Course Case Studies

Geriatric Polypharmacy

Course #99022 - $30 -

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    • Review the course material online or in print.
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    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Learning Tools - Case Studies


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:

  • Serious and potentially fatal cardiovascular and thrombotic events, including myocardial infarction and stroke

  • Serious adverse gastrointestinal events such as bleeding, ulcer, and intestinal perforation (higher in elderly patients)

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.

Learning Tools - Case Studies


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.

Learning Tools - Case Studies


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:

  • Metoprolol ER: 50 mg daily

  • Aspirin: 325 mg daily

  • Omeprazole: 20 mg daily

  • Lisinopril: 10 mg daily

  • Furosemide: 40 mg every day

  • Potassium chloride: 20 mEq twice daily

  • Atorvastatin: 20 mg daily

  • Acetaminophen: 650 mg twice daily

  • Tramadol: 50 mg, as needed

  • Multivitamin

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:

  • Levofloxacin: 500 mg daily

  • Prednisone: 20 mg daily

  • Tiotropium bromide, inhalation: One puff daily

  • Levalbuterol tartrate, inhalation solution for nebulizer: As needed for shortness of breath

  • Promethazine: 25 mg every six hours as needed

  • Haloperidol: 1 mg every four hours as needed

  • Bisacodyl: 10 mg every day as needed

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.


Blood pressure112/62 mm Hg
Temperature97.8° F
Heart rate92 beats per minute
Respiration rate22 breaths per minute
Height5 feet 9 inches (175 cm)
Weight65.3 kg (144 pounds) (usual: 154 pounds)
Heart soundsS1, S2 with 2/6 systolic ejection murmur
Lung soundsFew expiratory wheezes noted anteriorly
ExtremitiesNo significant edema

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).





Considerations for Reduction
or Discontinuation of Drugs
Metoprolol extended-release (50 mg daily)HypertensionNoIf blood pressure or heart rate fall, or symptoms of orthostasis or hypotension occur, dosage reduction should be considered.
Aspirin (325 mg daily)Heart diseaseYesLowest effective dose. Would 81 mg dose be as effective with less risk of gastrointestinal (GI) bleeding?
Omeprazole (20 mg daily)GastritisYesPossibility that this may no longer be necessary if given for an acute episode. Consideration for GI prophylaxis related to steroids and/or aspirin.
Lisinopril (20 mg daily)Congestive heart failure, hypertensionNoACE inhibitor should be part of treatment plan for patients with congestive heart failure. Renal function must be monitored.
Furosemide (40 mg daily)Congestive heart failureYesConsideration of the lowest effective dose. During acute illness (except congestive heart failure), especially with dehydration, dose reduction or holding dose may be appropriate.
Potassium chloride (20 mEq [oral] daily)ReplacementNoPotassium levels should be monitored, with adjustment of dose as required.
Atorvastatin (20 mg daily)HyperlipidemiaYesLimited evidence base for use of statins in patients older than 80 years of age. Comorbid heart disease is an important consideration. Monitoring of lipid levels and liver function levels guides treatment.
Acetaminophen (650 mg [oral] twice daily)ArthritisNo1,300 mg of acetaminophen daily is well below the maximum recommended dose. Caution when used with alcohol or other drugs metabolized by the liver.
Tramadol (50 mg every four hours as needed)PainYesNot used regularly.
Multivitamin (1 tablet daily)SupplementNoThis was started because the patient had weight loss and poor intake of food and fluid. The nutritional support could potentially help.

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).


Metoprolol extended-release (25 mg daily)Patient was experiencing some orthostasis with position changes that placed him at risk for falls. The daily dose was reduced to 25 mg, which helped normalize the blood pressure readings while still providing the benefits of a beta-blocker.
Enteric-coated aspirin (81 mg daily)Dosage was reduced due to risk of bleeding.
Lisinopril (10 mg daily)Dose was reduced to the lowest effective dose, and blood pressure improved.
Furosemide (20 mg daily)Dosage reduced as the patient's heart failure was stable. Chest x-ray clear, no edema.
Potassium chloride (20 mEq [oral] daily)As the furosemide is reduced, the potassium dosage can be reduced, with follow-up testing ordered to monitor levels.
Atorvastatin (10 mg daily)When tested, the cholesterol was 159 mg/dL, so the dosage was reduced.
Acetaminophen (650 mg twice daily)This helped with his arthritis pain, so it was continued for pain management.
Multivitamin (1 tablet daily)This was continued for nutritional support.

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.

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.