Beers Criteria- Criteria 2 (syndrome view)
American Geriatrics Society 2023 updated AGS Beers Criteria®
for potentially inappropriate medication use in older adults Reference
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)  Back to All Criteria View

Cardiovascular - Heart failure

 aspirin
Comments > 325 mg/day
Drug ⇆ 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
 celecoxib (CeleBREX)
Drug ⇆ 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
 cilostazol (Pletal)
Drug ⇆ 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
 dextromethorphan-quiNIDine (Nuedexta)
Drug ⇆ disease or syndrome dextromethorphan-quiNIDine ⇆ Heart failure
Rationale Concerns about QT prolongation.
Recommendation Avoid
 Quality of evidence: Low, Strength of Recommendation: Strong
 diclofenac (Cambia, Cataflam, Voltaren)
Drug ⇆ 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
 diflunisal (Dolobid)
Drug ⇆ 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
 diltiaZEM (Cardizem, Dilacor)
Drug ⇆ 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
 dronedarone (Multaq)
Drug ⇆ 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
 etodolac (Lodine)
Drug ⇆ 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
 flurbiprofen (Ansaid, Ocufen)
Drug ⇆ 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
 ibuprofen (Caldolor, Motrin)
Drug ⇆ 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
 indomethacin (Indocin)
Drug ⇆ 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
 ketorolac (Acular, Toradol)
Drug ⇆ 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
 magnesium salicylate (Doan's)
Drug ⇆ 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
 meloxicam (Mobic)
Drug ⇆ 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
 nabumetone (Relafen)
Drug ⇆ 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
 naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Drug ⇆ 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
 oxaprozin (Daypro)
Drug ⇆ 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
 pioglitazone (Actos)
Drug ⇆ 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
 piroxicam (Feldene)
Drug ⇆ 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
 sulindac (Clinoril)
Drug ⇆ 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
 verapamil (Calan, Covera, Isoptin)
Drug ⇆ 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

Cardiovascular - Syncope

 amitriptyline (Elavil)
Drug ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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
 clomiPRAMINE (Anafranil)
Drug ⇆ 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
 donepezil (Aricept)
Drug ⇆ 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
 doxazosin (Cardura)
Drug ⇆ 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
 doxepin (SINEquan)
Comments >6 mg/day
 
Drug ⇆ 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
 galantamine (Razadyne)
Drug ⇆ 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
 imipramine (Tofranil)
Drug ⇆ 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
 OLANZapine (ZyPREXA)
Comments 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 ⇆ 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
 prazosin (Minipress)
Drug ⇆ 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
 rivastigmine (Exelon)
Drug ⇆ 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
 terazosin (Hytrin)
Drug ⇆ 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

Central Nervous System - Delirium

 acetaminophen-codeine (Tylenol #3)
Drug ⇆ 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
 acetaminophen-HYDROcodone (Lortab, Norco, Vicodin)
Drug ⇆ 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
 acetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)
Drug ⇆ 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
 acetaminophen-traMADol (Ultracet)
Drug ⇆ 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
 ALPRAZolam (Xanax)
Drug ⇆ 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
 amitriptyline (Elavil)
Drug ⇆ 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
 amoxapine (Asendin)
Drug ⇆ 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
 ARIPiprazole (Abilify)
Comments 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 ⇆ 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
 asenapine (Saphris)
Comments 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 ⇆ 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
 atropine
Comments excludes ophthalmic
 
Drug ⇆ 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
 benztropine (Cogentin)
Drug ⇆ 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
 brexpiprazole (Rexulti)
Comments 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 ⇆ 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
 brompheniramine (Dimetane, Dimetapp)
Drug ⇆ 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
 cariprazine (Vraylar)
Comments 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 ⇆ 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
 chlordiazePOXIDE (Librium)
Comments alone or in combination with amitriptyline or clidinium
 
