Polypharmacy and Deprescribing

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Target exams

Red flags

• Any new symptom in an older patient on multiple medications is an adverse drug reaction until proven otherwise — always do a medication review before adding a new drug
• A normal serum creatinine in a frail older adult does NOT mean normal renal function — muscle mass is low, so creatinine underestimates renal impairment; estimate GFR and dose renally-cleared drugs accordingly
• The prescribing cascade — metoclopramide causing drug-induced parkinsonism treated with levodopa, or a diuretic causing gout treated with allopurinol — adds drugs to treat side effects; suspect it whenever a new drug is started for a symptom that could be an adverse effect
• Benzodiazepines, anticholinergics and antipsychotics are independently associated with falls and cognitive impairment in older adults and are on every list of potentially inappropriate medications
• Warfarin, insulin, opioids and digoxin account for a disproportionate share of drug-related hospital admissions — they require dose individualisation, monitoring and frequent review in the elderly
• A patient admitted on 15 medications and discharged on 16 has been failed by the system — every hospital admission is a mandatory medication reconciliation and deprescribing opportunity