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Safer Medication Use in Older Persons Information Page
 
 
 

The information on this web page has not been updated. Please see our new initiative.



Welcome to the Safer Medication Use in Older Persons Information Page.



This information page is part of an awareness campaign designed to provide care team members in long term care homes, hospitals and the community with information on medications that are poorly tolerated by older persons. Here, you will find information on the Beers List and other high risk medications for older persons, along with an explanation of their effects and suggestions for safer alternatives. Our ultimate goal is to see medication use in older persons achieve the desired therapeutic effect with fewer adverse effects.


The materials were compiled by an advisory group of leaders and practitioners in long-term care and are intended for:

  • Pharmacists
  • Physicians
  • Nurses
  • Nurse Practitioners
  • Other Healthcare Practitioners
  

For feedback on this information page, please complete the evaluation survey.


For more information on this information page, please contact ISMP Canada, 416-733-3131. For information about the campaign partners please click on the links below.


NOTE: This website does not provide medical advice. If you require medical assistance or information specific to a clinical situation, contact your healthcare provider or Telehealth Ontario 1-866-797-0000. If you think you may have a medical emergency, call 911.


Potentially Harmful Medications
 
 

As a result of potential adverse effects due to pharmacokinetic and pharmacodynamic changes in older people, certain medications should be avoided, or used cautiously with monitoring. This site provides information about the "Beers List"1 and other drugs which are potentially harmful when used inappropriately. If used, documentation should note the reason for use and show that monitoring is in place.


The information provided is intended for practitioners caring for the older person in all settings i.e. home, long term care, and acute care.


About the "Beers List"
About Other Potentially Harmful Medications in Older Persons
Drug-Drug Interactions

About the "Beers List"
 
 

What is the "Beers List"?

The Beers List is a consensus list of potentially inappropriate medications for older persons developed by Dr Mark Beers and an American panel of experts. It was first published in 1991, with the goal of reducing preventable adverse drug effects among older persons in nursing homes. The Beers List was updated in 1997 and 2003 and is now targeted to all older persons, including those living in the community. Building on Dr Beers' work, a Canadian review of inappropriate prescription practices in older persons was conducted in 1997. This review, carried out by McLeod and colleagues and based on a survey of a 32 member national panel of experts, also considered reasons for prescribing the medications, comorbidities, and duration of therapy.


The Beers criteria was updated and released in 2012. See AGS releases updated Beers criteria.


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What drugs are included on the "Beers List"?

AGS Beers criteria for potentially inappropriate medication use in older adults from the American Geriatrics Society Printable Pocket Card.


Websites are available offering more detailed information about each drug (generally US FDA approved drug information). For example, a couple of sites are:


Drugs approved for use in Canada, along with Canadian monographs, can be found through Health Canada's Drug Product Database.


Safety information/warnings from Health Canada can be viewed at Recent Advisories Warnings and Recalls; as well as Canadian Adverse Reaction newsletters.


Not all of the medications on the Beers list are funded through the Ontario Public Drug Programs. Availability of a particular medication in the Ontario Drug Benefit Formulary/Comparative Drug Index can be found at: https://www.healthinfo.moh.gov.on.ca/formulary/index.jsp


AGS Beers Criteria 2012 - Summary


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How widespread is the problem?

Because the Beers List has been updated several times and also varies across jurisdictions, comparable data related to the use of these drugs and their effects are difficult to obtain. A 2001 study found that 21% of community-dwelling elderly US patients were on at least one of 33 potentially inappropriate medications. A more recent study found that 34% to 47% of elderly outpatients and nursing home Medicare and Medicaid Service residents in the United States were taking at least one Beers List medication.


In Canada, concerns related to the use of drugs on the Beers List have been flagged by several organizations including the Canadian Institute for Health Information8, Ontario Joint Task Force on Medication Management in Long-term Care,9 and the Health Quality Ontario.10 The Canadian Institute for Health Information last reviewed usage of Potentially Inappropriate Medications in 200711. Reported rates of inappropriate prescribing vary depending on the source of information, the drugs studied and prescription practices. Older persons living in the community or coming from hospital to a long term care home are more likely to be on a Beers List medication than those in long term care12. The likelihood of being prescribed a drug inappropriately increases with the number of prescription medications and prescribing physicians.13


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What are the alternatives to using these medications?

