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The prescribing and management of medications is a clinical procedure that takes time, expertise, and accuracy to improve patient outcomes. Appropriate prescribing for patients of any age balances a particular medication’s potential benefits against the known risks for that individual. Appropriate prescribing avoids clinical inertia but limits the medication list to what is absolutely necessary to prevent disease or decline, manage chronic diseases, and improve quality of life. While extreme polypharmacy (taking 10 or more medications) has been associated with increased adverse events, including death,^40‐44 there is no known ‘appropriate polypharmacy threshold’ for people with multimorbidity. Appropriate prescribing will always consider the patient’s age, goals of care, functional status, and life expectancy.

With patients’ increasing age, prescribers need to heed the principle of the happy medium for chronic disease management. That is, as we age, the benefit of tight disease control decreases and the risk of overtreatment increases. For many chronic diseases, the clinical targets shift to become more liberalized depending on the individual person’s age and functional status. As an example, people over the age of 70 with hypertension have a U‐shaped mortality curve with increased risk with very high blood pressure and low blood pressure. This curve becomes sharper with each decade of life.⁴⁵ However, recent clinical trials suggest that the individual’s functional status is just as important, if not more so, than age alone. Robust patients over age 80 may benefit from stricter blood pressure control, while frail or disabled patients will have worse outcomes with stricter blood pressure control.^46‐48

Medications used for primary prevention of diseases, such as cardiovascular disease, become less effective as patients near the end of life. If certain drugs take years to show benefit, then the risk of side effects may outweigh benefits in those with less than 5‐ to 10‐year life expectancy. Life expectancy tables based on age and gender exist to help guide decision‐making.^49,50 Caution should be taken not to underestimate life expectancy, especially in healthy older people. Prognostication is more accurate if you combine clinical judgment with life tables, functional status assessment, and severity of comorbid conditions. Appropriate prescribing, therefore, needs to include a good geriatric assessment that evaluates for frailty, physical function, physical fitness, and life expectancy. For evaluation of these, please see Chapters 7 (‘Physical Fitness and Exercise’), 95 (‘Maintaining Functional Status’), 97 (‘Frailty’), and 120 (‘End‐of‐Life and Palliative Care’).

When prescribing medications for older adults, remember the following basic principles:

 Consider the Eight Cs of Appropriate Prescribing (Figure 10.1):Care goals should always be at the centre of every medication prescribing decision, and patient‐related factors will help determine appropriate drug use.Compliance: Assess for cognitive impairment, conditions (multimorbidity, depression, decreased hearing, poor vision, unwanted or unintended side effects), complicated regimens, and excessive medication cost, which can all lead to treatment burden and decrease medication compliance. The treatment burden is the perception of the effort required to self‐manage the patient’s medical conditions and adhere to a prescribed regime, and the impact that this has on general well‐being.51‐54 Treatment burden can be minimized by including the patient and caregiver in decision‐making and helping them understand the risks versus the benefits of the various treatment options. Engaging the clinical team, such as pharmacists, nurses, and social workers, can help identify and minimize treatment burden issues.Avoid the prescribing Cascade: Consider every new symptom to potentially be a medication side effect, and don’t prescribe a medication to treat a symptom without first considering stopping the potentially offending medication. In addition, can the list be simplified by using one medication to treat multiple symptoms?

 Never be the first to start a new medication that hasn’t been well tested in this population, and never the be last to stop using an old, unsafe, or ineffective medication.

 Start on the lowest dose of the most cost‐effective medication, and slowly titrate up to the goal (‘start low and go slow’).

 Prescribe evidence‐based non‐pharmacologic alternatives to treat diseases and symptoms.

 Ask yourself the following questions:Medication efficacy: Do I really expect this will make a significant difference to the patient? What is the expected outcome? What is the evidence for using this medication for this age/clinical condition?Cost: Is there a cheaper alternative that is just as effective?Drug timing: Can a once–a‐day regimen be as effective?Drug dosing: What is the lowest effective dose for this patient?Potential side‐effects: How well will this person tolerate this drug? What concerns do I have in starting it?Drug–drug/drug–disease interactions: Do any contraindications exist?

Figure 10.1 The Eight C considerations of appropriate prescribing.

Consider the following example. Mr. Xavier Smith is a 79‐year‐old man brought to your office by his wife with complaints of memory loss. He has a diagnosis of systolic heart failure, urinary incontinence, chronic bronchitis, hyperlipidemia, and a lacunar infarct at age 70. You find that he scores low on a cognitive evaluation, indicating probable early dementia. He has also lost about 25 pounds in the last six months due to a decreased sense of taste and appetite with some nausea related to constipation. He had two witnessed falls when his legs suddenly ‘gave out’. His heart rate is 56, and his blood pressure is 98/50. His wife requests a medication to help his memory, as his goals are to ‘take care of myself and keep driving. I don’t want to be an invalid in a home’. Before you start an acetylcholinesterase inhibitor, you review his current medication list, which includes perindopril (an ACE inhibitor), metoprolol (a beta blocker), oxybutynin (an anticholinergic medication), furosemide (a loop diuretic), a combination beta‐agonist/inhaled corticosteroid inhaler, aspirin, and simvastatin (an HMG‐CoA reductase inhibitor). After discussion with Mr Smith and his wife, you decide to forego starting an acetylcholinesterase inhibitor due to the drug’s risk of worsening bradycardia (falls or heart block), nausea, and anorexia (weight loss). In addition, you stop the anticholinergic agent, which could be worsening his memory, adjust the doses of some of the other medications, and institute aggressive non‐pharmacologic interventions for his memory, falls, and urinary incontinence.