Drug ⇆ 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
 chlorpheniramine (Chlor-Trimeton)
Drug ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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 ⇆ 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
 cimetidine (Tagamet)
Drug ⇆ 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
 clidinium-chlordiazePOXIDE (Librax)
Drug ⇆ 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
 cloBAZam (Onfi, Sympazan)
Drug ⇆ 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
 clomiPRAMINE (Anafranil)
Drug ⇆ 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
 clonazePAM (KlonoPIN)
Drug ⇆ 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
 clorazepate (Tranxene)
Drug ⇆ 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
 cloZAPine (Clozaril)
Comments 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 ⇆ 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 ⇆ 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
 codeine
Drug ⇆ 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
 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 ⇆ 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
 cyclobenzaprine (Flexeril)
Drug ⇆ 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
 cyproheptadine (Periactin)
Drug ⇆ 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
 darifenacin (Enablex)
Drug ⇆ 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
 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 ⇆ 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
 desipramine (Norpramin)
Drug ⇆ 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
 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 ⇆ 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
 diazePAM (Valium)
Drug ⇆ 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
 dicyclomine (Bentyl)
Drug ⇆ 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
 dimenhyDRINATE (Dramamine)
Drug ⇆ 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
 diphenhydrAMINE (Benadryl)
Comments diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.
 
Drug ⇆ 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
 doxepin (SINEquan)
Comments >6 mg/day
 
Drug ⇆ 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
 doxylamine (Unisom)
Drug ⇆ 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
 droperidol (Inapsine)
Comments 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 ⇆ 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
 estazolam (Prosom)
Drug ⇆ 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
 eszopiclone (Lunesta)
Drug ⇆ 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
 famotidine (Pepcid, Pepcid suspension)
Drug ⇆ 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
 fentaNYL (Sublimaze)
Drug ⇆ 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
 fesoterodine (Toviaz)
Drug ⇆ 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
 flavoxATE (Urispas)
Drug ⇆ 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
 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 ⇆ 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
 fluPHENAZine (Prolixin)
Comments 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 ⇆ 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
 haloperidol (Haldol)
Comments 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 ⇆ 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
 homatropine (Hycodan, Hydromet)
Drug ⇆ 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
 hydrocortisone (Anusol-HC, Cortaid, Cortenema, Hytone, Solu-CORTEF, Westcort)
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 ⇆ 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
 HYDROmorphone (Dilaudid)
Drug ⇆ 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
 hydrOXYzine (Atarax, Vistaril)
Drug ⇆ 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
 hyoscyamine (Hyosyne, Levsin, Levsinex)
Drug ⇆ 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
 iloperidone (Fanapt)
Comments 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 ⇆ 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
 imipramine (Tofranil)
Drug ⇆ 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
 LORazepam (Ativan)
Drug ⇆ 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
 loxapine (Loxitane)
Comments 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 ⇆ 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
 lurasidone (Latuda)
Comments 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 ⇆ 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
 meclizine (Antivert)
Drug ⇆ 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
 meperidine (Demerol)
Drug ⇆ 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
 methadone (Dolophine)
Drug ⇆ 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
 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 ⇆ 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
 midazolam (Versed)
Drug ⇆ 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
 morphine (Oramorph SR, Roxanol)
Drug ⇆ 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
 nizatidine (Axid)
Drug ⇆ 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
 nortriptyline (Pamelor)
Drug ⇆ 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
 OLANZapine (ZyPREXA)
Comments 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 ⇆ 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 ⇆ 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
 orphenadrine (Norflex)
Drug ⇆ 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
 oxazepam (Serax)
Drug ⇆ 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
 oxybutynin (Ditropan)
Drug ⇆ 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
 oxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)
Drug ⇆ 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
 oxyMORphone (Numorphan, Opana)
Drug ⇆ 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
 paliperidone (Invega)
Comments 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.
 PARoxetine (Paxil)
Drug ⇆ 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
 perphenazine (Trilafon)
Comments 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 ⇆ 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 ⇆ 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
 pimavanserin (Nuplazid)
Comments 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 ⇆ 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
 pimozide (Orap)
Comments 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 ⇆ 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
 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 ⇆ 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 ⇆ 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
 prochlorperazine (Compazine)
Comments 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 ⇆ 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 ⇆ 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
 promethazine (Phenadoz, Phenergan)
Drug ⇆ 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
 QUEtiapine (SEROquel)
Comments 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 ⇆ 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
 risperiDONE (RisperDAL)
Comments 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 ⇆ 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
 scopolamine (Transderm Scop)
Drug ⇆ 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
 solifenacin (Vesicare)
Drug ⇆ 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
 SUFentanil (Sufenta)
Drug ⇆ 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
 temazepam (Restoril)
Drug ⇆ 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
 thioridazine (Mellaril)
Comments 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 ⇆ 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
 thiothixine (Navane)
Drug ⇆ 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
 tolterodine (Detrol)
Drug ⇆ 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
 traMADol (Ultram)
Drug ⇆ 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
 triazolam (Halcion)
Drug ⇆ 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
 trifluoperazine (Stelazine)
Comments 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 ⇆ 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
 trihexyphenidyl (Artane)
Drug ⇆ 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
 triprolidine (Histex, Zymine)
Drug ⇆ 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
 trospium (Sanctura)
Drug ⇆ 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
 zaleplon (Sonata)
Drug ⇆ 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
 ziprasidone (Geodon)
Comments 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 ⇆ 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
 zolpidem (Ambien)
Drug ⇆ 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

