#99022: Geriatric Polypharmacy

In older adults, certain drugs are considered inappropriate when the adverse pharmacodynamics, pharmacokinetics, and/or risk of drug interactions outweigh the potential benefits. In 1991, Mark H. Beers, MD, and his colleagues established a list of medications considered potentially inappropriate for patients 65 years of age or older. Known as the AGS Beers criteria (Table 1), the resource was designed to educate prescribers, improve prescribing practices, and enhance quality assurance. Prescribers should review the medication regimen and determine the medical necessity of each drug the patient takes. The Beers criteria list continues to be updated (most recently in 2019) and used to guide and evaluate prescribing practices in geriatric patients. Notable new inclusions to the 2019 update of the list are glimepiride, methscopolamine, and pyrilamine [4].

The Beers list separates potentially inappropriate medications into several categories according to the strength of the recommendation and the potential adverse event. The first category includes drugs that are "potentially inappropriate" due to a higher risk of adverse effects and/or reduced efficacy in older patients; the AGS recommends that prescribers consider avoiding these agents [4]. The second category is for medications used in the treatment of common health problems (e.g., heart failure, seizures) that may exacerbate comorbidities in older patients. The third category is for potentially inappropriate medications that should be used with caution (and perhaps increased monitoring) in elderly patients [4]. Finally, the AGS provides a list of medications with potentially clinically important non-anti-infective drug-drug interactions that should be avoided in older adults or should be decreased in dose in those with impaired kidney function. Careful consideration should be given when prescribing medications that are on the Beers list. The criteria are meant to support good clinical judgment [46]. If the listed medications are used, they should be prescribed at the lowest effective dose for the shortest duration possible.

The Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria focus on the avoidance of potentially inappropriate prescribing in elderly patients experiencing acute illness [5]. This tool places a special focus on potential drug-drug interactions, duplicate drug class prescriptions, and techniques to minimize adverse drug reactions. Criteria are organized according to physiologic system, which may make the tool easier to use. STOPP is designed to be used in conjunction with the Screening Tool to Alert doctors to the Right Treatment (START) criteria, which provides guidance on the medications that are recommended for older patients with specific conditions/diseases (e.g., arthritis, depression) [18]. STOPP/START criteria were first published in 2008 and were updated in 2014, with a 31% increase in the number of criteria [49]. Several new categories were included in the 2014 update, including STOPP categories of antiplatelet/anticoagulant drugs; drugs affecting, or affected by, renal function; and drugs that increase anticholinergic burden. New START categories include urogenital system drugs, analgesics, and vaccines [49].

A 2016 study comparing the effectiveness of the original STOPP and the 2003 and 2012 Beers criteria in identifying potential adverse drug events (including hospitalizations and emergency department visits) found that STOPP was slightly more specific (though less sensitive) than either Beers criteria [41]. The authors of this study recommended using the Beers and STOPP tools together for the best predictive value.

Patient A is 82 years of age with a history of congestive heart failure, glaucoma, hypertension, and osteoarthritis. Her current medications are furosemide, potassium, lisinopril, metoprolol, aspirin, timolol maleate opthamic solution (Timoptic), acetaminophen (as needed), multivitamin, and a calcium/vitamin D supplement (800 IU daily). She has an appointment with a new orthopedic physician. During the appointment, the patient complains of persistent arthritic pain in her knee. The physician prescribes the nonsteroidal anti-inflammatory drug (NSAID) meloxicam (7.5 mg per day) for pain and inflammation.

Comments and Discussion : From the orthopedic standpoint, prescription of meloxicam is good practice, as it should help to ameliorate patient A's symptoms. However, from a cardiac standpoint, this is a risky approach due to the potential side effect of fluid retention and its effect on the heart. In general, NSAIDs can be dangerous for an individual of Patient A's age. NSAIDs (including meloxicam, but also over-the-counter options like ibuprofen) have been issued "black box" warnings by the U.S. Food and Drug Administration (FDA) for the increased risk of:

Patient A has a good working relationship with her primary care provider, who has instructed her to contact him regarding any changes in her medication regimen. She calls her physician prior to taking the medication, and he advises her not to take the NSAID. Instead, he devises a pain management plan that minimizes the potential risks. Previously, Patient A was taking acetaminophen as needed, averaging up to one dose daily. This is increased to twice daily extended-release acetaminophen (650 mg). For breakthrough pain, tramadol 25 mg every four hours (as needed) is prescribed. Another option considered was the topical anti-inflammatory diclofenac sodium 1% topical gel, which would have fewer side effects than systemic agents. Aside from pharmacotherapy, the patient is scheduled with a physical therapist to create a safe exercise plan, including strengthening and range-of-motion exercises.

