Polypharmacy; A Case-based Primer on the Practice in the

Geriatric Population Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing

medical education (CME) opportunities in subject areas mandated and suggested by the State of

Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the

St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance

with the Accreditation Council on Continuing Medical Education (ACCME).

This issue of Northeast Florida Medicine includes an article, “Polypharmacy; A Case-based Primer on the Practice in the Geriatric

Population” authored by Michael J. Schuh, PharmD, MBA, FAPhA, Haya S. Kaseer, PharmD, Robert P. Shannon, MD, FAAHPM,

and Jessica Peterson, PharmD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME

requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Michael J. Schuh, PharmD, MBA, FAPhA, Clinical Pharmacist, Assistant Professor of Family and Palliative Medicine, Assistant

Professor of Pharmacy, School of Health Sciences, College of Medicine, Mayo Clinic, Haya S. Kaseer, PharmD, Mayo Clinic, Robert

P. Shannon, MD, FAAHPM, Assistant Professor of Family and Palliative Medicine, Jessica Peterson, PharmD, Clinical Pharmacist,

Maine Medical Center

Objectives:

1. Identify patients at high risk for complications associated with polypharmacy.

2. Be able to create a plan of care to mitigate the risk of drug-drug interactions on behalf of the patient.

3. Be able to evaluate and counsel the patient who needs additional comprehensive medication management pharmacy

consultation.

Date of release: Sept. 1, 2018 Date Credit Expires: Sept. 1, 2020 Estimated Completion Time: 1 hour

How to Earn this CME Credit:

1) Read the “Polypharmacy; A Case-based Primer on the Practice in the Geriatric Population” article.

2) Complete the posttest. Scan and email your test to Kristy Williford at kristy@dcmsonline.org.

3) You can also go to www.dcmsonline.org/NEFMCME to read the article and take the CME test online.

4) All non-members must submit payment for their CME before their test can be graded.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a

certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a

certificate of credit/completion will be emailed within four weeks of submission. If you have any questions, please contact Kristy

Williford at 904-355-6561 or kristy@dcmsonline.org.

Faculty Disclosure:

Michael J. Schuh, PharmD, MBA, FAPhA, Haya S. Kaseer, PharmD, Robert P. Shannon, MD, FAAHPM, and Jessica Peterson,

PharmD report no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer

associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control

the content of this educations activity to disclose any real or apparent conflict of interest they may have as related to the content of this

activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies

mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care

recommendations.

Joint Sponsorship Accreditation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council

for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical

Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM

Physicians should only claim credit commensurate with the extent of their participation in the activity.

Polypharmacy; A Case-based Primer on the Practice in the Geriatric Population

Michael J. Schuh, PharmD, MBA, FAPhA,1 Haya S. Kaseer, PharmD,2 Robert P. Shannon, MD,

FAAHPM,3 and Jessica A. Peterson, PharmD4

1 Department of Pharmacy, School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, FL

2 University of Florida, College of Pharmacy, Gainesville, FL

3Department of Family and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, FL

4 Maine Medical Center, Portland, ME

Address correspondence to:

Michael J. Schuh, PharmD, MBA, FAPhA

Mayo Clinic

4500 San Pablo Road

Jacksonville, FL 32224

Phone: (904) 953-2673

Email: schuh.michael@mayo.edu

Abstract

Polypharmacy in the geriatric population is challenging for all caretakers involved. Those

patients often have a variety of comorbid medical conditions requiring numerous medications.

On occasion, these medications are no longer consistent with the treatment goals and can cause

serious side effects. Geriatric patients may benefit from the expertise of pharmacists who are

well-trained in pharmacology, pharmacokinetics and pharmacodynamics working in

collaboration with primary physicians in both the inpatient and outpatient setting. The authors

present a case-based primer on the principles of polypharmacy in the geriatric population.

