A topic that runs through the whole exam
Polypharmacy is not confined to one section of the Geriatric Medicine SCE. It appears in questions about falls, delirium, cognitive decline, constipation, continence and end-of-life care. In many stems the correct answer is to stop or reduce a medicine rather than to add one. Candidates who think about deprescribing first often pick up marks that others miss.
Pharmacology of ageing
Ageing changes how the body handles drugs. Renal function declines, so drugs cleared by the kidneys can accumulate. Body fat increases and lean mass falls, which prolongs the action of fat-soluble drugs such as many benzodiazepines. Older people are also more sensitive to the effects of sedatives, anticholinergics and antihypertensives on the brain and circulation. Remember to estimate renal function and adjust doses accordingly.
STOPP/START criteria
The STOPP/START criteria, now in version 3 published in 2023, are widely used in the UK and Europe to identify potentially inappropriate prescribing in older people. STOPP criteria highlight medicines that are likely to cause harm in a given situation, for example long-term benzodiazepines in someone who falls. START criteria highlight beneficial treatments that have been omitted, such as bone protection after a fragility fracture. In the exam, these criteria give you a structured way to judge which drug to stop and which to start.
Anticholinergic burden
Many common medicines have anticholinergic effects, including some bladder antimuscarinics, tricyclic antidepressants, first-generation antihistamines and certain antipsychotics. The cumulative effect is linked with confusion, constipation, urinary retention, falls and possibly cognitive decline. Scales that add up the anticholinergic burden of a patient's medicines help identify those at greatest risk. When an older patient develops new confusion after starting a bladder medicine, think of anticholinergic toxicity.
How to deprescribe safely
Deprescribing is a planned process, not simply stopping tablets. Start with a full medication review that includes over-the-counter products. Agree goals with the patient and their family, considering life expectancy, frailty and what matters most to them. Prioritise medicines with the highest risk of harm or the least benefit, and stop one drug at a time so that effects can be monitored. Some drugs, such as benzodiazepines, antidepressants, beta blockers and corticosteroids, need gradual tapering to avoid withdrawal or rebound effects.
Common exam scenarios
Typical questions include an older patient on several antihypertensives presenting with falls and postural hypotension, a person with dementia started on an antipsychotic for agitation, a frail patient near the end of life still taking a statin, or new hyponatraemia after starting an antidepressant. In each case, identify the medicine most likely responsible and choose the option that reduces harm while respecting the patient's priorities.
Practise with License Medical
The License Medical Geriatric Medicine question bank includes questions on prescribing in older people, adverse drug reactions and deprescribing, each with a guideline-based explanation. Try a free test before you subscribe at license-medical.com/question-bank-details/geriatric/.
Source: O'Mahony D, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine, 2023.