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Assess medication-related risks using Beers Criteria and polypharmacy principles. Identify high-risk medications and prioritize deprescribing opportunities.
Include prescription and over-the-counter medications. Polypharmacy: ≥5, Excessive: ≥10
Count the number of medications in each category:
E.g., diphenhydramine, oxybutynin, hydroxyzine, first-generation antihistamines
E.g., lorazepam, diazepam, alprazolam, clonazepam
E.g., ibuprofen, naproxen, indomethacin, ketorolac
E.g., omeprazole, esomeprazole, pantoprazole, lansoprazole
E.g., haloperidol, risperidone, quetiapine, olanzapine
E.g., amitriptyline, doxepin, paroxetine
Polypharmacy Status
High-Risk Medications
0
Deprescribing Priority
Total Medications: 0
Polypharmacy: ≥5 medications | Excessive Polypharmacy: ≥10 medications
Deprescribing Recommendations:
Anticholinergics
Diphenhydramine (Benadryl), hydroxyzine, oxybutynin, tolterodine, first-generation antihistamines
Benzodiazepines
Diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin)
NSAIDs (chronic use)
Ibuprofen, naproxen, indomethacin, ketorolac - avoid chronic use in elderly
PPIs (chronic use)
Omeprazole, esomeprazole, pantoprazole, lansoprazole - avoid if no clear indication after 8 weeks
High-Risk Antipsychotics
Haloperidol, risperidone, quetiapine, olanzapine - increased stroke risk in dementia
High-Risk Antidepressants
Amitriptyline, doxepin, paroxetine - high anticholinergic burden
Polypharmacy, typically defined as the concurrent use of five or more medications, is increasingly common in older adults with multiple chronic conditions. While some polypharmacy is appropriate and necessary, it carries significant risks including adverse drug events, drug-drug interactions, falls, hospitalization, and mortality.
The American Geriatrics Society Beers Criteria identifies potentially inappropriate medications for older adults. Updated regularly since 1991, these criteria help clinicians identify medications that may pose more risks than benefits in elderly patients. The criteria include medications to avoid, dose adjustments needed, and drug-disease interactions to prevent.
Deprescribing is the systematic process of reducing or stopping medications that may no longer be beneficial or may be causing harm. The process involves reviewing all medications, identifying those with unfavorable risk-benefit ratios, planning tapering schedules when necessary, and monitoring for both adverse withdrawal effects and improvements in patient outcomes.
Polypharmacy increases risk of adverse drug events by 7-10% for each additional medication. High-risk medications like anticholinergics increase falls and delirium risk. Benzodiazepines double fall and fracture risk. NSAIDs cause GI bleeding and renal impairment. Drug interactions become exponentially more likely with each added medication.
Polypharmacy is most commonly defined as the concurrent use of five or more medications. Excessive polypharmacy refers to ten or more medications. However, quality matters more than quantity - even a small number of medications can be inappropriate if they're not indicated, duplicative, or potentially harmful.
Never stop medications abruptly without consulting your healthcare provider. Some medications require gradual tapering to avoid withdrawal (benzodiazepines, antidepressants, beta-blockers, corticosteroids). Others can be stopped immediately. Your provider should develop a personalized deprescribing plan with monitoring for both withdrawal effects and symptom recurrence.
Anticholinergic medications block acetylcholine, a neurotransmitter important for memory and muscle function. In older adults, they increase risk of confusion, delirium, falls, constipation, urinary retention, and dry mouth. Long-term use is associated with cognitive decline and increased dementia risk. Common culprits include diphenhydramine (Benadryl) and medications for overactive bladder.
The Beers Criteria recommends avoiding benzodiazepines in older adults due to increased sensitivity and risks of cognitive impairment, delirium, falls, and fractures. Risk increases with dose and duration. If discontinuing, taper slowly over weeks to months. Consider alternatives like cognitive behavioral therapy for insomnia or SSRIs for anxiety. Short-term use for procedures may be appropriate.
Long-term PPIs are appropriate for erosive esophagitis, Barrett's esophagus, chronic NSAID use with high GI risk, and Zollinger-Ellison syndrome. However, many patients continue PPIs without clear indication. After 8 weeks of treating reflux or ulcers, attempt discontinuation or switch to H2 blocker. Long-term PPI use carries risks of fractures, C. difficile infection, and nutrient malabsorption.
Use a pill organizer with daily or twice-daily compartments. Set phone alarms for medication times. Keep an updated medication list with names, doses, and purposes. Use one pharmacy for all prescriptions to enable interaction screening. Consider medication synchronization programs that align refill dates. For complex regimens, home health or family assistance may be needed.
A brown bag review involves bringing all medications (prescription, OTC, supplements, herbal products) to an appointment in a bag. The provider reviews each medication for appropriateness, interactions, duplications, and adherence barriers. This comprehensive review often identifies medications that can be discontinued, simplified, or optimized. Recommended annually for older adults.
Yes. Clinical pharmacists are medication experts who can conduct comprehensive medication reviews, identify drug interactions and inappropriate medications, recommend alternatives, and help coordinate care between multiple prescribers. Many insurance plans cover pharmacist consultations. Medication therapy management (MTM) services are especially valuable for those with polypharmacy or multiple chronic conditions.
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