Introduction to Polypharmacy

Polypharmacy is simply defined as “the administration of multiple medications concomitantly or

the administration of excessive medications.”1 Approximately 61 percent of individuals older

than 65 take at least one prescription medication, and most are taking an average of three,

exclusive of over-the-counter (OTC) medications or supplements.2

Another recent analysis found the prevalence of polypharmacy in the United States (defined as

≥8 medications) was 15.7 percent; females had a higher rate of polypharmacy than males.

Polypharmacy is most dominant in the southern region of the United States. Between 1988 and

2010, multiple medication use increased dramatically. The median number of prescription

medications used in adults aged ≥ 65 has doubled, and the proportion of adults taking five

medications or more has tripled from 12.8 percent to 39.0 percent.3,4

Clinical practice guidelines often recommend several medications to treat chronic disease.

Consequently, an elderly patient with at least two medical conditions, such as hypertension and

diabetes, will often be on more than five medications.5

Polypharmacy in the Elderly

Polypharmacy in the elderly is associated with increased healthcare expenses and emergency

room visits.6 Geriatric patients are at increased risk for adverse drug events due to drug

interactions, altered drug metabolism, or absorption from declining organ function. Medications

also contribute to increased fall risk in geriatric patients. It is estimated that 1 in 3 older adults

fall annually, associated with increased emergent care visits, increased cost, and death. Reducing

polypharmacy can reduce the number of falls and subsequent debility.7

Many elderly patients take medications without a clear indication. Often, drugs are not routinely

assessed for continued need. Examples include long term use of proton pump inhibitors for a

history of acid reflux, xanthine oxidase inhibitors for a distant episode of gout, and hormone

replacement therapy in patients long past menopause. Studies of community-based older patients

have documented an average of one unnecessary drug per patient, including drugs with no

identifiable current indication or those that provide marginal benefit for the disease indication.8

Additionally, the elderly often self-medicate, sometimes preferring supplements for health and

medical conditions.9 A recent study showed analgesics, vitamins and dietary supplements are

commonly self-administered by older adults. Dietary supplements may be viewed as benign by

patients and providers, but can have major interactions with prescription medications. This view

is problematic in the setting of polypharmacy and decreased organ function, and increases the

risk for drug interactions and adverse effects.10

Patient Centered Medical Home/Beers Criteria

The Patient Centered Medical Home (PCMH) is a healthcare delivery model recognized to

improve the quality and efficiency of care while responding to each patient’s unique needs. This

model focuses on a team approach, incorporating physicians, nurses, social workers, and

pharmacists. The PCMH provides comprehensive, patient-centered care, including acute care,

chronic condition management, and preventative services to patients from childhood to end of

life.11,12

The Beers Criteria is an evidence-based list of medications from The American Geriatric Society

which helps identify the risk level of certain medications that can cause harm to elderly patients.

The list includes common drug-drug interactions associated with harmful outcomes, and

identifies drugs to avoid in patients with kidney impairment. A clinician can use this list to

monitor medication use and recommend discontinuation, dose adjustments, and/or increased

monitoring.13

Pharmacy Medication Management: The Evolving Role of Pharmacist

Numerous studies demonstrate the benefits of clinical pharmacist interventions in the setting of

polypharmacy.7, 14,15,16, 17 Medication therapy management (MTM) clinically integrates

pharmacists in the PCMH in a variety of practice models. Physicians may be time-limited during

office visits and unable to address polypharmacy or conduct comprehensive medication reviews.

MTM is a comprehensive, patient-centered service that can enhance therapeutic outcomes while

ensuring individualized care. MTM provides face to face patient education to review medication

use, simplify medication regimens, and improve adherence.

MTM focuses on improving the quality of care in elderly patients, utilizing clinical guidelines

and patient goals. The pharmacist reviews the patient’s medications, counsels the patient on

proper administration and management of side effects, and educates the patient on non-

pharmacological interventions. The pharmacist identifies potential concerns, and reviews the

medical and relevant drug history to suggest a plan that meets the patient’s goals. After

composing the recommendations, the pharmacist discusses modifications with the physician to

improve quality of life and prevent potential complications.

