1. drahmadtemimi@gmail.com
and
Rational Prescribing
in Elderly Patients

2. By the end of this lecture, you should be able to:
1. Define POLYPHARMACY and its contributing
factors.
2. Describe the Prevalence of Polypharmacy and
its impact on older adults.
3. Discuss the Consequences of Polypharmacy,
including adverse drug reactions and
medication nonadherence.
4. Explore the Principles of Rational Geriatric
Prescribing and their importance in
preventing polypharmacy.
5. Explain the Deprescribing Process and its role
in reducing the risk of adverse drug reactions
and medication-related harm.
Learning Objectives

3. Introduction
The elderly represent one of the fastest
growing segments of the population and
their use of medication is increasing
significantly.
The primary care physician plays an
important role in addressing an array of
pharmaceutical issues and concerns for
elderly patients, including:
 Polypharmacy.
 Adverse drug reactions (ADRs).
 Medications nonadherence.
 Undertreatment of certain conditions.

4. Prevalence  A large survey estimated that roughly
40% of elderly people take 5 or more
medications.
 Nearly, 1 in 20 of these patients risked a
major drug–drug interaction.
 Polypharmacy is estimated to cause 10%
of hospital admissions in elderly people.
 The WHO estimates that more than half
of all medication-related hospital
admissions in elderly people are
preventable.
 Polypharmacy is more common in
women.
 The number of medications used by
older adults increases with age.

5. What is
polypharmacy ? Polypharmacy is typically defined as
the prescription of five or more
medications.
It also refers to the prescription of
medications that do not have a
specific current indication, that
duplicate other medications, or that
are known to be ineffective for the
condition being treated.
In other words, polypharmacy is the
use of multiple medications that are
unnecessary and have the potential
to do more harm than good.

6. Factors leading to
Polypharmacy in elderly
Poor patient education.
Multiple pathology.
Attending multiple specialist
clinics.
Lack of routine review of
medications.
Poor communication between
specialists.
Self-treat with over-the-counter
medications.

7. Prescribing
Cascade
 Elderly people can be the victim of
a harmful “Prescribing Cascade”.
 This happened when an adverse
drug effect is misinterpreted as a
new medical condition, for which
another drug is then prescribed,
and this new medication in turn
have adverse effects that result in
further prescribing.
 It adds an unnecessary burden to
the patient’s already complicated
medication regimen.
Drug 1
Adverse drug effects
misinterpreted as new
medical condition
Drug 2
Adverse
drug effect

8. Examples of
Frequent
Prescribing
Cascades

9. Age-related
Physiological Changes
Knowledge of the physiologic
changes that occur with aging is
essential when prescribing
medications to elderly patients.
The changes can affect the way the
body absorbs, distributes,
metabolizes and eliminates drugs.
These changes include increased
body fat, decreased body water,
decreased muscle mass, and
changes in renal and liver function.
These changes can cause ADRs in
older people.

10. Using multiple drugs at the same
time doesn't always connote
inappropriate prescribing; it can
actually be reasonable.
Often, 3 medications are needed to
manage symptoms of heart failure
or control high blood pressure to
meet national guidelines.
Patients with type 2 DM often
require at least two medications
for effective glucose control.

11. Polypharmacy
Consequences
Polypharmacy recently became an
important public health problem due
to its many possible negative
consequences, including:
Risk of adverse drug reactions.
Risk of medication nonadherence.
Risk of multiple geriatric
syndromes (e.g., cognitive
impairment, impaired balance and
falls).
Risk of hospitalization and nursing
home placement, and mortality.
Increased health care utilization
and costs.

12. Adverse Drug
Reactions
An ADR is defined as any noxious, unintended,
or undesired response to a therapeutic agent.
They are at least twice as common in elderly
patients as in younger patients.
Polypharmacy is a major risk factor for ADRs.
The probability of ADRs increases with the
number of medications being taken.
The three most common drug classes
associated with ADRs in the elderly are
cardiovascular drugs, psychotropic drugs, and
NSAIDs.
The orthostatic hypotension is potentially the
most serious drug reaction.
Always, consider an ADR as a cause of any new
patient symptom.

13. Types of ADRs
 Side effects
(dry mouth from tricyclic antidepressants and
hypokalemia from diuretics).
 Drug toxicity
(GIT bleeding and renal dysfunction caused by
NSAIDs, and cognitive impairment and falls
caused by CNS depressants).
 Drug-drug interaction
(The combined therapy of anticoagulants and
antiplatelet agents can increase the risk of
bleeding).
 Drug-disease interaction
(drugs with anticholinergic properties may affect
the cognitive function of patients with Alzheimer
disease).
 Drug withdrawal syndromes
(beta blocker withdrawal leads to angina or
tachycardia).

14. Medication
Nonadherence
Forms of nonadherence include:
Forgetting to take medication.
Taking medication at the wrong
dose.
Taking medication at the wrong
time.
Incorrectly administering
medications.
Discontinuing medications
prematurely.
Medication Nonadherence refers to
the failure of a patient to take
medications as prescribed.

15. Reasons for medication
nonadherence
Polypharmacy.
Cognitive Impairment.
Physical Impairment.
Cost.
Side Effects.
Lack of Understanding.
Forgetfulness.
Lack of Social Support.
Depression.
Fear of dependence.

16. Consequences of
Medication Nonadherence
Increased risk of
morbidity and
mortality.
Reduced quality of
life.
Increased healthcare
costs
Increased burden on
caregivers.

17. Interventions to improve
Medication Adherence
Simplifying medication regimens.
Use a medication that can treat
multiple indications.
Try to combine medications into single
pills to reduce pill burden.
Recommending low-cost or generic
alternatives when appropriate.
Educate the patient and caregiver.
Using medication reminders, such as
pillboxes, alarms, or smartphone apps.
Regular medication reviews.

