NRNP 6540 Week 4 Polypharmacy Review Example

Course	NRNP 6540 Advanced Practice Care of Older Adults
Week	Week 4
Paper type	Medication review
Length	About 770 words, 5 pages
Format	APA 7 student paper
School	Walden University
Program	Master of Science in Nursing (MSN)
Updated	October 2026

Free sample paper for NRNP 6540 Week 4

Polypharmacy Review for an 84-Year-Old Man Taking Twelve Medications: Beers Flags, a Prescribing Cascade, and an Omission

Student Name

College of Nursing, Walden University

NRNP 6540: Advanced Nurse Practice in Primary Care Adult Gerontology II

Instructor Name

Month Day, Year

What this page is doingThe title names the three kinds of finding the review produced: drugs to avoid, a chain of prescriptions where one drug treated another's side effect, and something missing. A medication review that found only excess would miss half the purpose of the STOPP/START approach.

Polypharmacy Review for an 84-Year-Old Man Taking Twelve Medications: Beers Flags, a Prescribing Cascade, and an Omission

Patient

J.O., a composite 84-year-old retired machinist, lives with his wife and sees four prescribers: a primary care nurse practitioner, a cardiologist, a urologist, and an urgent care clinic he visited last winter. His conditions are hypertension, type 2 diabetes with moderately increased urine albumin, benign prostatic hyperplasia with overactive bladder symptoms, osteoarthritis, and insomnia. His wife reports that he is dizzy when he stands, constipated, and complains of a dry mouth, and that his ankles have been swollen for a year.

Medication Table

Each row: drug; prescriber; indication in the chart; indication still active; expected benefit at this stage of life; harm observed or likely; verdict.

Amlodipine 10 mg; cardiologist; hypertension; yes; moderate; ankle edema observed, dose related; reduce.

Furosemide 20 mg; urgent care; "leg swelling"; no heart failure documented; low; dizziness, nocturia, volume depletion; stop.

Lisinopril: not prescribed; see omission below.

Metformin 1,000 mg twice daily; primary care; diabetes; yes; moderate; kidney function adequate; continue.

Glyburide 5 mg twice daily; primary care, years ago; diabetes; yes; low relative to risk; prolonged hypoglycemia, flagged under the AGS Beers Criteria; replace.

Oxybutynin 5 mg three times daily; urologist; overactive bladder; partly; modest; dry mouth, constipation, confusion risk, flagged under Beers; replace.

Tamsulosin 0.4 mg; urologist; benign prostatic hyperplasia; yes; moderate; adds to orthostatic dizziness; continue, take at bedtime.

Diphenhydramine 50 mg nightly, over the counter; self; insomnia; yes; low; anticholinergic, sedating, flagged under Beers; stop.

Omeprazole 20 mg; urgent care, for a one-time dyspepsia episode 14 months ago; no; none now; long-term use without indication; deprescribe.

Atorvastatin 40 mg; primary care; cardiovascular prevention; yes; moderate; tolerated; continue.

Acetaminophen 650 mg as needed; self; osteoarthritis; yes; moderate; safe at his dose; continue.

Docusate twice daily; self; constipation; the constipation is drug induced; low; none; stop once the cause is removed.

What this page is doingOne row per medication, with the same columns throughout, makes each verdict checkable. The prescriber column shows how four clinicians each added reasonable drugs that no one reviewed together, and the indication column is where the unneeded omeprazole and the unexplained furosemide become visible.

Three Beers Flags

The American Geriatrics Society Beers Criteria flag three of his medications (2023 American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Diphenhydramine, a first-generation antihistamine taken for sleep, is strongly anticholinergic and associated with confusion, constipation, and falls. Oxybutynin is also strongly anticholinergic. Glyburide, a long-acting sulfonylurea, carries a high risk of prolonged hypoglycemia in older adults, especially as kidney function declines.

A Prescribing Cascade

A prescribing cascade occurs when a drug's adverse effect is mistaken for a new condition and treated with another drug (Rochon & Gurwitz, 1997). Here, amlodipine at its highest dose caused dose-related ankle edema; at an urgent care visit the swelling was treated with furosemide, which does not reliably relieve calcium channel blocker edema and added dizziness, nocturia, and volume depletion. Tracing the two rows together shows that the furosemide treats a side effect, not a disease.

An Omission Caught by START

The STOPP/START criteria screen for both inappropriate drugs and beneficial drugs that are missing (O'Mahony et al., 2023). START identifies an omission: he has diabetes with moderately increased albuminuria and is not taking an ACE inhibitor or angiotensin receptor blocker, which would protect his kidneys and help control his blood pressure.

Combined Anticholinergic Burden

His dry mouth, constipation, and dizziness are not three separate problems. Diphenhydramine and oxybutynin together produce a substantial anticholinergic load: dry mouth from reduced salivation, constipation from slowed gut motility, and dizziness and unsteadiness from central effects, compounded by orthostatic drops from tamsulosin and furosemide. The docusate was added for a side effect of the others.

Plan: Three Changes, in Order

Change 1, this week: stop diphenhydramine and furosemide. Sleep is addressed with a regular schedule and limiting evening fluids. Watch for: rebound insomnia, ankle swelling, blood pressure, and dizziness at a nurse visit in one week.

Change 2, in two weeks: reduce amlodipine to 5 mg and start lisinopril, addressing the edema and the START omission together. Watch for: blood pressure, a basic metabolic panel ten days after the ACE inhibitor starts, and cough.

