Polypharmacy and inappropriate medications for elderly patients

No consensus definition of polypharmacy (“you know it when you see it”). High prevalence: >50% inpts >75yo.

Polypharmacy increases likelihood of Adverse Drug Reactions (ADRs), Drug-Drug Interactions, delirium, falls, and other negative outcomes. Should communicate with PCP about simplifying med list.

Medication classes to (usually) AVOID in geriatric patients:

 • Anticholinergics: Risk of delirium, falls, and other side effects. Avoid antihistamines, TCAs, MAOIs, antimuscarinics (oxybutynin), muscle relaxants (cyclobenzaprine), prochlorperazine.

 • Benzodiazepines: avoid due to risk of delirium, falls, cognitive impairment, etc. (also risk w/ non-BZD hypnotics)

 • Antipsychotics: concern for increased mortality with antipsychotics in the elderly

 • Peripheral alpha blockers and central alpha-agonists: -zosins and clonidine confer risk of orthostasis and falls

 • Long-acting sulfonylureas: risk of hypoglycemia

 • PPIs: attempt switch to H2 blockers unless clear indication for PPI (risk of C. diff, bone loss/fracture)

 • NSAIDs (especially in elderly patients with decreased CrCl): risk of GI bleed and AKI See American Geriatric Society Beer’s List and STOPP-START for further details on potentially inappropriate meds

• Parkinson’s disease: ondansetron is anti-emetic of choice. Avoid metoclopramide and prochlorperazine (as well as antipsychotics)

• Dosage adjustments: ensure appropriate renal dose adjustment for anticoagulants (enoxaparin, apixaban, rivaroxaban, and dabigatran), antibiotics, etc.



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