In some cases there may be a non-pharmacological alternative or another, possibly safer, medication available. Suggestions are noted in the following references. Evidence-based guidelines as well as a person's clinical status, co-morbidities, other treatments and organ function should be considered. Regular monitoring and medication reviews can assist in identifying possible adverse effects and allows for management of such effects in a timely manner.


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About Other Potentially Harmful Medications in Older Persons
 
 

There are other medications that could lead to serious adverse events in older persons depending on the pharmacology of the drug, patient characteristics, and monitoring requirements.

High Alert Medications

High alert medications (drugs that bear a heightened risk of causing significant patient harm when they are used in error) have been defined for acute care16 and community care17.


Based on analysis of medication incident reports and published literature, drugs often considered high alert in the community, including LTC, include:
  • Warfarin
  • Oral antiplatelet18
  • Insulin and oral hypoglycemics18
  • Opioids, and
  • Digoxin.19, 20



Drugs with Anticholinergic Properties

Older persons are often sensitive to the anticholinergic effects of drugs and combinations of drugs with these properties can lead to cumulative effects. For information about "Anticholinergic Burden" see:



General Information about Drug Use in Older Persons


This section will continue to evolve over time as information is brought to our attention or new information is published. If you would like to suggest additions please contact us.

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Drug-Drug Interactions
 
 

Drug-Drug Interactions in the Geriatric Population — Summary of Selected Pharmacoepidemiological Studies in Ontario (Nested Case-Control, Retrospective Cohort, and Case Cross-Over Studies)* [Updated April 25, 2013]


PDF Version


Drug-Interaction Pair Demographics / Background Information Comments
Continuous
Medication		 Added
Medication
Glyburide1 Trimethoprim-sulfamethoxazole (TMP-SMX) Study Population:
Older than 66 years treated with glyburide. A total of 909 cases.

Drug Toxicity/ Adverse Event:
Hypoglycemia

Possible Mechanism of Action:

Sulfamethoxazole can directly cause pancreatic insulin release (at higher doses due to structural similarity to sulfonylurea) in patients with renal impairment.


Sulfonamide antibiotics inhibit CYP 2C9. Glyburide is metabolized by CYP 2C9.

The concomitant use of TMP-SMX with glyburide was associated with increased risk of hospitalization due to hypoglycemia in the elderly.


Juurlink et al. estimated that patients who were hospitalized due to hypoglycemia while using glyburide were around 6 times more likely to have been treated with TMP-SMX within 1 week.

Digoxin1 Clarithromycin Study Population:
Older than 66 years treated with digoxin. A total of 1,051 cases. A total of 51,896 controls.

Drug Toxicity/ Adverse Event:
Digoxin toxicity

Possible Mechanism of Action:

Clarithromycin inhibits P-glycoprotein which leads to decreased renal clearance of digoxin.

The concomitant use of clarithromycin and digoxin was associated with increased risk of hospitalization due to digoxin toxicity in the elderly.


Juurlink et al. estimated that patients who were hospitalized due to digoxin toxicities while using digoxin were around 12 times more likely to have been treated with clarithromycin.

Angiotensin-converting enzyme inhibitors (ACEIs)1 Potassium-sparing diuretics (amiloride, triamterene, or spironolactone) Study Population:
Older than 66 years treated with an ACEI. A total of 523 cases. A total of 25,807 controls.

Drug Toxicity/ Adverse Event:
Hyperkalemia

Possible Mechanism of Action:

ACEIs and potassium sparing diuretics both increase serum potassium levels. When used together they may precipitate hyperkalemia.

The concomitant use of ACEIs and potassium sparring diuretics was associated with an increased risk of hospitalization due to hyperkalemia in the elderly.


Juurlink et al. estimated that patients who were hospitalized due to hyperkalemia while using ACEIs are 20 times more likely to have been treated by potassium sparing diuretics.

Lithium2 ACEIs or loop diuretics Study Population:
Older than 66 years treated with lithium. A total of 413 cases and 1,651 controls.