More than 3 million Americans receive care in skilled nursing facilities each year, and 1.4 million Americans reside in nursing homes [7]. The Centers for Medicare and Medicaid Services (CMS) work to promote nursing home quality improvement, address reimbursement issues, and ensure compliance with CMS-defined best practices. Nursing facilities are required to comply with CMS regulatory requirements in order to receive payments under the Medicare or Medicaid programs.

CMS regulations state that nursing facility residents should only receive medications when the potential benefits outweigh the risks or burden of treatment [12,50]. There must be a clear clinical indication and diagnosis for any medication, and prescribed medications should be given for the proper duration at the correct dose. State surveyors review patients' medication regimens to assess for unnecessary medications. If a patient is found to have been prescribed an unnecessary drug, the facility may receive a citation (referred to as F-Tag 757 or F757) for violating the CMS requirement to avoid unnecessary medications. In 2014, CMS issued a memo indicating that surveyors have been trained to increase investigations for unnecessary drugs, particularly antipsychotic medications in the management of dementia [20]. In 2017, F-tag 758 (F758) was issued as a unique survey item to ensure the patient's drug regimen is free from unnecessary psychotropic medications [52]. These regulations are intended to help promote or maintain the patient's highest functional, emotional, and physical level of wellness. To comply with F757 and F758, each patient's drug regimen should be monitored on a regular basis, with goals of treatment identified. Only drugs that are medically necessary should be administered in the correct dosages and for only the clinically indicated duration. After a medication has been ordered, the patient should be monitored for therapeutic response, adverse reactions, interactions, and necessity of ongoing treatment. Any significant decline in functional or physical status should be immediately correlated with any new drugs or changes in drug dosages. Significant declines in status should be recognized and evaluated, with adjustment of the medication regimen if warranted.

Patient B is a man, 78 years of age, who resides in a nursing facility. One year ago, he fell and fractured his left hip and underwent surgical repair. He returned to the nursing facility, completed rehabilitation, and regained most of his prior function. After the surgery, Patient B was prescribed warfarin to prevent deep vein thrombosis (DVT) after surgery.

During a routine survey, a state surveyor discovers that Patient B is still being administered warfarin. After further investigation, it is discovered that the warfarin was never discontinued after the appropriate duration after the hip fracture repair. The surveyor considers warfarin an unnecessary drug, and a citation (F757) is issued. After contacting the attending physician, the warfarin is promptly discontinued.

Comments and Discussion : Patient B 's case is an example of using the right drug but not using it for the correct duration. After orthopedic surgery, warfarin is usually indicated for approximately two to three months or until activity/ambulation has increased to a point that the risk of DVT is reduced. There is a substantial burden of treatment with warfarin, including weekly evaluations of prothrombin time/international normalized ratio (PT/INR), adverse reactions, interactions, and increased risk of bleeding and brain hemorrhage, especially for patients with a history of falls.

There is shared responsibility for this error between the prescriber/healthcare provider and the facility. The provider did not follow through and discontinue the medication when it was no longer needed, and the facility nursing staff should have realized that the drug was no longer necessary and approached the provider for an order to discontinue. The nursing facility could have called the orthopedic physician for orders and duration of warfarin treatment after surgery. When a medication is started, the stop date for that medication should be considered and established. The consultant pharmacist could have intervened as well.

As noted, adverse events associated with warfarin is one of the leading causes of emergency department visits and hospitalizations among older adults [9]. As such, improved management of anticoagulants has the potential to significantly reduce morbidity and mortality in this population. First used in the 1950s, warfarin is considered the criterion standard for anticoagulation and is widely used to prevent and treat thrombosis and thromboembolism. Other indications for warfarin include atrial fibrillation, artificial heart valve, and pulmonary embolism. Dosing of warfarin is individualized and closely monitored by the INR, which measures serum viscosity. In general, INR should be between 2 and 3 in patients taking warfarin. For high-risk patients or those with prosthetic valves, the desired range may be 2.5–3.5, and older adults who are at high risk for complications may be maintained at 1.8–2.

