Tertiary tricyclic antidepressants (TCAs) are avoided in Beers Criteria due to risk of which effects?

• A. Orthostatic hypotension or bradycardia
• B. Seizures
• C. Hyperglycemia
• D. Hypertension

Answer: (A)

Older adults are especially vulnerable to the cardiovascular and anticholinergic effects of tertiary TCAs. Their strong alpha-1 adrenergic blockade reduces vascular tone, so standing up can cause a rapid drop in blood pressure—orthostatic hypotension. This increases the risk of dizziness, falls, and injury. They also influence cardiac conduction and autonomic balance, so bradycardia can occur in some patients, particularly with existing heart disease or other meds. Because these risks are particularly harmful in frail older adults, Beers Criteria flags tertiary TCAs as inappropriate. Seizures, hyperglycemia, or hypertension are not the primary Beers-related concerns for these drugs in this context, though overdose can affect seizure threshold; the main safety signal here is orthostatic hypotension and bradycardia.