NU648 Unit 8 Beers Criteria Prescribing Review Example

Six Flags in Eleven Orders: An Older Adult Prescribing Review Against the 2023 Beers Criteria for an 88-Year-Old Admitted After a Fall

[Student Name]

Purdue University Global

NU648: Specialized Pharmacology for the AGACNP

Unit 8 Older Adult Prescribing Review

[Instructor Name]

[Date]

The patient is composite; doses, weights and laboratory values are bracketed, and changes are proposed to the admitting team rather than made by the reviewer alone.

The Patient

Mrs. [P.] is an [88]-year-old woman, widowed and living by herself, who was found on her kitchen floor by a neighbor. She had been there for about [three] hours. On arrival she was confused, with urinary frequency, a temperature of [38.1] degrees Celsius and a urinalysis consistent with infection; the urine culture later grew Escherichia coli. She weighs [52] kg. Her creatinine is [1.2] mg/dL, and her creatinine clearance is about [26] mL/min by Cockcroft-Gault using actual body weight. She has atrial fibrillation, type 2 diabetes managed with diet alone at home, hypothyroidism and chronic low back pain.

Her eleven active orders after the first hospital night are promethazine for nausea, meclizine for dizziness, cyclobenzaprine for back spasm, nitrofurantoin for the infection, insulin lispro by sliding scale alone, rivaroxaban for atrial fibrillation, metoprolol tartrate, levothyroxine, acetaminophen as needed, polyethylene glycol and a vitamin D supplement.

The AGS Beers Criteria list medications that are potentially inappropriate for adults aged 65 and older, with tables for drugs to avoid in general, drugs to avoid with certain conditions, drugs to use with caution, interactions and doses to adjust for kidney function (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). The panel describes the list as a guide for judgment, not a set of prohibitions, and the review uses it that way.

The Six Flagged Orders

Promethazine. Flag: first-generation antihistamine, strongly anticholinergic, on the list of drugs to avoid. For a confused woman who has just fallen, confusion and sedation are the harms that matter most. Action: stop. Nausea began with the fever and has settled with fluids; if it returns, the team will look for a cause before choosing an antiemetic.

Meclizine. Flag: the same antihistamine class and the same anticholinergic burden. Dizziness is a symptom, not a diagnosis, and hers is most likely from dehydration and infection, since her orthostatic blood pressures dropped by [24] mm Hg on standing. Action: stop, and treat the cause with fluids and a repeat orthostatic check.

Cyclobenzaprine. Flag: skeletal muscle relaxant, poorly tolerated by older adults because of anticholinergic effects and sedation, with questionable effectiveness at doses they can tolerate. Action: stop. Back pain is covered by scheduled acetaminophen and heat.

Three of the six flags are the same problem in different bottles: drugs that make an old brain slower and less steady, given to a woman who is confused and has just fallen.

Nitrofurantoin. Flag: the kidney function table advises against it once clearance falls under 30 mL/min, because drug levels in the urine are too low to work while systemic toxicity rises. Nitrofurantoin is a first-line agent for uncomplicated cystitis in women (Gupta et al., 2011), but her clearance of [26] mL/min places it outside that role. Action: replace with cephalexin at a dose adjusted for her clearance, guided by the culture result, which shows susceptibility.

Sliding-scale insulin alone. Flag: insulin given only as short-acting correction doses without basal insulin is on the list to avoid, because it raises the risk of low glucose without improving control. The American Diabetes Association also advises against sliding-scale insulin as the only regimen in the hospital (American Diabetes Association Professional Practice Committee, 2025). Her glucose readings have run [110] to [168] mg/dL on diet alone. Action: stop the sliding scale, check glucose before meals, and start basal insulin only if readings stay above [180] mg/dL.

Rivaroxaban. Flag: the 2023 update advises avoiding rivaroxaban for long-term treatment of atrial fibrillation in favor of safer anticoagulant alternatives, because of higher bleeding rates in older adults. Stopping anticoagulation would be worse than the flag: at her age, with atrial fibrillation and hypertension, her stroke risk is high. Action: resolve the flag within the class by switching to apixaban at [2.5 mg] twice daily, the lower dose its labeling sets for a patient who is 80 or older and weighs 60 kg or less, starting when the next rivaroxaban dose would have been due.

The Five Orders Not Flagged

1. Metoprolol tartrate: continue; rate control for atrial fibrillation, heart rate [72].

2. Levothyroxine: continue; last TSH within range.

3. Acetaminophen: change from as needed to scheduled [650 mg] every [six] hours for her back, maximum [3 g] a day.

4. Polyethylene glycol: continue; she has had no bowel movement for [two] days.

5. Vitamin D: continue; no interaction or kidney concern at her dose.

Pacing the Changes

Six changes at once in a confused older adult would make it impossible to tell which one helped or harmed. The review sequences them:

1. Day 1, morning: stop promethazine and meclizine; begin scheduled acetaminophen.

2. Day 1, afternoon: replace nitrofurantoin with cephalexin, since the infection cannot wait.

3. Day 2, morning: stop cyclobenzaprine; stop the sliding scale and move to glucose checks before meals.

4. Day 2, evening: switch rivaroxaban to apixaban at the time the next dose falls due.

The anticholinergic drugs come off first because they are the likeliest contributors to her confusion. Confusion, falls risk, glucose and bleeding signs will be reviewed at each step.

Summary

Of eleven orders, six were flagged and five were not. Three flagged drugs stop, two are replaced and one is resolved by changing to a safer drug in the same class. Each change is linked to a Beers table and to her own numbers, and the review will be sent to her primary care provider so that the stops made in the hospital are not reversed by an old prescription at home.

References

American Diabetes Association Professional Practice Committee. (2025). 16. Diabetes care in the hospital: Standards of care in diabetes 2025. Diabetes Care, 48(Suppl. 1), S321-S334. https://doi.org/10.2337/dc25-S016

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., Moran, G. J., Nicolle, L. E., Raz, R., Schaeffer, A. J., & Soper, D. E. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103-e120. https://doi.org/10.1093/cid/ciq257