Drug Toxicity/ Adverse Event:
Lithium toxicity

Possible Mechanism of Action:

ACEIs reduce glomerular perfusion via inhibition of angiotensin II.

Concomitant use of lithium and ACEIs or loop diuretics was associated with increased risk of hospitalization due to lithium toxicities in the elderly.


Juurlink et al. estimated that patients who were hospitalized due to lithium toxicity while using lithium are 2 times more likely to have been treated by ACEIs or loop diuretics.

Warfarin3 Nonsteroidal anti-inflammatory drugs (NSAIDs)

[nonselective NSAIDs or COX-2 inhibitors (celecoxib and rofecoxib)] 		Study Population:
Older than 66 years treated with warfarin. A total of 361 cases. A total of 1,437 controls

Drug Toxicity/ Adverse Event:
Upper gastrointestinal (GI) hemorrhage

Possible Mechanism of Action:

S-warfarin (active enantiomer) and NSAIDs are substrates for CYP 2C9. Both NSAIDs and warfarin can increase risk of GI bleeding.

Concomitant use of warfarin and NSAID or COX-2 inhibitor was associated with increased risk of upper GI hemorrhage in the elderly.


Battistella et al. estimated that patients who were hospitalized due to an upper GI bleed while using warfarin were around 2 times more likely to have used an NSAID or COX-2 inhibitor within 90 days.

Digoxin4 Macrolide antibiotics Study Population:
Over the age of 66 treated with digoxin. A total of 1,659 cases. A total of 6,439 control cases.

Drug Toxicity/ Adverse Event:
Digoxin toxicity

Possible Mechanism of Action:

Macrolide antibiotics can reduce re-circulation of digoxin by reducing Eubacterium lentum in the gut.


Clarithromycin may inhibit P-glycoprotein-mediated tubular secretion of digoxin.

Concomitant use of digoxin and macrolide antibiotics may lead to increased risk of hospitalization in the elderly.


Gomes et al. estimated that patients who are hospitalized due to digoxin toxicity are 15 times more likely to be taking clarithromycin and 4 times more likely to be taking azithromycin or erythromycin.

Clopidogrel5 Proton pump inhibitors (PPIs) Study Population:
Over the age of 66 years treated with clopidogrel. A total of 734 cases. A total of 2,057 controls.

Drug Toxicity/ Adverse Event:
Re-infarction

Possible Mechanism of Action:

Clopidogrel is a pro-drug requiring activation by CYP 2C19. Omeprazole, lansoprazole and rabeprazole inhibit CYP 2C19 which leads to reduced anti-platelet action.

Concomitant use of clopidogrel and PPIs (except pantoprazole) is associated with increased risk of re-infarction in the elderly.


Juurlink et al. report in patients who are hospitalized for a re-infarct and using clopidogrel are more likely to be using a PPI within 30 days.


Pantoprazole was not associated with increased hospitalization.

ACEIs/ Angiotensin receptor blockers (ARBs)6 TMP-SMX Study Population:
Over the age of 66 years treated with ACEI or ARBs. A total of 369 cases. A total of 1,417 controls.

Drug Toxicity/ Adverse Event:
Hyperkalemia

Possible Mechanism of Action:

ACEIs and ARBs impair urinary potassium excretion


TMP reduces urinary potassium excretion.

Concomitant use of TMP-SMX and ACEIs or ARBs is associated with increased risk of hospitalization due to hyperkalemia in the elderly.


Antoniou et al. estimated in patients who are hospitalized for hyperkalemia and using ACEIs or ARBs are about 7 times more likely to have received TMP-SMX.

Warfarin7 TMP-SMX, ciprofloxacin Study Population:
Over the age of 66 years treated with warfarin. A total of 2,151 cases. A total of 10,201 controls.

Drug Toxicity/ Adverse Event:
Hemorrhagic complications

Possible Mechanism of Action:

TMP-SMX inhibits CYP 2C9. S-warfarin (active enantiomer) metabolized predominantly by CYP 2C9.

