Managing the medication portfolio and avoiding polypharmacy in the older adult.

MRS. G IS AN 83-YEAR-OLD WOMAN whom you started seeing one month ago. Her previous medical records are still in transit from New York, following her move to RI in order to live near her daughter. She presented with a known history of chronic atrial fibrillation, managed on Coumadin and Digoxin; hypertension on Toprol, Diovan and Norvasc; reflux disease on Nexium; congestive heart failure on Lasix; insomnia on Trazadone; hypothyroidism on Synthroid; and depression on Zoloft. She also takes over the counter Tylenol as needed for osteoarthritis, Benadryl as needed, a daily multivitamin and Calcium with vitamin D. She is adjusting well to the move, likes being near her daughter, and enjoys her new apartment on the East Side of Providence. She remains very independent, only requiring transportation assistance to get to the store to do grocery shopping. You discuss wanting to make her medication regimen simpler, but decide to wait for records from her previous physician; she agrees and is to return to the office in one month. Two weeks later, after a record-breaking Rhode Island summer heat wave, you receive a panicked call from the patient’s daughter after finding her mother on the floor in her apartment confused and disoriented, and in a pool of urine. She is rushed to the Emergency department for evaluation. Managing medications in the older adult becomes more complex; causes include 1) multiple underlying illness requiring intricate medications regimens, 2) multiple physicians – primary, specialist and sub-specialist prescribing medications, and 3) frequent use of over the counter or herbal remedies. In addition to large numbers of concurrently used drugs, prescribing medications for older adults is challenging due to the changes Division of Geriatrics Quality Partners of RI Department of Medicine EDITED BY ANA C. TUYA, MD