Is scopolamine on the Beers (Potentially Inappropriate Medications for Older Adults) list?

Scopolamine on the Beers Criteria List

Yes, scopolamine is included on the American Geriatrics Society (AGS) Beers Criteria® list of potentially inappropriate medications for older adults due to its strong anticholinergic properties.

Background on Beers Criteria

The AGS Beers Criteria® is an explicit list of potentially inappropriate medications (PIMs) that should typically be avoided in adults 65 years and older in most circumstances or under specific situations 1. This list is regularly updated, with the most recent updates published in 2019 and 2023 1, 2.

Why Scopolamine is on the Beers List

Scopolamine (also known as hyoscine) is classified as a strong anticholinergic medication on the Beers list for several important reasons:

• It competitively inhibits muscarinic receptors for acetylcholine and acts as a nonselective muscarinic antagonist 3
• It produces both peripheral antimuscarinic effects and central sedative, antiemetic, and amnestic effects 3
• In older adults, anticholinergic medications like scopolamine can cause:
  • CNS impairment including delirium and slowed comprehension
  • Vision problems
  • Urinary retention
  • Constipation
  • Sedation
  • Increased fall risk 4

Clinical Implications

When considering scopolamine for older adults, clinicians should be aware of:

1. Anticholinergic burden: Multiple anticholinergic drugs (including scopolamine) can have cumulative effects that adversely affect cognition and functionality 4

2. Drug Burden Index: Medications with strong anticholinergic properties like scopolamine are associated with:

   • Decline in cognition
   • Reduced functional status
   • Lower activities of daily living (ADL) scores 4

3. Increased risk of adverse events:

   • Injurious falls
   • Episodes of confusion or delirium
   • Emergency department visits
   • Hospitalizations 4

Formulations and Considerations

Scopolamine is available in multiple formulations, including:

• Transdermal therapeutic system (TTS-patch) containing 1.5 mg with a release rate of 5 μg/h over 3 days 5
• Oral tablets
• Parenteral forms for injection 3

While the transdermal formulation was developed to minimize side effects through steady-state delivery 3, the anticholinergic properties remain problematic for older adults regardless of delivery method.

Deprescribing Recommendations

When managing older adults on scopolamine:

1. Consider deprescribing: The process of withdrawing medications to reduce polypharmacy and adverse drug reactions should be considered for anticholinergic medications like scopolamine 4

2. Evaluate anticholinergic burden: Assess the cumulative effect of all anticholinergic medications the patient is taking 4

3. Explore alternatives: Consider non-anticholinergic alternatives for the condition being treated 4

4. Monitor closely: If scopolamine must be used, implement close monitoring for anticholinergic side effects 4

Conclusion

When prescribing for older adults, clinicians should be aware that scopolamine is on the Beers Criteria list of potentially inappropriate medications due to its strong anticholinergic properties and associated risks. Alternative medications with lower anticholinergic burden should be considered whenever possible to reduce the risk of adverse events and improve outcomes in this vulnerable population.