Concomitant use of TMP-SMX or ciprofloxacin with warfarin increases the risk of hospitalization due to hemorrhagic complications


Fischer et al. estimated patients, who were hospitalized with hemorrhagic complications while using warfarin, are 3 times more likely to have been exposed to TMP-SMX and 2 times more likely to have been using ciprofloxacin

Tamoxifen8 Paroxetine Study Population:
2,430 women over the age of 66 years treated with tamoxifen for breast cancer on concurrent treatment with a single selective serotonin reuptake inhibitor (SSRI).

Drug Toxicity/ Adverse Event:
Breast cancer mortality

Possible Mechanism of Action:

Tamoxifen is a pro-drug metabolized by CYP 2D6 to the active endoxifen.


Paroxetine is a potent CYP 2D6 inhibitor and may reduce the activation of tamoxifen.

Kelly et al. report paroxetine use during tamoxifen treatment increases breast cancer mortality. The median overlap time of tamoxifen and paroxetine treatment in this study was 41%. It is estimated that this level of overlap would result in one additional breast cancer death at 5 years for every 20 women treated.


This is a retrospective cohort study.

Calcium channel blockers (CCBs) (verapamil, diltiazem, nifedipine, amlodipine, or felodipine)9 Macrolide antibiotics (erythromycin, clarithromycin, and azithromycin) Study Population:
Over the age of 66 years treated with CCBs. A total of 7100 in cohort. A total of 176 cases.

Drug Toxicity/ Adverse Event:
Hypotension

Possible Mechanism of Action:

Two macrolides, erythromycin and clarithromycin, inhibit CYP 3A4. Azithromycin does not inhibit CYP 3A4. Calcium channel blockers are CYP 3A4 substrates.

Concomitant use of CCBs and macrolide antibiotics are associated with increased risk of hospitalization due to hypotension.


Wright et al. found in patients who are admitted to hospital due to hypotension while using a CCB are more likely to have received clarithromycin or erythromycin prior to hospitalization. Azithromycin was not associated with hypotension.


This is a case cross-over study.

Theophylline10 Ciprofloxacin Study Population:
Over the age of 66 treated with theophylline. A total of 180 cases. A total of 9,000 controls.

Drug Toxicity/ Adverse Event:
Theophylline toxicity

Possible Mechanism of Action:

Theophylline is metabolized by CYP 1A2. Ciprofloxacin is a potent inhibitor of CYP 1A2. Ciprofloxacin is a commonly used antibiotic given to chronic obstructive pulmonary disease (COPD) patients.

Concomitant use of theophylline and ciprofloxacin may lead to increased risk of hospitalization due to theophylline toxicity.


Antoniou et al. estimated that patients hospitalized due to theophylline toxicity were 2 times more likely to have been treated with ciprofloxacin.

Phenytoin11 TMP-SMX Study Population:
Over the age of 66 years treated with phenytoin. A total of 796 cases. A total of 3,148 controls.

Drug Toxicity/ Adverse Event:
Phenytoin toxicity

Possible Mechanism of Action:

Phenytoin is metabolized by CYP 2C8. TMP-SMX is a potent CYP 2C8 inhibitor and may lead to increase in phenytoin level.

Concomitant use of phenytoin and TMP-SMX increases the risk of hospitalization due to phenytoin toxicity.


Antoniou et al. estimated patients who are hospitalized due to phenytoin toxicity are 2 times more likely to have received TMP-SMX within 30 days.

Spironolactone12 TMP-SMX, Nitrofurantoin Study Population:
Over the age of 66 years treated with spironolactone. A total of 248 cases (median age, 82 years). A total of 783 controls (median age, 81 years).

Drug Toxicity/ Adverse Event:
Hyperkalemia

Possible Mechanism of Action:

Spironolactone and TMP-SMX both decrease urinary excretion of potassium.

Concomitant use of TMP-SMX or nitrofurantoin with spironolactone has been associated with increased risk of hospitalization due to hyperkalemia.


Antoniou et al. estimated that patients hospitalized due to hyperkalemia while using spironolactone are 12 times more likely to have been using TMP-SMX and 2 times more likely to have been using nitrofurantoin.