The FDA has issued a black box warning for warfarin regarding the risk of major or fatal bleeding. This risk is increased in patients older than 65 years of age with high-intensity coagulation (i.e., INR >4), variable INR, and/or other comorbidities [45]. Frequent INR monitoring is recommended along with careful dosage adjustment. Warfarin is contraindicated in patients with active bleeding, gastrointestinal bleeding, hemorrhagic stroke, blood dyscrasias, recent surgery, a high risk for non-compliance, and moderate-to-severe hepatic impairment. Caution is recommended in patients older than 65 years of age and in patients with a history of falls due to the risk of subdural hematoma and severe or fatal bleeding.

Aside from the risk of serious bleeding, common adverse reactions to warfarin include bruising, abdominal pain, nausea, vomiting, fatigue, headache, dizziness, taste changes, dermatitis, and fever. Over-the-counter medications can also interact with anticoagulants. The anticoagulant effects of warfarin and the antiplatelet effects of clopidogrel can be enhanced by the simultaneous use of ibuprofen, with the potential for internal bleeding. While the adverse interaction of warfarin with aspirin and NSAIDs is common knowledge, the significant potential interaction between warfarin and acetaminophen is less well known. Liver metabolism, drug and food interactions, and genetic factors also affect the efficacy of warfarin. Vitamin K-rich foods, such as green leafy vegetables and soy, decrease the effect of warfarin, reducing the PT/INR to subtherapeutic levels. Patients should be advised to eat a consistent daily amount of these foods in order to maintain a constant INR.

The consumption of alcohol may also affect the action of warfarin. Acute alcohol intake of more than a few drinks increases the anticoagulant effects of warfarin and can lead to increased bleeding [42]. Conversely, chronic alcohol use is associated with increased warfarin metabolism and impaired anticoagulation. In general, patients who are taking warfarin should abstain from alcohol consumption or limit their intake to one or two servings of alcohol occasionally.

Other agents used for anticoagulation include heparin, low-molecular-weight heparin, rivaroxaban, and dabigatran, all of which require a very cautious approach when treating elderly patients. Close monitoring and follow-up over time are essential to improved outcomes. As patients age, their health and functional status may change, and providers should reassess patients for contraindications to anticoagulant therapy, including falls, gastrointestinal bleeding, and hemorrhagic stroke. These complications are life-threatening, and their risk may outweigh the potential benefit of anticoagulation, requiring the cessation of therapy. Another important consideration is the patient's adherence to the prescribed therapy and regular blood testing. Patients should not be prescribed warfarin if they are not able to comply with monitoring requirements.

The management of diabetes often requires the prescription of multiple medications for optimum control, and this coupled with multiple medical comorbidities and a lack of research focusing on geriatric patients can make treatment complex. The main goal of treatment of diabetes in the elderly is to decrease metabolic complications while maintaining functional status and quality of life. Individualized management is crucial.

Age-related changes in drug absorption, distribution, metabolism, and clearance should be considered in all older patients with diabetes. For frail patients, the risks of intensive glycemic control often outweigh the benefits. Elderly patients may have a variable dietary intake related to physical or mental illness. If a patient skips a meal because he or she feels ill but takes or is given the usual dosage of insulin (especially fast-acting insulin), hypoglycemia will occur. Even when adequate calories are consumed, the older adult's intestinal absorption of those calories is slowed. As a patient ages, the adrenergic response to low blood glucose diminishes or disappears. Additionally, the preliminary symptoms of hypoglycemia, including lack of motor skills and confusion, may be misdiagnosed or unrecognized [43]. This can result in hypoglycemia unawareness in elderly patients with diabetes, which can allow the condition to become more severe. Unawareness of hypoglycemia is associated with a six-fold and nine-fold increased risk of severe hypoglycemia in patients with type 1 and type 2 diabetes, respectively [44].

Risk factors for hypoglycemia include polypharmacy, chronic renal or hepatic impairment, poor nutrition, comorbidities, the use of insulin or sulfonylureas, and acute illness. The Beers criteria lists sliding-scale insulin as a potentially inappropriate medication for persons older than 65 years of age, with a higher risk of hypoglycemia without improvement in diabetic management regardless of care setting [4]. The preferred treatment for older patients who require insulin is a daily basal rate of long-acting insulin, such as insulin glargine or insulin detemir. As with other geriatric prescribing, it is important to start with a low dose and increase slowly. Weekly re-evaluation and close monitoring is required, especially when initiating insulin therapy in patients older than 60 years of age.