18. Common geriatric
presentations
that can be
caused by drugs
Common geriatric
presentations
that can be
caused by drugs

19. Principles of Rational
Geriatric Prescribing
Individualization.
Simplification.
Avoidance of potentially inappropriate
medications.
Monitoring for adverse drug reactions.
Consideration of non-pharmacologic
interventions.
Reasonable therapeutic goals.
Consideration of cost and patient
preferences.
Monitoring parameters.
Involvement of caregivers.

20. Drug initiation in the elderly should be
done cautiously.
Avoid prescribing before a diagnosis is
made.
Review medications before adding a
new medication.
Start one medication at a time.
For each medication, start very low and
go very slow.
Know the actions, adverse effects, and
toxicity of the medications you
prescribe.
Attempt to maximize dose before
switching to another.
Guideline to initiate
new drugs

21. The Deprescribing
process
Review the patient’s medication:
including prescription and over-the-
counter medications, supplements, and
vitamins.
Assess the patient’s response to each
medication.
Develop a deprescribing plan: this may
involve discontinuing certain
medications, tapering the dose of certain
medications, or switching to alternative
medications.
Monitor for any new symptoms or
adverse effects that may arise, and
adjust the plan as necessary.
Involve the caregiver in the
deprescribing process to ensure that it is
safe and effective.
The patient's preferences and goals for
treatment are taken into consideration.

22. Review Checklist
for each medication
Is there an indication for the medication?
Is the medication effective for the condition?
Is the dosage correct?
Is the duration of therapy acceptable?
Are the directions correct and practical?
Are there clinically significant drug-drug
interactions?
Are there clinically significant drug-
disease/condition interactions?
Is there unnecessary duplication with other
medication(s)?
Is this medication the least expensive
alternative?

23. Rational
Prescribing Tools
A number of helpful prescribing tools
for appropriate medication review in
older adults:
The Beers criteria developed by
the American Geriatrics Society.
STOPP (Screening Tool of Older
Person's Prescriptions).
START (Screening Tool to Alert to
Right Treatment).
MAI (Medication Appropriateness
Index).
ARMOR (Assess, Review, Minimize,
Optimize, Reassess).

24. Beers Criteria The Beers Criteria is a valuable tool for
healthcare providers to assess and optimize
medication use in older adults.
It is developed by the American Geriatrics
Society.
It is an expert generated list of medications
that are potentially inappropriate for use in
older adults.
The list is updated periodically according to the
evidence-based recommendations.
It can be helpful in reducing the risk of adverse
drug events and improving patient outcomes.
However, it is important to note that the
criteria should not be used as a substitute for
clinical judgement and individualized patient
care.

25. Medications that should be
avoided in older adults.
Medications that should be used
with caution.
Medications requiring dose
adjustment in older adults with
specific medical conditions.
Medications that may need to be
replaced with safer alternatives.
Recommendations
of Beers Criteria
The Beers Criteria includes
recommendations regarding:

27. Improving drug therapy in elderly patients: The Garfinkel Algorithm

28.  Polypharmacy is common among older
adults and can lead to adverse drug
events, increased healthcare costs, and
decreased quality of life.
 Rational prescribing and deprescribing
processes are essential for optimizing
medication use in this population.
 These processes involve evaluating
medications for appropriateness,
safety, and effectiveness, and
discontinuing or reducing unnecessary
medications.
 Incorporating these processes into
clinical practice can lead to better
health and quality of life for older
adults.

29. REFERENCES
 American Geriatrics Society. (2019). American Geriatrics
Society 2019 Updated AGS Beers Criteria(R) for Potentially
Inappropriate Medication Use in Older Adults. Journal of
the American Geriatrics Society, 67(4), 674-694.
 Chang, A. (2020). Current Diagnosis and Treatment:
Geriatrics, 3/e. McGraw Hill Professional.
 Endsley, S. (2018). Deprescribing Unnecessary
Medications: A Four-Part Process. Family Practice
Management, 25(3), 28–32.
 Evidence-Based Geriatric Nursing Protocols for Best
Practice. (2020). Springer Publishing.
 Fillit, H., Rockwood, K., & Young, J. (2017). Brocklehurst’s
textbook of geriatric medicine and gerontology. Elsevier.
 Fulmer, T. T., & Chernoff, B. (2019). Handbook of geriatric
assessment. Jones & Bartlett Learning.
 Ham, R. J. (2014). Ham’s primary care geriatrics: a case-
based approach. Saunders.
 Kim, L. K., Koncilja, K., & Nielsen, C. (2018). Medication
management in older adults. Cleveland Clinic Journal of
Medicine, 85(2), 129–135.
 Kwan, D., & Farrell, B. (2014). Polypharmacy:
optimizing medication use in elderly patients.
 Lee, A. G., Potter, J. F., & G. Michael Harper. (2021).
Geriatrics for Specialists. Springer Nature.
 Rakel, R. E., & Rakel, D. (2016). Textbook of family
medicine. Elsevier Saunders.
 Roller-Wirnsberger, R., Katrin Singler, & Maria
Cristina Polidori. (2018). Learning Geriatric
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 Sinclair, A. J., Morley, J. E., & Vellas, B. (2012).
Pathy’s Principles and Practice of Geriatric
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 Tallia, A. F., Scherger, J. E., & Dickey, N. (2021).
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 World Health Organization. (2015). Medication
safety in polypharmacy: Technical report.
https://apps.who.int/iris/bitstream/handle/10665/
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llowed=y