Implementation
Core content
Implementation is executing the plan: prescribing, counseling, coordinating, and documenting. For older adults, start low and go slow, estimate creatinine clearance with Cockcroft-Gault before using renally cleared drugs, and screen for interactions including OTC products and herbals. Avoid Beers Criteria medications when safer alternatives exist - long-acting benzodiazepines, strongly anticholinergic agents, long-acting sulfonylureas, chronic NSAIDs, and antipsychotics used for behavior.
Counseling skills belong here: motivational interviewing for behavior change, teach-back to confirm understanding, written instructions, and clear safety-net advice about when to call or return. Implementation also includes immunizations per the adult schedule, referrals with a specific clinical question, follow-up intervals tied to the intervention, and closing the loop on referrals.
Traps
Expect questions on the prescribing cascade - treating a drug side effect with another drug. Other traps: treating asymptomatic bacteriuria, prescribing antibiotics for viral upper respiratory infection, duplicating therapy, failing to adjust a dose for kidney function, and omitting documented indication or monitoring. A common distractor is a referral ordered with no stated question and no follow-up.
Rule of thumb
Every new prescription should have three documented elements: the indication, the monitoring plan, and a review or stop date.
Worked example
A 78-year-old with new atrial fibrillation, CHA2DS2-VASc of 4, weight 58 kg, and creatinine 1.6 mg/dL. Apixaban is appropriate, but the dose is reduced to 2.5 mg twice daily when at least two of three criteria are met: age 80 years or older, weight 60 kg or less, creatinine 1.5 mg/dL or higher. This patient meets two, so the reduced dose is correct.