Vol. 113 No. 6 June 2012

MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE

Use of the Beers criteria to identify potentially inappropriate druguse by community-dwelling older dental patientsDaniel D. Skaar, DDS, MS, MBA,a and Heidi L. O’Connor, MSb

Objective. Recognizing drugs with serious adverse experience (AE) potential in an aging population would assist practitionersin preventing drug safety issues. This study identifies drugs with potential for causing serious AEs, describes the AEs, andestimates prevalent use among older adults visiting the dentist.Study Design. Drugs with serious AE risk for older adults were identified with the use of the Beers criteria. Analyses of olderadults visiting the dentist using the Medicare Current Beneficiary Survey tested associations between demographic and health-related variables and use of these drugs. Potentially serious drug-related AEs are described.Results. More than 3 in 10 older adults visiting the dentist were prescribed a Beers-criteria drug. Commonly prescribed Beers-criteria drugs used in dentistry include benzodiazepines and long-acting nonsteroidal antiinflammatory analgesics.Conclusions. Awareness of potentially harmful drug-related AEs, their clinical consequences, and prescribing frequency forolder adults will assist dentists in clinically managing patients and avoiding inappropriate prescribing. (Oral Surg Oral Med

Oral Pathol Oral Radiol 2012;113:714-721)

Emerging demographic and clinical trends suggest thatoral health care for community-dwelling older adults willbe increasingly important for practicing dental profession-als.1,2 In the coming decades, there will be greater num-bers of older Americans seeking dental care owing topopulation growth trends, declining edentulism resultingin more complicated dental needs, and greater treatmentexpectations.2 Oral health providers will need to meet thechallenges of understanding their aging patients’ complexmedical conditions and related drug therapies to ensurepatient health and safety. Recognition of drugs with seri-ous adverse experience risk in older adults will be animportant aspect of reviewing their health histories.

The aging of America is well documented. It is ex-pected that the number of Americans aged �65 years willcontinue to grow from an estimated 37 million in 2006 to71.5 million by 2030.3 This will represent an increase tonearly 20% of the US population. Secular trends in toothloss indicate that edentulism will continue to fall as thepercentage of the elderly without any teeth has declinedfrom �46% in the early 1970s to 26% by 2006.3-5

As dental providers treat an aging population, they willfind patients presenting with a higher prevalence ofchronic diseases and taking greater numbers of drugs to

aDivision of Health Policy and Management, School of PublicHealth, University of Minnesota.bDivision of Developmental and Surgical Sciences, School of Den-tistry, University of Minnesota.Received for publication Sep 14, 2011; returned for revision Oct 31,2011; accepted for publication Dec 2, 2011.© 2012 Elsevier Inc. All rights reserved.2212-4403/$ - see front matter

doi:10.1016/j.oooo.2011.12.009

714

treat these conditions.6 It has been well documented thatdrug use increases with age.7 Adverse experiences (AEs)are expected to rise with increasing drug consumption andmay be exacerbated by age-related physiologic, pharma-cokinetic, and pharmacodynamic changes in drug absorp-tion, distribution, metabolism, and excretion.8,9

The potential consequences of inappropriate pre-scribing in older adults have been a quality of care issuereceiving significant attention in the medical litera-ture.10-12 The Beers criteria identifying potentially in-appropriate drugs with a high risk for AEs were devel-oped to address these issues and have been widelyadopted to identify drugs that should be avoided in thispopulation.13-17 A number of these drugs may be chron-ically taken by older adults seeking dental care. Severaldrugs on the list may be prescribed by dentists, includ-ing the nonsteroidal antiinflammatory drugs (NSAIDs)for analgesia and benzodiazepines, such as alprazolam(Xanax) for anxiolysis.

The objectives of the present article include the follow-ing: 1) to use a nationally representative administrativedata set, the Medicare Current Beneficiary Survey(MCBS), to estimate the prevalence of Beers-criteria drug

Statement of Clinical Relevance

Awareness of potentially harmful drug-related ad-verse experiences, their clinical consequences, andthe frequency with which the implicated drugs areprescribed to older adults will assist oral healthproviders in clinically managing patients and avoid-ing inappropriate prescribing.

OOOO MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATEVolume 113, Number 6 Skaar and O’Connor 715

use in older adult dental patients; 2) to identify demo-graphic characteristics of older dental patients that may beassociated with higher risk for taking Beers-criteria drugs;and 3) to review Beers-criteria drugs that may have anadverse effect on oral health care.

