Polypharmacy in Older Adults: Practical Applications Alongside a Patient Case

Published:January 05, 2020DOI:https://doi.org/10.1016/j.nurpra.2019.11.017

      Highlights

      • Polypharmacy is a prevalent concern among adults who may be taking a combination of medications.
      • This may result in various medication-related problems such as adverse effects, drug interactions, inappropriate therapy, or nonadherence.
      • It is important for health practitioners to be cognizant of the tools and methods to manage polypharmacy-related issues to optimize patient outcomes.

      Abstract

      Polypharmacy is a common observation among older adults secondary to their complex medical needs requiring management with 1 or more medications. The use of numerous medications may result in medication-related problems such as inappropriate indications, therapeutic duplication, adverse effects, drug interactions, unnecessary medications, poor adherence, and a strain on health care resources. Nurse practitioners will be required to review and streamline the appropriate and safe use of medications in patients to minimize some of the highlighted concerns. This article uses a case-based approach to showcase various issues that a nurse practitioner may encounter as it relates to polypharmacy and pharmacotherapeutic considerations. Tools are also explored to assess polypharmacy in the field.

      Keywords

      American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hours (including 1.0 hour of pharmacology credit), approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.
      Polypharmacy is a common health concern among older adults. Previous literature has reported an average rate of 40% to 50% in this population.
      • Morin L.
      • Johnell K.
      • Laroche M.L.
      • Fastbom J.
      • Wastesson J.W.
      The epidemiology of polypharmacy in older adults: register-based prospective cohort study.
      ,
      • Woodruff K.
      Preventing polypharmacy in older adults.
      Polypharmacy refers to the use of multiple medications in a patient, commonly an older adult. Interestingly, there is a lack of a standard definition for such a term.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      ,
      • Masnoon N.
      • Shakib S.
      • Kalisch-Ellett L.
      • Caughey G.E.
      What is polypharmacy? A systematic review of definitions.
      Polypharmacy has been described as the co-prescribing of multiple medications, the inappropriate use of medication(s), using medications without a clinical indication, visiting multiple pharmacies, and the use of 5 or more medications, and the list goes on.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      ,
      • Masnoon N.
      • Shakib S.
      • Kalisch-Ellett L.
      • Caughey G.E.
      What is polypharmacy? A systematic review of definitions.
      There is also literature that further delineates the degree, duration, and various settings of polypharmacy.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      ,
      • Masnoon N.
      • Shakib S.
      • Kalisch-Ellett L.
      • Caughey G.E.
      What is polypharmacy? A systematic review of definitions.
      Age, ethnicity, health status, education, and access to pharmacy are examples of varying risk factors associated with this medication-related concern.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      Regardless of the scenario, polypharmacy negatively affects patient care by potentially increasing health care costs and the risk of drug-related issues. Examples of such issues include nonadherence, therapeutic duplication, unnecessary drug exposure, adverse drug events, and drug interactions.
      • Maher R.L.
      • Hanlon J.T.
      • Hajjar E.R.
      Clinical consequences of polypharmacy in elderly.
      ,
      • Hilmer S.N.
      • Gnjidic D.
      The effects of polypharmacy in older adults.
      In fact, a study conducted by Abe et al
      • Abe T.
      • Tamiya N.
      • Kitahara T.
      • Tokuda Y.
      Polypharmacy as a risk factor for hospital admission among ambulance-transported old-old patients.
      concluded that polypharmacy resulting in symptomatic adverse drug events was a preventable risk factor for hospital admission among older adults.
      The following is a case-based approach to evaluating potentially inappropriate medication (PIM) use secondary to polypharmacy and addressing various pharmacotherapeutic considerations. This includes a discussion on the advantages and disadvantages of the therapies at hand based on the patient-related effects of the medications, safety concerns, drug interactions, and clinical practice guideline recommendations. Assessment tools used in the setting of polypharmacy are also explored.