The role of the pharmacist is especially significant in chronic disease management. The

pharmacist ensures that the patient understands short-term and long-term treatment goals,

therapeutic monitoring, and possible adverse effects, and can alleviate patient knowledge gaps in

understanding when complex treatments have been initiated by multiple physicians.18

Medication Reconciliation

Medication errors frequently occur during transitions of care. Errors result when patients can’t

recall home medications, and when records are unavailable.

Medication reconciliation is a required process of creating a medication list for a patient during

transitions of care. Medication reconciliation reduces the incidence and severity of medication

errors during both prescribing and dispensing. Maintaining an up-to-date list and accounting for

medication changes at every appointment helps to reduce inadvertent medication errors, and

harm to the patient.19,20

Screening tools are helpful in preventing medication errors in the elderly. The screening tool of

older people's prescriptions (STOPP) and screening tool to alert to right treatment (START)

criteria recognize the dual nature of inappropriate prescribing by including a list of potentially

inappropriate medications (STOPP criteria) and potential prescribing omissions (START

criteria).21 Potentially inappropriate medications identified by STOPP criteria include digoxin,

beta blocker with history of COPD, TCA with dementia, long-acting benzodiazepines, and

prolonged use of first generation antihistamines.22 Potential prescribing omissions, defined as

treatments indicated but not prescribed, by START criteria include ACE inhibitor following

acute myocardial infarction, ACE inhibitor in chronic heart failure with no existing

contraindications, statin therapy in patients with documented history of cardiovascular events,

and ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy.23 There is no

evidence that using the START/STOPP criteria reduces morbidity, mortality, or cost in the

geriatric population. However, these criteria may identify opportunities for better patient

prescribing practices.24

Comprehensive Geriatric Assessment

The geriatric assessment is a multidimensional tool intended to gather information on the

medical, psychological, social, and functional abilities and restrictions of the elderly population.

Areas to assess include current symptoms and their functional influence, current medications

along with indications and effects, past allergies and medical conditions, recent life changes,

current caregiver network, measure of cognitive function, nutritional status, and services

required. It is important to inquire about demographics, patient’s chief complaint and present

illness, past medical history, social history, daily nutritional health, physical activity, sleep

hygiene, and recreational activities. It is useful to perform regular physical examinations and

laboratory tests, and a thorough review of systems for every elderly patient.25

Opioids and Controlled Substance Treatment Plans

Opioids are listed on the Beers Criteria due to increased risk for falls, fractures, and potential

interaction with other psychotropic medications. Despite this recommendation, elderly patients

are frequently prescribed chronic opioids for nonmalignant pain. The use of prescription opioids

has increased in older adults in the United States.26, 27, 28

The elderly are at risk for adverse drug events due to opioid use, and they are not immune to

opioid misuse and overdose. Compassionate care requires a delicate balance of undertreating

pain and inappropriate prescribing. If opioids are deemed appropriate for long term use,

providers must discuss benefits and risks, including side effects and potential for dependence or

addiction.

Controlled Substance Treatment Plans should be formulated between the patient and physician,

including goals of treatment, with a schedule for periodic evaluations. Non-pharmacologic

treatments should be considered as alternatives or in conjunction with medications. Treatment

plans should outline appropriate medication use and define medication misuse. Providers should

address other medications that can interact with opioids and efforts should be made to minimize

other central nervous system (CNS) modulating medications.28

Palliative Care

Polypharmacy is common in patients at end of life. There is little guidance on appropriate

discontinuation of medications in the setting of palliative care. The pharmacist and members of

the palliative care interdisciplinary team should focus the conversation on the wishes of the

patient and family, and create a plan of care consistent with the notion of “assess, anticipate and

alleviate suffering.” All modalities aimed at comfort, including those on the Beers Criteria

should be considered and offered; all other treatments should become elective or discontinued.29

Continuing unnecessary medications can increase harm to patients and add to the burden of

polypharmacy, and providers should highlight the disadvantages of continuing medications.30

Medications such as aspirin or statins are particularly important in palliative care discussions.