MATERIALS AND METHODSThe Beers criteria were originally developed with anexpert panel consensus process involving literature re-views and questionnaires to assess inappropriate druguse among elderly nursing home residents.13,15 Theoriginal criteria were revised most recently using amodified Delphi technique to identify drugs to gener-ally avoid in the nursing facility and ambulatory elderlypopulations.17,18 Published in 2003, the updated criteriaidentified 48 drugs or classes of drugs to be avoided inambulatory older adults because of serious risk of AEs.17

MCBS is a continuous annual nationally representa-tive survey of the US Medicare population, coveringaged, disabled, and institutionalized beneficiaries.Medicare is a US government–administered insuranceprogram that includes health insurance for those �65years old. The data are collected from the Centers forMedicare and Medicaid Services (CMS) Medicare en-rollment file and disseminated through a contract withWestat Corp. For the present study, the 2006 MCBSCost and Use file was analyzed, including only thosealways-enrolled beneficiaries age �65 years and livingin the community to reflect those most likely to seekdental care. The file creates a continuous completeprofile of demographic characteristics, health care ser-vice utilization, health parameters, dental service utili-zation, and prescribed drugs. The rotating panel designallows �12,000 participants to be interviewed 3 timesannually over 4 consecutive years. Approximately 4,000sample persons are replaced annually because of deaths,refusals, and rotation out of the survey.

In the survey, each prescribed drug has a file thatincludes brand and generic names, National DrugCodes, prescription fill dates, and limited informa-tion on quantities. Over-the-counter drugs, such asibuprofen, are included only when there is a writtenprescription for them. Brand and generic name en-tries for each prescribed drug were reviewed foraccuracy and linked appropriately. A separate filewas created identifying prescribed drugs, by brandand generic names, designated as potentially inap-propriate for use in older adults according to themost recently updated Beers criteria.17 The profilereconciles information obtained from Medicareclaims, other insurance claims, receipts, and survey-reported events. Replicate sampling weights are usedin all analyses to estimate the numbers of always-

enrolled community-dwelling elderly within each de-

mographic, dental service utilization, and prescrip-tion drug utilization category. National estimates arereported accounting for the complex sampling designof MCBS using the Westvar software package. Stan-dard errors were estimated using Fay variant of bal-anced repeated replication methods (Westvar soft-ware). Given that the MCBS is a public deidentifieddata set, the University of Minnesota InstitutionalReview Board determined the study was exemptfrom review.

National estimates are reported for prescription druguse, including those meeting the Beers criteria, forolder adults with dental visits by demographic, health-related, and prescription drug variables. Dental visits(yes/no) and whether a respondent had received a pre-scription drug (yes/no) and any Beers-criteria drug(yes/no) were coded along with the names for each drugduring the year. Variable estimates and standard errorswere calculated (Westvar software).

Multivariate analyses were completed using logisticregression to identify variables associated with havinga prescription for a Beers-criteria drug (Westvar soft-ware). Independent variables tested for their relation-ships to the use of Beers-criteria drugs included demo-graphic characteristics, self-reported health status,comorbidities, and drug insurance coverage.

RESULTSTable I summarizes information for the individual drugsor drug classes currently considered to be potentiallyinappropriate for community-dwelling older adults, inde-pendently from diagnosis or condition, by the Beers con-sensus expert panel. Many of the drugs are prescribed forchronic conditions reported by older dental patients, in-cluding hormone replacement, cardiovascular disease, di-abetes, and mental health. The Beers-criteria drugs mostfrequently prescribed to community-dwelling older adultswith dental visits in 2006 are listed in Table II. Among theBeers-criteria drugs most frequently used, naproxen(Naprosyn), alprazolam (Xanax), and lorazepam (Ativan)are commonly prescribed by dentists.

National prevalence estimates for community-dwellingadults aged �65 years with a dental visit are reported foruse of prescribed drugs, and specifically those meeting theBeers criteria, by various demographic and health-relatedvariables in Table III. Overall, 96.2% reported having aprescription for any drug and 34.4% reported being pre-scribed a Beers-criteria drug. Prescriptions for �2 Beers-criteria drugs were reported by 13.3%. Increasing age wasassociated with a higher prevalence for prescriptions forany drug and for a Beers-criteria drug. The prevalence ofprescribing for all drugs and those on the Beers criteria listwas higher for women. Lower levels of income and edu-

cation were associated with a higher prevalence of Beers-

MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE OOOO716 Skaar and O’Connor June 2012

criteria drug prescriptions. The use of Beers-criteria drugsincreased with poorer self-reported health and higher

