CLINICAL PRINTABLE
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A one-page Medication Reconciliation / Polypharmacy clinical reference is on the way.
1 · Recognition / Alarm Features
- Polypharmacy: commonly defined as ≥5 medications. Problematic polypharmacy: medications that are inappropriate, duplicative, or no longer indicated. Affects 40% of older adults. Associated with adverse drug events, drug-drug interactions, falls, cognitive impairment, non-adherence, and hospitalizations.
- Medication reconciliation: the process of comparing a patient's medication orders to all medications the patient has been taking. Required at every transition of care (admission, transfer, discharge). Discrepancies are common — studies show 30–70% of patients have at least one medication error at discharge.
- High-risk medications in older adults (Beers Criteria): benzodiazepines (falls, cognitive impairment), anticholinergics (confusion, urinary retention, constipation), NSAIDs (GI bleed, renal failure, cardiovascular risk), first-generation antihistamines (diphenhydramine), muscle relaxants, antipsychotics (increased mortality in dementia), sulfonylureas (hypoglycemia), digoxin >0.125 mg/day.
- Anticholinergic burden: cumulative anticholinergic effects of multiple medications. Common anticholinergic drugs: diphenhydramine, oxybutynin, tricyclic antidepressants, first-generation antihistamines, some antipsychotics, some antidepressants. High anticholinergic burden is associated with cognitive impairment and falls in older adults.
- Post-discharge medication reconciliation: compare discharge medication list to pre-admission medications. Common errors: omission of home medications, continuation of hospital-only medications (PPIs, sliding scale insulin, DVT prophylaxis), dose changes not communicated, new medications added without indication.
2 · Differential / Secondary Causes
Adverse drug reaction vs disease progression
New symptoms after medication change may be an adverse drug reaction rather than disease progression. Common culprits: ACE inhibitors (cough, angioedema), statins (myopathy), metformin (GI symptoms), beta-blockers (fatigue, depression), SSRIs (GI upset, sexual dysfunction). Always ask 'could this be a medication side effect?' before adding another drug.
Drug-drug interactions
High-risk combinations: warfarin + NSAIDs (bleeding), ACE inhibitor + potassium-sparing diuretic (hyperkalemia), QT-prolonging drugs (fluoroquinolones + antipsychotics + azithromycin), serotonergic drugs (SSRIs + tramadol + linezolid = serotonin syndrome), CYP3A4 inhibitors + statins (myopathy), colchicine + CYP3A4 inhibitors (toxicity).
Prescribing cascade
A new drug is prescribed to treat the side effect of another drug. Classic examples: NSAID → hypertension → antihypertensive; metoclopramide → Parkinsonism → levodopa; calcium channel blocker → peripheral edema → diuretic. Identify and treat the root cause — the original offending drug.
3 · Treatment Pathway
Systematic medication review
For every medication, ask: (1) Is there an indication? (2) Is it effective? (3) Is it safe? (4) Is it necessary? Use the STOPP/START criteria or Beers Criteria as a framework. Involve the patient — ask about OTC medications, supplements, and herbal products. Reconcile with pharmacy records and prior provider notes.
Deprescribing
Systematic process of tapering or stopping medications that are no longer indicated, are causing harm, or are not aligned with the patient's goals. Prioritize: medications with high adverse effect burden, medications without clear indication, duplicates, and medications the patient is not taking. Taper rather than abruptly stop: benzodiazepines, opioids, SSRIs, beta-blockers, corticosteroids, PPIs.
Post-discharge follow-up
Schedule follow-up within 7 days of discharge for high-risk patients (elderly, multiple medications, new diagnoses). Review: new medications started in hospital (indication, duration), medications held or stopped (should they be restarted?), dose changes, and new drug-drug interactions. Reconcile with the patient's home medication list.
Patient education and adherence
Provide a clear, updated medication list at every visit and discharge. Explain the indication for each medication. Simplify regimens when possible (once-daily dosing, combination pills). Address cost barriers — generic substitutions, patient assistance programs. Involve caregivers for patients with cognitive impairment.
4 · Expected Response
- Deprescribing benzodiazepines: taper over weeks to months (10–25% dose reduction every 1–2 weeks). Withdrawal symptoms (anxiety, insomnia, tremor) are common — reassure and continue taper.
- Stopping PPIs: rebound acid hypersecretion for 2–4 weeks after discontinuation. Taper to every-other-day dosing before stopping. Use H2 blockers or antacids for rebound symptoms.
- Medication reconciliation at discharge: reduces 30-day readmission rates and adverse drug events when combined with structured follow-up.
5 · Escalation
- Suspected adverse drug reaction causing serious harm (anaphylaxis, severe bleeding, serotonin syndrome, agranulocytosis): discontinue the offending agent immediately and manage the acute reaction.
- Complex polypharmacy in older adults with multiple comorbidities: clinical pharmacist consultation for comprehensive medication review.
- Medication non-adherence due to cost: social work referral, patient assistance programs, generic substitutions, pill organizers, blister packs.
Apply It · Change One Detail
APPLY IT
A 78-year-old woman is discharged after a hip fracture. Her discharge medication list includes 14 medications. Review reveals: diphenhydramine (Benadryl) for sleep — Beers Criteria, anticholinergic, fall risk; oxybutynin for overactive bladder — high anticholinergic burden; a PPI started in the hospital without indication. Deprescribe the diphenhydramine (substitute low-dose melatonin or CBT-I), switch oxybutynin to mirabegron (lower anticholinergic burden), and discontinue the PPI. Document the rationale for each change.
CHANGE ONE DETAIL
Change one detail — the same patient was started on an NSAID for hip pain post-discharge. She is also on warfarin for atrial fibrillation. This is a high-risk drug-drug interaction: NSAIDs + warfarin dramatically increase bleeding risk. Substitute acetaminophen for pain management. Check INR. This is a prescribing cascade waiting to happen — the NSAID could also cause renal impairment, leading to a diuretic addition, leading to electrolyte abnormalities.
Bottom Line
At every transition of care, reconcile the medication list and ask: Is there still an indication? Is it safe? Is it necessary? Deprescribing is as important as prescribing — the goal is the right medications, not the most medications.
EVIDENCE & REFERENCES
- American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
- O'Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218. doi:10.1093/ageing/afu145
- Reeve E, et al. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738-747. doi:10.1111/bcp.12386