Central Nervous System - Dementia or cognitive impairment

 ALPRAZolam (Xanax)
Drug ⇆ 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
 amitriptyline (Elavil)
Drug ⇆ 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
 amoxapine (Asendin)
Drug ⇆ 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
 ARIPiprazole (Abilify)
Comments 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 ⇆ 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
 asenapine (Saphris)
Drug ⇆ 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
 atropine
Comments excludes ophthalmic
 
Drug ⇆ 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
 benztropine (Cogentin)
Drug ⇆ 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
 brexpiprazole (Rexulti)
Comments 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 ⇆ 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
 brompheniramine (Dimetane, Dimetapp)
Drug ⇆ 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
 cariprazine (Vraylar)
Comments 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 ⇆ 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
 chlordiazePOXIDE (Librium)
Comments alone or in combination with amitriptyline or clidinium
 
Drug ⇆ 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
 chlorpheniramine (Chlor-Trimeton)
Drug ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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
 clidinium-chlordiazePOXIDE (Librax)
Drug ⇆ 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
 cloBAZam (Onfi, Sympazan)
Drug ⇆ 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
 clomiPRAMINE (Anafranil)
Drug ⇆ 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
 clonazePAM (KlonoPIN)
Drug ⇆ 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
 clorazepate (Tranxene)
Drug ⇆ 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
 cloZAPine (Clozaril)
Comments 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 ⇆ 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 ⇆ 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
 cyclobenzaprine (Flexeril)
Drug ⇆ 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
 cyproheptadine (Periactin)
Drug ⇆ 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
 darifenacin (Enablex)
Drug ⇆ 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
 desipramine (Norpramin)
Drug ⇆ 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
 diazePAM (Valium)
Drug ⇆ 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
 dicyclomine (Bentyl)
Drug ⇆ 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
 dimenhyDRINATE (Dramamine)
Drug ⇆ 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
 diphenhydrAMINE (Benadryl)
Comments diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.
 
Drug ⇆ 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
 doxepin (SINEquan)
Comments >6 mg/day
 