Oral hypoglycemics can have a rebound hypoglycemic effect in patients with decreased renal or hepatic function (including age-related changes), and sulfonylureas (e.g., glipizide, glyburide) should be used with caution in elderly patients or those who are debilitated or malnourished [45]. Metformin has a low risk of hypoglycemia, but its use in older patients may be limited by comorbid illnesses such as renal/hepatic dysfunction, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Metformin begins to accumulate in the body when the glomerular filtration rate (GFR) is less than 50–60 mL/min/1.73 m2. Therefore, as a patient ages and renal function declines, it may be necessary to initiate more frequent monitoring of renal function and/or reduce or discontinue metformin use. For geriatric patients, especially those older than 80 years of age, the risks and potential adverse effects of metformin may preclude its use. If it is used, reduced dosage (250–500 mg twice daily) should be considered along with close monitoring of renal function and monthly metabolic panels.

Intense diabetes treatment and tight glycemic control can have serious consequences in elderly patients [21,22]. In the geriatric population, hypoglycemia is associated with an increased risk of myocardial infarction, functional decline, falls, and cognitive impairment. The AGS recommends a target glycated hemoglobin (HbA1c) of 7.5% to 8% in older patients with moderate comorbidities and life expectancy less than 10 years; the American Diabetes Association recommends a more relaxed goal of 8% to 8.5% for older patients with complex medical issues [23,51]. When diabetes is aggressively managed using guidelines more appropriate for younger adults, older patients are at risk for hypoglycemia and other complications. When deciding whether to offer or continue treatment of diabetes for patients older than 70 years of age, the benefit/risk ratio should factor in comorbidities, cognitive status, ability to self-manage, life expectancy, and vulnerability to hypoglycemia [24].

Most hospitalized patients with diabetes will require bolus insulin before meals and at bedtime based on blood glucose monitoring. These orders will be included on the discharge medication list if the patient is discharged to a skilled nursing facility. However, patients with stable type 2 diabetes should transition away from the daily blood glucose testing and on-demand insulin routinely ordered for hospitalized patients. One approach is to continue the bolus insulin at mealtimes for seven days while discontinuing bedtime doses to reduce the risk of nocturnal hypoglycemia. After seven days, the amount of insulin required daily may be used to establish a daily long-acting insulin regimen.

For example, if a patient required 72 units of regular insulin in one week, an average daily dose of about 10 units may be used as a starting point for long-lasting insulin (i.e., 10 units subcutaneous insulin each day). While in the process of adjusting insulin dosages, re-evaluation every week is prudent. Patients with glucose spikes may require the addition of bolus insulin before meals.

It is important to consider how often patients are willing to self-monitor blood glucose and give themselves insulin. While a small percentage of patients/caregivers would comply with testing and coverage four times per day, this is not a realistic expectation for most patients. Patients may complain about the pain of fingersticks and frequent injections of insulin, and episodes of hypoglycemia may make patients feel ill for days and require emergency intervention/hospitalization. Reducing any unnecessary medications, treatments, and intervention creates good rapport and allows more time to focus on improving the patient's quality of life.

Insomnia is a common complaint by elderly patients, causing many visits to primary care providers and psychiatrists. As a person ages, sleep patterns typically change. Increased sleep during the day causes a reduced need for sleep at night. There may be a perceived insomnia by the patient despite sleeping 7 hours or more in a 24-hour period. For patients with insomnia, providers should complete a comprehensive medical and psychologic assessment to diagnose underlying conditions that may cause a sleep disorder, including an acute stressor (e.g., grief), chronic pain, sleep apnea, anxiety, depression, or alcohol/substance misuse. Diagnosis and treatment of underlying comorbidities may make pharmacotherapy unnecessary.

