One-liner#

Systematic approach to medication review in older adults—identifying polypharmacy, recognizing adverse drug effects (ADEs), applying deprescribing principles, and using tools like the Beers Criteria to reduce medication burden and improve outcomes.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Anaphylaxis (urticaria, angioedema, hypotension, respiratory distress) → ED; stop offending drug
• Severe hypoglycemia (altered mental status, seizure) → ED
• Severe bleeding (GI bleed, intracranial hemorrhage on anticoagulants) → ED
• Severe hyponatremia (Na <120, seizures, altered mental status) → ED
• Serotonin syndrome (hyperthermia, rigidity, clonus, altered mental status) → ED
• Neuroleptic malignant syndrome (hyperthermia, rigidity, altered mental status, autonomic instability) → ED
• Stevens-Johnson syndrome/TEN (widespread skin sloughing, mucosal involvement) → ED
• Severe bradycardia or heart block → ED
• Acute kidney injury with hyperkalemia → ED

Urgent (same-day evaluation):

• Significant bleeding (not life-threatening)
• Symptomatic bradycardia
• Severe drug rash (not SJS/TEN)
• Acute confusion suspected medication-related
• Falls with injury

Key history#

Medication reconciliation (ESSENTIAL):

• Complete list of all medications (prescription, OTC, supplements, herbals)
• Ask patient to bring all pill bottles (“brown bag review”)
• Verify doses and frequencies
• Identify who prescribed each medication and why
• Assess adherence (missed doses, taking as prescribed)
• Check for duplicate therapies
• Identify medications no longer needed

Polypharmacy assessment:

• Total number of medications (≥5 = polypharmacy; ≥10 = excessive polypharmacy)
• Number of prescribers
• Recent medication changes
• Medications started in hospital that may no longer be needed

Symptom assessment (think “drug until proven otherwise”):

• New symptoms since starting a medication
• Symptoms that could be ADEs:
  • Falls, dizziness (many drugs)
  • Confusion, cognitive decline (anticholinergics, sedatives)
  • Fatigue, weakness (beta-blockers, sedatives)
  • GI symptoms (NSAIDs, antibiotics, metformin)
  • Bleeding (anticoagulants, antiplatelets, NSAIDs)
  • Constipation (opioids, anticholinergics, calcium channel blockers)
  • Urinary retention (anticholinergics)
  • Edema (calcium channel blockers, NSAIDs, gabapentin)
  • Dry mouth (anticholinergics)
  • Weight gain (antipsychotics, some antidepressants, insulin)

Prescribing cascade recognition:

• Drug A causes side effect → Drug B prescribed to treat side effect → Drug B causes side effect → Drug C prescribed…
• Common examples:
  • NSAID → HTN → antihypertensive
  • Amlodipine → edema → diuretic
  • Cholinesterase inhibitor → urinary incontinence → oxybutynin
  • Metoclopramide → parkinsonism → levodopa
  • Opioid → constipation → laxative → diarrhea → loperamide

Functional assessment:

• Can patient open pill bottles?
• Can patient read labels?
• Can patient remember to take medications?
• Who manages medications (patient, caregiver, facility)?
• Use of pill organizers, reminders

Goals of care:

• Life expectancy (affects benefit of preventive medications)
• Patient priorities (symptom control vs longevity)
• Functional status
• Cognitive status

Focused exam#

Vital signs:

• Blood pressure (hypotension from antihypertensives; hypertension from NSAIDs, stimulants)
• Heart rate (bradycardia from beta-blockers, digoxin; tachycardia from anticholinergics)
• Orthostatic vitals (many medications cause orthostasis)

General:

• Mental status (confusion, sedation)
• Hydration status
• Nutritional status

Skin:

• Rashes (drug eruptions)
• Bruising (anticoagulants, antiplatelets)
• Edema (CCBs, NSAIDs, gabapentin)

Neurologic:

• Gait and balance (sedatives, anticonvulsants)
• Tremor (lithium, valproate, SSRIs)
• Parkinsonism (antipsychotics, metoclopramide)
• Neuropathy (metformin → B12 deficiency)

Cardiovascular:

• Bradycardia (beta-blockers, digoxin, CCBs)
• Edema

GI:

• Abdominal tenderness (NSAIDs, GI bleeding)
• Constipation (opioids, anticholinergics)

GU:

• Bladder distension (anticholinergics, opioids)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Medication review tools:

Beers Criteria (AGS):

• List of potentially inappropriate medications (PIMs) in older adults
• Categories: Avoid, avoid in certain conditions, use with caution
• Updated regularly (most recent 2023)
• Key drugs to avoid in elderly:
  • First-generation antihistamines (diphenhydramine)
  • Benzodiazepines (all)
  • Non-benzodiazepine hypnotics (zolpidem, eszopiclone)
  • Anticholinergic bladder drugs (oxybutynin)
  • Muscle relaxants (cyclobenzaprine, methocarbamol)
  • Long-acting sulfonylureas (glyburide)
  • Meperidine
  • Proton pump inhibitors (long-term without indication)