Drug ⇆ 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
 doxylamine (Unisom)
Drug ⇆ 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
 droperidol (Inapsine)
Comments 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 ⇆ 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
 estazolam (Prosom)
Drug ⇆ 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
 eszopiclone (Lunesta)
Drug ⇆ 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
 fesoterodine (Toviaz)
Drug ⇆ 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
 flavoxATE (Urispas)
Drug ⇆ 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
 fluPHENAZine (Prolixin)
Comments 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 ⇆ 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
 haloperidol (Haldol)
Comments 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 ⇆ 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
 homatropine (Hycodan, Hydromet)
Drug ⇆ 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
 hydrOXYzine (Atarax, Vistaril)
Drug ⇆ 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
 hyoscyamine (Hyosyne, Levsin, Levsinex)
Drug ⇆ 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
 iloperidone (Fanapt)
Comments 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 ⇆ 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
 imipramine (Tofranil)
Drug ⇆ 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
 LORazepam (Ativan)
Drug ⇆ 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
 loxapine (Loxitane)
Comments 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 ⇆ 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
 lurasidone (Latuda)
Comments 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.
 meclizine (Antivert)
Drug ⇆ 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
 midazolam (Versed)
Drug ⇆ 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
 nortriptyline (Pamelor)
Drug ⇆ 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
 OLANZapine (ZyPREXA)
Comments 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 ⇆ 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 ⇆ 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
 orphenadrine (Norflex)
Drug ⇆ 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
 oxazepam (Serax)
Drug ⇆ 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
 oxybutynin (Ditropan)
Drug ⇆ 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
 paliperidone (Invega)
Comments 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 ⇆ 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
 PARoxetine (Paxil)
Drug ⇆ 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
 perphenazine (Trilafon)
Comments 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 ⇆ 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 ⇆ 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
 pimavanserin (Nuplazid)
Comments 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 ⇆ 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
 pimozide (Orap)
Comments 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 ⇆ 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
 prochlorperazine (Compazine)
Comments 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 ⇆ 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 ⇆ 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
 promethazine (Phenadoz, Phenergan)
Drug ⇆ 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
 QUEtiapine (SEROquel)
Comments 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 ⇆ 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
 risperiDONE (RisperDAL)
Comments 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 ⇆ 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
 scopolamine (Transderm Scop)
Drug ⇆ 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
 solifenacin (Vesicare)
Drug ⇆ 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
 temazepam (Restoril)
Drug ⇆ 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
 thioridazine (Mellaril)
Comments 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 ⇆ 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
 thiothixine (Navane)
Drug ⇆ 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
 tolterodine (Detrol)
Drug ⇆ 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
 triazolam (Halcion)
Drug ⇆ 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
 trifluoperazine (Stelazine)
Comments 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 ⇆ 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
 trihexyphenidyl (Artane)
Drug ⇆ 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
 triprolidine (Histex, Zymine)
Drug ⇆ 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
 trospium (Sanctura)
Drug ⇆ 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
 zaleplon (Sonata)
Drug ⇆ 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
 ziprasidone (Geodon)
Comments 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 ⇆ 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
 zolpidem (Ambien)
Drug ⇆ 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

Central Nervous System - History of falls or fractures

 acetaminophen-codeine (Tylenol #3)
Drug ⇆ 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
 acetaminophen-HYDROcodone (Lortab, Norco, Vicodin)
Drug ⇆ 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
 acetaminophen-oxyCODONE (Percocet, Roxicet, Tylox)
Drug ⇆ 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
 acetaminophen-traMADol (Ultracet)
Drug ⇆ 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
 ALPRAZolam (Xanax)
Drug ⇆ 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
 amitriptyline (Elavil)
Drug ⇆ 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 ⇆ 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
 amoxapine (Asendin)
Drug ⇆ 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
 ARIPiprazole (Abilify)
Comments 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 ⇆ 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
 asenapine (Saphris)
Comments 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 ⇆ 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
 atropine
Comments excludes ophthalmic
 
Drug ⇆ 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
 benztropine (Cogentin)
Drug ⇆ 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
 brexpiprazole (Rexulti)
Comments 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 ⇆ 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
 brivaracetam (Briviact)
Drug ⇆ 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
 brompheniramine (Dimetane, Dimetapp)
Drug ⇆ 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
 cannabidiol (Epidiolex)
Drug ⇆ 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 ⇆ 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
 cariprazine (Vraylar)
Comments 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 ⇆ 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
 cenobamate (Xcopri)
Drug ⇆ 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
 chlordiazePOXIDE (Librium)
Comments alone or in combination with amitriptyline or clidinium
 