*The information in this chart was taken from the individual drug interaction studies and does not necessarily represent the opinion of ISMP Canada. Healthcare organizations are encouraged to critically appraise these studies to determine the applicability to their specific practice settings.


  • 1 Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289(13):1652-1658.
  • 2 Juurlink DN, Mamdani MM, Kopp A, Rochon PA, Shulman KI, Redelmeier DA. Drug-induced lithium toxicity in the elderly: a population-based study. J Am Geriatr Soc. 2004;52(5):794-798.
  • 3 Battistella M, Mamdani MM, Juurlink DN, Rabeneck L, Laupacis A. Risk of upper gastrointestinal hemorrhage in warfarin users treated with nonselective NSAIDs or COX-2 inhibitors. Arch Intern Med. 2005;165(2):189-192.
  • 4 Gomes T, Mamdani MM, Juurlink DN. Macrolide-induced digoxin toxicity: a population-based study. Clin Pharmacol Ther. 2009;86(4):383-386.
  • 5 Juurlink DN, Gomes T, Ko DT, Szmitko PE, Austin PC, Tu JV, et al. A population-based study of the drug interaction between proton pump inhibitors and clopidogrel. CMAJ. 2009;180(7):713-718.
  • 6 Antoniou T, Gomes T, Juurlink DN, Loutfy MR, Glazier RH, Mamdani MM. Trimethoprim-sulfamethoxazole-induced hyperkalemia in patients receiving inhibitors of the renin-angiotensin system: a population-based study. Arch Intern Med. 2010;170(12):1045-1049.
  • 7 Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemorrhage during warfarin therapy associated with cotrimoxazole and other urinary tract anti-infective agents: a population-based study. Arch Intern Med. 2010;170(7):617-621.
  • 8 Kelly CM, Juurlink DN, Gomes T, Duong-Hua M, Pritchard KI, Austin PC, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study. BMJ. 2010;340:c693.
  • 9 Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ. 2011;183(3):303-307.
  • 10 Antoniou T, Gomes T, Mamdani M, Juurlink DN. Ciprofloxacin-induced theophylline toxicity: a population-based study. Eur J Clin Pharmacol. 2011;67(5):521-526.
  • 11 Antoniou T, Gomes T, Mamdani M, Juurlink DN. Trimethoprim/sulfamethoxazole-induced phenytoin toxicity in the elderly: a population-based study. Br J Clin Pharmacol. 2011;71(4):544-549.
  • 12 Antoniou T, Gomes T, Mamdani MM, Yao Z, Hellings C, Garg AX, et al. Trimethoprim-sulfamethoxazole induced hyperkalemia in elderly patients receiving spironolactone: nested case-control study. BMJ. 2011;343:d5228.

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Additional Articles of Interest

The following are additional epidemiological studies of different drug-drug combinations that did not demonstrate an increased risk for adverse effects in the elderly population:


  1. Juurlink DN, Mamdani MM, Kopp A, Herrmann N, Laupacis A. A population-based assessment of the potential interaction between serotonin-specific reuptake inhibitors and digoxin. Br J Clin Pharmacol 2005;59(1):102-107
  2. Hutson JR, Fischer HD, Wang X, Gruneir A, Daneman N, Gill SS, et al. Use of clarithromycin and adverse cardiovascular events among older patients receiving donepezil: a population-based, nested case-control study. Drugs Aging. 2012;29(3):205-211.
  3. Kurdyak PA, Juurlink DN, Kopp A, Herrmann N, Mamdani MM. Antidepressants, warfarin, and the risk of hemorrhage. J Clin Psychopharmacol. 2005;25(6):561-564.
  4. Weir MA, Juurlink DN, Gomes T, Mamdani M, Hackam DG, Jain AK et al. Beta-blockers, trimethoprim-sulfamethoxazole, and the risk of hyperkalemia requiring hospitalization in the elderly: a nested case-control study. Clin J Am Soc Nephrol. 2010;5(9):1544-1551.

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About the Campaign
 
 



Why was the Campaign launched?

The Campaign on Safer Medication Use in Older Persons began as a collaborative effort to reduce the use of Beers List Drugs in long-term care homes across Ontario. Beers List medication use was flagged for potential improvement in recent reports of the Health Quality Ontario16 and the Ministry of Health and Long-Term Care17. Discussion with front line practitioners working in long term care also indicated a lack of awareness of these drugs.