A sleep hygiene regimen is a universally applicable prevention and treatment strategy that can improve sleep quality for those with and without a specific sleep disorder. Sound sleep hygiene practices should be discussed with patients and/or caregivers, and willingness to undertake these and other nonpharmacologic options should be assessed and encouraged [16]. Exercise history should also be obtained, and when levels are inadequate, exercise as treatment should be discussed. Increased physical activity has been shown to be as effective as benzodiazepines in improving sleep patterns in several studies [17]. Other nonpharmacologic treatment options include relaxation therapy and sleep restriction [17]. These are often first-line treatments due to the low cost, lack of side effects, and no risk of dependency. The use of over-the-counter sleep aids (especially those containing antihistamines) should be discouraged, as should the use of alcohol, due to marginal efficacy and reduction in sleep quality and because they may cause residual drowsiness and have the potential for dependency [17].

If medication is indicated to treat insomnia, the benzodiazepine temazepam (7.5 mg in older patients) is frequently used, as it is available in a generic form with a relatively low cost. According to the AGS Beers criteria, benzodiazepines are potentially inappropriate medications in the elderly and should be avoided if possible. Safer alternatives to temazepam include sedative-hypnotics (e.g., suvorexant) and melatonin. If a hypnotic is selected, it should be prescribed at a lower dose than for younger patients. Melatonin may be of benefit to a subset of patients with delayed sleep phase syndrome (a disturbance of the circadian rhythm), but it does not appear to be helpful for most people who have insomnia. It is safe when used in modest dosage (0.2–0.3 mg per night) for short periods (three months or less) [39]. Melatonin is unregulated by the FDA, so formulations vary in strength, and higher doses can lead to adverse side effects (e.g., disrupted sleep, fatigue, headache).

Another frequently used sleep aid is diphenhydramine, with multiple over-the-counter formulations available. Despite its widespread use, diphenhydramine is included on the Beers criteria as a potentially inappropriate medication in the elderly. Diphenhydramine is a first-generation antihistamine that is metabolized by the liver through the CYP-450 pathway. It non-selectively antagonizes central and peripheral histamine H1 receptors. It is a substrate/inhibitor, has a half-life of 3.4 to 9.2 hours, and is excreted in the urine. It has strong anticholinergic effects, which may cause constipation, dry mouth, impaired coordination, urinary retention, and hypotension. Drugs like this that have anticholinergic side effects may have a cumulative effect, leading to increased sedation or delirium. Drug-disease precautions include glaucoma, prostatic hypertrophy, asthma, COPD, and gastrointestinal obstruction. Tolerance may develop when used as a sleeping agent, causing reduced effect and resulting in patients increasing their dosages, with associated higher risks of adverse reactions. Caution is recommended when using this drug in elderly patients, especially those who take other central nervous system (CNS) depressants and/or anticholinergics. It should be avoided as a sleep aid in favor of better options.

The AGS also recommends that hypnotics (e.g., eszopiclone, zaleplon, zolpidem) should be avoided (without consideration of duration of use), particularly if any other CNS-active drugs are already prescribed. These drugs have adverse events in the elderly similar to benzodiazepines [4]. Liver impairment and concomitant alcohol use are relative contraindications. Again, prescribers should weigh the potential of a positive benefit to the patient versus the risk of an adverse event. After prolonged use, tapering of these medications is required to prevent withdrawal symptoms.

As noted, CMS regulations for long-term care facilities require psychotropic/antipsychotic drugs to be used only when necessary to treat a specific condition, as diagnosed and documented in the medical record and based on a comprehensive assessment of the resident [12]. The dosage of these medications should be gradually reduced until the lowest effective dose is established, unless clinically contraindicated. Of particular concern is the chemical restraint of elderly long-term care facility residents, which has resulted in increased scrutiny of psychotropic medication prescribing by state and federal regulatory agencies.

Typical (e.g., haloperidol, thorazine) and atypical antipsychotics (e.g., olanzapine, risperidone) are considered dangerous when used in patients with dementia, and the FDA has issued a black box warning that elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk for death (mainly due to cardiovascular or infectious causes) compared with placebo [45]. In terms of liability, the burden of proof lays with providers and caregivers to provide the documentation that the medication is medically necessary.

Antipsychotic medications are used to treat psychosis associated with bipolar disorder, schizophrenia, agitated depression, delusions, dementia, and paranoia. However, before prescribing antipsychotic drugs, any medical or toxic causes of the behavior should be ruled out. A thorough patient history, physical examination, and laboratory studies (e.g., complete blood count, comprehensive metabolic panel, urinalysis, drug levels) are indicated for differential diagnosis.