Table I. Potentially inappropriate drugs for use in oldPropoxyphene (Darvon) and combination products (Darvon with ASIndomethacin (Indocin and Indocin SR)Pentazocine (Talwin)Trimethobenzamide (Tigan)Muscle relaxants and antispasmodics: methocarbamol (Robaxin), ca

not consider extended-release Ditropen XLFlurazepam (Dalmane)Amitriptyline (Elavil), chlordiazepoxide-amitriptyline (Limbitrol), anDoxepin (Sinequan)Meprobamate (Miltown and Equanil)Short-acting benzodiazepines at doses greater than 3 mg lorazepam

temazepam (Restoril), and 0.25 mg triazolam (Halcion)Long-acting benzodiazepines: chlordiazepoxide (Librium), chlordiaz

diazepam (Valium), quazepam (Doral), halazepam (Paxipam), andDisopyramide (Norpace and Norpace CR)Digoxin (Lanoxin) �0.125 mg/dShort-acting dipyridamole (Persantine). Do not consider the long ac

older adults except with patients with artificial heart valves.Methyldopa (Aldomet) and methyldopa-hydrochlorothiazide (AldoriReserpine �0.25 mgChlorpropamide (Diabinese)Gastrointestinal antispasmodic drugs: dicyclomine (Bentyl), hyoscya

alkaloids (Donnatal and others), and clidinium-chlordiazepoxide (Anticholinergics and antihistamines: chlorpheniramine (Chlor-Trime

cyproheptadine (Periactin), promethazine (Phenergan), tripelennamDiphenhydramine (Benadryl)Ergot mesyloids (Hydergine) and Cyclospasmol (cyclandelate) �32Ferrous sulfateAll barbiturates (except phenobarbital) except when used to controlMeperidine (Demerol)Ticlopide (Ticlid)Ketorolac (Toradol)Amphetamines and anorexic agentsLong-term use of full-dosage longer half-life nonCOX-selective NS

and piroxicam (Feldene)Daily fluoxetine (Prozac)Long-term use of stimulant laxatives: Bisacodyl (Dulcolax), cascaraAmiodarone (Cordarone)Orphenadrine (Norflex)Guanethidine (Ismelin)Guanadrel (Hylorel)Cyclandelate (Cyclospasmol)Isoxsuprine (Vasodilan)Nitrofurantoin (Macrodantin)Doxazosin (Cardura)Methyltestosterone (Android, Virilon, and Testrad)Thioridazine (Mellaril)Mesoridazine (Serentil)Short-acting nifedipine (Procardia and Adalat)Clonidine (Catapres)Mineral oilCimetidine (Tagamet)Ethacrynic acid (Edecrin)Desiccated thyroidAmphetamines (excluding methylphenidate hydrochloride and anoreEstrogens only (oral)

Fick DM, Cooper JW, Wade WE, Waller, JL, Maclean, JR, Beers, Min older adults. Ann Intern Med 2003;163:2716-24.

numbers of comorbidities.

Table IV presents the results of multivariate logisticregression identifying characteristics associated with

lts: independent of diagnosis or conditionsvon-N, and Darvocet-N)

ol (Soma), chlorzoxazone (Paraflex), metaxalone (Ditropan); do

henazine-amitriptyline (Triavil)

), 60 mg oxazepam (Serax), 2 mg alprazolam (Xanax), 15 mg

-amitriptyline (Limbitrol), clidinium-chlordiazepoxide (Librax),zepate (Tranxene)

yridamole (which has better properties than the short-acting in

Levsin and Levsinex), propantheline (Pro-Banthine), belladonna

phenhydramine (Benadryl), hydroxyzine (Vistaril and Atarax),xchlorpheniramine (Polaramine)

s

aproxen (Naprosyn, Anaprox, and Aleve), oxaprozin (Daypro),

a, and neoloid except in the presence of opiate analgesic use

dating the Beers criteria for potentially inappropriate medication use

er aduA, Dar

risoprod

d perp

(Ativan

epoxidechlora

ting dip

l)

mine (Librax)ton), diine, de

5 mg/d

seizure

AIDs: n

sagrad

xics)

H. Up

the use of Beers-criteria drugs by older adults with a

OOOO MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATEVolume 113, Number 6 Skaar and O’Connor 717

dental visit. Female sex, �2 comorbidities, poor/fairself-reported health, and geographic region (south andwest) were associated with having prescriptions forBeers-criteria drugs.