Specialty-based

Geriatrics: Geriatric patients are often cared for by multiple specialists. When care is not

coordinated between each provider, patients are at risk for polypharmacy, duplications in

therapy, drug interactions and increased side effects.31

Oncology: Cancer progression and treatment affect the overall quality of life, functioning, and

life expectancy of older adults. Polypharmacy is a serious concern in cancer patients.32

Chemotherapy agents are associated with several adverse effects, including gastrointestinal

abnormalities, peripheral neuropathy, hand and foot syndrome, and hypersensitivity reactions. In

the setting of polypharmacy, toxicity and adverse effects may increase due to drug-drug

interactions or metabolism-induced complications. This can lead to lack of adherence, treatment

failure and suffering. A patient’s medications should be evaluated thoroughly to avoid

therapeutic barriers and adverse consequences.

Neurology & Psychiatry: With each amendment of the Beers Criteria, there is a greater focus on

antipsychotics, benzodiazepines, tricyclic antidepressants, opioids, and other CNS-impacting

agents. Polypharmacy with multiple of these medications is risky and dangerous.28 When

managing mental health and controlling pain in the elderly, it is imperative to evaluate each

patient’s medications and ensure the use of CNS-impacting agents is limited to what is truly

needed. Subjective assessment of a patient’s mental and pain status is essential to manage these

medications, including listening to caregivers in patients with cognitive impairment.

Cardiology: Hypertension, atrial fibrillation, and heart failure are some chronic disease states

commonly seen in the geriatric population necessitating the use of anti-hypertensives, nitrates,

antiplatelets drugs, and anticoagulants. Cardiac medications have risks of bleeding, orthostatic

hypotension, bradycardia, and falls that are often seen in the geriatric population. Therefore,

polypharmacy requires special attention to ensure appropriate medications are prescribed, and

adverse effects are managed. Patient education and monitoring are crucial to achieving treatment

goals.

Case Introduction

Case #1

Demonstrates the diversity of symptoms resulting from polypharmacy.

Illustrates how fragmented care contributes to polypharmacy.

Shows the “multiplier effect” of iatrogenic symptoms.

A 64-year-old female presented to her pulmonologist for evaluation of dyspnea. Her

medications included diclofenac, cyclobenzaprine, and hydrocodone/acetaminophen from her

chronic pain physician, clonazepam, nortriptyline, and duloxetine from her psychiatrist, and

topiramate, gabapentin, and cetirizine from her primary care physician. The patient also had

chronic renal disease, cognitive impairment, six falls over several months, anxiety, mydriasis,

episodes of sweating, nausea, and occasional myoclonic jerks and tremor. She was unmotivated

to exercise or socially engage, was anemic, and gained 20 pounds over the last year.

Case #2

Illustrates the importance of screening for potential medication-medication and

medication-nutrition interactions.

Demonstrates the importance of respecting a patient’s autonomy and goals of care.

Identifies necessary dose modifications in the setting of impaired renal function.

A 71-year-old female was referred for a comprehensive medication review with a pharmacist by

her family physician. Her chief concerns included feeling fatigued and depressed. She reported

dizziness, nausea, acid reflux, and “wanted to stay in bed all day.” Her blood pressure was

significantly elevated with systolic readings in the 170-180’s.

Her past medical history was significant for undifferentiated connective tissue disease,

uncontrolled hypertension, renal dysfunction, and hypothyroidism. Current medications include

apixaban, atorvastatin, calcium carbonate, carvedilol, chlorthalidone, hydralazine,

hydroxychloroquine, levothyroxine, nitrofurantoin, prednisone, spironolactone, tramadol, ferrous

sulfate, and vitamin B complex.

