Human Development

Geriatric polypharmacy and Beers criteria deprescribing

Clinical Overview and When to Suspect Polypharmacy Harm

— New falls, syncope, or orthostasis in a previously stable elder

— Cognitive decline, delirium, or "sundowning" after a recent med addition

— Urinary incontinence, constipation, dry mouth (anticholinergic burden)

— Weight loss, anorexia, or functional decline without clear medical cause

— Unexplained hypoglycemia, hyponatremia, or bradycardia

— Donepezil → urinary incontinence → oxybutynin → confusion → "dementia progression"

— Amlodipine → ankle edema → furosemide → hypokalemia + falls

— Metoclopramide → parkinsonism → carbidopa-levodopa

— Beers Criteria (AGS, updated 2023): potentially inappropriate medications (PIMs) in adults ≥65

— STOPP/START: explicit stop list + start list (European, but tested)

— Medication Appropriateness Index (MAI): implicit, 10-item tool

— Deprescribing.org algorithms: PPIs, benzodiazepines, antipsychotics, antihyperglycemics

Board pearl: Any new symptom in an elder is a drug side effect until proven otherwise — Step 3 stems that open with "an 82-year-old on 9 medications develops…" are testing your reflex to review the med list before ordering workup or adding therapy.

Definition: Polypharmacy = concurrent use of ≥5 chronic medications; "hyperpolypharmacy" ≥10. Prevalence rises sharply after age 65, with ~40% of community-dwelling elders on ≥5 drugs and >90% of nursing-home residents.

Why Step 3 cares: The exam frames polypharmacy as a longitudinal ambulatory problem — your job is to recognize a prescribing cascade, deprescribe systematically, and prevent iatrogenic geriatric syndromes.

When to suspect medication-related harm:

Prescribing cascade pattern (classic vignette):

Risk factors for polypharmacy harm: multiple prescribers, frequent transitions of care, low health literacy, frailty (Fried criteria ≥3), CrCl <60, weight <60 kg, age ≥80.

Frameworks you must know:

Presentation Patterns and Key History

— Falls: benzodiazepines, Z-drugs (zolpidem), opioids, TCAs, antipsychotics, alpha-blockers, sulfonylureas (hypoglycemia), antihypertensives causing orthostasis

— Delirium/cognitive impairment: anticholinergics (diphenhydramine, oxybutynin, TCAs), benzodiazepines, opioids (meperidine worst), H2 blockers (especially in CKD), corticosteroids, muscle relaxants

— Incontinence: diuretics, cholinesterase inhibitors, alpha-blockers (stress incontinence in women)

— Constipation: opioids, anticholinergics, calcium, iron, verapamil

— Orthostasis: alpha-blockers, diuretics, nitrates, tamsulosin, TCAs, trazodone

— Have the patient bring every bottle, including OTCs, supplements, eye drops, topicals

— Ask separately about: PRN sleep aids, "nerve pills," herbals (St. John's wort, ginkgo), NSAIDs, antacids

— Clarify who prescribed each med, when, and for what indication

— Ask: "Are there any medications you don't think you need?" — patient-centered deprescribing

— Pill counts, pharmacy refill records, MPR (medication possession ratio)

— Cognitive screen (Mini-Cog) if any concern — adherence is impossible without intact executive function

— Visual acuity, dexterity, ability to open bottles

— Who fills the pillbox? Lives alone? Caregiver burden?

— Recent hospitalization (medication reconciliation errors peak at transitions)

— Goals of care — limited life expectancy shifts the risk/benefit toward deprescribing

Step 3 management: At every annual Medicare wellness visit, perform an explicit medication reconciliation using the Beers list as a checklist. Document indication for each drug; if no indication, deprescribe. This is a billable, board-favored intervention.

The "geriatric giants" as drug-effect mimics — memorize these mappings:

Targeted history — the "brown bag review":

Adherence assessment:

Functional context:

Physical Exam Findings and Functional Assessment

— Orthostatic vitals (supine → 1 min → 3 min standing): drop ≥20 SBP or ≥10 DBP, or HR rise ≥30 → suspect antihypertensives, diuretics, alpha-blockers, TCAs, dehydration from over-diuresis

— Resting bradycardia (<50): beta-blockers, non-DHP CCBs, donepezil, digoxin

— Hypothermia: phenothiazines, opioids, alcohol

— Weight trajectory: unintended loss of >5% in 6–12 mo prompts review of SSRIs, metformin, donepezil, digoxin

— Neuro: pill-rolling tremor, bradykinesia, rigidity → drug-induced parkinsonism (metoclopramide, prochlorperazine, antipsychotics)

— Mental status: Mini-Cog or MoCA; acute change → screen with CAM for delirium

— Cardiac: new murmur, irregular rhythm; check for signs of digoxin toxicity (rare exam findings — mostly history)

— Skin: bruising (anticoagulants, steroids), purpura, pressure injuries

— Mouth: xerostomia from anticholinergics → dental decay

— Timed Up and Go (TUG): ≥12 sec → high fall risk; trigger med review

— Gait speed: <0.8 m/s correlates with frailty and adverse drug events

— Grip strength: sarcopenia marker → altered drug distribution

— Visual acuity and hearing: affect adherence and adverse-event reporting

— Frail elder with SBP 110, on 3 antihypertensives → deprescribe even if "controlled"; SPRINT did not enroll frail nursing-home residents

Board pearl: Orthostatic hypotension in an elder on ≥2 BP meds is a deprescribing trigger, not an indication for fludrocortisone. Always peel back the offending agent first before adding new therapy — this is a classic Step 3 prescribing-cascade trap.