      Patient Case

      A 74-year-old obese African American female (height = 5’6” and weight = 90 kg) has a past medical history of chronic kidney disease (CKD) stage 2, glaucoma, heart failure with reduced ejection fraction (HFrEF), hyperlipidemia, hypertension (HTN), osteoarthritis, and type 2 diabetes mellitus (T2DM). The patient also occasionally complains of constipation, heartburn, and insomnia for which she takes medications as needed. She has no known drug allergies. Based on the latest medication profile, the patient is receiving the medications listed in Table 1.
      Table 1A List of Medications the Patient Is Currently Taking for Each Health Problem
      Health ProblemMedication NameInstructions
      ConstipationDocusate100 mg by mouth 3 times daily as needed
      GlaucomaTimolol (ophthalmic)1 drop in both eyes twice daily
      HeartburnFamotidine20 mg by mouth twice daily
      Calcium carbonate antacid1 tablet as needed
      HFrEF/HTNCarvedilol12.5 mg by mouth twice daily
      Furosemide40 mg by mouth daily
      HLDAtorvastatin20 mg by mouth daily
      InsomniaZolpidem10 mg by mouth at bedtime as needed
      T2DMMetformin500 mg by mouth twice daily
      OsteoarthritisAcetaminophen500 mg by mouth 4 times daily as needed
      Ibuprofen200 mg by mouth 4 times daily as needed
      HFrEF = heart failure with reduced ejection fraction; HLD = hyperlipidemia; HTN = hypertension; T2DM = type 2 diabetes mellitus.
      The following relevant vital signs and laboratory data are provided:
      • Vital signs: blood pressure = 150/85 mmHg and heart rate = 78 beats/min
      • Renal function and electrolytes: serum creatinine = 1 mg/dL, blood urea nitrogen = 15 mg/dL, urinary albumin-to-creatinine ratio ≥ 300 mg/g, estimated glomerular filtration rate (eGFR) = 64 mL/min/1.73 m2, and serum potassium = 3.5 mEq/L
      • Lipid panel: total cholesterol = 245 mg/dL, high-density lipoprotein = 55 mg/dL, low-density lipoprotein = 190 mg/dL, and triglycerides = 150 mg/dL
      • Liver enzyme tests: aspartate aminotransferase = 32 IU/L and alanine aminotransferase = 35 IU/L
      A list of PIMs as it pertains to the patient case is described in Table 2
      • Maenpaa J.
      • Pelkonen O.
      Cardiac safety of ophthalmic timolol.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Wong E.
      Metformin: its history, safety and updated labelling recommendations.
      • DeFronzo R.
      • Fleming G.A.
      • Chen K.
      • Bicsak T.A.
      Metformin-associated lactic acidosis: Current perspectives on causes and risk.
      U.S. Food and Drug Administration
      FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR [5-14-2013].
      • Grundy S.M.
      • Stone N.J.
      • Bailey A.L.
      • et al.
      2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      NKF and NSAID Alliance declares NSAID awareness week.
      • Marcum Z.A.
      • Hanlon J.T.
      Recognizing the risks of chronic nonsteroidal anti-inflammatory drug use in older adults.
      • Hurdon V.
      • Viola R.
      • Schroder C.
      How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      alongside a description of the pharmacotherapeutic concerns and recommendations.
      Table 2Case-Based Analysis of Potentially Inappropriate Medications (PIMs)
      • Maenpaa J.
      • Pelkonen O.
      Cardiac safety of ophthalmic timolol.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Wong E.
      Metformin: its history, safety and updated labelling recommendations.
      • DeFronzo R.
      • Fleming G.A.
      • Chen K.
      • Bicsak T.A.
      Metformin-associated lactic acidosis: Current perspectives on causes and risk.
      U.S. Food and Drug Administration
      FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR [5-14-2013].
      • Grundy S.M.
      • Stone N.J.
      • Bailey A.L.
      • et al.
      2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      NKF and NSAID Alliance declares NSAID awareness week.
      • Marcum Z.A.
      • Hanlon J.T.
      Recognizing the risks of chronic nonsteroidal anti-inflammatory drug use in older adults.
      • Hurdon V.
      • Viola R.
      • Schroder C.
      How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      PIMsDescriptionManagement Strategies
      Timolol, carvedilol
      • Both agents are beta blockers.

        Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Timolol and carvedilol are used for ophthalmic and systemic indications, respectively.
      • The combined use may result in additive cardiovascular effects (eg, bradycardia and hypotension).
        • Maenpaa J.
        • Pelkonen O.
        Cardiac safety of ophthalmic timolol.
        ,

        Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Beta blockers may also mask the signs and symptoms of hypoglycemia in patients with diabetes.

        Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Increased monitoring for the cardiovascular and glycemic effects are advised.

        Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Metformin
      • Metformin is renally eliminated.

        Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      • Patients with CKD and unstable heart failure may be at an increased risk of adverse effects such as lactic acidosis.
        • Wong E.
        Metformin: its history, safety and updated labelling recommendations.
        ,
        • DeFronzo R.
        • Fleming G.A.
        • Chen K.
        • Bicsak T.A.
        Metformin-associated lactic acidosis: Current perspectives on causes and risk.
      Zolpidem
      Atorvastatin
      • Atorvastatin 10-20 mg daily is a moderate intensity statin dose.
      • There are several high-risk conditions (LDL = 190 mg/dL, T2DM, HTN, age ≥ 65 years, and HF) for future atherosclerotic cardiovascular disease events in this patient for which the patient may benefit from a high-intensity statin.
        • Grundy S.M.
        • Stone N.J.
        • Bailey A.L.
        • et al.
        2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
        American Diabetes Association
        Standards of medical care in diabetes–2019.
      • Evaluate the risk versus benefit of high-intensity statin dosing (atorvastatin 40-80 mg daily).
        • Whelton P.K.
        • Carey R.M.
        • Aronow W.S.
        • et al.
        2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
        ,
        American Diabetes Association
        Standards of medical care in diabetes–2019.
      Ibuprofen
      Docusate
      CKD = chronic kidney disease; HF = heart failure; HTN = hypertension; LDL = low-density lipoprotein; NSAID = nonsteroidal anti-inflammatory drug; T2DM = type 2 diabetes mellitus.

      Discussion

      Despite the varying definitions, polypharmacy is a term generally associated with patients who are taking multiple medications.
      • Morin L.
      • Johnell K.
      • Laroche M.L.
      • Fastbom J.
      • Wastesson J.W.
      The epidemiology of polypharmacy in older adults: register-based prospective cohort study.
      • Woodruff K.
      Preventing polypharmacy in older adults.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      • Masnoon N.
      • Shakib S.
      • Kalisch-Ellett L.
      • Caughey G.E.
      What is polypharmacy? A systematic review of definitions.
      Older patients with multiple comorbidities often require management with more than one medication, inherently increasing the risk of polypharmacy and the negative outcomes previously identified. Beyond prescription products, over-the-counter medications and dietary supplements can contribute to this complex health matter.
      • Steinman M.A.
      Polypharmacy-time to get beyond numbers.
      ,
      • Francis S.A.
      • Barnett N.
      • Denham M.
      Switching of prescription drugs to over-the-counter status: is it a good thing for the elderly?.
      The medication management process in the older population is multifaceted with considerations for drug dosing, drug interactions, adverse effects, adherence, social issues, clinical practice guidelines, and altered physiology, among other factors.
      There are various tools described in the literature that may be used as a guide to identifying and assessing patients for polypharmacy-related issues.
      American Geriatrics Society
      American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults.
      • Budnitz D.S.
      • Lovegrove M.C.
      • Shehab N.
      • et al.
      Emergency hospitalizations for adverse drug events in older Americans.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      • Kuhn-Thiel A.M.
      • Weiβ
      • Wehling M.
      Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly.
      • Michalek C.
      • Wehling M.
      • Schlitzer J.
      • Frohnhofen H.
      Effects of "Fit fOR The Aged" (FORTA) on pharmacotherapy and clinical endpoints—a pilot randomized controlled study.
      • Wehling M.
      • Burkhardt H.
      • Kuhn-Thiel A.
      • et al.
      VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification.
      • Pazan F.
      • Weiss C.
      • Wehling M.
      • et al.
      The EUROFORTA (Fit fOR The Aged) list: international consensus validation of a clinical tool for improved drug treatment in older people.
      • Garfinkel D.
      • Zur-Gil S.
      • Ben-Israel J.
      The war against Polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.
      • Hanlon J.T.
      • Samsa G.P.
      • Weinberger M.
      • Uttech K.M.
      • Lewis I.K.
      • Feussner J.R.
      A method for assessing drug therapy appropriateness.
      • Scott I.A.
      • Gray L.C.
      • Martin J.H.
      • Mitchell C.A.
      Minimizing inappropriate medications in older populations: a 10-step conceptual framework.
      • Vogt-Ferrier N.
      Reviewing a complicated geriatric drug regimen.
      • Hoskins B.L.
      Safe prescribing for the elderly.
      • Lee R.D.
      Polypharmacy: a case report and new protocol for management.
      One of the most commonly used tools is the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
      American Geriatrics Society
      American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults.
      The Beers Criteria consists of 5 categories of medications to be avoided or used with caution in older adults: medications that are potentially inappropriate, medications that are potentially inappropriate with certain conditions, medications that should be used with caution, potentially clinically important drug-drug interactions that should be avoided, and medications that should be avoided or have their dosage reduced with varying levels of kidney function.
      • Scott I.A.
      • Gray L.C.
      • Martin J.H.
      • Mitchell C.A.
      Minimizing inappropriate medications in older populations: a 10-step conceptual framework.
      The list is based on various trials and expert opinions and consists of 88 drug/drug classes. When examining the impact of adverse drug events on hospitalizations in older adults, 6.6% of adverse drug-related hospitalizations were caused by medications on the Beers Criteria.
      • Budnitz D.S.
      • Lovegrove M.C.
      • Shehab N.
      • et al.
      Emergency hospitalizations for adverse drug events in older Americans.
      Limitations to the Beers Criteria include that it does not provide information on underprescribed medications and alternative medications.
      Unlike the Beers Criteria, the STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatments) criteria provide guidance on inappropriate medications as well as medications that are underprescribed.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      ,
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      The STOPP/START includes 80 different criteria for stopping and 34 different criteria for starting medications. The STOPP/START criteria are organized by organ system (eg, cardiovascular and central nervous system), adverse events (eg, medication that increases risk of falls and antimuscarinic/anticholinergic), and other drug classes (eg, vaccines and analgesics). When comparing the Beers Criteria with the STOPP/START criteria in older hospitalized patients, the STOPP criteria identified more PIMs.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      ,
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      Additionally, a greater proportion of those PIMs identified with the STOPP/START criteria were associated with an adverse drug event.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      ,
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      The STOPP/START criteria does not suggest alternative medications or provide renal dosing adjustments.
      The FORTA (Fit fOR The Aged) classification, which was initially developed in Germany, is another tool that can be used to screen for PIMs.
      • Kuhn-Thiel A.M.
      • Weiβ
      • Wehling M.
      Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly.
      • Michalek C.
      • Wehling M.
      • Schlitzer J.
      • Frohnhofen H.
      Effects of "Fit fOR The Aged" (FORTA) on pharmacotherapy and clinical endpoints—a pilot randomized controlled study.
      • Wehling M.
      • Burkhardt H.
      • Kuhn-Thiel A.
      • et al.
      VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification.
      • Pazan F.
      • Weiss C.
      • Wehling M.
      • et al.
      The EUROFORTA (Fit fOR The Aged) list: international consensus validation of a clinical tool for improved drug treatment in older people.
      • Garfinkel D.
      • Zur-Gil S.
      • Ben-Israel J.
      The war against Polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.
      Like the STOPP/START criteria, the FORTA classification includes both recommendations for PIMs and underused medications and is categorized by disease state. All drugs/drug classes are ranked from a scale of A through D with A as indispensable, B as beneficial, C as questionable, and D as avoid. Wehling et al
      • Wehling M.
      • Burkhardt H.
      • Kuhn-Thiel A.
      • et al.
      VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification.
      showed that the use of the FORTA criteria resulted in significant improvements in over/undertreatment, adverse drug reaction, and activities of daily living in hospitalized patients. The FORTA has further expanded to include geriatric/pharmacologic expertise from other European countries to become the EURO-FORTA criteria. The EURO-FORTA list includes 264 drugs/drug classes and 26 diagnoses.
      • Pazan F.
      • Weiss C.
      • Wehling M.
      • et al.
      The EUROFORTA (Fit fOR The Aged) list: international consensus validation of a clinical tool for improved drug treatment in older people.
      Limitations of the FORTA list include limited rationale for recommendations and no information on drug-drug interactions, drug-disease interactions, and renal dosing adjustments.
      Although more drug-specific tools are available, they all have strengths and limitations to their use. The combinations of these tools may be able to circumvent some of these limitations. Various drug interaction tools (eg, Lexicomp Online