Thyroid-stimulating hormone and calcium levels were elevated. Patient reported taking her

levothyroxine one hour apart from her ferrous sulfate. She wished to stop as many medications

as possible and was not agreeable to starting additional medications for hypertension.

Case #3

Illustrates the positive impact of de-prescribing.

Demonstrates role of judicious and appropriate use of comfort medications even if on the

Beers Criteria list.

Shows the need for earlier palliative care interventions.

A 76-year-old female who was in transit from Virginia to St. Augustine, Florida was seen in the

palliative medicine clinic following an overnight observation in the emergency department for

acute altered mental status superimposed on advanced dementia, renal impairment, hypertension,

hyperlipidemia, osteoarthritis, sarcopenia, anemia, weight loss, acute urinary retention, and

constipation. She was on several medications including a diuretic, a statin, and donepezil. The

patient was hallucinating intermittently, frequently agitated, and seemed to be in pain. Beyond

“sundowning,” she had sleep-wake cycle disruption. The physical exam showed advanced

dementia with poor functional capacity: she was wheelchair bound and incontinent of urine and

feces with very little verbal capacity.

Resolution of Case Presentations

Case #1

The clinical pharmacist MTM suggestions:

Taper to stop the scheduled clonazepam and use lorazepam only for acute anxiety

attacks. Clonazepam has an extended half-life in the elderly and through accumulation is

additive with other CNS depressants, contributing to fall risk, depression, respiratory

depression and dyspnea.

Taper down gabapentin and topiramate doses since glomerular filtration rate (GFR) is 50

mL/min, to prevent reduced cognition and additive CNS/respiratory depression.

Minimize all serotonergic medications if possible, (duloxetine, cyclobenzaprine,

nortriptyline) as patient exhibited possible signs of serotonin toxicity.

Consider recommended sleep hygiene protocol or alternative agents for

depression/sleep; current therapy may be ineffective.

Dyspnea may be multifactorial. Deconditioning, added weight, and respiratory

depression from multiple medications are likely contributory factors.

Refer patient to the pain rehabilitation clinic (PRC) for overall taper of pain and CNS

depressive medications to lowest possible dose or discontinuation.

The pulmonologist suggested that the patient and her primary physicians follow the pharmacist

recommendations. After enrollment into a PRC, the above recommendations were followed, and

following the 21-day program, the total prescription and over-the counter medication count was

reduced from 19 to 7.

Case #2

The clinical pharmacist MTM suggestions:

Maximize doses of current antihypertensives instead of adding additional agents.

Recommended home blood pressure monitoring, lifestyle modifications, and appointment

with registered dietician.

Separate levothyroxine and ferrous sulfate administration by at least four hours. Recheck

Thyroid-Stimulating Hormone (TSH) in six weeks.

Take tramadol only as needed. Tramadol requires dosing adjustments in patients with

impaired renal function. The active metabolite of tramadol is excreted in the kidney and

the half-life may be prolonged in patients with renal dysfunction, leading to increased

CNS depression, somnolence and fatigue. Augment analgesia with acetaminophen if

needed.

Elevated calcium may contribute to nausea. Stop calcium carbonate use for reflux

symptoms. Utilize non-pharmacologic methods or ranitidine. Check parathyroid

hormone. Consider withdrawal of chlorthalidone if serum calcium is still elevated.

Nitrofurantoin is not recommended with patient’s current renal function impairment;

however, she was convinced this medication prevented UTIs which reoccurred whenever

she discontinued use in the past. Therefore, in this case it was continued.

Consider wean off prednisone which can contribute to CNS symptoms and increase blood

pressure. Patient was unsure of clinical indication or efficacy.

After discussion with the primary provider, the patient’s hydralazine dose was increased. Patient

reduced tramadol use and added acetaminophen. She had a consultation with a registered

dietician and blood pressure normalized. Repeat TSH was within normal limits.