DISCUSSIONIt is anticipated that the aging US population will beincreasingly ambulatory and more likely to seek den-tal care. However, many will be medically compro-mised and present with a higher prevalence of com-mon diseases, such as hypertension, stroke, anddiabetes.18 These older adults will typically consumemore drugs and be more vulnerable to drug-relatedadverse experiences and may be subject to inappro-priate prescribing.11 Effective dental management ofthese older adults will require understanding of boththeir more complex medical conditions and concom-itant drug therapies. An important aspect of evaluat-ing patient drug profiles, monitoring responses todrug therapies, and making informed prescribing de-cisions is an awareness of drugs, such as those on theBeers criteria list, with a high risk for AEs. Althoughclinical situations may necessitate the prescribing ofa Beers-criteria drug, and oral health care providersare unlikely to routinely question medical decisionsto prescribe these drugs, familiarity with the Beerscriteria list in Table I can assist practitioners inmonitoring for and recognizing existing adverse drugexperiences. Identification of clinically relevantdrug-related AEs affecting oral health care, such asxerostomia and sedation, certainly may warrant con-sultation with a patient’s medical providers to deter-mine the appropriateness of a change in drug ther-

Table II. Prevalence estimates for the 15 most fre-quently prescribed Beers-criteria drugs

Prevalence

% SE

Estrogens 5.30 0.36Digoxin 4.27 0.32Naproxen 3.49 0.32Alprazolam 3.29 0.27Lorazepam 3.28 0.29Nifedipine 2.80 0.30Doxazosin 2.54 0.26Promethazine 2.26 0.26Oxybutynin 2.13 0.26Fluoxetine 1.91 0.23Hydroxyzine 1.52 0.20Clonidine 1.44 0.25Ketorolac 1.30 0.19Temazepam 1.27 0.18Indomethacin 1.26 0.18

Community-dwelling Medicare beneficiaries �65 years old with adental visit in 2006 (estimated n � 14,361,198; SE � 230,745).

apy.

This study updates and confirms earlier reports ofrelatively high drug utilization by community-dwellingolder adults.19,20 For participants with a dental visit, ahigher proportion reported being prescribed a drug(96.2%) than those without a dental visit (92.7%; P �.001). High overall prescription drug use by those witha history of dental care is unexplained, and causes mayinclude a higher propensity for seeking health caregenerally, a greater proportion retaining private healthinsurance with prescription drug coverage, and higherlevels of affluence.

A key finding was that in 2006 more than 3 out of 10community-dwelling older adults presenting for dentalcare had prescriptions for potentially inappropriate drugsas defined by the Beers criteria. Those with dental visitswere also high utilizers of Beers-criteria drugs, with�13% having prescriptions for �2 Beers-criteriadrugs. These findings reinforce the importance of oralhealth care providers carefully evaluating drug historiesof older patients for potentially inappropriate prescrib-ing that may lead to AEs.

Logistic regression identified those demographiccharacteristics most strongly associated with the pre-scribing of Beers-criteria drugs, Table IV. Health statuswas the most significant factor predicting use of theBeers-criteria drugs. Those with �2 comorbidities(odds ratio [OR] 2.19, 95% confidence interval [CI]1.50-3.20) and poor/fair self-reported health (OR 1.62,95% CI 1.26-2.07) were more likely to receive a Beers-criteria drug. Older women were more likely to beprescribed a Beers-criteria drug than older men (OR1.39, 95% CI 1.17-1.65). The higher use of these drugsby older adults residing in the southern (OR 1.52, 95%CI 1.21-1.91) and western (OR 1.60, 95% CI 1.27-2.01)regions of the US may be partially attributable to dif-ferences in prescribing practices. The drug histories forpatients with these characteristics should be evaluatedcarefully, because they may be more likely to be takinga Beers-criteria drug and at higher risk for a drug-related adverse experience. Extrapolating the regres-sion results to smaller populations, such as individualdental practices, has not been studied.

The Beers criteria list identifies a number of commonlyused drugs that may affect oral health care (Table V).Patient positioning should be monitored for patients tak-ing gastrointestinal antispasmodics, such as belladonnaalkaloids (Donnatal), propantheline (Pro-Banthine), andvasodilators, including dipyridamole (Persantine). Thesedrugs may increase the risk for orthostatic hypotension.Patients being prescribed tricyclic antidepressants, such asamitriptyline (Elavil), common antihistamines such aschlorpheniramine (Chlor-Trimeton) or diphenhydramine(Benadryl), and muscle relaxants, including cycloben-

zaprine (Flexeril), may exhibit anticholinergic effects, in-

ure, stro

MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE OOOO718 Skaar and O’Connor June 2012

cluding xerostomia, which may increase risk for caries,candidiasis, and discomfort wearing dental prostheses.Chronic use of long-acting benzodiazepines such asflurazepam (Dalmane) and barbiturates may produce se-dation, confusion, and higher risk of falls at the dentaloffice.

