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Polypharmacy and deprescribing
In an older adult every drug must justify its place against the patient's goals; polypharmacy increases side effects, falls and confusion, so the list is reviewed regularly and drugs whose harm outweighs their benefit are withdrawn gradually.
Why it matters in the exam
The exam presents an older adult with a new symptom — confusion, a fall, constipation, urinary retention — and asks which drug on the list is responsible. Candidates need to recognise anticholinergic drugs, benzodiazepines, hypnotics, sulfonylureas and anti-inflammatory drugs, and to know the "prescribing cascade" — a side effect treated with another drug instead of stopping the first.
Candidates are also asked about the tools: the Beers Criteria (2023 update) and STOPP/START (version 3, 2023), and about the principles of deprescribing: one drug at a time, gradually for drugs that cause withdrawal symptoms, and follow-up of the result. Kidney clearance falls with age, so doses are adjusted by Cockcroft-Gault even when the creatinine looks "normal".
Further questions deal with dangerous interactions that come up again and again: warfarin with antibiotics or with amiodarone (rising INR and bleeding), an ACE inhibitor or angiotensin receptor blocker combined with a diuretic and NSAIDs (acute kidney injury), and the combination of several anticholinergic or sedative drugs. Candidates are also asked about the importance of a complete medication list, including over-the-counter drugs and supplements, and about the "brown bag review" — the patient brings every medicine at home to the visit.
Key points
- Polypharmacy = 5 or more drugs; it increases falls, confusion and admissions.
- A new symptom in an older adult — suspect a drug first; look for a prescribing cascade.
- Beers 2023 and STOPP/START version 3 are the main tools.
- Avoid: anticholinergics, benzodiazepines, sulfonylureas, long-term NSAIDs.
- Stop one at a time and gradually; add a beneficial drug that is missing.
Summary table
| Group | Why it is a problem | Alternative or action |
|---|---|---|
| Anticholinergics (oxybutynin, first-generation antihistamines, tricyclics) | Confusion, constipation, urinary retention, falls | Mirabegron for overactive bladder; no diphenhydramine for sleep |
| Benzodiazepines and Z-drugs | Falls, fractures, confusion, road accidents | Gradual taper; cognitive behavioural therapy for insomnia |
| Sulfonylureas (glibenclamide) | Prolonged hypoglycaemia | Metformin, SGLT2 inhibitor, GLP-1 RA, DPP-4 inhibitor |
| Long-term NSAIDs | Bleeding, kidney injury, heart failure | Paracetamol, topical treatment |
| Antipsychotics in dementia | Increased stroke and mortality | Non-drug management; a drug only for danger, at a low dose, for a short time |
| PPI beyond 8 weeks without an indication | C. difficile infection, fractures, B12 deficiency | Step down and stop |
In the full version for subscribers
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Sources
- American Geriatrics Society Beers Criteria for potentially inappropriate medication use in older adults, 2023 update — Drugs to avoid and drugs to use with caution
- STOPP/START criteria for potentially inappropriate prescribing in older people, version 3 (2023) — Screening criteria
- Geriatrics Review Syllabus (American Geriatrics Society), 11th edition (2022) — Pharmacotherapy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.