What are the potential risks and management strategies for a 60-year-old patient taking multiple medications, including pain relievers, antihypertensives, and mental health medications?

Medication Review for 60-Year-Old Patient with Polypharmacy

This patient requires immediate deprescribing of high-risk medications, particularly the dangerous combination of ibuprofen 800mg every 6 hours, lorazepam, and trazodone, which collectively increase risks of falls, bleeding, cognitive impairment, and mortality. 1, 2

Critical High-Risk Medications Requiring Immediate Action

Concurrent NSAIDs (Ibuprofen + Diclofenac)

• Discontinue one NSAID immediately - this patient is taking both ibuprofen 800mg every 6 hours (3200mg daily) and topical diclofenac, creating excessive NSAID exposure 1, 3, 4
• The combination increases risk of GI bleeding, renal toxicity, cardiovascular events, and hypertension exacerbation - particularly dangerous given this patient's hypertension requiring triple therapy (clonidine, hydrochlorothiazide, amlodipine) 1, 3
• NSAIDs reduce the efficacy of ACE-inhibitors, diuretics (hydrochlorothiazide), and can cause fluid retention that worsens blood pressure control 3
• Replace with scheduled acetaminophen 650mg every 6 hours (maximum 3250mg daily) for mild-to-moderate musculoskeletal pain, which is safer in elderly patients 1, 5
• If NSAIDs are absolutely necessary, use the lowest effective dose of a single agent for the shortest duration, with baseline and every 3-month monitoring of blood pressure, BUN, creatinine, liver function, CBC, and fecal occult blood 1, 3

Benzodiazepine (Lorazepam 0.5mg Twice Daily)

• Initiate gradual taper using the EMPOWER protocol - educate about risks (falls, cognitive impairment, habituation, withdrawal syndromes), discuss tapering benefits, obtain patient agreement 1, 5
• Reduce dose by 25% every 1-2 weeks to prevent life-threatening withdrawal including seizures, delirium tremens, rebound anxiety, and hallucinations 1, 5
• Never abruptly discontinue - benzodiazepine withdrawal carries greater risks than opioid withdrawal 5
• Replace with cognitive-behavioral therapy for anxiety or consider SSRIs/other non-benzodiazepine antidepressants if anxiety disorder requires pharmacotherapy 5
• Benzodiazepines cause sedation, cognitive impairment, unsafe mobility with injurious falls, motor skill impairment, and are particularly dangerous in patients over 60 years 1

Trazodone 50mg at Bedtime

• Taper gradually if discontinuing - abrupt discontinuation causes withdrawal syndrome 6
• Monitor for increased bleeding risk given concurrent NSAID use, as trazodone combined with drugs that interfere with serotonin reuptake increases bleeding risk 6
• If sleep is the primary indication rather than depression, consider cognitive-behavioral therapy for insomnia as first-line, which also increases benzodiazepine tapering success rates 5
• Alternative non-pharmacologic strategies include prayer, massage, aromatherapy, music therapy, and multisensory stimulation 5

Cardiovascular Medication Optimization

Triple Antihypertensive Therapy Assessment

• This patient takes clonidine 0.1mg every 12 hours, hydrochlorothiazide 50mg daily, and amlodipine 5mg daily - evaluate whether triple therapy is necessary or if regimen complexity can be reduced 1, 2
• Simplify to once or twice daily dosing whenever possible to improve adherence 2
• NSAIDs (ibuprofen, diclofenac) directly antagonize antihypertensive effects and can cause hypertension to develop or worsen - discontinuing NSAIDs may allow reduction in antihypertensive medications 1, 3
• Monitor blood pressure closely after NSAID discontinuation to assess need for continued triple therapy 3

Atorvastatin 20mg at Bedtime

• Continue if aligned with patient's life expectancy and goals of care 2
• Consider discontinuation if estimated life expectancy is shorter than time to cardiovascular benefit, focusing instead on symptom control 2

Pain Management Strategy

Current Regimen Problems

• Acetaminophen 650mg every 6 hours (2600mg daily) PLUS ibuprofen 800mg every 6 hours (3200mg daily) PLUS topical diclofenac represents excessive analgesic burden 1
• Consolidate to scheduled acetaminophen 650mg every 6 hours as the safest option for chronic musculoskeletal pain in elderly patients 1, 5
• Reserve topical diclofenac for targeted joint pain (lower left extremity as prescribed) but discontinue oral ibuprofen 4
• Warn patient to avoid sun exposure on treated knee due to increased risk of ultraviolet light-induced skin damage with topical diclofenac 4