During the campaign planning process, it became clear that the scope of the campaign was too narrow. The partners therefore decided to expand the focus of the campaign to all older persons, since those living in the community and coming from hospital to long-term care are more likely to be on a Beers List drug. The partners also decided to expand beyond the Beers List to include a short list of other high risk drugs that have serious side effects and should be carefully monitored when used in older persons.


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What are the goals of the Campaign?

The Campaign for Safer Medication Use in Older Persons is a three year social marketing campaign designed to:

  • develop consensus among key stakeholders on common messages to promote safer medication use in older persons.
  • increase awareness of Beers List and other high risk medications used in the elderly
  • reduce use of a short list of potentially inappropriate medications in long term care homes.

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Who are the Partners?

The founding partners in this campaign are:

  • Classic Care Pharmacy
  • Geriatrx Pharmacy
  • Institute for Clinical and Evaluative Sciences (ICES)
  • Institute for Safe Medication Practices (ISMP) Canada
  • Jeffers' Pharmacy Limited
  • Medical Pharmacies Group Limited
  • MediSystem Pharmacy
  • Nurse Practitioners Association of Ontario
  • Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS)
  • Health Quality Ontario
  • Ontario Long Term Care Physicians (OLTCP)
  • Ontario Long Term Care Association (OLTCA)
  • Ontario Pharmacists Association (OPA)
  • Registered Nurses' Association of Ontario (RNAO)
  • Summit Pharmacy Inc.
  • Westmount Pharmacy
  • Ministry of Health and Long-Term Care


What are the expectations of Campaign partners?


Campaign partners contribute to the campaign by endorsing its goals, educating their staff, membership and community stakeholders about potentially inappropriate medications for use in the elderly, implementing safer medication practices and monitoring their performance with respect to adverse drug events and other safety and quality indicators.


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What are the key messages of the Campaign?

  1. Some medications such those on the Beers List, have serious adverse effects in older persons.
  2. Safer medications may be available and should be considered by health care professionals and their patients.
  3. If a safer medication is not available, the reason for continued use of the listed drug should be documented and its effect monitored on a regular basis.

All medications should be regularly reviewed for safety and effectiveness. In healthcare settings, regular review may take place on admission and discharge, following a change in health status, or on a quarterly basis. For more information on how to conduct a best possible medication history and other resources, visit ISMP Canada's website.


Some provinces have programs in place to ensure patients are getting the most benefit from their drug therapy. These programs enable pharmacists to conduct comprehensive medication reviews and identify potentially harmful drug interactions or side effects. Ontario's Medscheck Program covers medication reviews in community and long-term care settings. For more information click here.


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How can I get involved?

If you are interested in joining the campaign, please contact ISMP Canada or Paula Neves, Director of Health Planning and Research, Ontario Long Term Care Association (OLTCA).


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Resources
 
 

This section contains links to relevant resources including:

Joint ISMP Canada / SHRTN Communities of Practice webinars on Medication Safety in LTC

  • Pain management in older persons: An evidence-based approach, May 15, 2013
    (slide presentation)
  • Safer Prescribing in the Elderly: Focus on Antipsychotics, March 21, 2013
    (Intro | Q&A)
  • Our experience in implementing e-MAR, February, 2013
    (slide presentation | view recording)
  • The Canadian Pharmaceutical Bar Coding Project: Its importance to improving the medication system and enhancing patient safety, November 2012
    (slide presentation | view recording)
  • Medication Safety Self-Assessment (MSSA) for Long Term Care: What the Results Tell Us, October 2012
    (slide presentation)
  • Drug Interaction Pairs Associated with an Increased likelihood of Hospitalization: A New Look at the Evidence, September 20, 2012
    (slide presentation)
  • Part 1: The Changing Culture in Healthcare, September 22, 2011
    (slide presentation)
  • Part 2: Vulnerabilities in the Medication Use Process and Strategies to Enhance Medication Safety, October 20, 2011
    (slide presentation)
  • Part 3: How MedsCheck for Long-Term Care Can Improve Medication Management in Long-Term Care Homes, November 17, 2011
    (slide presentation)
  • Part 4: An Update from Accreditation Canada on Medication Reconciliation in Long-Term Care, February 16, 2012
    (slide presentation)
  • Part 5: Contemporary Issues in the Use of Psychotropic Medications in Long-Term Care, March 21, 2012
    (slide presentation)

Peer Reviewed Articles

  • Beers MH, Ouslander JG, Rollingher J, Reuben DB, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825-1832.