Vitals as drug-effect detectors:

Targeted system exam:

Functional/geriatric exam (high-yield Step 3 maneuvers):

Hemodynamic phenotype matters:

Diagnostic Workup — Initial Labs and Medication Review Tools

— BMP: eGFR (Cockcroft-Gault preferred in elderly for drug dosing, not CKD-EPI), Na (SSRIs, thiazides, carbamazepine → SIADH), K (ACEi/ARB, spironolactone, NSAIDs)

— CBC: anemia from NSAIDs, aspirin, SSRIs (GI bleed risk)

— LFTs: statins, acetaminophen burden (total daily <3 g in elderly)

— TSH: amiodarone, lithium

— Vitamin B12: chronic metformin or PPI use (≥2 yr) → screen

— HbA1c: target 7.5–8.0% in frail elders; <7% with sulfonylurea or insulin = overtreatment, deprescribe

— INR if on warfarin: time in therapeutic range; consider DOAC switch

— Drug levels where relevant: digoxin (target <0.9 ng/mL in HF elderly), lithium, phenytoin, vancomycin

— AGS Beers Criteria 2023: 5 categories — PIMs to avoid, PIMs to avoid in specific conditions, PIMs to use with caution, drug-drug interactions, renal dose adjustments

— STOPP/START version 3 (2023): 190+ criteria

— Anticholinergic Cognitive Burden (ACB) scale: score ≥3 → cognitive risk

— Drug Burden Index: sedative + anticholinergic load

— Medication Appropriateness Index (MAI): indication, effectiveness, dose, directions, interactions, duplication, duration, cost

— Good Palliative-Geriatric Practice algorithm: decision tree per drug

— Hospital admission, transfer between units, discharge, post-discharge clinic visit at 7–14 days

CCS pearl: On any elderly inpatient CCS case, "medication reconciliation" is an orderable that prevents downstream complications. Order it on admission, at transfer, and at discharge — three documented reconciliations are the safety standard.

Baseline labs that change deprescribing decisions:

Explicit screening tools (know these by name):

Implicit tools:

Reconciliation moments (CCS-tested transitions):

Diagnostic Workup — Advanced Assessment and Pharmacogenomics

— Recurrent falls or delirium despite first deprescribing round

— Suspected drug-drug or drug-disease interaction not obvious on initial pass

— Failed therapy with multiple agents in same class (e.g., 3 SSRIs ineffective)

— Medicare Part D Medication Therapy Management (MTM) program — annual CMR is covered for beneficiaries with ≥3 chronic conditions, ≥8 chronic meds, and projected drug spend over threshold

— Documented to reduce ED visits and improve adherence

— Strong CYP3A4 inhibitors (clarithromycin, ketoconazole, diltiazem, grapefruit) ↑ levels of statins (rhabdo), apixaban, tacrolimus

— Strong CYP2D6 inhibitors (fluoxetine, paroxetine, bupropion) block tamoxifen activation, ↑ TCA levels

— Warfarin (CYP2C9): TMP-SMX, metronidazole, amiodarone, fluconazole → ↑INR

— QT-prolonging combinations: ondansetron + citalopram + methadone + azithromycin — additive risk

— CYP2C19 for clopidogrel response (especially post-PCI, stroke prevention)

— HLA-B5701 before abacavir; HLA-B1502 before carbamazepine in Asian ancestry

— TPMT/NUDT15 before azathioprine

— Not routinely indicated for warfarin or SSRIs at this time

— NSAIDs in HF, CKD, or on anticoagulant

— Anticholinergics in dementia, BPH, narrow-angle glaucoma

— Benzos in OSA, COPD, fall history

— PPIs >8 weeks without indication

Key distinction: Beers is a list of drugs to avoid; STOPP/START is a paired tool that also tells you what to start (e.g., statin in diabetic ≥40, bisphosphonate in chronic steroid use). Step 3 may test the START side — under-prescribing is also bad prescribing.

