← Diagnosis and Management Guides
Polypharmacy and Medication Reconciliation
Key considerations: Anticholinergic burden causing cognitive impairment, Drug-drug interactions causing toxicity, Inappropriate medications per Beers Criteria in elderly
Cannot miss
- Anticholinergic burden causing cognitive impairment
- Drug-drug interactions causing toxicity
- Inappropriate medications per Beers Criteria in elderly
Likely diagnoses
- Polypharmacy (>5 medications)
- Inappropriate prescribing
- Medication non-adherence
- Adverse drug reaction
Red flags
- >5 medications
- Age >65
- Cognitive impairment
- Renal or hepatic impairment
- Recent hospitalization
- Multiple prescribers
Workup
- history: Complete medication list including OTC and supplements, adherence assessment, side effect screening; exam: Orthostatic vital signs, cognitive screening (if elderly), fall risk assessment; labs: Renal function for dose adjustments, drug levels if applicable (digoxin, phenytoin, lithium); imaging: Not typically indicated; bedside: Beers Criteria review, anticholinergic burden score, drug interaction check
Management
- immediate: Not applicable — systematic review process; general: Deprescribing: review each medication for ongoing indication, appropriate dose, monitoring; Beers Criteria medications to avoid in elderly: benzodiazepines, anticholinergics, sedating antihistamines, NSAIDs, sliding scale insulin; Simplify regimen (once daily preferred); Involve pharmacist in complex cases; STOPP/START criteria application
Disposition
- admit: Not applicable; discharge: Outpatient — document changes and communicate to all prescribers; consults: Clinical pharmacist, geriatrics for complex cases
Clinical pearls
- STOPP/START criteria and Beers Criteria are the two main tools for identifying potentially inappropriate medications in older adults
- Every medication added increases adverse drug reaction risk exponentially, not linearly
- Always ask about OTC medications and supplements — they account for many drug interactions
Source and review
- AGS Beers Criteria 2023, STOPP/START v3 2023. Last reviewed: 2024-11-01