Change 3, in four weeks: replace glyburide with a lower-risk agent chosen with him, and ask the urologist to replace oxybutynin with a non-anticholinergic option. Watch for: glucose readings, bladder symptoms, and whether dry mouth and constipation improve enough to stop docusate. Omeprazole will be tapered after the other changes settle.

One change at a time means that if a problem appears, its cause is clear. His wife will keep a simple log of dizziness, bowel movements, and sleep. The final list will be sent to all four prescribers and to his single chosen pharmacy, so that the next prescription is written against the whole list rather than one part of it.

References

2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

O'Mahony, D., Cherubini, A., Guiteras, A. R., Denkinger, M., Beuscart, J.-B., Onder, G., Gudmundsson, A., Cruz-Jentoft, A. J., Knol, W., Bahat, G., van der Velde, N., Petrovic, M., & Curtin, D. (2023). STOPP/START criteria for potentially inappropriate prescribing in older people: Version 3. European Geriatric Medicine, 14(4), 625-632. https://doi.org/10.1007/s41999-023-00777-y

Rochon, P. A., & Gurwitz, J. H. (1997). Optimising drug treatment for elderly people: The prescribing cascade. BMJ, 315(7115), 1096-1099. https://doi.org/10.1136/bmj.315.7115.1096

What the NRNP 6540 Week 4 instructions ask for

Week 4 of NRNP 6540 often asks for a medication review for an older adult with polypharmacy. You list every medication with its indication, apply tools such as the Beers Criteria and STOPP/START, look for prescribing cascades and omissions, assess anticholinergic burden, and propose prioritized changes. Faculty grade coverage first, so every row must be addressed. Cite the tools in APA 7. Changes should be made one at a time with monitoring. Communication with other prescribers belongs in the plan. A table is the usual format for the medication list. In NRNP 6540 the medication table should include dose, prescriber and indication for each row, so cascades and duplications show up. State the anticholinergic burden score and the scale used. Say which change comes first and why it leads.

How this NRNP 6540 Week 4 example is built

The review is a table with one row per medication. Columns record the drug, who prescribed it, the indication in the chart, whether that indication is still active, the benefit expected at this stage of life, the harm observed or likely, and a verdict. Three rows are flagged under the AGS Beers Criteria, including a sedating antihistamine taken for sleep. A prescribing cascade is traced across two rows: a blood pressure drug causing ankle swelling, and a diuretic added to treat the swelling. The STOPP/START criteria catch one omission as well as the excesses. Beneath the table, a short section connects the dry mouth, constipation, and dizziness to a combined anticholinergic burden. The plan names three changes, the order they happen in, and what will be watched after each.

Where the marks sit in the NRNP 6540 Week 4 rubric

Coverage decides the first share of the grade: a review that discusses the three obvious problems and leaves eleven rows untouched has not reviewed the list. This example gives each agent a row and a verdict. Criteria use is graded next: applying the AGS Beers Criteria earns credit, and pairing them with a check for omissions shows the reviewer knows inappropriate prescribing runs in both directions. Identifying the cascade usually lifts a review noticeably, because it is the kind of harm a drug-by-drug glance misses. Stopping several drugs at once with no sequence loses marks; so do changes made without asking what the patient values, and silence about who prescribed each drug and how the change will reach them.

Common NRNP 6540 Week 4 mistakes, and how to avoid them

Reviews lose their first share of credit when three obvious problems are discussed and the rest of the list is untouched. Address every row, even if only to keep it. Another common gap is missing a prescribing cascade, where one drug's side effect is treated with another drug. Look for new prescriptions that followed a change. Writers also treat the Beers Criteria as a list of banned drugs. They flag caution, not prohibition. Avoid changing several drugs at once. Check START for omissions. Name the other prescribers you will contact. Close with when each change will be reviewed. Writers also forget the urgent care prescription, which often stays on the list long after its purpose ended. Ask whether it is still needed. Check kidney function before keeping any renally cleared drug.

Get a NRNP 6540 Week 4 example written to your instructions

Send the Week 4 prompt, rubric, and the medication list in your case. The review that returns examines every drug on it, applies the criteria your course teaches, and sequences each change. The first custom sample is free, with delivery in 24-48 hours, and the table format adjusts to whatever template you were given.

More NRNP 6540 papers and MSN samples

NRNP 6540 Week 4 questions, answered

What is a prescribing cascade?

It is a chain in which a side effect of one drug is mistaken for a new condition and treated with a second drug. In the example, ankle swelling from a blood pressure medication led to a diuretic. Cascades are hard to see when drugs are reviewed in isolation, which is why the example links rows across the table, and graders reward finding one.

Why change only one medication at a time?

So that any new symptom or improvement can be attributed to a specific change. When several drugs are stopped together and the patient feels worse or better, the review cannot say why. The example sequences three changes with an observation period after each, and its plan states what will be watched. Rubrics at this level assess that sequencing directly.

Are the Beers Criteria a list of banned drugs?

No. They identify medications that are potentially inappropriate for older adults, meaning the risks often outweigh the benefits and alternatives deserve consideration. A flagged drug may still suit a particular person. The example treats each flag as a prompt for a decision and records that decision in the verdict column, rather than reading the criteria as automatic stop orders.

Where can I find a free NRNP 6540 Week 4 sample paper?

J.O.'s twelve-medication review is printed here with the full table, the Beers flags, the prescribing cascade, the START omission and the three ordered changes.

How many medications are reviewed in NRNP 6540 Week 4?

Twelve, from four prescribers, each row reviewed in a full medication table with Beers and START checks.