Drug ⇆ 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
 chlorpheniramine (Chlor-Trimeton)
Drug ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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 ⇆ 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
 citalopram (CeleXA)
Drug ⇆ 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
 clidinium-chlordiazePOXIDE (Librax)
Drug ⇆ 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
 cloBAZam (Onfi, Sympazan)
Drug ⇆ 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 ⇆ 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
 clomiPRAMINE (Anafranil)
Drug ⇆ 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 ⇆ 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
 clonazePAM (KlonoPIN)
Drug ⇆ 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 ⇆ 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
 clorazepate (Tranxene)
Drug ⇆ 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
 cloZAPine (Clozaril)
Comments 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 ⇆ 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 ⇆ 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
 codeine
Drug ⇆ 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
 cyclobenzaprine (Flexeril)
Drug ⇆ 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
 cyproheptadine (Periactin)
Drug ⇆ 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
 darifenacin (Enablex)
Drug ⇆ 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
 desipramine (Norpramin)
Drug ⇆ 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 ⇆ 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
 desvenlafaxine (Pristiq)
Drug ⇆ 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
 diazePAM (Valium)
Drug ⇆ 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 ⇆ 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
 dicyclomine (Bentyl)
Drug ⇆ 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
 dimenhyDRINATE (Dramamine)
Drug ⇆ 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
 diphenhydrAMINE (Benadryl)
Comments diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.
 
Drug ⇆ 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
 divalproex (Depakote)
Drug ⇆ 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
 doxepin (SINEquan)
Comments >6 mg/day
 
Drug ⇆ 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 ⇆ 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
 doxylamine (Unisom)
Drug ⇆ 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
 droperidol (Inapsine)
Comments 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 ⇆ 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
 DULoxetine (Cymbalta)
Drug ⇆ 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 ⇆ 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 ⇆ 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
 estazolam (Prosom)
Drug ⇆ 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
 eszopiclone (Lunesta)
Drug ⇆ 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
 ethosuximide (Zarontin)
Drug ⇆ 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
 everolimus (Afinitor, Zortress)
Drug ⇆ 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
 felbamate (Felbatol)
Drug ⇆ 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 ⇆ 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
 fentaNYL (Sublimaze)
Drug ⇆ 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 ⇆ 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 ⇆ 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
 FLUoxetine (PROzac)
Drug ⇆ 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
 fluPHENAZine (Prolixin)
Comments 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 ⇆ 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
 fLuvoxaMINE (Luvox)
Drug ⇆ 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
 gabapentin (Neurontin)
Drug ⇆ 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
 ganaxolone (Ztalmy)
Drug ⇆ 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
 haloperidol (Haldol)
Comments 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 ⇆ 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
 homatropine (Hycodan, Hydromet)
Drug ⇆ 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
 HYDROmorphone (Dilaudid)
Drug ⇆ 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
 hydrOXYzine (Atarax, Vistaril)
Drug ⇆ 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
 hyoscyamine (Hyosyne, Levsin, Levsinex)
Drug ⇆ 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
 iloperidone (Fanapt)
Comments 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 ⇆ 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
 imipramine (Tofranil)
Drug ⇆ 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 ⇆ 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
 lacosamide (Vimpat)
Drug ⇆ 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 ⇆ 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 ⇆ 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 ⇆ 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
 LORazepam (Ativan)
Drug ⇆ 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 ⇆ 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
 loxapine (Loxitane)
Comments 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 ⇆ 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
 lurasidone (Latuda)
Comments 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 ⇆ 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
 meclizine (Antivert)
Drug ⇆ 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
 meperidine (Demerol)
Drug ⇆ 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
 methadone (Dolophine)
Drug ⇆ 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
 midazolam (Versed)
Drug ⇆ 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 ⇆ 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 ⇆ 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
 morphine (Oramorph SR, Roxanol)
Drug ⇆ 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
 nortriptyline (Pamelor)
Drug ⇆ 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 ⇆ 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
 OLANZapine (ZyPREXA)
Comments 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 ⇆ 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 ⇆ 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
 orphenadrine (Norflex)
Drug ⇆ 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
 oxazepam (Serax)
Drug ⇆ 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 ⇆ 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 ⇆ 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
 oxyCODONE (Oxaydo, OxyCONTIN, Oxyfast, Oxy-IR, Percodan, Roxicodone, Roxybond, Xtampza)
Drug ⇆ 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
 oxyMORphone (Numorphan, Opana)
Drug ⇆ 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
 paliperidone (Invega)
Comments 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 ⇆ 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
 PARoxetine (Paxil)
Drug ⇆ 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 ⇆ 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
 perampanel (Fycompa)
Drug ⇆ 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
 perphenazine (Trilafon)
Comments 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 ⇆ 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 ⇆ 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
 PHENobarbital (Luminal)
Drug ⇆ 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 ⇆ 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
 pimavanserin (Nuplazid)
Comments 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 ⇆ 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
 pimozide (Orap)
Comments 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 ⇆ 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
 pregabalin (Lyrica)
Drug ⇆ 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
 primidone (Mysoline)
Drug ⇆ 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
 prochlorperazine (Compazine)
Comments 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 ⇆ 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 ⇆ 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
 promethazine (Phenadoz, Phenergan)
Drug ⇆ 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
 QUEtiapine (SEROquel)
Comments 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 ⇆ 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
 risperiDONE (RisperDAL)
Comments 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 ⇆ 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
 rufinamide (Banzel)
Drug ⇆ 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
 scopolamine (Transderm Scop)
Drug ⇆ 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
 sertraline (Zoloft)
Drug ⇆ 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
 solifenacin (Vesicare)
Drug ⇆ 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 ⇆ 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
 SUFentanil (Sufenta)
Drug ⇆ 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
 temazepam (Restoril)
Drug ⇆ 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
 thioridazine (Mellaril)
Comments 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 ⇆ 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
 thiothixine (Navane)
Drug ⇆ 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
 tiaGABine (Gabitril)
Drug ⇆ 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 ⇆ 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 ⇆ 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
 traMADol (Ultram)
Drug ⇆ 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
 triazolam (Halcion)
Drug ⇆ 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
 trifluoperazine (Stelazine)
Comments 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 ⇆ 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
 trihexyphenidyl (Artane)
Drug ⇆ 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
 triprolidine (Histex, Zymine)
Drug ⇆ 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
 trospium (Sanctura)
Drug ⇆ 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, Depakote, Stavzor)
Drug ⇆ 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 ⇆ 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
 vigabatrin (Sabril)
Drug ⇆ 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
 zaleplon (Sonata)
Drug ⇆ 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
 ziprasidone (Geodon)
Comments 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 ⇆ 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
 zolpidem (Ambien)
Drug ⇆ 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 ⇆ 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

