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Beers Criteria - Criteria 2 (drug-centric view)

Beers Criteria (Criteria 2)

NAV Top A B C D E F G H I K L M N O P Q R S T V Z

American Geriatrics Society 2023 updated AGS Beers Criteria^®
for potentially inappropriate medication use in older adults. Reference Back to All Criteria View

Criteria 2: Potentially inappropriate medication use in older adults due to drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome. (Table 3)

Suggested Alt.Tx acetaminophen-codeine (Tylenol #3)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx acetaminophen-HYDROcodone (Lortab, Norco, Vicodin)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx acetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx acetaminophen-traMADol (Ultracet)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx alfuzosin (Uroxatral)

Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.

Drug(s) ⇆ disease or syndrome	selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx ALPRAZolam (Xanax)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx amitriptyline (Elavil)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tertiary tricyclic antidepressants (TCAs) ⇄ Syncope
Rationale	Tertiary TCAs increase the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

amoxapine (Asendin)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx ARIPiprazole (Abilify)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx asenapine (Saphris)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx aspirin

Comments	> 325 mg/day
Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Comments	> 325 mg/day
Drug(s) ⇆ disease or syndrome	aspirin ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx aspirin-dipyridamole (Aggrenox)

aspirin > 325 mg/day

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	aspirin ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx atropine

excludes ophthalmic

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

atropine-diphenoxylate (Lomotil)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx benztropine (Cogentin)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx brexpiprazole (Rexulti)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

brivaracetam (Briviact)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx brompheniramine (Dimetane, Dimetapp)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

cannabidiol (Epidiolex)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

carBAMazepine (Carbatrol, TEGretol)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx carbinoxamine (Clistin, Karbinal)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx cariprazine (Vraylar)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

celecoxib (CeleBREX)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Low, Strength of Recommendation: Strong

cenobamate (Xcopri)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx chlordiazePOXIDE (Librium)

alone or in combination with amitriptyline or clidinium

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx chlorpheniramine (Chlor-Trimeton)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx chlorproMAZINE (Thorazine)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (selected) ⇄ Syncope
Rationale	Antipsychotic selected increases the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

cilostazol (Pletal)

Drug(s) ⇆ disease or syndrome	cilostazol ⇄ Heart failure
Rationale	Potential to increase mortality in older adults with heart failure
Recommendation	Avoid
Quality of evidence: Low, Strength of Recommendation: Strong

cimetidine (Tagamet)

Drug(s) ⇆ disease or syndrome	H2-receptor antagonists ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Low, Strength of Recommendation: Strong

citalopram (CeleXA)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx clidinium-chlordiazePOXIDE (Librax)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx cloBAZam (Onfi, Sympazan)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx clomiPRAMINE (Anafranil)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tertiary tricyclic antidepressants (TCAs) ⇄ Syncope
Rationale	Tertiary TCAs increase the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx clonazePAM (KlonoPIN)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx clorazepate (Tranxene)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx cloZAPine (Clozaril)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx codeine

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

cortisone (Cortone)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx cyclobenzaprine (Flexeril)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx cyproheptadine (Periactin)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

darifenacin (Enablex)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

deflazacort (Emflaza)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx desipramine (Norpramin)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

desvenlafaxine (Pristiq)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

dexamethasone (Decadron)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

dextromethorphan-quiNIDine (Nuedexta)

Drug(s) ⇆ disease or syndrome	dextromethorphan-quiNIDine ⇄ Heart failure
Rationale	Concerns about QT prolongation.
Recommendation	Avoid
Quality of evidence: Low, Strength of Recommendation: Strong

Suggested Alt.Tx diazePAM (Valium)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx diclofenac (Cambia, Cataflam, Voltaren)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx dicyclomine (Bentyl)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx diethylstilbestrol (DES)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx diflunisal (Dolobid)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

diltiaZEM (Cardizem, Dilacor)

Drug(s) ⇆ disease or syndrome	non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Avoid in heart failure with reduced ejection fraction.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx dimenhyDRINATE (Dramamine)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx diphenhydrAMINE (Benadryl)

diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

donepezil (Aricept)

Drug(s) ⇆ disease or syndrome	cholinesterase inhibitors (AChEIs) ⇄ Syncope
Rationale	AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx doxazosin (Cardura)