When to go deeper than the brown-bag review:

Pharmacist-led comprehensive medication review (CMR):

CYP450 interaction screening:

Pharmacogenomic testing (limited but tested):

Drug-disease mismatches to flag:

Risk Stratification and Deprescribing Logic

1. Reconcile — comprehensive list with indication for each drug

2. Assess risk — patient factors, drug factors, anticholinergic/sedative burden

3. Prioritize — highest harm, lowest benefit, no indication, duplication

4. Plan taper — drug-specific schedule, monitor for withdrawal/recurrence

5. Monitor and document — follow-up at 1–4 weeks per drug

— No current indication (e.g., PPI started in hospital, never stopped)

— Therapeutic duplication (two SSRIs, two benzos, ACEi + ARB)

— PIM with safer alternative (diphenhydramine → cetirizine or melatonin)

— Drug treating side effect of another drug (prescribing cascade)

— Limited time-to-benefit exceeds life expectancy (statins, bisphosphonates, intensive glycemic control)

— Statins for primary prevention: TTB ~2.5 years

— Bisphosphonates for fracture prevention: TTB ~1 year

— Tight glycemic control (microvascular benefit): TTB 8+ years

— If estimated life expectancy < TTB → deprescribe

— ePrognosis.org (Lee, Schonberg indices)

— "Surprise question": would you be surprised if this patient died in the next year?

— Discuss goals, fears (rebound, recurrence), and pill burden

— Document patient/family agreement; involve power of attorney if cognitively impaired

Step 3 management: In a frail 85-year-old with limited life expectancy, the correct answer to "what statin dose?" is often discontinue the statin for primary prevention. Choosing wisely beats choosing harder.

The 5-step deprescribing framework (memorize):

Prioritization matrix — what comes off first:

Time-to-benefit (TTB) for primary prevention — Step 3 favorite:

Life expectancy estimation tools:

Shared decision-making:

Pharmacotherapy — High-Yield Beers-Listed Drugs to Avoid

— First-gen antihistamines: diphenhydramine, hydroxyzine, chlorpheniramine → substitute loratadine/cetirizine; for sleep use sleep hygiene, CBT-I, low-dose melatonin

— TCAs (tertiary): amitriptyline, imipramine, doxepin >6 mg → use nortriptyline if TCA required, or SNRI for neuropathic pain

— Antispasmodics: dicyclomine, hyoscyamine

— Bladder antimuscarinics: oxybutynin IR → prefer mirabegron or behavioral therapy

— Muscle relaxants: cyclobenzaprine, methocarbamol, carisoprodol

— Benzodiazepines (all): ↑ falls, cognitive impairment, MVA; if used for anxiety, taper slowly (10–25% per 1–2 weeks)

— Z-drugs: zolpidem, eszopiclone — same risks as benzos

— Barbiturates: never

— Digoxin >0.125 mg/day — avoid; ↑ toxicity in CKD

— Nifedipine IR — reflex tachycardia, hypotension

— Alpha-1 blockers (doxazosin, terazosin) for HTN — orthostasis; OK for BPH

— Amiodarone — first-line only if structural heart disease or HF

— Aspirin for primary prevention ≥60 — USPSTF/Beers recommend against

— Long-acting sulfonylureas: glyburide → severe prolonged hypoglycemia; use glipizide if SU needed, or switch to DPP-4i, SGLT2i, or GLP-1 RA per indication

— Sliding-scale insulin alone in nursing home — avoid

— Estrogen oral/patch (non-vaginal) for systemic use

— PPIs >8 weeks without indication → ↑ C. diff, fractures, B12 deficiency, AKI

— Metoclopramide >12 weeks → tardive dyskinesia

— NSAIDs chronic (esp. with anticoag, HF, CKD)

— Meperidine — neurotoxic metabolite

— Skeletal muscle relaxants — sedation

Board pearl: Glyburide → glipizide; oxybutynin → mirabegron; diphenhydramine → loratadine; diazepam → taper off entirely. Memorize these four swaps — they appear repeatedly.

Strong anticholinergics (avoid in all elderly):

Sedative-hypnotics:

Cardiovascular:

Endocrine:

GI:

Pain:

Deprescribing Protocols — Drug-Specific Tapering

— Reduce by 10–25% every 1–2 weeks; slow further in last quarter

— Convert short-acting (alprazolam, lorazepam) to long-acting (diazepam, clonazepam) equivalent if abrupt withdrawal symptoms

— Adjunct: CBT-I, sleep hygiene; avoid trazodone substitution if possible (orthostasis, falls)

— Monitor for rebound anxiety, insomnia, seizures (rare but real with high-dose chronic use)

— Indications to continue: Barrett's, severe esophagitis (LA grade C/D), ZES, chronic NSAID with bleed risk

— Taper: halve dose × 2–4 weeks → every-other-day → stop; or step down to H2 blocker

— Counsel about rebound acid hypersecretion for 2–4 weeks; offer antacids PRN

— Black box warning: ↑ mortality in dementia

— After 3 months of stability, reduce by 25–50% every 2 weeks

— Non-pharm first: DICE approach (Describe, Investigate, Create plan, Evaluate)