Central Nervous System - Parkinson disease

 ARIPiprazole (Abilify)
Comments 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 ⇆ 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
 asenapine (Saphris)
Comments 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 ⇆ 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
 brexpiprazole (Rexulti)
Comments 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 ⇆ 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
 cariprazine (Vraylar)
Comments 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 ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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
 droperidol (Inapsine)
Comments 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 ⇆ 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
 fluPHENAZine (Prolixin)
Comments 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 ⇆ 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
 haloperidol (Haldol)
Comments 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 ⇆ 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
 iloperidone (Fanapt)
Comments 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 ⇆ 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
 loxapine (Loxitane)
Comments 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 ⇆ 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
 lurasidone (Latuda)
Comments 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 ⇆ 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
 metoclopramide (Reglan)
Drug ⇆ 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
 OLANZapine (ZyPREXA)
Comments 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 ⇆ 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
 paliperidone (Invega)
Comments 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 ⇆ 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
 perphenazine (Trilafon)
Comments 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 ⇆ 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
 pimozide (Orap)
Comments 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 ⇆ 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
 prochlorperazine (Compazine)
Comments 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 ⇆ 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 ⇆ 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
 promethazine (Phenadoz, Phenergan)
Drug ⇆ 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
 risperiDONE (RisperDAL)
Comments 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 ⇆ 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
 thioridazine (Mellaril)
Comments 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 ⇆ 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
 thiothixine (Navane)
Drug ⇆ 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
 trifluoperazine (Stelazine)
Comments 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 ⇆ 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
 ziprasidone (Geodon)
Comments 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 ⇆ 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

Gastrointestinal - History of gastric or duodenal ulcers

 aspirin
Comments > 325 mg/day
Drug ⇆ 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
 diclofenac (Cambia, Cataflam, Voltaren)
Drug ⇆ 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
 diflunisal (Dolobid)
Drug ⇆ 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
 etodolac (Lodine)
Drug ⇆ 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
 flurbiprofen (Ansaid, Ocufen)
Drug ⇆ 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
 ibuprofen (Caldolor, Motrin)
Drug ⇆ 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
 indomethacin (Indocin)
Drug ⇆ 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
 ketorolac (Acular, Toradol)
Drug ⇆ 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
 meloxicam (Mobic)
Drug ⇆ 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
 nabumetone (Relafen)
Drug ⇆ 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
 naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Drug ⇆ 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
 oxaprozin (Daypro)
Drug ⇆ 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
 piroxicam (Feldene)
Drug ⇆ 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
 sulindac (Clinoril)
Drug ⇆ 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