Medication Regimen Complexity Reduction

Dosing Schedule Consolidation

• Current regimen requires 11 different dosing times across 24 hours - this excessive complexity predicts nonadherence, adverse reactions, and hospital readmission 1, 7, 8, 9
• Medication Regimen Complexity Index (MRCI) scores ≥8 predict increased risk for adverse drug event-related readmission 9
• Consolidate to 4 standardized daily time intervals (morning, midday, evening, bedtime) using universal medication schedule principles 8
• Patients with limited literacy particularly struggle to consolidate regimens efficiently - provide written instructions with specific times rather than vague directions like "twice daily" 8

Specific Consolidation Recommendations

• Morning (8:00-9:00): Advair, hydrochlorothiazide, clonidine (if continuing during taper)
• Midday (12:00-13:00): Acetaminophen
• Evening (18:00-19:00): Acetaminophen, clonidine (if continuing during taper), lorazepam (during taper only)
• Bedtime (20:00-21:00): Atorvastatin, trazodone, acetaminophen

Monitoring and Follow-Up Requirements

Laboratory Monitoring

• Baseline and every 3 months: CBC, comprehensive metabolic panel (BUN, creatinine, liver function), blood pressure 1, 3
• Assess for NSAID-related renal toxicity (BUN or creatinine doubling), hepatotoxicity (liver enzymes >3x upper limit normal), and hematologic toxicity 1, 3
• Monitor for signs of GI bleeding: epigastric pain, dyspepsia, melena, hematemesis, fecal occult blood 3

Clinical Assessment During Deprescribing

• Weekly contact during benzodiazepine taper to monitor for withdrawal symptoms and anxiety control 1, 5
• Assess for falls, cognitive changes, sedation, orthostatic hypotension at each medication adjustment 1, 5
• Re-evaluate medication effects based on drug half-life after each dose change - one abnormal assessment should not immediately trigger further changes; observe trends 5

Critical Drug Interactions to Address

Current Dangerous Interactions

• Ibuprofen + hydrochlorothiazide: NSAIDs reduce natriuretic effect of thiazide diuretics and increase risk of renal failure 3
• Ibuprofen + amlodipine/clonidine: NSAIDs diminish antihypertensive effects of all blood pressure medications 3
• Trazodone + NSAIDs: Increased bleeding risk when serotonergic drugs combine with NSAIDs 6
• Lorazepam + trazodone: Additive CNS depression increasing fall risk, cognitive impairment, and respiratory depression 1, 5

Monitoring for Additional Interactions

• Screen all medications including over-the-counter and herbal supplements using drug interaction databases 5
• Eliminate herbal supplements that add medication burden without proven benefit and carry drug interaction concerns 1, 5

Team-Based Implementation Approach

Interdisciplinary Coordination

• Involve clinical pharmacist for comprehensive medication review, drug therapy problem identification, and interaction screening 1, 2, 5
• Coordinate with all prescribers to prevent duplication and ensure safe medication use 2
• Engage patient and family in shared decision-making about deprescribing risks versus benefits 1, 2

Patient and Caregiver Education

• Provide written instructions because patients do not recall verbal discussions, particularly those on sedating medications 1, 5
• Educate about specific risks: falls, bleeding, cognitive impairment, withdrawal syndromes, and when to seek emergency care 5, 3, 6
• Instruct to avoid alcohol and additional sedating medications during benzodiazepine taper 5
• Teach warning signs of NSAID toxicity: nausea, fatigue, jaundice, right upper quadrant pain, difficulty breathing, facial swelling, black stools 3

Pitfalls to Avoid

• Never combine multiple NSAIDs - this patient's dual NSAID therapy is inappropriate and dangerous 1, 4
• Never abruptly stop benzodiazepines - life-threatening withdrawal can occur 1, 5
• Do not ignore medication complexity - regimens requiring >4 dosing times daily predict adverse outcomes 7, 8, 9
• Avoid prescribing cascade - do not add medications to treat adverse effects of other medications (e.g., adding proton pump inhibitor for NSAID-induced dyspepsia rather than stopping NSAID) 1
• Do not assume patients consolidate medications logically - explicitly provide consolidated schedule rather than expecting patients to figure it out 8