For residents in long-term care facilities, nonpharmacologic methods of behavior control should be attempted and documented before antipsychotics are initiated. As with any treatment, a risk-benefit analysis should be performed, and the patient's/caregiver's agreement to use the drug should be documented (Table 2).

Healthcare providers should work to promote and maintain the independence and mobility of patients with dementia without relying on antipsychotics. The first step for those in skilled nursing facilities is maintaining consistent staffing. Additional interventions should focus on maximizing independent activity and enhancing function while adapting and developing skills and may include:

Patient T is a man, 84 years of age, who resides in a long-term care facility. He has been diagnosed with congestive heart failure, hypertension, arthritis, and hyperlipidemia and has a history of two myocardial infarctions (eight and two years previously). He requires minimal assistance with his activities of daily living and remains ambulatory with a cane. His usual medications are:

At baseline, he takes 10 medications/supplements.

Patient T is transferred to the emergency department for increased shortness of breath. He is diagnosed with bronchitis and spends 24 hours in the hospital for observation before being transferred back to the long-term care facility for ongoing care. At the care facility, the receiving practitioner reviews the medication list from the hospital:

Including the as-needed medications, Patient T is currently prescribed 17 drugs. Physical assessment reveals an elderly debilitated man who is in no acute distress (Table 3). He is alert and oriented and answers questions appropriately. His intake of food and fluids has been poor since his return from the hospital, and he is using oxygen per nasal cannula at 2 L/minute.

As noted, Patient T's new diagnosis is bronchitis, and he does not appear to be having an exacerbation of his CHF. The first step in medication reconciliation is to discontinue any as-needed medications ordered in the hospital that are no longer necessary. Haloperidol is frequently used to treat delirium in geriatric patients in the hospital setting, but it is considered inappropriate for this use in long-term care facilities. Secondly, duration should be established for levofloxacin and prednisone. The receiving practitioner contacts the ordering physician and determines the levofloxacin should be continued for seven days and the prednisone continued for two weeks with a plan for tapering to discontinue. A pulmonary consultation follow-up is scheduled in two weeks, during which the pulmonologist will determine the duration of the inhalation drugs started during the hospitalization. The oxygen therapy was also acquired during the hospitalization, and serial oxygen saturation readings will be used to determine whether Patient T will require long-term oxygen therapy.

As discussed, the reduction or discontinuation of medications should be done cautiously, generally one medication at a time. The provider reviews the drugs the patient usually takes, evaluating for polypharmacy or any prescribing problems with the drugs ordered (Table 4).

When reconciling the medication regimen, the first step is to identify the clinical indication for each medication. There are no obvious inappropriate prescribing practices in Patient T's record, and in a patient with multiple comorbidities, polypharmacy may become the standard. However, attempts at medication reduction and discontinuation should be attempted.

His primary care provider discusses the medication regimen with the patient and his daughter, who is his healthcare surrogate. They express interest in attempting to reduce the number of medications Patient T is taking.

The provider discontinues tramadol and writes orders to taper off omeprazole by giving every other day for 10 days, then stopping. The aspirin dose is reduced to 81 mg every day, and the atorvastatin is reduced to 10 mg daily with a plan for serial lipid measurements.

The ongoing dosages of furosemide and potassium are determined by the level of heart failure. When patients decline and lose weight, adjustments to diuretic dosages are required to prevent subsequent dehydration. Older patients are at increased risk of falls and complications due to orthostatic hypotension, and if the patient is dehydrated, the effects are more profound and potentially dangerous. Measurement of orthostatic vital signs will help to determine the appropriate dosage of metoprolol, lisinopril, and even furosemide. After the reconciliation, omeprazole and tramadol are discontinued and the dosages of several drugs are reduced (Table 5).

Comments and Discussion : Mr. T's case shows an example of multiple comorbid conditions and polypharmacy. There are no obviously inappropriate drugs, and each medication has a clinical indication consistent with evidence-based medicine. This makes medication reduction and reconciliation difficult.

When medication regimens are adjusted, the patient should be monitored and re-evaluated regularly to detect any adverse reactions. In some cases, a trial dosage reduction or discontinuation of a medication, with close monitoring of the patient response, is necessary.

Medication reduction in the elderly should be done slowly and conservatively to prevent rebound effects. Manufacturer and FDA recommendations should be followed for tapering to reduce or discontinue medications. The provider must refer to packaging inserts and information.