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Syncope
Rationale	Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx doxepin (SINEquan)

>6 mg/day

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tertiary tricyclic antidepressants (TCAs) ⇄ Syncope
Rationale	Tertiary TCAs increase the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx doxylamine (Unisom)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

droNABinol (Marinol)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx dronedarone (Multaq)

Drug(s) ⇆ disease or syndrome	dronedarone ⇄ Heart failure
Rationale	Potential to increase mortality in older adults with heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx droperidol (Inapsine)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

DULoxetine (Cymbalta)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

escitalopram (Lexapro)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

eslicarbazepine (Aptiom)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estazolam (Prosom)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx esterified estrogens-methylTESTOSTERone (Estratest)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estradiol (Alora, Climara, Estrace, Vivelle-Dot)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estrogen/progesterone combinations (Prempro, Premphase)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estrogens, conjugated (Cenestin)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estrogens, esterified (Menest)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx estropipate (Ogen, Ortho-Est)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx eszopiclone (Lunesta)

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx ethinyl estradiol-norethindrone (Femhrt)

Drug(s) ⇆ disease or syndrome	estrogen, oral and transdermal (excludes intravaginal estrogen) ⇄ Urinary incontinence (all types) in women
Rationale	Lack of efficacy.
Recommendation	Avoid in women. See also recommendation on estrogen (Table 2)
Quality of evidence: High, Strength of Recommendation: Strong

ethosuximide (Zarontin)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx etodolac (Lodine)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

everolimus (Afinitor, Zortress)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

famotidine (Pepcid)

Drug(s) ⇆ disease or syndrome	H2-receptor antagonists ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Low, Strength of Recommendation: Strong

felbamate (Felbatol)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

fenfluramine (Fintepla)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx fentaNYL (Sublimaze)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

fesoterodine (Toviaz)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

flavoxATE (Urispas)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

fludrocortisone (Florinef)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

FLUoxetine (PROzac)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx fluPHENAZine (Prolixin)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx flurbiprofen (Ansaid, Ocufen)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

fLuvoxaMINE (Luvox)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx gabapentin (Neurontin)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

galantamine (Razadyne)

Drug(s) ⇆ disease or syndrome	cholinesterase inhibitors (AChEIs) ⇄ Syncope
Rationale	AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

ganaxolone (Ztalmy)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx haloperidol (Haldol)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx homatropine (Hycodan, Hydromet)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

hydrocortisone (Solu-CORTEF, Cortef)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx HYDROmorphone (Dilaudid)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx hydrOXYzine (Atarax, Vistaril)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx hyoscyamine (Hyosyne, Levsin, Levsinex)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx ibuprofen (Caldolor, Motrin)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx iloperidone (Fanapt)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx imipramine (Tofranil)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tertiary tricyclic antidepressants (TCAs) ⇄ Syncope
Rationale	Tertiary TCAs increase the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx indomethacin (Indocin)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx ketorolac (Toradol)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

lacosamide (Vimpat)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

lamoTRIgine (LaMICtal)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

levETIRAcetam (Keppra)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

levomilnacipran (Fetzima)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx LORazepam (Ativan)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx loxapine (Loxitane)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx lumateperone (Caplyta)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (selected) ⇄ Syncope
Rationale	Antipsychotic selected increases the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

Suggested Alt.Tx lurasidone (Latuda)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx magnesium salicylate (Doan's)

Drug(s) ⇆ disease or syndrome	nonacetylated salicylates ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx meclizine (Antivert)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx meloxicam (Mobic)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx meperidine (Demerol)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx methadone (Dolophine)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

methylPREDNISolone (DEPO-Medrol, Medrol, Solu-MEDROL)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx metoclopramide (Reglan)

Drug(s) ⇆ disease or syndrome	antiemetics ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx midazolam (Versed)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

milnacipran (Savella)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx morphine (Oramorph SR, Roxanol)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx nabumetone (Relafen)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

nizatidine (Axid)

Drug(s) ⇆ disease or syndrome	H2-receptor antagonists ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Low, Strength of Recommendation: Strong

Suggested Alt.Tx nortriptyline (Pamelor)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	tricyclic antidepressants (TCAs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx OLANZapine (ZyPREXA)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (selected) ⇄ Syncope
Rationale	Antipsychotic selected increases the risk of orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