Case #3

Fortunately, despite the advanced dementia, the patient had valid documentation of advance care

planning including designation of healthcare surrogate and a living will declaring her wish to

“allow a natural death” while focusing on comfort care.

Deprescibing is a thoughtful process of discontinuing medications especially pertinent in the case

when the patient’s survival time wanes.33 After discussion with the family on the risk/benefit

ratio, potential for drug-induced harm, and ways to stay consistent with her primary goal of

comfort, the family concurred that she no longer needed the diuretic, statin or donepezil; hence,

all were discontinued.

To attend to the patient’s agitation and sleep/wake cycle disruption, a very low dose of

quetiapine was combined with low dose mirtazapine at bedtime. Oxycodone for arthritic pain

was offered simultaneously with constipation mitigation strategies, and a referral for hospice was

accomplished. She perked up cognitively for a few days and then died with her family at her

side. While the patient’s wishes were articulated on paper, she was not afforded timely counsel

to focus earlier on comfort goals, exposing her to potential missed opportunities of life, pain, and

existential suffering.

Authors’ Recommendations:

Evaluate and treat the problems that the patient declares important.

Review completely the medication list for safety and efficacy.

Create plan of care consistent with patient/surrogate goals.

Assess benefits versus burdens, alternatives and probabilities of reaching individual goals.

Recommend for or against implementation, continuation or discontinuation.

Reassess periodically for achievement of goals.

Ask for help at every step in the process as needed.

Conclusion

Polypharmacy in geriatric patients is a common issue leading to poorer health outcomes,

increased costs and decreased quality of life. Primary care providers need to be aware of the

unique characteristics of the geriatric population, including altered organ function, impaired drug

clearance, and cognitive impairment. Providers should also attempt to advocate and coordinate

the multiple recommendations from specialist providers in the geriatric population. A

multidisciplinary approach, utilizing all the specialized skill sets of various healthcare providers,

including pharmacists and palliative care physicians, can be helpful in identifying medication

related issues, managing polypharmacy, and streamlining regimens for patients’ preference and

treatment goals. Ultimately, the patient’s treatment goals should be respected while maintaining

the safest and most efficacious care possible.

References

1. Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: Misleading, but manageable. Clin Interv

Aging. 2008 Jun; 3(2):383–89.

2. Prybys K, Melville K, Hanna J, et al. Polypharmacy in the elderly: Clinical challenges in emergency

practice: Part 1: overview, etiology, and drug interactions. Emerg Med Rep. 2002 May 19;23(11):145–53.

3. Cashion W, McClellan W, Howard G, et al. Geographic region and racial variations in polypharmacy in the

United States. Ann Epidemiol. 2015 Jun;25(6):433-438.e1.

4. Charlesworth CJ, Smit E, Lee DSH, et al. Polypharmacy among adults aged 65 Years and older in the

United States: 1988–2010. Journals Gerontol A Biol Sci Med Sci. 2015 Aug;70(8):989-95.

5. Maher RL, Hanlon JT, Hajjar ER. Clinical Consequences of Polypharmacy in Elderly. Expert Opin Drug

Saf. 2014 Jan;13(1):10.1517/14740338.2013.827660.

6. Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the

pharmacist. Drugs Aging. 2003;20(11):817-32.

7. Fritsch MA, Shelton PS. Geriatric polypharmacy: pharmacist as key facilitator in assessing for falls risk.

Clin Geriatr Med. 2017 May;33(2):205-23.

8. Steinman MA, Hanlon JT. Managing medications in clinically complex elders “There's got to be a happy

medium.” JAMA. 2010 Oct 13;304(14):1592-1601. doi:10.1001/jama.2010.1482

9. Pitkälä KH, Suominen MH, Bell JS. Herbal medications and other dietary supplements. A clinical review

for physicians caring for older people. Ann Med. 2016 Dec;48(8):586-602.