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      and IBM Micromedex
      IBM Micromedex Healthcare Series [internet database]. Greenwood Village, CO: Thomson Healthcare. Update periodically.
      ) can also be used to help the busy clinicians identify interactions with therapy. Many of these tools will incorporate information from the Beers Criteria and STOPP/START criteria into their recommendations. Continued advancements in technology will improve the practical implementation of these tools into clinical practice and are currently being studied and developed.
      Although these tools (eg, Beers Criteria, STOPP/START, and FORTA) are useful and provide detailed drug information, they must be used in conjunction with good clinical judgment. Compared with the aforementioned tools that provide guidance on specific medications to avoid, underprescribed medications, dosing adjustments, and drug interactions, there are clinical decision algorithms or questionnaires that can be used. Many of these algorithms or questionnaires require more judgment because they do not provide any drug-specific information. Some examples of these include The Good Palliative-Geriatric Practice Algorithm,
      • Garfinkel D.
      • Zur-Gil S.
      • Ben-Israel J.
      The war against Polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.
      Medication Appropriateness Index,
      • Hanlon J.T.
      • Samsa G.P.
      • Weinberger M.
      • Uttech K.M.
      • Lewis I.K.
      • Feussner J.R.
      A method for assessing drug therapy appropriateness.
      and the 10-step drug minimization guide.
      • Scott I.A.
      • Gray L.C.
      • Martin J.H.
      • Mitchell C.A.
      Minimizing inappropriate medications in older populations: a 10-step conceptual framework.
      Based on the medication profile, the patient has several comorbidities for which she is taking a total of 11 different medications, 7 routine medications for the management of chronic health conditions, and 4 medications as needed for other ailments. The combination of these medications warrants further evaluation to ensure safe, continued use. For instance, some medications are indicated and appropriate for the management of chronic medical conditions, but their continued use may require increased monitoring. Some medication regimens may need dosing adjustments because of patient-specific characteristics and physiologic changes observed in older adults. There may also be a need to deprescribe and prescribe other medications because of current literature and practice guidelines to optimize patient outcomes. As such, it is essential for the nurse practitioner (NP) to systematically evaluate every aspect of the pharmacotherapy used in patients to avoid polypharmacy and its negative consequences.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      Examples of detection, assessment, and management strategies for medication-related issues (increased monitoring, Beers Criteria, deprescribing, and clinical practice guidelines) as they apply to the patient case are as follows.

