Polypharmacy and deprescribing — KFP-style written assessment

KFP 1 (10 marks)

An 84-year-old woman attends with her daughter. Her repeat list includes amlodipine 10 mg daily, furosemide 40 mg daily (started six months ago for ankle swelling), metoclopramide 10 mg three times daily (started after a gastric virus), oxybutynin for urgency, temazepam 15 mg at night for two years, omeprazole 20 mg daily for four years without documented indication, plus analgesics. She has fallen twice this month. ^[4][8]

1. Identify TWO prescribing cascades on her list and name the correct resolution for each. (4) ^[4]
2. List THREE medicines here that are Beers/STOPP-flagged for older adults and the harm each carries. (3) ^[8]
3. She asks why so many tablets. Frame your opening deprescribing sentence using patient-centred language. (3) ^[2]

Model answers

1. Cascade one: amlodipine → ankle oedema → furosemide ("fluid overload"); resolution is reduce or switch the calcium channel blocker rather than treat vasodilatory oedema as heart failure. Cascade two: metoclopramide → drug-induced parkinsonian symptoms risk; resolution is stop metoclopramide rather than add anticholinergics or levodopa. Both furosemide (aSHR 2.98 for injurious falls) and anticholinergic oxybutynin compound her falls. ^[4]
2. Temazepam (Beers: older adults avoid — falls, cognitive impairment, crashes); oxybutynin (strong anticholinergic — confusion, urinary retention, cumulative burden associated with mortality); metoclopramide beyond short course (extrapyramidal effects); long-term undocumented PPI also qualifies under STOPP-style review. Any three with harms stated score. ^[8]
3. "Your body changes how it handles medicines over time, and some of these may now be doing more harm than good. I'd like to test stopping things carefully, one at a time, with a plan — not take away anything you actually need." Reeve's framework centres the patient through every step: history → identify candidates → decide together → taper plan → monitor/support/document. ^[2]