10. Locquet M, Honvo G, Rabenda V, et al. Adverse health events related to self-medication practices among

elderly: a systematic review. Drugs Aging. 2017 May;34(5):359-365.

11. Patient-Centered Primary Care Collaborative. Defining the medical home [Internet]. 2017 [cited 2017 May

19]. Available from: https://www.pcpcc.org/about/medical-home.

12. AAFP. The patient-centered medical home (PCMH) [Internet]. 2017 [cited 2017 May 19]. Available from:

http://www.aafp.org/practice-management/transformation/pcmh.html.

13. American Geriatrics Society Beers Criteria Update Expert Panel: Updated Beers criteria for potentially

inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227–46.

14. Wong LY, Chua SS, Husin AR, et al. A pharmacy management service for adults with asthma: a cluster

randomized controlled trial. Fam Pract. 2017 Sep 1;34(5):564-73.

15. Fera T, Bluml BM, Ellis WM. Diabetes ten city challenge: final economic and clinical results. J Am Pharm

Assoc. 2009 May-Jun;49(3):383-91.

16. Isetts BJ, Schondelmeyer SW, Artz MB, et al. Clinical and economic outcomes of medication therapy

management services: the Minnesota experience. J Am Pharm Assoc. 2008 Mar-Apr;48(2):203–211.

17. Ramalho de Olivera D, Brummel AR, Miller DB. Medication therapy management:10 Years of experience

in a large integrated health care system. J Manag Care Pharm. 2010 Apr;16(3):185-95.

18. Bluml BM. Definition of medication therapy management: development of profession wide consensus. J

Am Pharm Assoc. 2005 Sep-Oct;45(5):566-72.

19. Agency for Healthcare Research and Quality. Medication reconciliation. 2017 Jun [cited 2017 Jun 29].

Available from: https://psnet.ahrq.gov/primers/primer/1/medication-reconciliation.

20. Simone A. Pharmacists key to improving medication reconciliation. Pharmacy Times. 2014 Feb 24.

21. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate

prescribing in older people: version 2. Age Ageing. 2015;44(2):213-8.

22. 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. Age Ageing.

2008 Nov;37(6):673-9.

23. Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment) ― an

evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007

Nov;36(6):632-8.

24. Therapeutic Research Center. PL detail-document #270906, STARTing and STOPPing medications in the

elderly. Pharmacist’s letter/prescriber’s letter. [Internet]. 2011 Sep. Available from:

https://www.ngna.org/_resources/documentation/chapter/carolina_mountain/STARTandSTOPP.pdf.

25. Comprehensive Geriatric Assessment [Internet]. Boston (MA): Tufts University; 2017 [cited 2017 May 9].

25 p. Available from: http://ocw.tufts.edu/data/42/499797.pdf.

26. Olfson M, Wang S, Crystal S, et al. National trends in the office-based prescription of schedule II opioids. J

Clin Psychiatry. 2013 Sep;74(9):932-9.

27. Gerlach LB, Olfson M, Kales HC, et al. Opioids and other central nervous system–active polypharmacy in

older adults in the United States. J Am Geriatr Soc. 2017 Sep;65(9):2052-56

28. Maust DT, Gerlach LB, Gibson A, et al. Trends in central nervous system–active polypharmacy among

older adults seen in outpatient care in the United States. JAMA Intern Med. 2017 Apr 1;177(4):583-5.

29. Geijteman ECT, Dees MK, Tempelman MMA, et al. Understanding the continuation of potentially

inappropriate medications at the end of life: perspectives from individuals and their relatives and

physicians. J Am Geriatr Soc. 2016 Dec;64(12):2602–4.

30. McNeil MJ, Kamal AH, Kutner JS, et al. The burden of polypharmacy in patients near the end of life. J

Pain Symptom Manage. 2016 Feb;51(2):178–183.e2.