Several drugs prescribed by dentists for older patientsare included on the Beers criteria list. Analgesics to beavoided include propoxyphene (Darvon) and its combina-tion products, pentazocine (Talwin), meperidine (De-merol), and the long-term use of longer-acting NSAIDs.

Table III. Prevalence estimates for prescription drugs

Demographic characteristic

An(est. n �

%

Age65–69 92.870–74 96.975–79 96.480–84 97.685‡ 98.2

SexMale 95.4Female 96.8

RaceUnknown 49.4White 96.1Black 96.5Other 94.6Asian 97.9Hispanic 100.0Native American 100.0

Income0–$25,000 96.9$25,001–$50,000 95.7�$50,000 95.9

EducationUnknown 100.0�8th grade 95.69th-12 grade/HS grad 96.6Post-HS 95.7College grad/post-grad 96.2

Self reported healthUnknown 100.0Excellent 89.4Very good 97.2Good 97.7Fair 99.1Poor 100.0

Comorbidity count*0 77.41 92.32 96.83 97.7�4 99.6

Total 96.2

Community-dwelling Medicare beneficiaries �65 years old with a d*Comorbidity count: diagnosed conditions, such as high blood press

Propoxyphene-N with acetaminophen (Darvocet-N) as re-

cently as 2008 was ranked 29th in total generic prescrip-tions.21 In 2010, the US Food and Drug Administration(FDA) requested a halt to all US marketing of propoxy-phene products because of evidence showing interferencewith cardiac electrical activity and higher risk of arrhyth-mias.22 Meperidine (Demerol) is a relatively ineffectiveoral opioid analgesic with a normeperidine metabolite thatmay act as a central nervous system stimulant, causingsymptoms such as confusion or tremors in older adults.Pentazocine (Talwin) is a mixed agonist-antagonist nar-cotic analgesic with a risk of confusion and hallucinations

ose with a dental visit

,975)Any Beers-criteria drug

(est. n � 4,941,245)

SE % SE

1.1 31.3 1.90.6 35.3 1.60.7 32.8 1.70.5 36.4 1.60.6 38.5 2.4

0.7 29.5 1.10.4 38.1 1.2

35.3 0.0 0.00.4 34.0 0.81.4 39.3 4.75.5 35.6 8.02.2 43.5 9.00.0 45.0 8.70.0 43.0 12.4

0.5 39.4 1.50.6 32.5 1.20.8 30.4 1.3

0.0 49.5 15.51.3 40.7 3.00.6 34.9 1.50.7 32.9 1.50.6 33.9 1.3

0.0 31.2 7.91.3 24.7 1.50.5 30.2 1.20.5 39.2 1.60.5 44.7 3.10.0 59.2 5.4

3.0 20.3 2.91.5 22.0 1.90.6 29.3 1.50.6 36.0 1.80.2 44.2 1.70.4 34.4 0.8

isit in 2006 (estimated n � 14,361,198).ke, cancer, diabetes, rheumatoid arthritis, and psychiatric disorders.

for thy drug13,809

ental v

in older adults.

OOOO MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATEVolume 113, Number 6 Skaar and O’Connor 719

Long-term use of naproxen (Naprosyn), a longerhalf-life/duration NSAID analgesic, should be avoidedin many older dental patients owing to risk of dyspep-sia, gastrointestinal bleeding, and ulceration. NSAID-related gastrointestinal injury may result from topicalmucosal damage and depletion of protective prosta-glandins (PGE2 and PGI2) due to cyclooxygenase-1inhibition. Alternative analgesics for older adults in-clude acetaminophen (APAP) as a single agent or incombination with opioids, such as codeine or hydro-codone. Hepatotoxicity has been associated with exces-sive doses of APAP when primary conjugation path-ways are overwhelmed. As a result, cytochrome P450isozyme metabolism increases, leading to the accumu-lation of a toxic metabolite (N-acetyl-p-benzoquinon-eimine). There is no clear evidence, however, thatAPAP used in the doses and duration typically pre-scribed in dentistry will result in liver damage. Never-theless, practitioners should be alert to the possibility ofliver toxicity when prescribing APAP. Opiod selectionand dosing decisions should account for potential se-dating effects. A selective cyclooxygenase-2 (COX-2)inhibitor, such as celecoxib (Celebrex), or a shorter–half-life NSAID, such as ibuprofen, may be prescribedin the lowest effective doses and for the shortest dura-tion possible. Prescribers of NSAIDs, particularly se-lective COX-2 inhibitors, should be familiar with thecardiovascular disease risk warnings associated with

