Medication Management
Polypharmacy is defined as the regular use of five or more medications. It increases the risk of adverse drug effects, drug-drug interactions, or prescribing cascades whereby additional drugs are prescribed to treat other drugs’ adverse events. Therefore, it is important to evaluate for polypharmacy by performing a medication reconciliation on admission, during transitions of care, and every clinic visit to determine if deprescribing is necessary.
- Pharmacologic considerations for older adults
- Pharmacokinetic (PK): Decreased hepatic and renal clearance. Reduction in first pass metabolism. Drug distribution changes due to decreased TBW and lean body mass resulting in relative increase in fat.
- Pharmacodynamic (PD): Exaggerated responses to pharmacologic therapy (therapeutic and adverse effects).
- Mantra for prescribing = “start low and go slow”
- Be aware of Prescribing Cascades:
- Mantra for prescribing = “start low and go slow”
- NSAIDs can lead to gastritis, which can lead to prescription of PPI, which can lead to B12 deficiency and prescription of vitamins
- Amlodipine can cause lower extremity edema leading to a diuretic prescription that can then lead to urinary incontinence and prescription of oxybutynin
- Common PIMs (Potentially Inappropriate Meds) see Beer’s Criteria® (QR code below for full consideration)
- Anticholinergics (e.g. antispasmodics, muscle relaxants, TCAs, antihistamines): confusion, dry mouth, constipation.
- Anticholinergic burden calculator: https://www.acbcalc.com/
- Aspirin: Would only consider for secondary prevention
- Benzodiazepines: increased risk of clinical dependence, falls, fractures, and delirium
- Proton pump inhibitors: Avoid >8 weeks unless high risk patient due to risk of C.diff, PNA, nutritional deficiencies, and fractures
- Sulfonylureas: higher risk of all-cause mortality, cardiovascular events, and hypoglycemia compared to other oral hypoglycemic agents
- Nitrofurantoin: Avoid with CrCl <30 mL/min. Potential for pulmonary toxicity, hepatotoxicity, and peripheral neuropathy
Tips for med adherence:
- Assess current system for medication management
- Determine if medication timing is optimal for individual patient (e.g. diuretic dosing at night can increase nocturia but during day can risk incontinence/frequency)
- If organization is a barrier provide pillboxes or arrange blister packs for meds
Recommended Tools: deprescribing.org (App available); medstopper.com
