• Define polypharmacy
• Describe age-related changes in drug metabolism
• Recognize delirium as a common adverse drug event
• List the side-effects of anticholinergic medications
• List prescribing practices that help reduce the risk of an adverse drug event in older adults

Angela R. Curtis, PhD
Managing Editor
Assistant Professor, Geriatric Education Manager

Kellie L. Flood, MD
Assistant Professor

Division of Gerontology, Geriatrics and Palliative Care
University of Alabama at Birmingham
Birmingham, Alabama

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

The term "polypharmacy" may be defined several different ways and may refer to:

• The use of many medications at the same time
• Prescribing more medication than is clinically indicated
• A regimen that includes at least one inappropriate medication
• The use of 5 or more medications.[1]

Mrs. M is an 80 year old African American woman who is a new patient to your office. She has a history of mild Alzheimer’s dementia, hypothyroidism, hypertension, recurrent UTIs, and depression. Her daughters brought her to see you for a second opinion. The patient has been experiencing diarrhea for the last 3 months, worsening weakness, falling, and increased confusion.

The family reports that Mrs. M moved into an assisted living facility about 1 year ago because of difficulty caring for herself at home. She is widowed had to quit driving several years ago due to episodes of getting lost and near accidents. After moving into the assisted living facility Mrs. M made new friends and seemed to adapt well at first. But four months ago Mrs. M complained of sadness, which she attributed to the deaths of several friends and relatives. Her prior physician started her on sertraline for depression. He scheduled her for follow-up in 3 months, but she returned to see him in 1 month because of diarrhea. She previously had a BM every 1-2 days, but now has 3-5 loose stools daily. There is no melena or hematochezia, and a thorough evaluation revealed no evidence of infection, metabolic abnormality, or malignancy. Three months ago she was prescribed clidinium/chlordiazepoxide (Librax) twice daily as needed for diarrhea. The diarrhea continued so her physician told her she could also take diphenoxylate/atropine (Lomotil) 1-2 tabs tid-qid prn diarrhea. One month ago she started having trouble making to the bathroom on time and had several episodes of fecal incontinence at night. She said that she just felt too weak to be able to rush to the bathroom. Her doctor added hyoscyamine (Levsin) at bedtime. The diarrhea has decreased to only twice a day and she still has no melena or hematochezia.

Her current medications are:
Aricept (Donepezil) 10mg po daily for 2 years
Synthroid (Levothyroxine) 0.05mg po daily for 5 years
Lasix (Furosemide) 40mg po daily for 1 year
KCl 10meq po daily for 1 year
Toprol XL (Metoprolol) 50mg po daily for 7 years
Bactrim DS (Trimethoprim/sulfamethoxazole) one tablet po daily for 1 year
Zoloft (Sertraline) 50 mg po daily for 5 months
Librax [Clidinium/chlordiazepoxide (Librium)] 1 tab bid prn for 3 months
Lomotil (Diphenoxylate/atropine) 1-2 tabs tid-qid prn for 2 months
Levsin (Hyoscyamine) one tab po qhs for 1 month

On physical exam Mrs. M is an elderly woman looking her stated age, slumped in wheelchair, generally lethargic, but in no acute distress, clean and well-groomed. Her vital signs are:

Wt 120 lbs., ht 5’5”, T 37.6, RR 18, HR 45
BP seated 130/70, standing 100/55 (with symptoms of lightheadedness)

Other notable findings include dry mucus membranes, normal thyroid exam, and bradycardia without murmurs. Abdominal exam reveals normal, active bowel sounds, moderately distended but non-tender with no hepatosplenomegaly. Rectal exam reveals no masses and guaiac negative brown stool. Neurologic exam reveals the patient is lethargic, arouses to voice, but is inattentive, oriented only to name. Cranial nerves are intact, muscle tone is normal without tremor, cogwheeling, or rigidity, and reflexes are 1+ symmetric throughout. The patient requires assistance of 2 people to stand, Romberg is positive with eyes open, and she is too lightheaded to walk.