— Slow taper 10% per month for chronic users; faster early, slower late

— Co-prescribe naloxone; screen for OUD with prolonged use

— If SBP <130 with orthostasis or falls, deprescribe one agent

— Reasonable BP target in frail ≥80: SBP 130–150

— Life expectancy <1–2 yr → discontinue; secondary prevention usually continued

— A1c <6.5% on insulin/SU → deintensify; relax target to 7.5–8%

— Stop SU first, then basal insulin reduction

— Calculate ACB; target score <3

— Sequential substitution one drug at a time, reassess in 2–4 weeks

CCS pearl: On a CCS case, sequence is: (1) reconcile, (2) stop the offending drug, (3) schedule follow-up at 2 weeks, (4) advance clock and reassess symptoms — don't add new meds to fix old-med problems.

Benzodiazepines / Z-drugs:

PPIs:

Antipsychotics for BPSD (dementia behavioral symptoms):

Opioids:

Antihypertensives in frail elders:

Statins for primary prevention:

Diabetes meds:

Anticholinergic burden reduction:

Special Populations — Pharmacokinetics in Aging and Organ Impairment

— ↓ Lean body mass, ↑ fat: lipophilic drugs (diazepam, amiodarone) have prolonged half-lives

— ↓ Total body water: hydrophilic drugs (lithium, digoxin, aminoglycosides) reach higher serum concentrations — lower doses

— ↓ Hepatic blood flow & phase I metabolism: ↑ levels of CYP-metabolized drugs (diazepam, propranolol). Phase II (glucuronidation — lorazepam, oxazepam) better preserved

— ↓ Renal clearance: GFR falls ~1 mL/min/year after 40; use Cockcroft-Gault for drug dosing

— ↑ Receptor sensitivity: to benzos, opioids, anticoagulants — "start low, go slow"

— Apixaban: reduce to 2.5 mg BID if 2 of 3: age ≥80, weight ≤60 kg, Cr ≥1.5

— Dabigatran: avoid if CrCl <30

— Rivaroxaban: avoid if CrCl <15; caution 15–50

— Gabapentin, pregabalin: reduce per CrCl; sedation risk

— Spironolactone: avoid if CrCl <30 or K >5

— Nitrofurantoin: avoid if CrCl <30 (Beers)

— NSAIDs: avoid if CrCl <30 or on RAAS blocker

— Metformin: avoid if eGFR <30; reduce 30–45

— SGLT2i: check label thresholds (empagliflozin OK to eGFR 20)

— Child-Pugh B/C: avoid acetaminophen >2 g/day, NSAIDs, oral anticoagulants need adjustment

— Statins: rosuvastatin and pravastatin less hepatically metabolized

— Sarcopenia + low albumin → ↑ free fraction of highly protein-bound drugs (phenytoin, warfarin)

Board pearl: Use Cockcroft-Gault, not eGFR from the lab, for renal drug dosing in elderly — CKD-EPI overestimates clearance in low-muscle-mass patients and can lead to overdosing of DOACs and antibiotics.

Age-related PK/PD changes (high-yield):

Renal dose adjustments (Beers 2023 list):

Hepatic impairment:

Frailty considerations:

Special Populations — End of Life, Dementia, and Nursing Home

— Stop: statins (RCT-proven safe to discontinue in advanced illness, improves QOL), bisphosphonates, vitamins, ASA primary prevention, intensive glycemic agents, cholinesterase inhibitors when no clear benefit

— Continue: symptom-control meds (analgesics, antiemetics, anxiolytics), seizure prophylaxis, anti-anginals as needed

— Hospice enrollment triggers comprehensive deprescribing review

— Cholinesterase inhibitors (donepezil, rivastigmine, galantamine): trial deprescribing if severe dementia (FAST 7), no functional benefit, or intolerance; taper over 4 weeks

— Memantine: similar; continue if family reports clear benefit

— Antipsychotics for BPSD: time-limited; reassess every 3 months; CMS F-tag scrutiny in nursing homes

— Avoid: anticholinergics, benzos, Z-drugs, opioids when possible

— CMS regulations require quarterly medication regimen review by consultant pharmacist

— Antipsychotic gradual dose reduction (GDR) required unless clinically contraindicated and documented

— "Unnecessary drug" regulation (F757)

— 1 in 5 develops an adverse drug event during admission

— Avoid sleep meds, restraints (chemical), routine bowel/PPI orders without indication

— Discharge med rec is mandatory — compare pre-admission, inpatient, and discharge lists

Step 3 management: When a patient enters hospice or has life expectancy < weeks, the next best step for chronic preventive meds (statin, ASA primary prevention, bisphosphonate, donepezil at FAST 7) is discontinue — not "continue at lower dose."