Table IV. Use of Beers-criteria drugs in community-dwelling Medicare beneficiaries �65 years old with adental visit in 2006

Characteristic* Odds ratio estimate 95% CI

SexFemale 1.39 (1.17–1.65)

Income($25,001-50,000) 0.84 (0.71–0.99)

Comorbidity count†�2 2.19 (1.50–3.20)

General healthPoor/fair 1.62 (1.26–2.07)

RegionSouth‡ 1.52 (1.21–1.91)West§ 1.60 (1.27–2.01)

Odds ratios and confidence intervals (95% CI) based on logisticregression analysis for estimated n � 14,163,308 (SE � 221,681).*Age, insurance drug coverage, race, education, population density,and marital status were nonsignificant.†Comorbidity count: diagnosed conditions, such as high blood pres-sure, stroke, cancer, diabetes, rheumatoid arthritis, and psychiatricdisorders.‡South: Delaware, District of Columbia, Florida, Georgia, Maryland,N. Carolina, S. Carolina, Virginia, W. Virginia, Alabama, Kentucky,Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, Texas.§West: Arizona, Colorado, Idaho, New Mexico, Montana, Utah,Nevada, Wyoming, Alaska, California, Hawaii, Oregon, Washington.

these drugs.

Anxiolytics identified by the Beers criteria consensuspanel to avoid because of sedation potential and risk forfalls and fractures include short-acting benzodiazepinesin high doses (triazolam [Halcion] �0.25 mg) andlong-acting benzodiazepines, such as diazepam (Va-lium) and flurazepam (Dalmane). Conversion of fluraz-epam and diazepam to active metabolites, N-dealkyl-flurazepam and desmethyldiazepam, extends theirelimination half-lives and effects. Options for dentalanxiety include the shorter-acting benzodiazepines,such as lorazepam (Ativan) or alprazolam (Xanax), atappropriate lower doses. Owing to strong anticholin-ergic effects and sedative properties, dentists treatingolder orofacial pain patients should be particularlymindful of prescribing long-term benzodiazepines (di-azepam [Valium]), muscle relaxants, such as cycloben-zaprine (Flexeril), and tricyclic antidepressants, such asamitriptyline (Elavil). In addition to the aforementionedAEs, clinicians should be alert for potential drug-re-lated allergic reactions.

The Beers criteria have been studied extensively in avariety of health care settings to assess quality of care.The criteria have met with some criticism for being toosimplistic, failing to account for clinical judgment andlacking translation into measurable quality improve-ments.15,18,23 Based on these and other limitations,some have modified the Beers-criteria drug list.24,25

Nevertheless, the Beers criteria have gained wide ac-ceptance for use in assessing inappropriate prescribingin the ambulatory elderly.17 It will be important forproviders to keep current with evolving drug utilizationreview tools, such as the Beers criteria, to account fornew drug introductions, changes in available clinicalscientific information, and new trends in therapeuticinterventions.16,17,26

The limitations of the MCBS need to be consid-ered when interpreting the present data. Prescriptiondrug and dental visit data may be subject to recallerrors because it is self or proxy reported. Recall biashas been reduced by periodic interviews and collec-tion of receipts and claim forms. Previously, it hasbeen published that prescriptions may be underre-ported.27 Interviewers check old prescription con-tainers and query respondents about their continuinguse of medications to reduce recall bias. Underre-porting of prescriptions may be less likely for chron-ically used medications being regularly refilled be-cause of periodic surveying. However, the datareported could be incomplete and may underestimatesubjects visiting the dentist and prescription medica-tion utilization. Although specific drug strength, dos-ing, and duration of treatment data may be incom-plete, each drug meeting the Beers criteria was

included in assessing AE risk. This may result in an

MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE OOOO720 Skaar and O’Connor June 2012

overestimate of risk for those taking Beers-criteriadrugs at lower doses or shorter durations than in-cluded in the criteria.

