What is the management approach for a 75-year-old female who has ingested 3 days' worth of her home medications?

Management of Medication Overdose in a 75-Year-Old Female

Immediately activate emergency medical services (EMS) and do not administer anything by mouth unless specifically directed by poison control, as this may cause harm including emesis and aspiration. 1

Immediate Life-Threatening Assessment

Critical initial actions:

• Call 911/EMS immediately if the patient exhibits any signs of life-threatening conditions including altered mental status, seizures, difficulty breathing, or vomiting 1
• Contact Poison Control Center (1-800-222-1222 in the US) immediately to determine specific toxicity and management based on the exact medications ingested 1
• Implement life-support measures if needed: assess airway, breathing, circulation; place unconscious patients in left lateral head-down position 2

Essential History to Obtain

Specific information required from patient/family/caregivers:

• Exact identity and doses of ALL home medications ingested (bring pill bottles to hospital) 1, 2
• Timing of ingestion (critical for determining treatment window and serum level interpretation) 3, 2
• Intent of ingestion (self-harm vs. accidental confusion) - any stated self-harm requires immediate ED referral regardless of amount 3
• Presence of symptoms: vomiting, abdominal pain, confusion, drowsiness, respiratory depression, bleeding 2, 4
• Baseline cognitive status and whether patient has dementia or confusion that could explain accidental overdose 1

High-Risk Medication Classes in Elderly Requiring Urgent Evaluation

Priority concerns based on geriatric toxicology:

• Anticoagulants (warfarin, rivaroxaban, apixaban) - assess for bleeding, check INR/PT if warfarin 1, 4
• Antidiabetic agents (insulin, sulfonylureas, metformin) - check glucose immediately, risk of severe hypoglycemia 1, 5
• Opioids - assess respiratory rate and mental status; naloxone may be needed 1, 2
• Benzodiazepines - risk of respiratory depression, especially if combined with opioids 1
• Cardiovascular medications (beta-blockers, calcium channel blockers, digoxin) - check vital signs, ECG 1
• Acetaminophen - can cause delayed hepatotoxicity; requires specific timing of serum levels and N-acetylcysteine treatment 3, 6

Gastrointestinal Decontamination Decisions

Activated charcoal considerations:

• May be administered ONLY if less than 2 hours since ingestion, patient is fully conscious and can swallow safely, and a toxic dose of a charcoal-adsorbable drug was ingested 1, 3, 2
• Do NOT give activated charcoal unless specifically advised by poison control 1
• Do NOT induce vomiting with ipecac under any circumstances 1, 2
• Do NOT administer water or milk for dilution - no evidence of benefit and may cause aspiration 1

Specific Antidote Considerations

Time-sensitive treatments:

• N-acetylcysteine for acetaminophen: most effective within 8-10 hours of ingestion; can prevent hepatotoxicity if given within 24 hours 3, 2, 6
• Naloxone for opioids: reverses respiratory depression but requires continuous monitoring as duration shorter than most opioids 2
• Fomepizole may be considered for massive acetaminophen overdose (>500 mg/kg) along with hemodialysis 6

Geriatric-Specific Risk Factors

Elderly patients have increased vulnerability:

• Cognitive impairment, renal insufficiency, polypharmacy, and dependence on caregivers are major predictors of drug-related problems 1
• Declining renal function requires consideration of prolonged drug elimination and increased toxicity risk 1, 5
• Drug-drug interactions occur in 27-31% of elderly patients on multiple medications 5
• Baseline functional status and frailty increase risk of adverse outcomes 1

Hospital Referral Criteria

Mandatory emergency department evaluation:

• Any stated or suspected self-harm regardless of amount ingested 3
• Unknown amount or timing of ingestion 3, 2
• Any symptoms consistent with toxicity (repeated vomiting, altered mental status, vital sign abnormalities) 3, 2
• Ingestion of potentially lethal dose of any high-risk medication 2
• Patients at increased baseline risk (cognitive impairment, multiple comorbidities, living alone) 1, 5

Psychiatric and Social Assessment

Suicide risk evaluation:

• All cases of intentional overdose require psychiatric evaluation before discharge, even if medically stable 2
• Hospital admission should be proposed or imposed until acute suicide risk subsides 2
• Assess for medication management capacity and need for supervised administration going forward 1, 5
• Evaluate living situation and caregiver support - consider whether patient can safely manage medications independently 1

Post-Acute Management Planning

Preventing recurrence:

• Implement supervised medication administration with family member or caregiver filling weekly pillboxes 1, 5
• Simplify regimen to once or twice daily dosing to improve adherence 1, 5
• Consider deprescribing medications without clear benefit given patient's life expectancy and functional status 1, 5
• Store medications in caregiver's home rather than with patient if cognitive impairment present 1
• Coordinate care among multiple prescribers to prevent duplication and ensure safe medication use 5