (Darvon) and combination products (Darvocet-N, Darvon-N, Darvon with ASA) | All use should be avoided; it has little advantage over
acetaminophen. Other analgesics are safer and more effective. |
Low |
| Pentazocine (Talwin) | All use should be avoided. Other narcotics are more effective and safer. |
High |
| Ergot Mesyloids (Hydergine) and Cyclandelate | All use should be avoided. Have not been shown effective in the doses studied. |
Low |
| Diphenhydramine (Benadryl) | Use only in the smallest effective dose and only for emergency treatment of allergic reactions. Causes confusion and sedation. |
High |
Anticholinergics and Antihistamines
|
All nonprescription and many prescription antihistamines can have potent anticholinergic effects and cause confusion and sedation. To treat allergic reactions, use nonanticholinergic antihistamines rather than these agents. |
High |
| Dipyridamole | Short-acting form (Persantine) may cause orthostatic hypotension. Long-acting form may be appropriate in persons who have artificial heart valves. |
Low |
| Digoxin (Lanoxin) | Doses should not exceed 0.125 mg/d except when treating atrial arrhythmias. Diminished renal clearance increases the risk of toxicity. |
Low |
| Disopyramide (Norpace and Norpace CR) | Strong anticholinergic and negative inotropic effects make this agent a poor antiarrhythmic choice. |
High |
| Ferrous Sulfate > 325mg/d | Higher doses do not substantially increase iron absorption but do cause increased constipation. |
Low |
Muscle relaxants - antispasmodics
|
The doses needed to achieve a therapeutic effect generally produce anticholinergic side-effects poorly tolerated by the elderly. |
High |
GI antispasmodics
|
All have uncertain effectiveness and are strongly
anticholinergic. Avoid all use - particularly long-term use. |
High |
| Trimethobenzamide (Tigan) | All use should be avoided. This is the least effective antiemetic and it causes extrapyramidal effects. |
High |
| Meperidine (Demerol) | Not an effective oral analgesic. Causes confusion and its metabolites can cause seizures. |
High |
| Ticlopidine (Ticlid) | No more effective than ASA in preventing clotting; safer alternatives exist. |
High |
| Ketorolac (Toradol) | Avoid all use in older patients since many have asymptomatic GI pathology. |
High |
| Amphetamines and anorexic agents | Potential for dependence, angina, hypertension and myocardial infarction. |
High |
Long-term use of full-dose non-COX selective NSAIDs:
|
Potential for renal failure, GI bleeding, hypertension and heart failure. |
High |
| Daily Fluoxetine (Prozac) | Has a long half-life and can produce insomnia and agitation. Safer alternatives exist. |
High |
Long-term use of stimulant laxatives:
|
May be appropriate in the presence of opiate analgesic use. Otherwise, may exacerbate bowel dysfunction. |
High |
| Amiodarone (Cordarone) | Associated with QT prolongation and torsades de pointes. Lack of efficacy in the elderly. |
High |
| Orphenadrine (Norflex) | Causes more sedation and anticholinergic effects than its alternatives do. |
High |
| Guanethidine (Ismelin) | Causes orthostatic hypotension. Safer antihypertensives exist. |
High |
| Guanadrel (Hylorel) | Causes orthostatic hypotension. Safer antihypertensives exist. |
High |
| Cyclandelate (Cyclospasmol) | Lack of efficacy. |
Low |
| Isoxsuprine (Vasodilan) | Lack of efficacy. |
Low |
| Nitrofurantoin (Macrodantin) | Potential for renal impairment; safer alternatives exist. |
High |
| Doxazosin (Cardura) | Potential for hypotension and dry mouth. Can exacerbate symptoms of stress incontinence and mixed-cause incontinence. |
Low |
| Methyltestosterone (Android, Virilon, and Testrad) | Potential for prostatic hypertrophy and cardiac problems. |
High |
| Thioridazine (Mellaril) | Greater potential for CNS and extrapyramidal side effects. |
High |
| Mesoridazine (Serentil) | CNS and extrapyramidal side effects. |
High |
| Short-acting nifedipine (Procardia and Adalat) | Potential for hypotension and constipation. |
High |
| Clonidine (Catapres) | Potential for hypotension and CNS side effects. |
Low |
| Mineral oil | Potential for aspiration and adverse effects. Safer alternatives are available. |
High |
| Cimetidine (Tagamet) | Can cause confusion and delirium. |
Low |
| Ethacrynic acid (Edecrin) | Potential for hypotension and electrolyte and fluid imbalances. Safer alternatives are available. |
Low |
| Desiccated thyroid | Concerns about cardiac effects. Safer alternatives are available. |
High |
| Amphetamines (other than methylphenidate HCl and anorexics addressed elsewhere in this table) | Adverse CNS stimulation effects. |
High |
| Oral estrogens | No cardioprotective effect. Significant risk of carcinogenic effects (breast and endometrial cancer.) |
Low |
The following medications should be avoided in persons aged 65 years and over who have the following health conditions or diagnoses.