It is clear from the nationally representative MCBSthat oral health practitioners should be aware of thehigh reported prescribing of drugs on the Beers criterialist for older adults presenting for care in their prac-tices. With more than 3 out of 10 community-dwellingdental patients aged �65 years prescribed �1 of theBeers-criteria drugs in 2006, oral health care providersshould be familiar with the Beers criteria list of drugs.Knowledge of this list will assist in critically assessingpatient drug histories to identify possible drug-relatedAEs. Although this drug utilization tool should notreplace clinical judgment, familiarity with these drugsand understanding the potential AEs they may causeshould advance providers’ ability to assess patienthealth status and to make better prescribing decisions.28

Table V. Beers-criteria drugs with dental consideratioBeers-criteria drug

AnalgesicMeperidine (Demerol)Propoxyphene (Darvon)* and combinationsPentazocine (Talwin)Longer–half-life NSAIDs Naproxen (Aleve), oxaprozin (Daypro),

(Feldene)Cardiovascular

Guanethidine (Ismelin)Guanadrel (Hylorel)Doxazosin (Cardura)Clonidine (Catapres)Nifedipine (Procardia)Dipyridamole (Persantine)Disopyramide (Norpace)

PsychotherapeuticThioridazine (Mellaril)

Mesoridazine (Serentil)Long-acting benzodiazepines Diazepam (Valium), flurazepam (Da

chlorazepate (Tranxene), chlordiazepoxide (Librium)Amitriptyline (Elavil)Doxepin (Sinequan)

Skeletal muscle relaxantMethocarbamol (Robaxin)Carisoprodol (Soma)Cyclobenzaprine (Flexeril)Oxybutynin (Ditropan)Metaxalone (Skelaxin)

AntispasmodicDicyclomine (Bentyl)Propantheline (Pro-Banthine)Belladonna alkaloids (Donnatal)

AntihistamineDiphenhydramine (Benadryl)Hydroxyzine (Vistaril)Chlorpheniramine (Chlor-Trimeton)

*US marketing discontinued.

Recognition and discussion of clinically important AEs

caused by these drugs with patients and, as required,physicians and other health care providers will improvepatient safety and enhance the role of dentistry withinthe health care team. Other significant causes of inap-propriate prescribing, such as drug-drug interactions,drug-disease interactions, and underprescribing havenot been addressed. The clinical impact of inappropri-ate prescribing on dental patients and the appropriateintervention role for dental professionals is an area forfuture investigation. To our knowledge, there are nopreviously published reports using the Beers criteria toaddress the prevalence of potentially inappropriate pre-scribing in community dwelling older adults seekingdental care.

The authors thank Scott Lunos, MS, Bryan Micha-lowicz, DDS, MS, and Ronald Hadsall, PhD, for theircontributions in the analysis of the Medicare CurrentBeneficiary Survey database and review of the manu-

Dental considerations in older adults

Sedation/fall risk; confusion; orthostatic hypotensionSedation/fall risk; xerostomia; few analgesic advantagesSedation/fall risk; confusion; xerostomia;

am GI bleeding and ulceration

Orthostatic hypotensionOrthostatic hypotensionOrthostatic hypotension; xerostomiaOrthostatic hypotension; xerostomia; abnormal tasteGingival overgrowth; hypotensionOrthostatic hypotensionOrthostatic hypotension; xerostomia

Xerostomia; orthostatic hypotension; extrapyramidalmotor symptoms (tardive dyskinesia)

Xerostomia; orthostatic hypotension, Sedation/fall risk; xerostomia; orthostatic hypotension

Sedation/fall risk; xerostomia; orthostatic hypotensionSedation/fall risk; xerostomia; orthostatic hypotension

Sedation/fall risk; xerostomia; orthostatic hypotensionSedation/fall risk; xerostomia; orthostatic hypotensionSedation/fall risk; xerostomia; orthostatic hypotensionSedation/fall risk; xerostomia; orthostatic hypotensionSedation/fall risk; xerostomia; orthostatic hypotension

XerostomiaXerostomiaXerostomia

Sedation/fall risk; xerostomiaSedation/fall risk; xerostomiaSedation/fall risk; xerostomia

ns

piroxic

lmane)

script.

OOOO MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATEVolume 113, Number 6 Skaar and O’Connor 721

REFERENCES1. U.S. Department of Health and Human Services. Oral health in

America: a report of the SURGEON General. National Instituteof Dental and Craniofacial Research, National Institutes ofHealth; 2000. Available at: http://www.surgeongeneral.gov. Ac-cessed March 20, 2011.

2. Vargas CM, Kramarow EA, Yellowitz JA. The oral health ofolder Americans; aging trends, no. 3. Hyattsville (MD). Avail-able at: http://www.cdc.gov/nchs. Accessed April 10, 2011.

3. Federal Interagency Forum on Aging Related Statistics. OlderAmericans 2008: key indicators of well-being. Available at:http://www.agingstats.gov. Accessed April 20, 2011.