End-of-life deprescribing:

Dementia-specific issues:

Nursing home / long-term care:

Hospitalized elderly:

Pregnancy/pediatrics: not applicable to this geriatric topic — but transition-of-care principles apply universally

Complications and Adverse Outcomes

— Cause ~10% of ED visits in adults ≥65; ~30% lead to hospitalization

— Four drug classes drive most emergency hospitalizations: warfarin, oral antiplatelets, insulin, oral hypoglycemics (especially sulfonylureas)

— Add: digoxin, opioids, anticholinergics for cognitive ADEs

— Falls → hip fracture → 20–30% 1-year mortality; benzos, opioids, antihypertensives, hypoglycemics, anticholinergics

— Delirium → ↑ mortality, prolonged LOS, post-discharge cognitive decline

— Functional decline → loss of independence, nursing home placement

— Hospital-acquired complications: C. diff (PPI, antibiotics), AKI (NSAID, ACEi + diuretic + contrast = "triple whammy")

— Digoxin toxicity: N/V, anorexia, yellow-green vision (xanthopsia), arrhythmias (PVCs, AV block, bidirectional VT); precipitated by hypokalemia, hypomagnesemia, AKI, amiodarone, verapamil

— Lithium toxicity: tremor, ataxia, confusion; precipitated by NSAIDs, ACEi, thiazides, dehydration

— Serotonin syndrome: SSRI + tramadol/linezolid/MAOI; hyperreflexia, clonus, fever

— NMS: antipsychotic introduction; lead-pipe rigidity, hyperthermia

— Warfarin bleeding: intracranial hemorrhage risk doubles with each decade after 70

— SIADH/hyponatremia: SSRIs (especially first 4 weeks), thiazides, carbamazepine

— Hypoglycemia unawareness: beta-blockers blunt symptoms

— Polypharmacy ↑ readmission within 30 days by 30–50%

Key distinction: Falls + new medication = adverse drug event until proven otherwise. Do not order CT head, carotid Doppler, or tilt table before reviewing the medication list — Step 3 stems reward the cheap, high-yield intervention first.

Adverse drug events (ADEs) in elderly — scope:

Geriatric syndromes attributable to drugs:

Specific drug toxicities to recognize:

Healthcare utilization:

When to Escalate Care — Consult, Hospitalize, or Specialist Referral

— Suspected digoxin toxicity with arrhythmia or K abnormality → admit, Digibind if life-threatening

— Serotonin syndrome / NMS → ICU, supportive care, cyproheptadine or dantrolene/bromocriptine

— Major bleeding on anticoagulant → reverse (4F-PCC for warfarin/factor Xa inhibitors, idarucizumab for dabigatran, andexanet for apixaban/rivaroxaban)

— Severe hypoglycemia on sulfonylurea → admit; octreotide for refractory SU-induced hypoglycemia

— Delirium with safety concerns at home → consider admission for workup if cannot rule out medical cause

— Acute symptomatic bradycardia on rate-control drugs → ED, pacing if unstable

— Clinical pharmacist (MTM) — first-line for complex polypharmacy, often the right Step 3 answer over specialist

— Geriatrician — for comprehensive geriatric assessment in frail patients with recurrent falls, delirium, or functional decline

— Palliative care — limited life expectancy, complex symptom burden, goals-of-care clarification

— Pharmacogenomics/genetics — recurrent ADRs across multiple classes (rare)

— Psychiatry — for safe benzo or antipsychotic deprescribing in patients with primary psychiatric disease

— Hospital discharge: schedule follow-up within 7–14 days

— SNF transfer: send updated med list with indication for every drug

— New prescriber added (e.g., post-op specialist): primary care must reconcile within 30 days

— Repeated ADE-related ED visits → trigger MTM enrollment, home health, possibly capacity assessment

CCS pearl: "Consult clinical pharmacy / medication therapy management" is a frequently correct CCS order for elderly outpatients with ≥8 meds and recent ADE — cheap, evidence-based, and often the highest-yield action.

Escalate to inpatient / ED:

Outpatient consults to consider:

Care transitions — high-risk windows:

Red flag for system-level escalation:

Key Differentials — Same-Category Causes of "Confusion in an Elder"

— Anticholinergic delirium: diphenhydramine (Benadryl, "PM" formulations, sleep aids), oxybutynin, TCAs, scopolamine patch, hyoscyamine. Onset within days of starting; dry mouth, mydriasis, urinary retention

— Sedative-induced: benzos, Z-drugs, opioids, gabapentinoids; somnolence, ataxia

— Cardiovascular: beta-blocker bradycardia → cerebral hypoperfusion; digoxin toxicity → visual changes + confusion

— Hyponatremia-mediated: SSRIs (sertraline, citalopram especially), thiazides, carbamazepine, oxcarbazepine — check Na in any confused elder on these

— Hypoglycemia-mediated: sulfonylureas (glyburide worst), insulin — fingerstick is mandatory

— Steroid psychosis: prednisone ≥20 mg/day

— Antibiotic neurotoxicity: fluoroquinolones, cefepime (especially in CKD), metronidazole prolonged courses