      Examples of Increased Monitoring

      Beta Blockers: Timolol and Carvedilol

      The coadministration of ophthalmic timolol and oral carvedilol results in a potential drug-drug interaction.
      • Maenpaa J.
      • Pelkonen O.
      Cardiac safety of ophthalmic timolol.
      ,

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Ophthalmic timolol is a commonly prescribed beta blocker used for glaucoma that is associated with local effects of the eye (eg, burning, itching, dryness, or visual disturbances).

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Despite its topical administration, ophthalmic timolol is absorbed into the systemic circulation and may result in serious cardiac effects (eg, bradyarrhythmias, hypotension, and heart block).
      • Maenpaa J.
      • Pelkonen O.
      Cardiac safety of ophthalmic timolol.
      These effects may be amplified when coadministered with other medications and increase the risk of falls and syncope.
      • Maenpaa J.
      • Pelkonen O.
      Cardiac safety of ophthalmic timolol.
      ,

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      In this case, the patient is receiving oral carvedilol for the management of HTN and HFrEF; however, she still has an elevated blood pressure and normal heart rate while on the combined regimen. Prospectively, it is advised that the patient be monitored for the additive adverse effects of these products with parameters such as heart rate and blood pressure.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Additional therapy for the management of blood pressure will be discussed within the clinical practice guidelines section.
      Beta blockers also have the potential to affect glucose levels. In patients with diabetes, it may mask the signs and symptoms of this adverse effect.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Although it is not a contraindication to use this drug class in our patient who is receiving carvedilol and has T2DM, additional monitoring is warranted to ensure that the targeted glycemic goals are achieved safely. The patient should also be educated on the management of hypoglycemia as delineated by the American Diabetes Association.
      American Diabetes Association
      Standards of medical care in diabetes–2019.

      Metformin

      Metformin is an oral blood glucose–lowering agent that is renally eliminated.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Renal impairment and unstable heart failure are notable risk factors for metformin-induced lactic acidosis.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      ,
      • DeFronzo R.
      • Fleming G.A.
      • Chen K.
      • Bicsak T.A.
      Metformin-associated lactic acidosis: Current perspectives on causes and risk.
      In a patient who is older, has kidney disease, has otherwise stable heart failure, and is simultaneously receiving metformin, the NP should monitor for signs and symptoms of an adverse outcome including malaise, myalgia, respiratory distress, and somnolence.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      This is in addition to the patient’s renal function and overall glycemic control.
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      It is also important to be mindful of the most recent labeling recommendations that account for a patient’s renal function while considering eGFR as follows: do not initiate metformin in patients with an eGFR < 30 mL/min/1.73 m2; it is not recommended to initiate metformin in those with an eGFR between 30 and 45 mL/min/1.73 m2; for those who are already on metformin and the eGFR falls below 45 mL/min/1.73 m2, metformin should be evaluated for risks versus benefits and closely monitored; and metformin should be discontinued if the eGFR fall below 30 mL/min/1.73 m2.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      ,
      • Wong E.
      Metformin: its history, safety and updated labelling recommendations.
      Our patient has an eGFR of 64 mL/min/1.73 m2 and can be continued on this therapy at this time. Should the patient’s kidney disease advance or the heart failure become unstable, alternative pharmacotherapy to manage T2DM may need to be sought.

