0Regular medicationsTick a list on the left.
0Anticholinergic burdenCount the drugs, not just name them.
Drug–drug alarms on this list
Beers Criteria — potentially inappropriate here
What the burden looks like at the bedside
Why the same dose behaves differently at 85Distribution. Total body water falls from about 60 percent of body weight to roughly 50 percent in men and 45 percent in women while fat rises, so water-soluble drugs — digoxin, gentamicin, lithium, ethanol — reach higher peaks from the same dose, and fat-soluble drugs — diazepam, amiodarone, most anaesthetics — accumulate with a much longer half-life. Albumin (normal 3.5–5.0 g/dL) falls with illness, leaving more free drug: a “therapeutic” phenytoin level at an albumin of 2.4 g/dL may in fact be toxic. Metabolism. Phase I oxidation slows; phase II conjugation holds up — which is why lorazepam, oxazepam and temazepam are the least dangerous benzodiazepines here and diazepam is among the worst. Excretion is the biggest issue of all. Pharmacodynamics. The ageing brain is more sensitive to opioids, benzodiazepines and anticholinergics at any given concentration. Start low and go slow — but go: undertreated pain, untreated depression, unanticoagulated atrial fibrillation and untreated osteoporosis harm this population just as reliably as overtreatment does.
1Prescribing cascadePick the drug that starts it.
What a cascade isAn adverse drug effect is misread as a new disease and treated with another drug. Each round adds cost, interaction risk and a fresh set of adverse effects — and each one is undone by asking what the patient was started on shortly before the new symptom appeared.
◯Monitoring deskPick a drug or a habit on the left.
The nurse’s specific contributionYou are the one who sees the patient sway on standing after the new alpha-blocker, sleep through breakfast after the new hypnotic, and stop eating after the new drug for something else. Deprescribing is a team activity that the nurse frequently initiates — and the observation is what starts it.