— Lithium toxicity: narrow window, often precipitated by added NSAID or ACEi

— Withdrawal states: abrupt benzo or alcohol cessation → delirium tremens

— Onset relative to medication change: within 1–7 days → strong drug link

— Pupillary findings: dilated (anticholinergic), pinpoint (opioid)

— Vitals: bradycardia (BB, CCB, digoxin), tachycardia (anticholinergic, withdrawal)

— Skin: dry/flushed (anticholinergic) vs diaphoretic (serotonin syndrome, withdrawal)

— Benzo withdrawal can present 1–7 days after stopping a long-acting agent — easy to miss

— Opioid withdrawal: GI symptoms, myalgia, mydriasis, yawning

Board pearl: "Confusion + dry mouth + urinary retention + tachycardia + mydriasis" in an elder = anticholinergic toxicity; reverse the offending med (often diphenhydramine in OTC sleep aid). Physostigmine is rarely the answer on Step 3 — deprescribing and supportive care is.

Within drug-related causes — which drug? Approach systematically by class:

Differentiating clues:

Withdrawal differentials:

Key Differentials — Non-Drug Causes That Must Not Be Missed

— Infection: UTI, pneumonia, cellulitis, bacteremia → CBC, UA, CXR, blood cultures; classic afebrile delirium presentation in elders

— Metabolic: hyponatremia (could be drug or SIADH from other cause), hypercalcemia (malignancy, primary HPT), uremia, hepatic encephalopathy, hypothyroidism, hyperthyroidism (apathetic in elderly)

— Cardiovascular: silent MI (often presents as confusion or weakness in elders, not chest pain), CHF exacerbation, arrhythmia

— Neurologic: stroke (TIA), subdural hematoma (especially on anticoagulant — falls risk!), seizure, normal-pressure hydrocephalus, neurodegenerative disease progression

— Hypoxia/hypercarbia: PE, COPD exacerbation

— Delirium: acute onset, fluctuating, inattention → CAM positive; reversible

— Dementia: chronic, progressive, attention preserved early; not reversible

— Depression: insidious, complains of memory loss (in dementia, family complains)

— CBC, BMP, Ca, Mg, Phos, LFTs, TSH, B12, UA, CXR, ECG, fingerstick glucose

— Medication review in parallel — don't choose one over the other

— CT head if focal deficit, anticoagulant, fall, or no clear cause

— LP if febrile and meningeal signs (rare clear signs in elderly)

— Cardiac (orthostatic vitals, ECG), neuro, MSK, vision/hearing

— Plus medication review

Key distinction: Drug effects and medical illness coexist in elders — finding a UTI does not absolve the medication list of contribution. Always document review of both axes; Step 3 vignettes love the "both are right" framing.

Even when polypharmacy is suspected, you must exclude:

Dementia vs delirium vs depression ("3 Ds"):

Workup minimum in acutely confused elder:

Fall workup parallels — same dual approach:

Secondary Prevention and Long-Term Plan After Deprescribing

— Update problem list and med list at every visit; mark deprescribed drugs with reason ("avoid — fall risk")

— Communicate changes to all prescribers and the pharmacy — closed-loop communication prevents reinstatement

— Educate patient/family: explicit "do not restart unless I review" instruction

— Document indication for every remaining drug — durable for downstream providers

— Statin for established ASCVD regardless of age (secondary prevention)

— ACEi/ARB post-MI, HFrEF, diabetic nephropathy

— Anticoagulant for AF with CHA₂DS₂-VASc ≥2 (DOAC preferred over warfarin in most)

— Bisphosphonate + Ca/vitamin D for osteoporosis (T-score ≤−2.5, prior fragility fracture, or chronic steroid)

— Vaccines: influenza annually, COVID per CDC, PCV20 or PCV15+PPSV23, RSV (≥75 or 60–74 with risk factors via shared decision), shingles (Shingrix ≥50), Tdap

— Aspirin for secondary prevention (not primary in ≥60)

— Exercise (resistance + balance — Tai Chi reduces falls)

— Vitamin D 800 IU if deficient (USPSTF: insufficient evidence for routine supplementation in community-dwelling to prevent falls/fractures, but reasonable if deficient)

— Home safety evaluation (PT/OT referral)

— Sleep hygiene, CBT-I for insomnia rather than restarting hypnotic

— Annual at minimum; after every hospitalization; with each new prescriber; with significant clinical change (new dx, weight loss, falls, cognitive change)

Board pearl: Deprescribing is not "doing nothing" — it is an active, billable, evidence-based intervention. Pair every stopped drug with a positive prescription: exercise, CBT-I, behavioral therapy, or a safer agent.

