Medication Management and Polypharmacy
Review every drug, every visit
Polypharmacy (often ≥5 medications) increases falls, delirium, bleeding, hypoglycemia, and hospitalization. Use the Beers criteria and STOPP/START to identify potentially inappropriate medications and prescribing omissions. High-risk classes: benzodiazepines and Z-drugs, antipsychotics, anticholinergics (diphenhydramine, oxybutynin, amitriptyline), NSAIDs, sulfonylureas, proton pump inhibitors beyond indication, and overlapping antihypertensives.
Apply pharmacokinetic principles: reduced renal clearance, reduced hepatic phase I metabolism, lower total body water, and higher fat alter distribution. Check creatinine clearance before dosing DOACs, antibiotics, and renally cleared drugs. Watch for prescribing cascades-for example, an anticholinergic causes constipation, a laxative is added, and the anticholinergic is never stopped.
Traps: treating each new symptom with a new drug; assuming a 'normal' creatinine means normal renal function; continuing sedatives for insomnia; and stopping disease-modifying therapy without considering goals and prognosis.
Worked example: an 84-year-old on amitriptyline for insomnia develops confusion, dry mouth, constipation, and urinary retention. This is anticholinergic toxicity. Taper and stop the amitriptyline, treat retention and constipation, and use CBT-I instead of a sedative.
Rule of thumb: start low, go slow-but also stop high and stop slow. Any new symptom deserves a medication review.