Appropriate prescribing also includes periodic deprescribing. Deprescribing is defined as ‘a patient‐centered, systematic optimization of a person’s medication list through the reduction, tapering, or stopping of medications that are not indicated or are causing real or potential harm’.⁵⁵ Systematic deprescribing has been associated with reduced falls, improved cognitive and psychomotor function, reduced mortality, and reduced healthcare utilization (ED visits and readmissions), all without an increased risk of adverse outcomes.^40,55‐60

Caution must be taken regarding unnecessarily treating conditions that are non‐problematic or largely asymptomatic, have an unlikely progression, or have a low chance to cause concerning symptoms. This is especially true in geriatrics, and some studies that have looked into ways of deprescribing have introduced the idea of ‘un‐diagnosing’ ailments in order to prescribe less. The mnemonic ERASE (Evaluate diagnoses through the consideration of Resolved conditions, Ageing normally, and Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines) can be used to prioritize and resolve clinical problem lists.⁶¹ On the other hand, underprescribing, or the omission of prescribing potentially beneficial medications, is a hallmark of ageism and another problematic issue. Using the START criteria and applying other mnemonics (Table 10.4) can help avoid unnecessary medications and prescribing inertia.

Table 10.4 Mnemonics for medication management.

Mnemonic	What each letter stands for	Description and use
SAIL/TIDE	SAIL: Keep meds as Simple as possible, remember Adverse effects, identify the Indication for each medication, List each drug and dose TIDE: Schedule Time during each visit to discuss medications, have awareness of Individual response to medications, avoid potential Drug/drug/disease interactions, Educate the patient	Useful for creating a standard approach to medication management and for teaching learners on the principles of medication management
AVOID TOO MANY	Alternatives available Vague history or symptoms OTC (over‐the‐counter) Interactions (drug–drug, drug–disease) Duration Therapeutic versus preventive Once per day (preferred) Other doctors Money Adverse drug effects Needs still? Yes/no (is the person actually taking the medication?)	Lists important considerations when assessing medication prescribing, compliance, and treatment burden
ARMOR (67)	Assess based on number of medications or drug class Review pharmacodynamics and pharmacokinetics Minimize medications Optimize doses Re‐assess – compliance, clinical impacts	Useful as a quality improvement tool in post‐acute and long‐term care Focus is on functional status and quality of life
ERASE	Evaluate diagnoses through the consideration of Resolved conditions Ageing normally Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines	A process for eliminating diagnoses to help prioritize drug deprescribing

It is important to remember that deprescribing is both a standardized and individualized process. The deprescribing process should follow the same format for all people and include delineating individualized treatment care goals based on age, functional status, life expectancy, and what matters most to the patient. Outcomes or benefits that are important to older people are usually similar to those of younger people, except that prioritising the outcomes may differ. For example, outcomes related to maintaining or improving physical function, cognitive function, and independence (e.g. prevention of nursing home admission) tend to become more important for people who are frail, have dementia, or are at the end of life. For some people, relief of suffering is the paramount goal, even if it comes with the cost of decreased life span. A recent qualitative analysis found that multimorbid older adults identified maintaining social relationships, a positive frame of mind or resilience, enjoyment of life, and independence as primary priorities of care.⁶² Clarifying these priorities will help the clinician to choose the right evidence‐based regimen and treatment approaches that follow appropriate guidelines tailored to the person’s personal medical history. Once the prescriber understands the process of deprescribing, the process will in essence be the same for every patient, but the actual treatment and outcome goals will be individualized.

Several deprescribing algorithms have been created, following a stepwise approach to assist the clinician at the point of care. The first is a five‐step deprescribing protocol and algorithm developed by Scott and colleagues.^55,63,64 One starts by compiling an accurate and complete medication list and then assessing the overall risk of drug‐induced harm using an algorithm to determine each drug’s discontinuation potential, prioritizing drugs for discontinuation, and finally establishing a monitoring plan following the deprescribing episode. Barnett and colleagues describe another patient‐centred deprescribing process that includes seven steps. The process begins by establishing the patient’s needs and overall goals and then proceeds to compile an accurate medication list; identify potentially inappropriate medications; discuss the risks versus benefits of each; reach an agreement about which to stop, reduce, or start; and finally set up a long‐term plan to communicate changes and monitor the patient.⁶⁵ A third useful resource is the recently described Deprescribing Rainbow, depicting a conceptual framework of the clinical, psychological, social, financial, and physical determinants that should be considered when approaching the deprescribing process in an individual patient. In this pictorial depiction, the patient is literally placed at the centre of the rainbow to emphasize the patient’s central importance. The authors of the paper remind us that ‘deprescribing will be more successful if it is respectful of the individual patient context and circumstances’.⁶⁶ These deprescribing frameworks, combined with a comprehensive geriatric syndrome assessment and the use of one of the previously described prescribing tools, can help clinicians develop a patient‐centred and systematic approach to medication management in older adults that can be used in daily clinical practice.