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
    • Pharmacokinetics (PK): Decreased hepatic and renal clearance, reduction in first pass metabolism, and drug distribution changes due to decreased total body weight and lean body mass resulting in relative increase in fat.
    • Pharmacodynamics (PD): Exaggerated responses to pharmacologic therapy (therapeutic and adverse effects). - Mantra for prescribing = “start low and go slow”
    • Be aware of prescribing cascades:
      • 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 Potentially Inappropriate Meds (PIMS): see Beer’s Criteria® (QR code below for full list)
    • Anticholinergics (e.g. antispasmodics, muscle relaxants, TCAs, antihistamines): confusion, dry mouth, constipation. Anticholinergic burden calculator: https://www.acbcalc.com/ 
    • Aspirin (New start): Would only consider for secondary prevention 
    • Benzodiazepines/"Z"-Drugs for Insomnia: 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, pneumonia, 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

Specific pharmacologic recommendations from AGS alternative Beers list not listed above for common chief complaints (recurrent UTIs, insomnia, pain, and pruritus) that are safe in order adults:

  • Recurrent UTI in females: trial vaginal estrogen 
  • Insomnia: CBT-I, doxepin 3 or 6 mg, ramelteon, or an orexin receptor antagonist (I.e. suvorexant)
  • Pain: Avoid oral NSAIDs, use topicals like capsaicin, lidocaine, or diclofenac
  • Pruritus: second or third generation antihistamines preferred over first generation

2023 AGS Beers Criteria:

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
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