      Example of STOPP/START and Beers Criteria

      Zolpidem

      Zolpidem is a commonly prescribed nonbenzodiazepine sedative hypnotic used for the management of insomnia. It has a relatively quick onset of action of approximately 30 minutes to achieve its effects but is associated with significant safety concerns.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      ,
      U.S. Food and Drug Administration
      FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR [5-14-2013].
      This includes neuropsychiatric symptoms, visual and auditory hallucinations, delirium, amnesia, sleepwalking, and nocturnal eating.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      ,
      U.S. Food and Drug Administration
      FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR [5-14-2013].
      Zolpidem is also a product listed in the American Geriatrics Society Beers Criteria and STOPP/START criteria because of its risk of delirium, falls, and fractures in older adults.
      American Geriatrics Society
      American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults.
      In this patient case, the use of zolpidem should be re-evaluated with considerations of stopping it.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      ,
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      If stopping it, consider slowly titrating the dose downward. If the patient requires additional therapy, cognitive behavioral therapy or pharmacologic alternatives such as ramelteon may be considered.
      • Sateia M.J.
      • Buysse D.J.
      • Krystal A.D.
      • Neubauer D.N.
      • Heald J.L.
      Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline.
      If the therapy is continued, close monitoring of the noted effects should be performed. In this patient, if zolpidem is to be continued and no safer alternative is available, it is suggested to decrease the dose to 5 mg because female patients have been found to be slower metabolizers of the product, resulting in prolonged effects of zolpidem.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      ,
      U.S. Food and Drug Administration
      FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR [5-14-2013].
      ,
      American Geriatrics Society
      American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults.

      Example of Deprescribing

      Docusate

      An example of deprescribing is docusate.
      • Scott I.A.
      • Hilmer S.N.
      • Reeve E.
      • et al.
      Reducing inappropriate polypharmacy: the process of deprescribing.
      Docusate is a stool softener that works by lowering surface water tension of the stool, thus softening it.
      • Hurdon V.
      • Viola R.
      • Schroder C.
      How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.
      ,

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      Historically, this product has been widely used as a laxative, although the data to support its efficacy are lacking.
      • Hurdon V.
      • Viola R.
      • Schroder C.
      How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.
      ,

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      In a randomized controlled trial comparing docusate versus psyllium, docusate had fewer bowel movement frequency compared with psyllium.
      • McRorie J.W.
      • Daggy D.P.
      • Morel J.G.
      • et al.
      Psyllium is superior to docusate sodium for treatment of chronic constipation.
      Because of its lack of efficacy, many practice settings have removed the product from formulary.

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      For this patient, consider deprescribing docusate from the medication regimen to reduce the polypharmacy-related issues because the patient is taking many other medications that are essential for chronic medical conditions.
      The patient in this case is 74 years old, and as one gets older, there are physiologic changes that occur involving the gastrointestinal tract. Such examples include decreased gastrointestinal motility that can lead to constipation.
      • McRorie J.W.
      • Daggy D.P.
      • Morel J.G.
      • et al.
      Psyllium is superior to docusate sodium for treatment of chronic constipation.
      ,
      • Bhutto A.
      • Morley J.E.
      The clinical significance of gastroinstestinal changes with aging.
      A common alternative laxative can be considered in this patient is a bulk-forming laxative such as psyllium.
      • Mounsey A.
      • Raleigh M.
      • Wilson A.
      Management of constipation in older adults.
      If the patient is taking bulk-forming laxatives and continues to experience constipation, then a stimulant or osmotic laxative (eg, polyethylene glycol) may be added.

      Professional Resource, Docusate. Pharmacist’s Letter/Prescriber’s Letter. September 2016. https://pharmacist.therapeuticresearch.com/Home/PL. Accessed October 6, 2019.

      ,
      • Mounsey A.
      • Raleigh M.
      • Wilson A.
      Management of constipation in older adults.

      Examples of Clinical Practice Guidelines

      Statins

      The patient has several high-risk conditions (low-density lipoprotein = 190 mg/dL, T2DM, HTN, age ≥ 65 years, and heart failure) for future atherosclerotic cardiovascular disease events.
      • Grundy S.M.
      • Stone N.J.
      • Bailey A.L.
      • et al.
      2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      According to the American College of Cardiology and American Heart Association, the patient is eligible for a high-intensity statin to reduce the risk of cardiovascular disease. This may include atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      The patient is currently receiving atorvastatin 20 mg daily, which is considered a moderate-intensity dosing strategy.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      Considering the latest recommendations, the statin dose should be reassessed in this patient and, if tolerated, may be titrated to a higher-intensity dose.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      Because of her age, the patient is also at a higher risk of adverse reactions and should be monitored for any adverse effects related to dose escalation such as muscle pain, liver enzyme tests, and lipid profiles.

