Polypharmacy and the Beers Criteria on the NCLEX
Why older adults handle drugs differently, Beers list logic, deprescribing, teaching.
Older adults take more drugs and clear them worse. NCLEX tests the logic, not the memorized list.
Why older bodies are different
Decreased renal clearance (even with a normal-looking creatinine, because muscle mass is low). Decreased hepatic metabolism. More body fat, less water: fat-soluble drugs linger, water-soluble drugs concentrate. Less albumin: more free drug for protein-bound meds like phenytoin and warfarin. Net effect: standard doses act like overdoses. Start low, go slow.
Beers Criteria logic
A consensus list of drugs that are potentially inappropriate in older adults because the risk usually beats the benefit. You do not need the whole list. Know the classes: Anticholinergics (diphenhydramine, TCAs, oxybutynin) → confusion, retention, falls. Benzodiazepines and sedative-hypnotics → falls, fractures, delirium. Long-acting sulfonylureas (glyburide) → prolonged hypoglycemia. Sliding-scale-only insulin → hypoglycemia without benefit. Chronic NSAIDs → GI bleed, renal injury, HF exacerbation. Muscle relaxants → sedation, falls.
Polypharmacy and the prescribing cascade
Polypharmacy: commonly defined as five or more medications. The prescribing cascade: a drug causes a side effect, the side effect gets treated with another drug, and so on. Any new symptom in an older adult: suspect a medication first.
Deprescribing
Planned, supervised dose reduction or stopping of drugs that no longer help. Nurse's role: complete an accurate med list, flag duplicates and Beers drugs, monitor for withdrawal and symptom return, reinforce that stopping was deliberate. Never tell a patient to just quit a benzo or beta blocker abruptly.
Teaching that shows up on the exam
Brown-bag review: bring every bottle, including OTC and herbals, to every visit. One pharmacy. One current list carried in the wallet. No sharing pills, no doubling a missed dose. OTC counts: diphenhydramine 'PM' products are a top offender.
Frequently asked
Why is diphenhydramine a bad sleep aid for older adults?
Strong anticholinergic. Confusion, urinary retention, dry mouth, falls. Sleep hygiene first.
Normal creatinine, so kidneys are fine?
Not in an older adult. Low muscle mass keeps creatinine deceptively normal while GFR falls. Check eGFR or creatinine clearance before renally dosed drugs.
Patient takes 12 meds from 3 prescribers. First action?
Full medication reconciliation. You cannot assess interactions or duplicates until one accurate list exists.
Quick check
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