Symptomatic polypharmacy

Specialty: Geriatrics.

• iatrogenic prescription cascade
• cumulative pharmacological toxicity
• overmedication syndrome in the elderly
• adverse effects due to polypharmacy

Why it occurs

• Prescription of new drugs to treat unrecognized side effects of already active medications (prescription cascade)
• Duplication of active ingredients due to fragmented care by multiple medical specialists without a care coordinator
• Physiological pharmacokinetic changes of aging, characterized by decreased lean body mass, increased body fat, and reduced renal and hepatic functions
• Self-medication with over-the-counter analgesics (NSAIDs) or phytotherapy products that interact with prescribed medication
• Lack of structured review and active deprescription plans for chronic treatments

Initial workup

Systematic therapeutic reconciliation of all the medication the patient takes; application of the Beers Criteria (American Geriatrics Society) and the STOPP/START Criteria to identify potentially inappropriate prescriptions; estimation of creatinine clearance using the Berlin formula or CKD-EPI adapted to the elderly; blood analysis with plasma levels of drugs with a narrow therapeutic range (digoxin, lithium, phenytoin), electrolytes (sodium, potassium) and liver and kidney function parameters.

Standard management

• Gradual and monitored withdrawal of potentially inappropriate drugs — for example, progressive tapering of long half-life benzodiazepines such as diazepam by reducing the dose by 10% to 25% every 1-2 weeks to avoid withdrawal syndrome
• Omeprazole — 20 mg orally per day as a protector of the gastric mucosa only if there is a strict indication for concomitant treatment with double antiplatelet therapy or anticoagulation plus antiplatelet therapy, discouraging its systematic use due to the risk of infections and osteoporotic fractures
• Downward adjustment of the doses of loop diuretics according to the patient's hydration status and fluid balance.