    A two-round survey, based on Delphi methods, was used with 13 nationally recognized experts to reach consensus on explicit criteria for defining the inappropriate use of medications in the US nursing home population. The criteria were designed to use pharmacy data with minimal additional clinical data so that they could be applied to chart review or computerized data sets. The 30 factors agreed on by this method identify inappropriate use of such commonly used categories of medications as sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine 2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, gastrointestinal antispasmodics, and antiemetics.


  • Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med. 1997;157:1531-1536.

    This study updates and expands explicit criteria defining potentially inappropriate medication use by the elderly. Additional goals were to address whether adverse outcomes were likely to be clinically severe and to incorporate clinical information on diagnoses when available. These criteria are meant to serve epidemiological studies, drug utilization review systems, health care providers, and educational efforts. Consensus from a panel of 6 nationally recognized experts on the appropriate use of medication in the elderly was sought. The expert panel agreed on the validity of 28 criteria describing the potentially inappropriate use of medication by general populations of the elderly as well as 35 criteria defining potentially inappropriate medication use in older persons known to have any of 15 common medical conditions. Updated, expanded, and more generally applicable criteria are now available to help identify inappropriate use of medications in elderly populations. These criteria define medications that should generally be avoided in the ambulatory elderly, doses or frequencies of administrations that should generally not be exceeded, and medications that should be avoided in older persons known to have any of several common conditions.





  • O'Mahony D., Gallagher PF. Inappropriate prescribing in the older population: need for new criteria Age and Ageing 2008; 37: 138-141

    Inappropriate prescribing (IP) is a common and serious global healthcare problem in elderly people, leading to increased risk of adverse drug reactions (ADRs), polypharmacy being the main risk factor for both IP and ADRs. IP in older people is highly prevalent but preventable; hence screening tools for IP have been devised, principally Beers' Criteria and the Inappropriate Prescribing in the Elderly Tool (IPET). Although Beers' Criteria have become the most widely cited IP criteria in the literature, nevertheless, they have serious deficiencies, including several drugs that are rarely prescribed nowadays, a lack of structure in the presentation of the criteria and omission of several important and common IP instances. New, more up-to-date, systems-based and easily applicable criteria are needed that can be applied in the routine clinical setting.


  • Gallagher P, O'Mahony D. STOPP (Screening tool of older persons' potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age Ageing 2008; 37: 673-679.

    STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) is a screening tool of older patients' medications. 18 experts in geriatric pharmacotherapy established the content validity of STOPP by two rounds of Delphi consensus method. Sixty-five potentially inappropriate prescribing practices in older people were identified. The screening tool incorporates commonly encountered instances of potentially inappropriate prescribing in older people including drug-drug and drug-disease interactions, drugs which adversely affect older patients at risk of falls, and duplicate drug class prescriptions. The list is arranged according to relevant physiological systems, and each criterion is accompanied by a concise explanation of as to why the prescription is potentially inappropriate. This study recognized STOPP for identifying significantly more potentially inappropriate medications than Beers' criteria, and also identifying potential adverse drug events in older people involving confusion, falls, or constipation.




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Evidence-Based Tools


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Reports & Policy Documents


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Other Useful Links


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ISMP Canada Bulletins


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ISMP Medication Safety Alert!


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Contact Us
 
 

For more information on the campaign or to suggest changes or additions to this website, please contact ISMP Canada, 416-733-3131.


To join the campaign or become a member of the advisory group, please contact Paula Neves, Ontario Long Term Care Association (OLTCA), 905-470-8995 ext 40.


For feedback on this information page, please complete the evaluation survey.


For information on the campaign partners, please click on the links below.


 
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