4. Weintraub JA, Burt BA. Oral health status in the United States:tooth loss and education. J Dent Educ 1985;49: No 6: 368-76.

5. Centers for Disease Control. The state of aging and health inAmerica 2007 report. Available at: http://www.cdc.gov/aging.Accessed April 1, 2011.

6. Centers for Disease Control. Public health and aging: trends inaging—United States and worldwide. Morb Mortal Wkly Rep2003;52:101-6.

7. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, MitchellAA. Recent patterns of medication use in the ambulatory adultpopulation of the United States. JAMA 2002;287:337-44.

8. Yagiela JA, Dowd FJ, Johnson BS, Mariotti AJ, Neidle EA,editors. Pharmacology and therapeutics for dentistry. St. Louis:Elsevier Mosby; 2011. p. 834-41.

9. Waldman SA, Terzic A, editors. Pharmacology and therapeuticsprinciples to practice. Philadelphia: Saunders Elsevier; 2009. p.257–64.

10. Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics:drug-related problems in the elderly. Ann Pharmacother 2000;34:360-5.

11. Gallagher P, Barry P, O’Mahoney D. Inappropriate prescribingin the elderly. J Clin Pharm Ther 2007;32:113-21.

12. Simon SR, Chan KA, Soumerai SB, Wagner AK, Andrade SE,Feldstein AC, et al. Potentially inappropriate medication use byelderly persons in U.S. health maintenance organizations, 2000–2001. J Amer Soc Geriatr 2005;53:227-32.

13. Beers MH, Ouslander JG, Rollinger J, Reuben DB, Brooks J,Beck JC. Explicit criteria for determining inappropriate medica-tion use in nursing home residents. Arch Intern Med 1991;151:1825-32.

14. Aparasu RR, Mort JR. Inappropriate prescribing for the elderly:Beer criteria–based review. Ann Pharmacother 2000;34:338-46.

15. Zhan C, Correa-de-Araujo R, Bierman AS, Sanji J, Miller MR,Wickizer SW, Stryer D. Suboptimal prescribing in elderly out-patients: potentially harmful drug-drug and drug-disease combi-

nations. J Am Geriatr Soc 2005;53:262-7.

16. Beers MH. Explicit criteria for determining potentially inappro-priate medication use by the elderly. Arch Intern Med 1997;157:1531-6.

17. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, BeersMH. Updating the Beers criteria for potentially inappropriate med-ication use in older adults. Arch Intern Med 2003;163:2716-24.

18. Baum BJ. Inadequate training in the Biological Sciences andmedicine for dental students. J Am Dent Assoc 2007;138:16-25.

19. Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, WickizerSW, Meyer GS. Potentially inappropriate medication use incommunity-dwelling elderly. JAMA 2001;286:2823-29.

20. Stuart B, Kamal-Bahl S, Briesacher B, Lee E, Doshi J, Zucker-man IH, et al. Trends in the prescription of inappropriate drugsfor the elderly between 1995 and 1999. Am J Geriatr Pharm2003;1:61-74.

21. Top 200 generic drugs by total prescriptions. Available at: http://www.drugtopics.com. Accessed March 20, 2010.

22. U.S. Food and Drug Administration. FDA drug safety commu-nication (11-19-2010). Available at: http://www.fda.gov/Drugs/DrugSafety. Accessed March 20, 2010).

23. O’Mahoney D, Gallagher PF. Inappropriate prescribing in the olderpopulation: need for new criteria. Age Ageing 2008;37:138-41.

24. Hajiar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderlypatients. Am J Geriatr Pharm 2007;5:345-51.

25. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P,Lindau ST. Use of prescription and over-the-counter medicationsand dietary supplements among older adults in the United States.JAMA 2008;300:2867-78.

26. Barry PJ, O’Keefe N, O’Connor KA, O’Mahoney D. Inappro-priate prescribing in the elderly: a comparison of the beerscriteria and the Improved Prescribing in the Elderly Tool (IPET)in acutely ill elderly hospitalized patients. J Clin Pharm Ther2006;31:617-26.

27. Poisal JA. Reporting of drug expenditures in the MCBS. HealthCare Finan Rev 2003;25:23-36.

28. Ettinger RL. Beers’ criteria—is it relevant to dentistry? SpecCare Dentist 2009;29:189-90.

Reprint requests:

Dr. Daniel D. SkaarDevelopmental and Surgical SciencesUniversity of Minnesota7-368 Moos Tower515 Delaware St SEMinneapolis, MN 55455

skaar003@umn.edu