Beers Criteria

[EMEDPA]

Just discussing this with my student. A good list of meds to avoid in the elderly. My example from this list was cyclobenzaprine. 

2019 Beers Criteria Pocket Guide - From THE AMERICAN GERIATRICS SOCIETY This guide has been - StuDocu

[iconic]

Honestly, one of the reasons we don't take medicare patients in psych and most psych practices don't either. Those patients do not want to give up their BEER meds 

[EMEDPA]

20 minutes ago, iconic said:

Honestly, one of the reasons we don't take medicare patients in psych and most psych practices don't either. Those patients do not want to give up their BEER meds 

or their beer.

[sas5814]

I have patients that transfer in from other places (elderly) that rage because I won't continue their nightly Ambien or won't give them a narc and a benzo at the same time.

I hear "I have been doing it for years" and "this is what I negotiated with my last doc". 

You can't negotiate malpractice.

[Reality Check 2]

I love the Beers List - I find the name humorous.

I show it to patients and discuss how we change as we age.

Agree with Scott - can't negotiate danger and stupidity.

Can't wait for Ambien to get pulled from the market - horrible drug.

[ventana]

also can reference start/stop lists

 

 

As for the upper downer sleepmeds stimu and all the other coktail of drugs

 

There is what is called a legacy patient - one that has been on these meds for so long that they litterally will never come off.  They might get dose reduction over time but it takes a huge effort.  These are the "tough ones" that a highly experienced provider needs to be managing.  

 

IE recent patient, 76 yrs old, CAD, DM on

chronic stable full agonist opi <50meq morphine)

Ambien for sleep

Short Acting BZD for anxiety

 

Yup my new patient I walk into.....

 

After first visit 

continue OPI (newer studies says this is the right thing to do)

stop the Ambien (Z drugs are a no go)

Change BZD to long acting taken at night (healthy dose to cover both the short acting bzd and ambien)

Started Fluoxetine for anxiety

 

 

i have been following for about 6m now

still asks for sleeping meds, still say "take your bzd at bed time"

 

anxiety tolerable

 

working towards a dose reduction on bzd but will likely be a tiny one.

 

not as simple as "don't write" cause if everyone does this the patient suffers and could die.....

 

[iconic]

There is no patient that will “never come off”. If it’s inappropriate, don’t prescribe it. If possible taper; if they don’t want to be tapered they can go somewhere else. Just don’t send them to psych and tell them that we will prescribe it, cause we won’t. 

[ventana]

4 hours ago, iconic said:

There is no patient that will “never come off”. If it’s inappropriate, don’t prescribe it. If possible taper; if they don’t want to be tapered they can go somewhere else. Just don’t send them to psych and tell them that we will prescribe it, cause we won’t. 

ugh

that is simply not true - 20+ years of working in the trenches has taught me a lesson or two 

 

read the newest studies on long term OPI

 

read about BZD dependency

 

read about the increasing death rates among those who are forced to cut meds

 

Remember first "do no harm" 

by your own logic the patient will get no-one to write for their meds, forcing and immediate and dangerous withdrawal.  

Who ever comes up with a black and white statement in medicine is bound to be wrong... they just don't exist.   

I personally have lost a few patient earlier in my career to this notion that you "must stop prescribing"

 

please don't preach something that you might not have seen every angle on.  (btw I am one of the hardest to get controlleds from - but when you have someone coming in on OPI and BZD for 20 years you can not, nor should you, simply stop meds.  Honestly some of these patients you can not get off. And I have tried repeatedly over the years.  

 

[LT_Oneal_PAC]

Agree with ventana. You can’t suddenly cut someone off a benzo. However when I was a PCP, I would take these people and explain that I could guarantee they would find no other provider that worked harder for them, spend as much time with them, and be available to them, but I required similar dedication from my patients. That meant they had to work with me on appropriate reducing and, if appropriate, eliminating medications. That does not mean I let them suffer, we both work hard to find a safe and appropriate regimen, finding safer alternatives. If they just want someone to prescribe what they’ve always gotten with a quick visit or telephone refill, there are plenty of people with open spots on their panel.

