Medications to Avoid in the Elderly and Alternatives

Medications of Risk Recommendations Alternatives Antihistamines: Confusion, oversedation, orthostatic hypotension, falls, constipation and urinary retention due to anticholinergic effects Diphenhydramine Avoid use as hypnotic Hypnotics: Hydroxyzine Avoid use as opioid adjunct Temazepam 7.5 mg hs Use lowest effective dose for Zolpidem 5 mg hs allergic reactions Trazodone 50mg hs Use a non-sedating antihistamine for Non-sedating antihistamines: seasonal allergy Loratadine 10 mg daily Fexofenadine 60 mg daily or bid Narcotic Analgesics: Meperidine - confusion, oversedation, orthostatic hypotension, falls, constipation and urinary retention due to anticholinergic effects; metabolite may produce agitation and seizures; short duration of analgesia. Propoxyphene - poor analgesic effect with usual opioid anticholinergic effects Meperidine Use alternative pain medication Acetaminophen - provides Propoxyphene analgesia equivalent to propoxyphene ; add codeine or oxycodone if pain relief inadequate: oxycodone 2.5 mg q4-6h Morphine: initially low doses (e.g. 2-4 mg q3-4h) suffice Benzodiazepines: Confusion, sedation and falls Diazepam Use shorter acting agent for anxiety, Anxiety or withdrawal: Chlordiazepoxide and for alcohol or benzodiazepine Lorazepam 0.5 – 1 mg q6h prn withdrawal; Oxazepam 10 mg q6h prn Use a low dose antipsychotic to treat Agitation/psychosis: agitation and psychosis Haloperidol 0.5 – 2 mg bid or tid Risperidone 0.5 mg bid Tricyclic Antidepressants: Confusion, oversedation, orthostatic hypotension, falls, constipation and urinary retention due to anticholinergic effects Amitriptyline Use less anticholinergic TCA for Neuropathic pain: Imipramine neuropathic pain; use alternative Desipramine 10 – 20 mg daily Doxepin agents (e.g., SSRI) for depression Nortriptyline 10 – 25 mg daily

Antiemetics: Confusion, oversedation, orthostatic hypotension, falls, constipation and urinary retention due to anticholinergic effects. Trimethobenzamide - low potency antiemetic, highly anticholinergic Promethazine Use lowest effective dose Promethazine 12.5 mg q6h prn Prochlorperazine Avoid use as opioid adjunct Prochlorperazine 5 mg q6h prn Trimethobenzamide Histamine – 2 Receptor Blocker:, Confusion, depression and headache due to decreased renal elimination Famotidine Reduce usual dose by 50% Famotidine 10-20 mg daily or 20 mg every other day

Reproduced from: Medications to Avoid in the Elderly in: Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially

Clinical Toolbox for Geriatric Care © 2004 Society of Hospital Medicine