STOPP/START Criteria:

• STOPP: Screening Tool of Older Persons’ Prescriptions (what to stop)
• START: Screening Tool to Alert to Right Treatment (what to start)
• European-developed; complements Beers

Anticholinergic Burden Scale:

• Scores medications by anticholinergic potency (0-3)
• Higher cumulative score = higher risk of cognitive impairment, falls, delirium
• Goal: Minimize total anticholinergic burden

Laboratory monitoring:

Initial management#

Deprescribing principles:

1. Review all medications with patient/caregiver
2. Identify medications to consider stopping:
   • No current indication
   • Indication resolved
   • Harm outweighs benefit (given life expectancy, goals)
   • Part of prescribing cascade
   • Beers Criteria PIMs
   • Duplicate therapy
3. Prioritize which to address first (highest risk, easiest wins)
4. Plan the taper (some drugs need gradual reduction)
5. Monitor for withdrawal or return of symptoms
6. Document rationale for deprescribing

Medications often appropriate to deprescribe in elderly:

Drugs that require tapering:

• Benzodiazepines (withdrawal seizures)
• Opioids (withdrawal syndrome)
• Beta-blockers (rebound tachycardia, angina)
• Clonidine (rebound hypertension)
• Corticosteroids (adrenal insufficiency)
• SSRIs/SNRIs (discontinuation syndrome)
• Gabapentin/pregabalin (withdrawal symptoms)
• PPIs (rebound acid hypersecretion)

Management by diagnosis#

Anticholinergic burden reduction#

Education:

• Many medications have “anticholinergic” effects that can cause confusion, dry mouth, constipation, and urinary problems
• These effects add up when taking multiple medications
• Reducing these medications can improve thinking and reduce side effects

High anticholinergic burden medications to target:

Follow-up: 2-4 weeks after changes; reassess cognition and symptoms.

Benzodiazepine deprescribing#

Education:

• Benzodiazepines increase fall risk, confusion, and car accidents in older adults
• Stopping them can be done safely with a slow taper
• Sleep and anxiety often improve after stopping

Taper protocol:

• Reduce dose by 10-25% every 1-2 weeks
• Slower taper for long-term use (months to years)
• Convert short-acting to long-acting (diazepam) for easier taper if needed
• Expect some temporary worsening of sleep/anxiety
• Provide non-pharmacologic support (sleep hygiene, CBT)

Example taper (lorazepam 1 mg TID):

• Week 1-2: 1 mg BID + 0.5 mg at bedtime
• Week 3-4: 0.5 mg TID
• Week 5-6: 0.5 mg BID
• Week 7-8: 0.5 mg at bedtime
• Week 9-10: 0.25 mg at bedtime
• Week 11+: Stop

Follow-up: Every 1-2 weeks during taper; support and encouragement.

PPI deprescribing#

Education:

• PPIs are often continued longer than needed
• Long-term use may increase risk of fractures, infections, and nutrient deficiencies
• Most people can stop or reduce without problems

When to continue PPI:

• Barrett’s esophagus
• Severe erosive esophagitis (LA grade C/D)
• History of GI bleeding on anticoagulation/antiplatelet
• Ongoing high-dose NSAID use (if can’t stop NSAID)

Taper protocol:

• Step down to lower dose for 2-4 weeks
• Then switch to H2 blocker or as-needed PPI for 2-4 weeks
• Then stop
• Warn about rebound symptoms (usually resolve in 2-4 weeks)

Follow-up: 4-6 weeks after stopping; reassess symptoms.

Statin deprescribing (in appropriate patients)#

Education:

• Statins prevent heart attacks and strokes in people at risk
• In very elderly or frail patients with limited life expectancy, the benefit may not outweigh the burden
• This is a shared decision based on your goals and priorities

Consider stopping if:

• Limited life expectancy (<1-2 years)
• Severe frailty
• Primary prevention only (no history of heart attack/stroke)
• Significant side effects (myalgias affecting function)
• Patient preference after informed discussion

Continue if:

• Recent cardiovascular event
• High cardiovascular risk with reasonable life expectancy
• Patient prefers to continue

Follow-up: Reassess cardiovascular risk factors; no specific monitoring needed after stopping.

