Medication management and polypharmacy

The Beer lists are used as a national guideline and reference guide forpharmacists and physicians to improve the use of medication in the elderly. Forseveral years, gerontologist Mark H. Beers, MD, has been advocating the use ofexplicit criteria-developed through consensus panels-for identifying inappropriateuse of medications. In a 1991 paper that looked at the nursing facility population,he wrote with colleagues that these explicit criteria were "based on the risk-benefitdefinition of appropriateness, i.e., that the use of a medication is appropriate if itsuse has potential benefits that outweigh potential risks." i His first set of criteriawas developed specifically with the frail elderly nursing facility resident in mind.
In 1997, Beers updated his criteria to include medication therapy inappropriate inall patients over 65 years old.3 Consultant pharmacists can use both sets ofcriteria in prescription processing and drug regimen review to improve thepharmacotherapeutic regimens of their elderly patients.
Below are the two tables developed by the study's Beer conducted. Table 1 isMEDICATIONS TO AVOID OR USE WITHIN SPECIFIED DOSE AND DURATIONRANGES IN ELDERLY PATIENTS and Table 2 is MEDICATIONS TO AVOID INELDERLY PATIENTS WITH SPECIFIC CONCOMITANT DISEASES.
The important question to ask is, what can facility's do with this information inmanaging medication use in the elderly? Below is a list of recommendationstandards: ! Make sure your consultant pharmacist has the lists.
! Mail the lists to the medical director and attending physicians with a cover letter stating the lists are used as a national guideline andreference guide for pharmacists and physicians to improve the use ofmedication in the elderly. Ask if there are any new systems orprocedures they would like to see at the facility.
! Set a standard that the pharmacist must address these drugs during ! The dispensing pharmacy reviews Table 1 list of drugs and discuss procedurally how the dispensing of these drugs could be handled on acase by case basis.
! Inservice the licensed staff and CMA's on the two tables, especially i Reference: Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicitcriteria for determining inappropriate medication use in nursing home residents. Arch Intern Med1991;151:1825-32.
2,3 Beers MH. Explicit criteria for determining potentially inappropriate medication use by theelderly: an update. Arch Intern Med 1997;157:1531-6.
TABLE 1: MEDICATIONS TO AVOID OR USE WITHIN SPECIFIED
DOSE AND DURATION RANGES IN ELDERLY PATIENTSa
MEDICATION(s)b
EXPLANATION OF
SEVERITY
PSYCHOTROPIC MEDICATIONS
Amitriptyline, alone or in
and increased fallsStrong anticholinergic and and increased fallsDoses > 3mg/day should beavoided; residents with psychotic disorders may requirehigher dosesTotal daily doses should not 30 mg or triazolam > 0.25 mgNot effective orally and has other narcotic analgesicsHighly addictive and sedating.
addicted to it.
Has more CNS side effects,including confusion and hallucinations; is a mixedagonist-antagonistFew advantages over acetaminophenAvoid doses > 30 mg/day;residents with known psychotic EENT AGENTS
Antihistamines (alone or in
combination, including
MEDICATION(s)b
EXPLANATION OF
SEVERITY
GASTROINTESTINAL AGENTS
Cimetdinec
therapy for > 12 weeksStrong anticholinergic activity therapy for > 12 weeksOne of the least effective ENDOCRINE AGENTS
serious hypoglycemai. Also cancause syndrome of CARDIAC AGENTS
Except for treatment of atrialarrhythmias, doses > 0.125 mg in the elderly should rarelyexceed this amountMay induce heart failurebecause of strong negative inotropic activity. Also hasstrong anticholinergic activity VASCULAR AGENTS
Causes orthostatic hypotension.
Beneficial only in patients with exacerbates depressionAvoid except when used to treatviolent behaviors; other beta penetration or more beta-receptor selectivityCauses depression, impotence, hypotensionMore toxic than aspirin, yet no MUSCULOSKELETAL AGENTS
MEDICATION(s)b
EXPLANATION OF
SEVERITY
HEMATOPOIETIC AGENTS
ANTI-INFECTIVE AGENTS
Avoid therapy for > four weeksexcept when treating osteomyelitis, prostatis,tuberculosis, or endocarditis a Adapted from references 2 and 3. Abbreviations: CNS=central nervous system;
EENT=eyes, ears, nose, and throat; NSAID=nonsteroidal anti-inflammatory drugs.
b Unless otherwise stated in the "Problems" column, use of these medications should
be avoided completely in all patients 65 years and older.
c These criteria were developed specifically for the frail elderly patient, especially those
who are residents of nursing facilities. Use in other elderly patients may be acceptable.
TABLE 2: MEDICATIONS TO AVOID IN ELDERLY PATIENTS
WITH SPECIFIC CONCOMITANT DISEASES
MEDICATION(s)
SEVERITY
NEUROLOGIC DISORDERS
PSYCHIATRIC DISORDERS
GASTROINTESTINAL DISORDERS
ENDOCRINE DISORDERS
In people being treatedwith insulin or oral RESPIRATORY DISORDERS
CARDIAC DISORDERS
negative inotropicactionLarge sodium load may VASCULAR DISORDERS
and inotropic activityNegative chronotropic UROLOGIC DISORDERS
and cause obstructionMay impair micturation and cause obstructionRelaxes the external Adapted from references. These criteria apply to all elderly patients, not just nursingfacility residents. Abbreviations: NSAID=nonsteroidal anti-inflammatory drugs;GERD=gastroesophagal reflux disease.

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