31. Rambhade S, Chakarborty A, Shrivastava A, et al. A Survey on Polypharmacy and Use of Inappropriate

Medications. Toxicol Int. 2012 Jan-Apr;19(1):68-73.

32. Lichtman S, Hurria A, Jacobsen P. Geriatric oncology: an overview. J Clin Oncol. 2014 Aug

20;32(24):2521-2.

33. Pruskowski J. Fast Facts and concepts # 321 [Internet]. 2016 Sep [cited 2017 Jul 10]. Available from:

https://www.mypcnow.org/copy-of-fast-fact-320. accessed July 10, 2017.

Post-Test

1. Which of the following most accurately describes polypharmacy?

a. Polypharmacy has a higher prevalence in female patients

b. Polypharmacy is a condition defined as taking greater than three medications.

c. Polypharmacy is easy to recognize.

d. Polypharmacy occurs at a higher rate in the Northwestern region of the United States.

2. Which statement is most accurate in regards to the Beers Criteria?

a. The Beers Criteria is a list of drugs to absolutely avoid in the geriatric population.

b. Drugs on the Beers Criteria list need to be avoided as a priority even in the setting of palliative

care.

c. The Beers Criteria is an evidence-based list to help clinicians identify the risk level of

medications.

d. The Beers Criteria lists alcohol-drug interactions as a strategy to moderate geriatric alcohol

consumption.

3. Medication Therapy Management is best described as:

a. It is a federally mandated program of the Affordable Care Act.

b. Another governmental intrusion of health care professionals into primary care.

c. A strategy that has been show to be beneficial in the setting of polypharmacy.

d. A shifting of responsibility of care to the pharmacists.

4. Whose job is it to ensure optimal care?

a. The pharmacist

b. The patient

c. The family

d. The physician

e. All of the above

5. In caring for a geriatric patient with multi-morbidity and polypharmacy, which strategies are

reasonable?

a. Reduction of dose

b. Elimination of the medication

c. In-patient or outpatient Pain Rehabilitation/treatment

d. Medication Therapy Management consultation

e. All of the above

6. Which of the following is true regarding benzodiazepines in geriatric patients?

a. Benzodiazepines must be avoided in geriatric patients as mandated by recent federal mandates.

b. Benzodiazepines can be used when the patient is appropriately evaluated, and the clinical

indication is clearly noted while used for the shortest duration and at the lowest dose.

c. Benzodiazepines should never be used in palliative care unless the patient is enrolled in hospice.

d. Benzodiazepine prescriptions should only be written by psychiatrists.

7. When treating patients for a given problem (for example; hypertension), it is reasonable and

preferable) to escalate the dose of a single medication rather than adding another medication:

a. Never

b. Most of the time

c. Some of the time.

d. Only when necessary.

8. An 80-year-old patient with acquired hypothyroidism cannot seem to keep her TSH in the

therapeutic zone (too high). A gastroenterologist recently added a new suggestion to her

treatment of non-specific non-ulcer dyspepsia. Which is the culprit?

a. Ranitidine

b. Famotidine

c. Cimetidine

d. Aluminum Hydroxide/Magnesium Carbonate

9. A 92 year-old gentlemen with advanced dementia who is now nonverbal, bed bound, incontinent

of bowel and bladder has recently stopped swallowing. Fortunately, his advance care

plan/living will (which is well written and previously documented in the electronic health

record) states that comfort measures as deemed by spouse, doctors, and hospice team are to

be maximized. Treatments to consider include: a. Morphine elixir for respiratory distress and pain.

b. Benzodiazepines for agitation.

c. Non-pharmacological strategies.

d. Massage & aromatherapy

e. All palliative strategies even if on Beers Criteria

f. All of the above

10. Screening tools to assist clinicians include:

a. START/STOPP

b. MAYBE

c. Beers Criteria

d. Controlled Substance Agreements