      Lexicomp Online, Lexi-Drugs Online [Internet database]. Hudson, OH: Wolters Kluwer Clinical Drug Information, Inc. Updated periodically. Accessed May 2, 2019.

      Nonsteroidal Anti-inflammatory Drugs

      Patients with CKD are at risk for developing end-stage kidney disease. As such, medications that are potentially harmful to the kidneys should be avoided. In this case, ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that may lead to decreased plasma flow to the kidney by decreasing prostaglandin synthesis, an important step in regulating the vasodilatory property within the glomerulus.
      • John R.
      • Herzenberg A.M.
      Renal toxicity of therapeutic drugs.
      For this reason, the National Kidney Foundation does not recommend NSAIDs to be used in the setting of CKD.
      NKF and NSAID Alliance declares NSAID awareness week.
      For this patient, an NSAID should be avoided because of 1) its potentially nephrotoxic effects, and 2) its associated and increased risk of gastrointestinal bleeds in older adults.
      NKF and NSAID Alliance declares NSAID awareness week.
      ,
      • Marcum Z.A.
      • Hanlon J.T.
      Recognizing the risks of chronic nonsteroidal anti-inflammatory drug use in older adults.
      This is an extremely important consideration when caring for older adults with high risk for polypharmacy-related issues. The patient also has cardiac issues to which NSAIDs should be avoided overall.

      Angiotensin-converting Enzyme Inhibitor/Angiotensin Receptor Blocker

      To slow the progression of CKD, an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) is recommended. According to the American Diabetes Association, these agents are recommended in patients with 1) a urinary albumin-to-creatinine ratio of 30 to 299 mg/g or 2) a urinary albumin-to-creatinine ratio ≥ 300 mg/g, and/or an estimated eGFR < 60 mL/min/1.73 m2.
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      Similarly, the American Heart Association and the American College of Cardiology recommend these agents for the management of HTN in patients with comorbidities such as HFrEF and CKD.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      With the latter, candidates for ACEi or ARB therapy include 1) CKD stage 3 or higher, or 2) CKD stage 1 or 2 with a urinary albumin-to-creatinine ratio of ≥ 300 mg/g.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      Collectively with a past medical history of CKD, HTN, HFrEF, and T2DM and the current blood pressure, the patient is a candidate for ACEi or ARB therapy. The electrolytes are within normal limits, and there are no other factors that would exclude the patient from this therapy at this time. While on therapy, renal function (albuminuria and eGFR), electrolytes (serum potassium), cough, angioedema, and blood pressure should be monitored routinely. The long-term blood pressure goal is dependent on the guidelines referenced and may range from a systolic pressure of 130 to 140 mmHg and a diastolic pressure of 80 to 90 mmHg.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.

      Antiplatelet Agents

      For the reduction of cardiovascular morbidity and mortality, antiplatelet agents are often considered. Per the American Diabetes Association guidelines, aspirin is recommended as a secondary prevention measure in patients with diabetes and a history of atherosclerotic cardiovascular disease.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.
      Aspirin may also be considered as a primary prevention measure in patients ≥ 50 years with diabetes at low bleeding risk and at an increased cardiovascular risk (family history of atherosclerotic cardiovascular disease, HTN, dyslipidemia, smoking, and CKD/albuminuria). Use in patients ≥ 70 years is debatable because of a greater risk versus benefit of initiating this agent and would require such considerations of the patient’s gastrointestinal bleeding risk and life expectancy. Applying these recommendations to our case, albeit a commonly prescribed agent, the addition of aspirin would have to be re-evaluated by the clinician alongside the patient.
      • Whelton P.K.
      • Carey R.M.
      • Aronow W.S.
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.
      ,
      American Diabetes Association
      Standards of medical care in diabetes–2019.