After successful deprescribing — sustain the gains:

START side — appropriately prescribing what is missing (STOPP/START):

Lifestyle and non-pharm reinforcement:

Long-term medication review cadence:

Follow-Up, Monitoring Parameters, and Counseling

— 1–2 weeks: after stopping a benzo, antipsychotic, or antihypertensive — assess withdrawal, rebound symptoms, BP, falls

— 2–4 weeks: after PPI taper — reflux symptoms; after anticholinergic stop — cognitive reassessment

— 3 months: A1c after deintensifying diabetes regimen

— 6 months: bone density if bisphosphonate stopped (drug holiday)

— Warfarin: INR weekly when initiating/changing, then monthly; TTR target >70%

— DOACs: annual CBC, BMP, LFTs; reassess dose with weight or renal changes

— Diuretics: BMP within 1–2 weeks of start/change; annually thereafter

— ACEi/ARB: Cr and K within 1–2 weeks; tolerate Cr rise up to 30% if K acceptable

— Statins: baseline LFTs; routine ALT monitoring not required; CK only if symptoms

— Lithium: level + Cr + TSH every 6 months

— Digoxin: trough level after dose change, annually; recheck with any AKI or new drug

— Antipsychotics: A1c, lipids, weight every 6 months; AIMS for tardive dyskinesia annually

— Brown-bag review at every annual visit

— Pillbox or blister-pack adherence aids

— Single pharmacy use — flags interactions

— Avoid OTCs containing diphenhydramine ("PM," ZzzQuil), pseudoephedrine, NSAIDs

— Driving safety: any new sedating med = re-evaluate fitness; ophthalmology annually

— Falls bundle: home safety, vision check, footwear, vitamin D if deficient, PT

— Signs of overmedication, when to call, after-hours triage

— Advance care planning re-discussed annually

Step 3 management: After stopping a benzodiazepine, schedule the follow-up visit at 2 weeks, not 3 months — withdrawal and rebound insomnia peak in the first 1–2 weeks and predict relapse if unaddressed.

Follow-up cadence after deprescribing:

Monitoring parameters by drug:

Counseling content:

Caregiver education:

Ethical, Legal, and Patient Safety Considerations

— Patients have the right to refuse deprescribing; conversely, continuing a drug without ongoing assessment of benefit is paternalistic and risky

— Use shared decision-making, document goals of care

— For patients lacking capacity, involve healthcare proxy / surrogate per state hierarchy; default to substituted judgment, then best interests

— Decision-specific (not global); requires the patient to understand, appreciate, reason, and express a choice

— Mild dementia does not equal incapacity for medication decisions

— Formal capacity assessment by psychiatry only when contested or complex

— Medication reconciliation errors occur in >50% of hospital admissions and discharges

— Required by Joint Commission National Patient Safety Goal 03.06.01

— Discharge summary must include: med list with changes highlighted, reason for each change, follow-up plan, who is responsible

— Post-discharge phone call within 48–72 hours reduces readmissions

— Elder abuse / neglect: suspected medication mismanagement by caregiver (under- or over-dosing, theft of opioids) is reportable to Adult Protective Services in all US states

— Driving impairment from new sedating med: state-specific reporting laws (some mandatory, some permissive — know your state); document discussion

— Controlled substance diversion: check state PDMP before every opioid/benzo refill

— Low health literacy, limited English proficiency, and cost (Part D donut hole, formulary gaps) drive non-adherence and ADEs — assess and address

— Use teach-back: have patient explain back the regimen

— HEDIS: Use of High-Risk Medications in Older Adults (DAE); Potentially Harmful Drug-Disease Interactions

— CMS Star Ratings link adherence and high-risk meds to plan reimbursement

Board pearl: A discharge summary that lists "continue home meds" without specifying what those are is a patient safety event. Step 3 frequently tests this — the correct answer is to perform a formal med reconciliation and provide a written, indication-labeled list to the patient and PCP.

Informed consent for deprescribing:

Capacity assessment:

Transitions of care — the highest-risk patient safety zone:

Mandatory reporting and special situations:

Health equity:

Quality measures:

High-Yield Associations and Rapid-Fire Clinical Facts

— Diphenhydramine and 1st-gen antihistamines

— Alpha-1 blockers as first-line HTN

— NSAIDs chronic

— Glyburide (long-acting SU)

— Estrogen oral

— Relaxants (skeletal muscle)

— Sedative-hypnotics (benzos, Z-drugs), Sliding-scale insulin alone, Scolpolamine

— Warfarin, antiplatelets, insulin, oral hypoglycemics (especially sulfonylureas)

— Donepezil → urinary urgency → oxybutynin → confusion

— Amlodipine → edema → furosemide → falls, hypoK, dehydration

— NSAID → HTN → antihypertensive added

— Metoclopramide → parkinsonism → carbidopa-levodopa

— Antipsychotic → constipation → laxative

— Thiazide → hyperuricemia → allopurinol

— Score 3+ on ACB → ↑ dementia risk; common offenders: oxybutynin, paroxetine, diphenhydramine, amitriptyline, hydroxyzine

