High-risk medications in the elderly

By Mariah Alford PharmD and Cory Bradley, PharmD - CareOregon

Historically both the Medicaid and Medicare formularies have restricted medications on the Beer’s list for members age 65 and older.  Clinically, these medications are generally to be avoided in the elderly due to increased risks of adverse events or ineffectiveness. However, CareOregon has determined that restricting access by requiring prior authorization in older adults was doing very little to discourage inappropriate use and was administratively burdensome. There was a high approval rate on these products as most providers demonstrated an awareness of their risk, but a continued desire to use. Additionally, the Beer’s list has been changed over the years and should be used more as a guide, not an exhaustive list of safe vs non-safe medications in older adults. CareOregon will continue to monitor use of these agents and address any clinical concerns via outreach, but has removed the age-based prior authorization criteria. Any limitation that existed for all ages will remain in place.

By removing high risk medication criteria from our Medicare Advantage plan, CareOregon is doing our part to implement Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®” by removing prior authorization criteria from most medications on the Beers Criteria which is one of the 7 key principles to guide optimal use. This change frees access to medications but should be used in conjunction with the other key principles that place additional responsibilities on the prescriber to evaluate potentially inappropriate medications (PIMs) before initiating therapy in a patient over the age of 65.

Here are other key principles that should guide use of the Beers Criteria and prescribing in older adults:

  • Read the Beers Criteria rationale and recommendations prior to prescribing
  • Understand why medications are included in the Beers Criteria
  • Identify potentially inappropriate medications
  • Offer safer alternatives (non-pharmacologic or pharmacologic) when appropriate
  • Remember that medications in the 2019 Beers Criteria are potentially inappropriate, not definitely inappropriate

High-Risk Medications – PA removed

PA Group



TCAs, paroxetine, Paxil Suspension


Guanfacine, methyldopa, methyldopa/HCTZ

Antiparkinson Agents

Benztropine, trihexyphenidyl

Estrogens and Progestins

Estradiol, estradiol/norethindrone, esterified estrogens, estradiol/nogestimate

Sedative Hypnotics

Eszopiclone, zaleplon, zolpidem, temazepam

Skeletal Muscle Relaxants

Chlorzoxazone, cyclobenzaprine, methocarbamol


Armour Thyroid, NP Thyroid, levothyroxine/liothyronine

Misc. Agents

Dipyridamole, butalbital containing products, clemastine, digoxin, disopyramide, ergoloid mesylates, hydroxyzine, megestrol, nitrofurantoin, phenobarbital, promethazine, scopolamine patch

Reference: Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. Journal of the American Geriatric Society; 67:644-646, 2019.