Medication Management and Polypharmacy
Why elders are vulnerable
Altered pharmacokinetics (reduced renal clearance, lower body water, higher fat fraction, reduced first-pass metabolism) combine with polypharmacy from multiple prescribers to produce adverse drug events, which often present atypically as falls, confusion, incontinence, or constipation rather than as a specific complaint.
Tools
Use the Beers criteria to identify potentially inappropriate medications in older adults, and STOPP/START to identify both inappropriate prescribing and prescribing omissions (e.g., missing statin, ACE inhibitor, bisphosphonate, or vitamin D). Quantify anticholinergic burden with a scale such as the Anticholinergic Cognitive Burden tool. Common offenders include diphenhydramine, oxybutynin, amitriptyline, paroxetine, and bladder antimuscarinics.
Prescribing cascades
A classic cascade: amlodipine causes ankle edema, a diuretic is added, the patient becomes incontinent and orthostatic, then an anticholinergic is added for urgency. Another: NSAID raises blood pressure, an antihypertensive is added, and renal function declines.
Deprescribing and monitoring
Ask at every visit about over-the-counter agents, supplements, alcohol, and adherence. Stop or taper medications with no ongoing indication, particularly benzodiazepines, sedative-hypnotics, proton pump inhibitors beyond indication, sulfonylureas with hypoglycemia, and antipsychotics used for behavior without a documented target. Avoid using sliding-scale insulin as monotherapy. Recognize interactions such as warfarin with antibiotics, SSRIs with NSAIDs and anticoagulants (bleeding), and ACE inhibitors with potassium-sparing diuretics.
Traps
Assuming a medication is safe because the patient has taken it for years; forgetting to adjust for renal function; treating a drug side effect with another drug rather than stopping the first.
Rule of thumb
"Start low, go slow" - for most drugs in frail elders, begin at half the usual adult dose. Reassess at every transition of care.