Suggested Alt.Tx opium (Paragoric)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx orphenadrine (Norflex)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx oxaprozin (Daypro)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx oxazepam (Serax)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

OXcarbazepine (Oxtellar XR)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

oxybutynin (Ditropan)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx oxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx oxyMORphone (Numorphan, Opana)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx paliperidone (Invega)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

PARoxetine (Paxil)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

perampanel (Fycompa)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx perphenazine (Trilafon)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx PHENobarbital (Luminal)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

phenytoin (Dilantin, Phenytek)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx pimavanserin (Nuplazid)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx pimozide (Orap)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

pioglitazone (Actos)

Drug(s) ⇆ disease or syndrome	thiazolidinediones ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx piroxicam (Feldene)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx prazosin (Minipress)

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Syncope
Rationale	Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

prednisoLONE (Orapred, PediaPred, Pred Forte, Prelone)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

predniSONE (Deltasone, Sterapred)

Comments	corticosteroids (oral and parenteral) Excludes inhaled and topical forms. Oral and parenteral corticosteroids may be required for conditions such as exacerbation of COPD but should be prescribed in the lowest effective dose and for the shortest possible duration.
Drug(s) ⇆ disease or syndrome	corticosteroids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. If needed, use the lowest possible dose for the shortest duration and monitor for delirium.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx pregabalin (Lyrica)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx primidone (Mysoline)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx prochlorperazine (Compazine)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiemetics ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx promethazine (Phenadoz, Phenergan)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antiemetics ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx QUEtiapine (SEROquel)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx risperiDONE (RisperDAL)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

rivastigmine (Exelon)

Drug(s) ⇆ disease or syndrome	cholinesterase inhibitors (AChEIs) ⇄ Syncope
Rationale	AChEIs cause bradycardia and should be avoided in older adults whose syncope may be due to bradycardia.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Strong

rufinamide (Banzel)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx scopolamine (Transderm Scop)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

sertraline (Zoloft)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SSRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx silodosin (Rapaflo)

Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.

Drug(s) ⇆ disease or syndrome	selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

solifenacin (Vesicare)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

stiripentol (Diacomit)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx SUFentanil (Sufenta)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx sulindac (Clinoril)

Drug(s) ⇆ disease or syndrome	NSAIDs and COX-2 inhibitors ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Use with caution in patients with heart failure who are asymptomatic; avoid in patients with symptomatic heart failure.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	non-COX-2 selective NSAIDs ⇄ History of gastric or duodenal ulcers
Rationale	May exacerbate existing ulcers or cause new/additional ulcers
Recommendation	Avoid unless other alternatives are not effective and the patient can take a gastroprotective agent (i.e., proton-pump inhibitor or miSOPROStol).
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx tamsulosin (Flomax)

Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.

Drug(s) ⇆ disease or syndrome	selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx temazepam (Restoril)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx terazosin (Hytrin)

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Syncope
Rationale	Non-selective peripheral alpha-1 blockers cause orthostatic blood pressure changes and should be avoided in older adults whose syncope may be due to orthostatic hypotension.
Recommendation	Avoid
Quality of evidence: High, Strength of Recommendation: Weak

Drug(s) ⇆ disease or syndrome	non-selective peripheral alpha-1 blockers ⇄ Urinary incontinence (all types) in women
Rationale	Aggravation of incontinence.
Recommendation	Avoid in women.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx thioridazine (Mellaril)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx thiothixene (Navane)

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

tiaGABine (Gabitril)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

tolterodine (Detrol)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

topiramate (Qudexy XR, Topamax)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx traMADol (Ultram)

Drug(s) ⇆ disease or syndrome	opioids ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Opioids: emerging data highlights an association between opioid administration and delirium. For older adults with pain, use a balanced approach, including the use of validated pain assessment tools and multimodal strategies that include nondrug approaches to minimize opioid use.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	opioids ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for pain management in the setting if severe acute pain.
Quality of evidence: Moderate, Strength of Recommendation: Strong

trandolapril-verapamil (Tarka)

Drug(s) ⇆ disease or syndrome	non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Avoid in heart failure with reduced ejection fraction.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx triazolam (Halcion)