If I ever prescribed a benzo to a patient having serious anxiety, they were sure to know they would get no more than 40 in a year and no more than 15 in a month. More than that, we aren’t prescribing the right chronic medication for their issue.

[iconic]

Overall I’m not a fan of the Beer’s criteria. Pretty much all psych drugs are on it - which really leaves me the question of what do they expect us to do for mood and behavioral disturbances? The FDA has a long history of anti-psych bias which has not done anything good for anyone 

Edited August 2, 2022 by iconic

[iconic]

While I do not have 20 years of experience, I would like to stay in practice for another 20+ years and I have practiced in psych, addiction and pain medicine. None of the attendings I worked for would prescribe a benzo to a patient on chronic opioid therapy. Some would offer a rapid taper. As long as the government keeps going after providers with patients with adverse outcomes from those drugs, I will not be engaging in that prescribing (and I really do not think those are good combos). Those patients usually find someone near retirement however to prescribe them meds, but it’s never beneficial to the patient to keep them at doses that would cause withdrawals should they loose their prescriber/end up in a place where they wouldn’t be continued on their med.

Edited August 2, 2022 by iconic

[VentiMacchiato]

One of my preceptors in PA school years ago told me my (also his) school will teach me what I need to know about medicine but he will teach me the art of medicine...and I believe he did.

I've "inherited" patients in situations as above. One patient was on Valium 10mg for probably close to 20 years. When her doctor retired and she started seeing me, we had a frank conversation of where we needed to go with tapering. Her fear was tapering off too fast. I assured her I will not do that so for the past 4 years, we decreased her dose slowly. I planned on decreasing it faster but then her husband died so it got delayed a while. We were finally at 1mg dose when her pain mgmt doc said either BZD or narcotics so it was easier to switch her. However, we still had to use a medication that is listed in the Beers List, Doxepin. She actually took herself off Belsomra this year because  the pharmacies were always out of it. 

I have patients who are still on daily PPIs unfortunately but would another EGD or undergoing Nissen be appropriate? Probably not. So we try and use the lowest effective dose. 

I have a new 93 y/o patient recently who has arthritis pain. She is not on any medications. Someone else checked her cholesterol and it was high 280s, H 40s, T 150s, L 200s). Statin is not in the Beer's list but I would not start her on a statin

I know all of these are anecdotal and does not always follow guidelines but I try to follow it . The Beers list is used as a guideline and it is a good reminder. When an 80 y/o has allergies to PCN & Bactrim while,  Nitrofurantoin is in Beers list, would you then use Cipro? Oh and BTW she's on Warfarin.

 

Edited August 2, 2022 by VentiMacchiato
Remove gazillion

[sas5814]

14 hours ago, iconic said:

There is no patient that will “never come off”. If it’s inappropriate, don’t prescribe it. If possible taper; if they don’t want to be tapered they can go somewhere else. Just don’t send them to psych and tell them that we will prescribe it, cause we won’t. 

Interestingly that's where we have to send long term sleepers like Ambien or long term benzo use. Its policy. 99.9% of the time psych just gives it to them. *shrug* The only time it gets sticky is when we are writing a narc and psych continues them on long term benzo. Then we have to make some kind of plan because that ain't happening.

[ventana]

10 hours ago, VentiMacchiato said:

One of my preceptors in PA school years ago told me my (also his) school will teach me what I need to know about medicine but he will teach me the art of medicine...and I believe he did.

I've "inherited" patients in situations as above. One patient was on Valium 10mg for probably close to 20 years. When her doctor retired and she started seeing me, we had a frank conversation of where we needed to go with tapering. Her fear was tapering off too fast. I assured her I will not do that so for the past 4 years, we decreased her dose slowly. I planned on decreasing it faster but then her husband died so it got delayed a while. We were finally at 1mg dose when her pain mgmt doc said either BZD or narcotics so it was easier to switch her. However, we still had to use a medication that is listed in the Beers List, Doxepin. She actually took herself off Belsomra this year because  the pharmacies were always out of it. 