| Disease or Condition | Drug Name or Class | Comments |
Severity |
| Heart Failure | Disopyramide (Norpace), and high sodium content drugs (sodium and sodium salts [alginate bicarbonate, biphosphate, citrate, phosphate, salicylate and sulfate]) | Negative inotropic effect. Potential to promote fluid retention and exacerbate heart failure. |
High |
| Hypertension | Phenylpropanolamine HCl (removed from the market in 2001), pseudoephedrine, diet pills, and amphetamines | Sympathomimetics can exacerbate hypertension. |
High |
| Gastric or duodenal ulcers | NSAIDs (COX-2 inhibitors excluded) and aspirin >325mg/d | May exacerbate existing ulcer disease or create new ulcers. |
High |
| Seizure disorders | Clozapine (Clozaril), chlorpromazine (Thorazine), thioridazine (Mellaril), and thiothixene (Navane) | These agents can lower the seizure threshold. |
High |
| Disorders of blood clotting (including anticoagulant therapy) | Aspirin, NSAIDs, dipyridamole (Persantin), ticlopidine (Ticlid), and clopidogrel (Plavix) | Increased risk of bleeding through multiple mechanisms of action. |
High |
| Bladder outflow obstruction | Anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditropan), flavoxate (Urispas), antidepressants, decongestants, and tolterodine (Detrol) | Can lead to urinary retention. |
High |
| Stress incontinence | alpha-blockers (Doxazosin, Prazosin, and Terazosin), tricyclic antidepressants (imipramine, doxepin and amitriptyline), and long-acting benzodiazepines | May worsen symptoms of incontinence. |
High |
| Arrhythmias | Tricyclic antidepressants (imipramine, doxepin and amitriptyline) | Proarrhythmic potential. |
High |
| Insomnia | Decongestants, theophylline (Theodur), methylphenidate (Ritalin), MAOIs, and amphetamines | CNS stimulant effects. |
High |
| Parkinson's Disease | Metoclopramide (Reglan), conventional antipsychotics and tacrine (Cognex) | Antidopaminergic and anticholinergic effects can worsen symptoms of Parkinsonism. |
High |
| Cognitive Impairment | Barbiturates, anticholinergics, antispasmodics, and muscle relaxants. CNS stimulants: DextroAmphetamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemolin, and fluoxetine (Prozac) | CNS-altering effects can worsen cognitive performance. |
High |
| Depression | Long-term benzodiazepine use. Sympatholytic agents: methyldopa (Aldomet), reserpine, guanethidine (Ismelin) | May produce or exacerbate depression. |
High |
| Anorexia and malnutrition | CNS stimulants: DextroAmpehtamine (Adderall), methylphenidate (Ritalin), methamphetamine (Desoxyn), pemolin, and fluoxetine (Prozac) | These agents suppress appetite. |
High |
| Syncope or falls | Short- to intermediate-acting benzodiazepines and tricyclic antidepressants (imipramine, doxepin and amitriptyline) | May produce ataxia, impair psychomotor function, and increase falls. |
High |
| SIADH/hyponatremia | SSRIs: fluoxetine (Prozac), citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) | May exacerbate or cause SIADH. |
Low |
| Seizure disorder | Bupropion (Wellbutrin) | May lower the seizure threshold. |
High |
| Obesity | Olanzapine (Zyprexa) | May stimulate appetite and cause weight gain. |
Low |
| COPD | Long-acting benzodiazepines: Chlordiazepoxide (alone or in combination: Librium, Librax, Limbitrol), Diazepam (Valium), Quazepam (Doral), Halazepam (Paxipam), and Chlorazepate (Tranxene); Beta-blockers: propranolol | CNS adverse effects. May induce respiratory depression. May exacerbate or cause respiratory depression. |
High |
| Chronic constipation | Calcium channel blockers, anticholinergics, and tricyclic antidepressants (imipramine, doxepin and amitriptyline) | May exacerbate constipation. |
Low |
Adapted from Fick, DM, et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Archives of Internal Medicine 2003;163, DEC 8/22:2716-2724.