— NSAID + HF/CKD; anticholinergic + dementia/BPH; benzo + falls/OSA; PPI + osteoporosis (chronic)

— ~50% of elderly take ≥1 PIM

— Each additional drug increases ADE risk by ~10–15%

— Falls cost: ~$50 billion/year in US

— Beers updated ~every 3 years (latest 2023)

— Glyburide → glipizide or DPP-4i

— Oxybutynin → mirabegron

— Diphenhydramine → cetirizine/loratadine; sleep: CBT-I

— Amitriptyline → duloxetine or nortriptyline

— Diazepam → taper off; for anxiety, SSRI + CBT

— PPI long-term → H2 blocker or stop

Key distinction: Beers ≠ contraindicated. Beers drugs are potentially inappropriate — clinical judgment, indication, and alternatives matter. The phrase "absolutely contraindicated" in a Step 3 answer is usually wrong.

Beers "always avoid" mnemonic (memorize for rapid recall):

Top 4 drugs causing ADE hospitalizations in elderly (CDC data):

Prescribing cascades — recognize on sight:

Anticholinergic burden quick check:

Drug-disease pitfalls:

Numbers worth knowing:

Switches you should reflexively know:

Board Question Stem Patterns

"An 82-year-old woman presents after a fall. Medications include lorazepam 0.5 mg QHS, amlodipine, metoprolol, glyburide, diphenhydramine PRN sleep, omeprazole, calcium, vitamin D. BP 118/72 supine, 98/60 standing. What is the next best step?"

→ Discontinue lorazepam and diphenhydramine; reassess in 2 weeks. Not CT head as first answer unless focal findings.

"78M with Alzheimer dementia started on donepezil 6 weeks ago. New urge incontinence; oxybutynin added. Now confused. Best next step?"

→ Stop oxybutynin (prescribing cascade); behavioral therapy or mirabegron if needed.

"85F with T2DM, A1c 6.4%, on glyburide and basal insulin, found unresponsive with FSG 38. After dextrose, next step?"

→ Stop glyburide, deintensify regimen, target A1c 7.5–8%.

"Postop hip fracture day 2, agitated; nurse requests order. Patient on scheduled diphenhydramine for sleep, oxycodone PRN, plus home oxybutynin."

→ Discontinue diphenhydramine and oxybutynin, treat pain with scheduled acetaminophen + reduced opioid, non-pharm delirium measures. Not haloperidol first-line.

"84M with metastatic pancreatic cancer enrolled in hospice, on atorvastatin for primary prevention."

→ Discontinue statin.

"Discharged 80F readmitted in 5 days with hyperkalemia. Discharge meds added spironolactone; outpatient list also has lisinopril, which was unchanged."

→ Medication reconciliation failure; teaching point is to compare all three lists at discharge.

"Nursing home resident with Alzheimer dementia, started on risperidone 3 months ago for agitation, now stable."

→ Attempt gradual dose reduction (CMS requirement) unless documented contraindication.

Step 3 management: The right answer almost always subtracts a drug rather than adds one. When in doubt between "start X" and "stop Y," choose stop.

Stem 1 — The fall:

Stem 2 — The cascade:

Stem 3 — Hypoglycemia:

Stem 4 — Delirium in hospital:

Stem 5 — Statin in advanced illness:

Stem 6 — Transitions:

Stem 7 — Antipsychotic in dementia:

One-Line Recap

In any older adult with a new geriatric syndrome — falls, delirium, incontinence, weight loss, hyponatremia, or functional decline — review the medication list first, deprescribe using AGS Beers and STOPP/START as your map, and substitute safer alternatives or non-pharmacologic care before adding new therapy.

Board pearl: When the Step 3 vignette opens with a long medication list, the highest-yield intervention is almost never another drug — it is a brown-bag review, a Beers cross-check, and a thoughtful subtraction.

The five-step move: Reconcile → assess anticholinergic/sedative/PIM burden → prioritize (no indication, duplication, cascade, low time-to-benefit) → taper drug-specifically → follow up at 1–4 weeks.

Four swaps to memorize: glyburide → glipizide/DPP-4i; oxybutynin → mirabegron/behavioral; diphenhydramine → loratadine/CBT-I; chronic benzo → slow taper + SSRI/CBT.

Four ADE drivers in elders: warfarin, antiplatelets, insulin, sulfonylureas — these are the ED visits you can prevent at the desk.

Three transitions where medication errors peak: hospital admission, hospital discharge, and any new prescriber — reconcile at each, with a 7–14 day post-discharge visit and indication documented for every remaining drug.

One ethical principle: deprescribing is an active, evidence-based, billable intervention requiring shared decision-making and clear communication to patient, family, pharmacy, and all prescribers — and in patients with limited life expectancy or advanced dementia, choosing to stop a preventive medication (statin, bisphosphonate, intensive glycemic agent) is not nihilism but good geriatric medicine that maximizes quality of remaining life while minimizing iatrogenic harm.