What is the appropriate medical management for an elderly patient with functional decline, multiple comorbidities, and polypharmacy?

Medical Management of Declining Health in Elderly Patients

The cornerstone of managing elderly patients with functional decline, multimorbidity, and polypharmacy is systematic deprescribing of high-risk medications using Beers Criteria or STOPP/START criteria, combined with a multidisciplinary team approach that prioritizes quality of life, functional independence, and symptom control over life extension. 1

Immediate Priority: Deprescribe High-Risk Medications

Target these medication classes first, as they directly cause functional decline, falls, cognitive impairment, and emergency department visits:

1. Anticholinergic Medications (Highest Priority)

• Discontinue immediately: diphenhydramine, cyclobenzaprine, oxybutynin, and other strongly anticholinergic drugs 1
• These medications cause vision problems, urinary retention, constipation, cognitive decline, falls, delirium, and hospitalizations through "anticholinergic burden" 1
• The Drug Burden Index demonstrates that sedating or anticholinergic drugs are directly associated with decline in cognition, functional status, and activities of daily living scores 1

2. Hypoglycemic Agents

• Deintensify diabetes regimens immediately if patient experiences any hypoglycemic episodes 1
• Sulfonylureas and short-acting insulin are the highest-risk medications causing emergency department admissions 1
• Relax hemoglobin A1c goals—tight glycemic control adds harm without benefit in elderly patients with limited life expectancy 1

3. Antihypertensives

• Reduce or discontinue in patients with orthostasis, syncope, falls, or intermittent low blood pressures 1
• Monitor blood pressure targets based on frailty, comorbidities, and cognitive status rather than rigid numerical goals 1
• Labile blood pressure patterns suggest the need for regimen adjustment with close monitoring 1

4. Statins

• Continue statins for secondary prevention (after coronary events) as they significantly reduce recurrence risk 1
• Discontinue statins for primary prevention in patients with limited life expectancy or end-of-life status, as time-to-benefit exceeds remaining lifespan 1
• Stopping statins in patients >75 years without previous cardiovascular disease increases cardiovascular event risk by 1.33 (95% CI 1.18-1.50), but this must be weighed against goals of care 1

5. Herbal Supplements and Vitamins

• Eliminate most supplements except vitamin D, as they contribute to medication burden, cost, side effects, and drug interactions without proven benefit 1

Establish Patient-Centered Goals of Care

Shift from disease-specific targets to patient-centered outcomes: 1

• Primary goals: Preserve quality of life, maintain functional capacity and independence, control symptoms, reduce treatment burden 1
• Secondary consideration: Life extension may be of less interest to elderly patients than to clinicians 1
• Incorporate time-to-benefit versus time-to-harm analysis—discontinue medications where time-to-harm is shorter than remaining life expectancy 1, 2

Implement Multidisciplinary Team Approach

Coordinated teamwork between cardiologist, medical specialists, nurses, pharmacists, social workers, family, and caregivers is essential: 1

• The team assists in decision-making, enables personalized treatment strategies, evaluates treatment complexity and adherence, and coordinates care across transitions 1
• Disease-specific guidelines applied without integration lead to contradictory recommendations, impractical regimens, and harm 1
• Multidisciplinary teams improve quality of care and reduce hospitalizations in patients with chronic cardiovascular disease and multimorbidity 1

Address Polypharmacy Systematically

Polypharmacy (>5 medications) is associated with: 1

• Higher mortality, complications, longer hospital stays, and need for facility discharge 1
• Exponentially increased drug-drug interactions (27-31% of elderly patients experience ≥1 interaction) 2
• Greater risk of adverse drug reactions, therapeutic omissions, and prescribing cascades 1

Use validated criteria to identify inappropriate medications: 1

• Beers Criteria identifies potentially inappropriate medications to avoid in older adults due to high adverse event incidence 1
• STOPP/START criteria identifies both medications to stop and undertreated indications 1
• Anticholinergic Cognitive Burden Scale quantifies anticholinergic risk 1

Conduct Comprehensive Geriatric Assessment

Evaluate these specific domains to guide deprescribing and treatment decisions: 1, 3

• Functional status: Activities of daily living, instrumental activities of daily living 1, 3
• Cognitive function: Screen for dementia and delirium using validated tools 1, 3
• Fall risk: Single screening question: "Have you fallen in the past year?" 4
• Nutritional status: Screen for unintentional weight loss and malnutrition 4
• Mood: Screen for depression with PHQ-2 or Geriatric Depression Scale 5, 4
• Medication adherence: Assess using MMAA, DRUGS, HMS, or MedMaIDE tools 1

Manage Specific Conditions in Context of Multimorbidity

Depression Management

• First-line: Sertraline 25 mg daily, titrate by 25 mg every 1-2 weeks 5
• Sertraline has the lowest drug interaction potential among SSRIs and requires no age-based dosage adjustment beyond "start low, go slow" 5
• Avoid combining SSRIs with MAOIs or benzodiazepines due to fall risk, cognitive impairment, and respiratory depression 5

Cardiovascular Disease Considerations

• Recognize drug-disease interactions: Beta-blockers worsen chronic obstructive lung disease; NSAIDs worsen heart failure and cause hypertension 1, 2
• Over one-fifth of older people with multimorbidity receive medications that adversely affect coexisting conditions 2

Monitor for Acute Decline and Delirium

Acute confusion requires immediate evaluation for reversible causes: 6

• Medication-induced: Anticholinergics, benzodiazepines, opioids are the most common precipitants 6
• Infections: UTI and pneumonia account for >80% of infection-related delirium 6
• Use two-step delirium screening: Delirium Triage Screen followed by Brief Confusion Assessment Method 6

Critical Pitfalls to Avoid

• Never apply disease-specific guidelines rigidly in patients with multimorbidity—this leads to contradictory recommendations and harm 1
• Never assume confusion is "just dementia"—delirium is a sensitive sign of physical illness requiring immediate investigation 6
• Never discontinue SSRIs abruptly—taper over 10-14 days to avoid discontinuation syndrome 5
• Never use antipsychotics for depression in dementia due to increased mortality risk 5
• Never treat asymptomatic bacteriuria in elderly patients—it leads to worse functional recovery and higher C. difficile infection rates 6
• Never ignore "anticholinergic burden"—multiple medications with anticholinergic properties compound cognitive impairment exponentially 1, 6

Ongoing Management Strategy

Conduct medication reviews at every care transition and regularly in stable patients: 1

• Care transitions (emergency department, hospital admission, discharge to facility) are critical opportunities to reevaluate treatment complexity 1
• Comprehensive medication reviews with management support result in fewer hospitalizations 1
• Assess adherence using validated tools and provide ongoing education to patients and caregivers 1
• Consider "rolling assessment" over several visits when multiple concerns are present 4, 7