Diabetes medication simplification#

Education:

• In older adults, overly tight blood sugar control can cause dangerous low blood sugars
• A slightly higher A1c target (7.5-8.5%) is often safer
• Simpler regimens are easier to manage

Targets in elderly:

• Healthy elderly: A1c <7.5%
• Complex/intermediate health: A1c <8%
• Very complex/poor health: A1c <8.5%; avoid hypoglycemia

Simplification strategies:

• Stop sulfonylureas (high hypoglycemia risk); use if needed: glipizide (short-acting)
• Reduce insulin if A1c at target with hypoglycemia
• Consider stopping metformin if GFR <30 or GI intolerance
• Avoid glyburide (long-acting, high hypoglycemia risk)
• SGLT2 inhibitors: Good in HF/CKD but watch for volume depletion, DKA risk
• GLP-1 agonists: Weight loss, CV benefit, but GI side effects, cost

Follow-up: A1c in 3 months; monitor for hypoglycemia.

Opioid reduction#

Education:

• Long-term opioids often don’t help chronic pain and can cause many problems
• Reducing opioids slowly is safe and often improves function
• We’ll work together and won’t leave you without pain management

Taper protocol:

• Reduce by 10% of original dose every 1-4 weeks
• Slower taper for long-term use
• Provide non-opioid pain management (acetaminophen, topical agents, PT)
• Address sleep, mood, function
• Consider buprenorphine if opioid use disorder

Follow-up: Every 1-2 weeks during taper; assess pain, function, withdrawal symptoms.

Follow-up#

After medication changes:

• 1-2 weeks for high-risk changes (stopping anticoagulant, starting new drug)
• 2-4 weeks for routine deprescribing
• Monitor for withdrawal symptoms or return of original condition

Ongoing medication review:

• At every visit: “Are you having any problems with your medications?”
• Comprehensive review at least annually
• After hospitalizations (reconcile and review new medications)
• After falls, confusion, or new symptoms

What to reassess:

• Symptom improvement after stopping medication
• Withdrawal symptoms
• Return of condition being treated
• New symptoms that might be ADEs
• Adherence to simplified regimen

Patient instructions#

• We’re reviewing your medications to make sure each one is still helping you and not causing problems.
• As we get older, our bodies handle medications differently, and some medications that were helpful before may now cause more harm than good.
• Please bring all your medications to every appointment—including over-the-counter drugs, vitamins, and supplements.
• Don’t stop any medication without talking to us first. Some medications need to be reduced slowly.
• Tell us about any new symptoms, especially dizziness, confusion, falls, stomach problems, or bleeding. These could be medication side effects.
• If cost is a problem, let us know. We can often find less expensive alternatives.
• Keep a list of all your medications and why you take them. Share this list with all your doctors.
• If you’re having trouble remembering to take your medications, we can help simplify your regimen or set up reminders.

Smartphrase snippets#

.MEDSREVIEW Comprehensive medication review performed. Patient currently on [X] medications. Reviewed indication, efficacy, and safety of each. Identified [PIMs / high-risk combinations / medications without clear indication]. Plan: [Stop/taper X; reduce Y; continue Z]. Discussed rationale with patient/caregiver. Will monitor for [withdrawal / return of symptoms / improvement]. Follow-up in [X weeks].

.DEPRESCRIBING Deprescribing discussion. [Medication] was started for [indication] [timeframe ago]. Given [limited life expectancy / resolved indication / side effects / Beers criteria / patient preference], discussed risks and benefits of continuing vs stopping. Patient [agrees to trial off / prefers to continue]. Plan: [Taper schedule / stop / continue with monitoring]. Will reassess in [X weeks].

.POLYPHARMACY Polypharmacy assessment in [age]-year-old on [X] medications from [X] prescribers. Anticholinergic burden: [low/moderate/high]. Beers criteria PIMs identified: [list]. Prescribing cascades identified: [list]. Medications without clear current indication: [list]. Plan: Prioritized deprescribing of [X]. Will address [Y] at next visit. Goal: Reduce medication burden while maintaining symptom control and safety.

.ADEEVALUATION Adverse drug effect evaluation. Patient presents with [symptom]. Temporal relationship to [medication started/increased X weeks ago]. Symptom consistent with known ADE of [medication]. Plan: [Stop/reduce medication]. Expect improvement in [timeframe]. Alternative treatment: [X]. Follow-up in [X] to confirm resolution. If symptoms persist, will consider other etiologies.

Coding/billing notes#

• T88.7: Unspecified adverse effect of drug or medicament
• Y57.9: Drug or medicament, unspecified, causing adverse effect
• Z79.899: Other long-term (current) drug therapy
• Z87.39: Personal history of other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (if history of drug reaction)

Medication reconciliation:

• Document time spent on medication reconciliation
• Can be billed as part of E/M service
• Chronic Care Management (CCM) includes medication review

Transitional Care Management (TCM):

• Includes medication reconciliation after hospital discharge
• 99495 (moderate complexity) or 99496 (high complexity)
• Must include medication reconciliation within 2 business days of discharge