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	benzodiazepines ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Benzodiazepines: shorter-acting ones are not safer than long-acting ones. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx trifluoperazine (Stelazine)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx trihexyphenidyl (Artane)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx triprolidine (Histex, Zymine)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	strongly anticholinergic drugs, except antimuscarinics for urinary incontinence ⇄ Lower urinary tract symptoms, benign prostatic hyperplasia
Rationale	May decrease urinary flow and cause urinary retention
Recommendation	Avoid in men
Quality of evidence: Moderate, Strength of Recommendation: Strong

trospium (Sanctura)

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	anticholinergics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

valproic acid (Depacon, Stavzor)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

venlafaxine (Effexor)

Drug(s) ⇆ disease or syndrome	antidepressants (selected classes: SNRIs) ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. Antidepressants (selected classes): evidence for risk of falls and fractures is mixed; newer evidence suggests that SNRIs may increase falls risk. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: Moderate, Strength of Recommendation: Strong

verapamil (Calan, Covera, Isoptin)

Drug(s) ⇆ disease or syndrome	non-dihydropyridine calcium channel blockers (CCBs) ⇄ Heart failure
Rationale	Potential to promote fluid retention and/or exacerbate heart failure.
Recommendation	Avoid in heart failure with reduced ejection fraction.
Quality of evidence: Moderate, Strength of Recommendation: Strong

vigabatrin (Sabril)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx zaleplon (Sonata)

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Suggested Alt.Tx ziprasidone (Geodon)

May be required to treat concurrent schizophrenia, bipolar disorder, and other selected mental health and neuropsychiatric conditions but should be prescribed in the lowest effective dose and for the shortest possible duration.

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium. Avoid for behavioral problems of dementia or delirium unless nonpharmacologic options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid, except in situations listed under the rationale statement.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics, chronic use or persistent as-needed use. ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects. Antipsychotics: increased risk of stroke and greater rate of cognitive decline and mortality in people with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	antipsychotics (except cloZAPine, pimavanserin, and QUEtiapine) ⇄ Parkinson disease
Rationale	DOPamine-receptor antagonists with the potential to worsen Parkinsonian symptoms Exceptions: cloZAPine, pimavanserin, and QUEtiapine appear to be less likely to precipitate the worsening of Parkinson disease than other antipsychotics.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Suggested Alt.Tx zolpidem (Ambien)

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Delirium
Rationale	Avoid in older adults with or at high risk of delirium because of the potential of inducing or worsening delirium.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) ⇄ Dementia or cognitive impairment
Rationale	Avoid because of adverse CNS effects.
Recommendation	Avoid
Quality of evidence: Moderate, Strength of Recommendation: Strong

Drug(s) ⇆ disease or syndrome	nonbenzodiazepine benzodiazepine receptor agonist hypnotics ("Z-drugs") ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid unless safer alternatives are not available.
Quality of evidence: High, Strength of Recommendation: Strong

zonisamide (Zonegran)

Drug(s) ⇆ disease or syndrome	antiepileptics ⇄ History of falls or fractures
Rationale	May cause ataxia, impaired psychomotor function, syncope, or additional falls. If one of the drugs must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures. (i.e., anticholinergics, selected antidepressants, antiepileptics, antipsychotics, sedative/hypnotics including benzodiazepines and, Nonbenzodiazepine benzodiazepine receptor agonist hypnotics, opioids) and implement other strategies to reduce fall risk.
Recommendation	Avoid except for seizures and mood disorders.
Quality of evidence: High, Strength of Recommendation: Strong

Pharmacy Contact Info:

Main Inpatient Pharmacy: ext 4599, 3503
Fax: 704-878-7283

Director of Pharmacy - Randi Raynor, PharmD: ext 4501
Clinical Coordinator - Laura Rollings, PharmD: ext 4597
Pharmacy Informaticist - Stephen Pringle, PharmD: ext 7645
Pharmacy Technician Supervisor - Amy Wingler, CPhT: ext 7385
Pharmacy Automation Coordinator (Omnicell) - Melissa Fulford, CPhT: ext 3556

This site is intended for the staff of Iredell Health System. While others may view accessible pages, Iredell Health System makes no warranty, express or implied, as to the use of this information outside of Iredell Health System. The content of this policy and procedure document serves as guidance to the delivery of quality patient care. Care providers are expected to exercise critical thinking and situational awareness skills, and in specific situations to take such action as is necessary for the delivery of quality patient care.