Kidney/urinary tract - Urinary incontinence (all types) in women

 alfuzosin (Uroxatral)
Comments Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
Drug ⇆ 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
 diethylstilbestrol (DES)
Drug ⇆ 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
 doxazosin (Cardura)
Drug ⇆ 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
 estradiol (Alora, Climara, Estrace, Vivelle-Dot)
Drug ⇆ 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
 estrogen/progesterone combinations (Premphase, Prempro)
Drug ⇆ 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
 estrogens, conjugated (Cenestin)
Drug ⇆ 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
 estrogens, esterified (Menest)
Drug ⇆ 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
 estropipate (Ogen, Ortho-Est)
Drug ⇆ 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
 ethinyl estradiol-norethindrone (Femhrt)
Drug ⇆ 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
 prazosin (Minipress)
Drug ⇆ 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
 silodosin (Rapaflo)
Comments Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
Drug ⇆ 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
 tamsulosin (Flomax)
Comments Data are limited for selective peripheral alpha-1 blockers (e.g., tamsulosin, silodosin, and others) but may apply as well.
 
Drug ⇆ 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
 terazosin (Hytrin)
Drug ⇆ 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

Kidney/urinary tract - Lower urinary tract symptoms, benign prostatic hyperplasia

 amitriptyline (Elavil)
Drug ⇆ 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
 amoxapine (Asendin)
Drug ⇆ 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
Comments excludes ophthalmic
 
Drug ⇆ 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
 benztropine (Cogentin)
Drug ⇆ 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
 brompheniramine (Dimetane, Dimetapp)
Drug ⇆ 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
 chlorpheniramine (Chlor-Trimeton)
Drug ⇆ 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
 chlorproMAZINE (Thorazine)
Comments 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 ⇆ 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
 clidinium-chlordiazePOXIDE (Librax)
Drug ⇆ 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
 clomiPRAMINE (Anafranil)
Drug ⇆ 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
 cloZAPine (Clozaril)
Comments 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 ⇆ 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
 cyclobenzaprine (Flexeril)
Drug ⇆ 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
 cyproheptadine (Periactin)
Drug ⇆ 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
 desipramine (Norpramin)
Drug ⇆ 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
 dicyclomine (Bentyl)
Drug ⇆ 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
 dimenhyDRINATE (Dramamine)
Drug ⇆ 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
 diphenhydrAMINE (Benadryl)
Comments diphenhydrAMINE (oral) Use of diphenhydrAMINE in situations such as acute treatment of severe allergic reactions may be appropriate.
 
Drug ⇆ 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
 doxepin (SINEquan)
Comments >6 mg/day
 
Drug ⇆ 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
 doxylamine (Unisom)
Drug ⇆ 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
 homatropine (Hycodan, Hydromet)
Drug ⇆ 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
 hydrOXYzine (Atarax, Vistaril)
Drug ⇆ 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
 hyoscyamine (Hyosyne, Levsin, Levsinex)
Drug ⇆ 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
 imipramine (Tofranil)
Drug ⇆ 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
 meclizine (Antivert)
Drug ⇆ 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
 nortriptyline (Pamelor)
Drug ⇆ 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
 OLANZapine (ZyPREXA)
Drug ⇆ 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
 orphenadrine (Norflex)
Drug ⇆ 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
 PARoxetine (Paxil)
Drug ⇆ 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
 perphenazine (Trilafon)
Comments 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 ⇆ 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
 prochlorperazine (Compazine)
Comments 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 ⇆ 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
 promethazine (Phenadoz, Phenergan)
Drug ⇆ 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
 scopolamine (Transderm Scop)
Drug ⇆ 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
 trihexyphenidyl (Artane)
Drug ⇆ 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
 triprolidine (Histex, Zymine)
Drug ⇆ 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

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



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