      Implications for Practice

      The provided case is an example of the complexities with medication management to support the multitude of health conditions in an older patient while introducing polypharmacy and pharmacotherapy-related issues. NPs are practitioners engaged in direct patient care and are able to identify PIMs, re-evaluate prescribing practices, and ensure the safe use of medication therapy. Through the initial dialogue with a patient, an NP can obtain a complete up-to-date list of medications (prescription and nonprescription products) and identify the challenges with medication therapy (eg, adherence, insurance, pharmacy, and language), the current and preferred pharmacy, and the past medical history, among other relevant information (Table 3). The next step is to assess and evaluate for PIMs; the efficacy and tolerability of each medication; and opportunities to deprescribe and/or prescribe considering the patient’s current health status, response to therapy, and available practice guidelines. Deprescribing may be challenging, especially when the patient is under the care of other providers, considering the risk and benefits of therapy, time constraints, public perception of medication use, and the pressure to prescribe. This would be a great opportunity to collaborate with a pharmacist or other health care providers who can support the initiative to review, deprescribe and prescribe appropriate pharmacotherapy, and reduce inappropriate polypharmacy.
      • Scott I.A.
      • Hilmer S.N.
      • Reeve E.
      • et al.
      Reducing inappropriate polypharmacy: the process of deprescribing.
      Table 3Essential Practitioner Questions: Evaluating the Safe Use of Pharmacotherapy
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      • Masnoon N.
      • Shakib S.
      • Kalisch-Ellett L.
      • Caughey G.E.
      What is polypharmacy? A systematic review of definitions.
      • Maher R.L.
      • Hanlon J.T.
      • Hajjar E.R.
      Clinical consequences of polypharmacy in elderly.
      • Hilmer S.N.
      • Gnjidic D.
      The effects of polypharmacy in older adults.
      ,
      American Geriatrics Society
      American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults.
      • Budnitz D.S.
      • Lovegrove M.C.
      • Shehab N.
      • et al.
      Emergency hospitalizations for adverse drug events in older Americans.
      • O’Mahony
      • O’Sullivan D.
      • Byrne S.
      • et al.
      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
      • Gallagher P.
      • O’Mahony D.
      STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria.
      • Kuhn-Thiel A.M.
      • Weiβ
      • Wehling M.
      Consensus validation of the FORTA (Fit fOR The Aged) list: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly.
      • Michalek C.
      • Wehling M.
      • Schlitzer J.
      • Frohnhofen H.
      Effects of "Fit fOR The Aged" (FORTA) on pharmacotherapy and clinical endpoints—a pilot randomized controlled study.
      • Wehling M.
      • Burkhardt H.
      • Kuhn-Thiel A.
      • et al.
      VALFORTA: a randomised trial to validate the FORTA (Fit fOR The Aged) classification.
      • Pazan F.
      • Weiss C.
      • Wehling M.
      • et al.
      The EUROFORTA (Fit fOR The Aged) list: international consensus validation of a clinical tool for improved drug treatment in older people.
      • Garfinkel D.
      • Zur-Gil S.
      • Ben-Israel J.
      The war against Polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.
      • Hanlon J.T.
      • Samsa G.P.
      • Weinberger M.
      • Uttech K.M.
      • Lewis I.K.
      • Feussner J.R.
      A method for assessing drug therapy appropriateness.
      • Scott I.A.
      • Gray L.C.
      • Martin J.H.
      • Mitchell C.A.
      Minimizing inappropriate medications in older populations: a 10-step conceptual framework.
      • Vogt-Ferrier N.
      Reviewing a complicated geriatric drug regimen.
      • Hoskins B.L.
      Safe prescribing for the elderly.
      • Lee R.D.
      Polypharmacy: a case report and new protocol for management.
      IBM Micromedex Healthcare Series [internet database]. Greenwood Village, CO: Thomson Healthcare. Update periodically.
      • Sateia M.J.
      • Buysse D.J.
      • Krystal A.D.
      • Neubauer D.N.
      • Heald J.L.
      Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline.
      • Does each medication have an indication?
      • Are there any medications that are duplicating therapeutic indications?
      • Are the dose, route, and frequency appropriate for each medication?
      • Has the patient experienced any adverse effects secondary to the medications received?
      • What is the risk versus benefit of each medication?
      • Are there any drug-drug, drug-disease, or drug-allergy interactions?
      • Does the patient use more than 1 pharmacy?
      • Does the patient have multiple prescribers?
      • Are there any concerns with adherence to the prescribed medications?
      • Is the patient taking any over-the-counter or herbal products?
      • Considering the identified health conditions, is the patient receiving therapy in accordance with the latest guideline recommendations?
      • Is the patient responding to therapy in accordance with the patient-specific goals?
      • Are there physiologic changes that would affect the patient’s response to therapy?
      • Does the patient have adequate support (eg, insurance and family/caregiver)?

      Conclusion

      As the number of older patients encountered in practice increase so does the complexities of their health management. Multiple comorbid disease conditions and polypharmacy naturally become prominent issues. Practitioners should continue to assess and re-evaluate patient medication regimens to minimize issues secondary to polypharmacy and optimize patient outcomes.

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      Biography

      Timothy Nguyen, PharmD, BCPS, CCP, FASCP, is a professor of pharmacy practice at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University in Brooklyn, NY, and can be contacted at [email protected]
      Elaine Wong, PharmD, BCPS, BC-ADM, is an associate professor of pharmacy at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University.
      Francesco Ciummo, PharmD, BCCCP, is an assistant professor of pharmacy practice at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University.