I have patients who are still on daily PPIs unfortunately but would another EGD or undergoing Nissen be appropriate? Probably not. So we try and use the lowest effective dose. 

I have a new 93 y/o patient recently who has arthritis pain. She is not on any medications. Someone else checked her cholesterol and it was high 280s, H 40s, T 150s, L 200s). Statin is not in the Beer's list but I would not start her on a statin

I know all of these are anecdotal and does not always follow guidelines but I try to follow it . The Beers list is used as a guideline and it is a good reminder. When an 80 y/o has allergies to PCN & Bactrim while,  Nitrofurantoin is in Beers list, would you then use Cipro? Oh and BTW she's on Warfarin.

 

people need to read and study this answer

this is the art of medicine

do not get suckered in the "guideline of the day" mentality and think one thing is an absolute.  That is academic knowledge not true medicine.

 

For almost all the meds we all write you really have to follow a harm reduction model. Nothing is easy (well the decision to NOT place a 93 yr old on a statin is pretty easy - as long as it is primary prevention)

 

 

Medicine is not making widgets - we all need to stop and think and ponder on what negative and positive outcomes our actions can have.

[rev ronin]

I've got one still on benzos and opioids. He's gone from 120 MED to 22.5 and 0.5 bid alprazolam to <10/month. Ironically, he's no a fan of MJ because it's a "drug" so he's never even tried CBDs which are legal here.

[EMEDPA]

On 8/1/2022 at 9:49 AM, Reality Check 2 said:

Can't wait for Ambien to get pulled from the market - horrible drug.

Agree. Someone put my 89 yr old mom on it at 10 mg/night and my sister called me in a panic because she was suddenly confused and ataxic. Stopped ambien and back to baseline

[EMEDPA]

13 hours ago, iconic said:

Overall I’m not a fan of the Beer’s criteria. Pretty much all psych drugs are on it - which really leaves me the question of what do they expect us to do for mood and behavioral disturbances?

ECT? Serious question.

[sas5814]

6 minutes ago, EMEDPA said:

ECT? Serious question.

Highly under utilized and not the cruelty of old movies and days gone by. My wife is a psych nurse and has seen some pretty good results when used correctly under the right circumstances.

I was discussing with a new doc this morning the use of SSRIs and SNRIs and how effective they actually are...which really isn't much.

[EMEDPA]

7 minutes ago, sas5814 said:

Highly under utilized and not the cruelty of old movies and days gone by. My wife is a psych nurse and has seen some pretty good results when used correctly under the right circumstances.

I was discussing with a new doc this morning the use of SSRIs and SNRIs and how effective they actually are...which really isn't much.

I have a friend who is a psych MD who told me if he had major depression he would elect for ECT over meds.

[VentiMacchiato]

Is TMS the same as ECT? 

[Reality Check 2]

Benzos are a dead end road. Nowhere good to go if used chronically.

I am with folks above - you get 4 benzos for flying. You don't drink and you don't drive on arrival.

Grieving and traumatic experiences on an individual basis. Is there family present? Alcohol issues? Circumstances? History?

NO ONE should be taking 1 mg of Ativan TID - but I have a few I inherited. Can't get 'em off of it - got Psych and Neuro to back up the long term habituation and we keep going. BUT no narcs with the benzos and I check urine alcohol and drug screen every 3 months.

P.S. Benzos don't show up on a standard UDS. You have to order urine benzo confirmation if they take them regularly.

Benzos and opioids is DUMB, just DUMB. Should not be done. Most of these folks drink to boot. And are over 60 or over 65. Dangerous and dumb. Taper one off and bring the other one down as low as can go.

Genetic testing for SSRIs has helped some - you know which enzyme they work with best. But they don't do it all.

ECT has a role - I have seen miraculous return to functionality and another has a chronic short circuit and spaces out like absence seizures - personality change, memory loss and generally not the same person as before.

Our world is not conducive to happiness right now - or for a while now. Too much information, too much to be depressed about. 

Back to the Beers List  - It is useful and exists for a reason.

Better living thru Chemistry is only a sometimes thing. 

Drugs are chemicals. They have side effects. They aren't magic bullets. 

DO NO HARM.

Medicine is an art and not a negotiation for customer service.

 

 

[iconic]

1 hour ago, EMEDPA said:

ECT? Serious question.

Well not for anxiety or dementia. A lot of bzo patients haven't even been on an SSRI so could be a good start. For dementia, behavioral interventions are first line.. but you know the family has to find a way to find those services for the patients 

Edited August 2, 2022 by iconic

[iconic]

7 hours ago, Reality Check 2 said:

Benzos are a dead end road. Nowhere good to go if used chronically.

I am with folks above - you get 4 benzos for flying. You don't drink and you don't drive on arrival.

Grieving and traumatic experiences on an individual basis. Is there family present? Alcohol issues? Circumstances? History?

NO ONE should be taking 1 mg of Ativan TID - but I have a few I inherited. Can't get 'em off of it - got Psych and Neuro to back up the long term habituation and we keep going. BUT no narcs with the benzos and I check urine alcohol and drug screen every 3 months.

P.S. Benzos don't show up on a standard UDS. You have to order urine benzo confirmation if they take them regularly.

Benzos and opioids is DUMB, just DUMB. Should not be done. Most of these folks drink to boot. And are over 60 or over 65. Dangerous and dumb. Taper one off and bring the other one down as low as can go.

Genetic testing for SSRIs has helped some - you know which enzyme they work with best. But they don't do it all.

ECT has a role - I have seen miraculous return to functionality and another has a chronic short circuit and spaces out like absence seizures - personality change, memory loss and generally not the same person as before.

Our world is not conducive to happiness right now - or for a while now. Too much information, too much to be depressed about. 

Back to the Beers List  - It is useful and exists for a reason.

Better living thru Chemistry is only a sometimes thing. 

Drugs are chemicals. They have side effects. They aren't magic bullets. 

DO NO HARM.

Medicine is an art and not a negotiation for customer service.

 

 

I am still scratching my head at prescribing BZOs for grieving.. there is no indication. Sometimes therapeutic communication is all patients need, and not another script..

 

8 hours ago, VentiMacchiato said:

Is TMS the same as ECT? 

No, but they are both a type of neuromodulation. They can be both done for treatment-resistant depression. TMS also received indication for OCD recently and has been studied in anxiety. ECT is used for depression, catatonia as well as self-injurious behaviors . ECT is done under anesthesia, whereas TMS is painless. 

ECT induces a seizures. TMS stimulates activity in an area of prefrontal cortex which presumably leads to neurogenesis. Both require multiple sessions 

Edited August 3, 2022 by iconic

[ventana]

ECT is not TMS

TMS is magnetic

ECT is electric

 

look out for Ketamine infusions for depression - pretty convincing data.....

[sas5814]

Ketamine data is looking really interesting but its suffering the same social stigma as marijuana.... party drug stuff. It will happen but there will be a lot of education before it hits mainstream.

 

Not to hijack the thread but someone mentioned dementia. Last Friday my MIL, who has dementia, went full tilt boogie psychotic. Screaming, hallucinations, violence. She was at home with my tiny little 90 pound FIL. It took a full 48 hours to get her medically evaluated and cleared and into a gero-psych unit because she couldn't and wouldn't sign herself in and Texas requires a SPECIAL kind of POA for anything psych related. General or medical POA doesn't suffice. Watching my wife and her family go through that just ground me up. We have some huge problems in our system.