Polypharmacy, Adverse Drug Events, and Medication-related Emergencies Practice Questions

25 multiple-choice questions on Polypharmacy, adverse drug events, and medication-related emergencies for paramedic and EMT students, from Chapter 45 (Geriatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Polypharmacy is commonly defined as the regular use of:

   1. A. Two or more medications
   2. B. Five or more medications
   3. C. Any prescription opioid
   4. D. Three or more supplements
   Show answer

   Answer: B. Five or more medications

   Polypharmacy usually means five or more medications, which sharply raises the risk of interactions and adverse events. Taking two drugs is common and is not, by itself, polypharmacy.

2. Which factor most increases the risk of adverse drug events in older adults?

   1. A. Several prescribers who do not coordinate
   2. B. Taking doses at the same time each day
   3. C. Using one pharmacy for every refill and new drug
   4. D. Keeping an updated medication list
   Show answer

   Answer: A. Several prescribers who do not coordinate

   Multiple prescribers unaware of each other's orders create duplications and interactions, compounded by declining kidney and liver function. A single pharmacy and an up-to-date list reduce, not increase, risk.

3. An 80-year-old with no history of heart disease or stroke takes daily aspirin 'to prevent a heart attack.' Under the 2023 AGS Beers Criteria, starting aspirin for this purpose is:

   1. A. Advised for adults once they reach age 75
   2. B. Use with caution if she has no ulcer history
   3. C. Safe as long as an enteric-coated tablet is used
   4. D. Best avoided, as bleeding risk outweighs benefit
   Show answer

   Answer: D. Best avoided, as bleeding risk outweighs benefit

   The 2023 Beers Criteria changed aspirin for primary prevention from 'use with caution' to 'avoid starting' (and consider stopping), because major bleeding risk rises steeply with age and trials in older adults showed no net benefit. This does not change emergency care: aspirin is still given for suspected acute coronary syndrome and is appropriate for secondary prevention in known heart disease. There is no recommendation to start aspirin at 75. 'Use with caution' was the 2019 wording, and a clean ulcer history does not remove the age-related bleeding risk. Enteric coating does not prevent GI or intracranial bleeding, because the antiplatelet effect acts throughout the body.

4. Which drug is on the Beers Criteria because of its strong anticholinergic effects?

   1. A. Acetaminophen
   2. B. Lisinopril
   3. C. Diphenhydramine
   4. D. Levothyroxine
   Show answer

   Answer: C. Diphenhydramine

   Diphenhydramine, a first-generation antihistamine found in many OTC sleep aids, causes confusion, urinary retention, constipation, and falls in older adults. Acetaminophen is generally the preferred analgesic for mild pain in older adults.

5. An 80-year-old started oxybutynin and an OTC sleep aid last week. She is now confused and flushed, with dry skin, a distended bladder, and a pulse of 112. The most likely cause is:

   1. A. Acute serotonin syndrome
   2. B. Anticholinergic toxicity
   3. C. Opioid toxicity
   4. D. Cholinergic crisis
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   Answer: B. Anticholinergic toxicity

   Oxybutynin and diphenhydramine-based sleep aids are both anticholinergic; combined, they produce delirium, dry flushed skin, urinary retention, and tachycardia. Cholinergic excess causes the opposite picture: wet skin, salivation, and bradycardia.

6. An 84-year-old has taken the same dose of digoxin for years without problems but now has nausea, confusion, and yellow-tinted vision. The most likely reason toxicity developed now is:

   1. A. Declining kidney function
   2. B. A sudden rise in body fat
   3. C. Improved medication absorption
   4. D. Faster liver metabolism
   Show answer

   Answer: A. Declining kidney function

   Digoxin is cleared mainly by the kidneys, so age-related or acute renal decline (often with dehydration or a new diuretic causing hypokalemia) raises levels on an unchanged dose. Digoxin is water-soluble, so a gain in body fat does not explain toxicity.

7. An 81-year-old with type 2 diabetes started pioglitazone 6 weeks ago. She now has ankle swelling, a 3-kg weight gain, and new shortness of breath when lying flat. The most likely cause is:

   1. A. Heart failure from the new diabetes drug
   2. B. Low blood sugar caused by the new medicine
   3. C. Normal swelling from sitting for long periods
   4. D. A blood clot in one of the deep leg veins
   Show answer

   Answer: A. Heart failure from the new diabetes drug

   Pioglitazone, a thiazolidinedione, causes the kidneys to retain sodium and water and can trigger or worsen heart failure, especially in older adults; it carries a boxed warning. Weight gain, edema, and orthopnea point to heart failure. A DVT usually causes one swollen leg, and pioglitazone alone rarely causes hypoglycemia.

8. A 78-year-old takes metoprolol from her cardiologist. A week ago another doctor added diltiazem for atrial fibrillation. She is dizzy, with a pulse of 40 and a BP of 86/50 mm Hg. The most likely cause is:

   1. A. An allergic reaction to the new diltiazem
   2. B. Combined AV-node slowing from the two drugs
   3. C. Rebound from missing her metoprolol doses
   4. D. Hypoglycemia caused by taking the diltiazem
   Show answer

   Answer: B. Combined AV-node slowing from the two drugs

   Beta blockers and nondihydropyridine calcium channel blockers both slow the SA and AV nodes and reduce contractility, so adding one to the other can cause marked bradycardia, heart block, and hypotension, a classic interaction when prescribers do not coordinate. Treat per bradycardia protocol (atropine, pacing, vasopressors); for frank toxicity the 2023 AHA update rates vasopressors and high-dose insulin as COR 1 and glucagon as COR 2a for beta-blocker poisoning, and calcium as 2a for calcium channel blockers. An allergic reaction would cause hives, wheezing, or swelling, not isolated bradycardia. Missed beta-blocker doses cause rebound tachycardia, not bradycardia. Diltiazem does not cause hypoglycemia.

9. An 83-year-old recently started gabapentin for nerve pain and also takes oxycodone. She is now very drowsy with a respiratory rate of 8. The most likely cause is:

   1. A. An allergic reaction to the new gabapentin
   2. B. Gabapentin blocking the effect of oxycodone
   3. C. Added breathing suppression from both drugs
   4. D. Withdrawal from her missed oxycodone doses
   Show answer

   Answer: C. Added breathing suppression from both drugs

   Gabapentin and pregabalin add to the sedation and respiratory depression of opioids, and the FDA warned in 2019 of serious breathing problems with this combination, especially in older adults and those with lung disease; the Beers Criteria advise avoiding it. Support ventilation, give naloxone for the opioid component, and transport. An allergic reaction would cause rash, swelling, or wheezing rather than sedation and slow breathing. Gabapentin enhances, not blocks, opioid effects. Opioid withdrawal causes agitation, yawning, and tachycardia, not a respiratory rate of 8.

10. A 79-year-old with glaucoma has a pulse of 44 and feels faint. Her only medications are eye drops: timolol in both eyes twice a day. You should recognize that:

    1. A. Eye drops stay in the eye, so look elsewhere
    2. B. Timolol speeds the heart, so this is unrelated
    3. C. Her bradycardia must be from the glaucoma itself
    4. D. Eye drops can be absorbed and slow the heart
    Show answer

    Answer: D. Eye drops can be absorbed and slow the heart

    Timolol is a nonselective beta blocker; drops drain through the tear duct into the nasal mucosa and are absorbed into the blood without first-pass metabolism, enough to cause bradycardia, heart block, hypotension, and bronchospasm in older adults; record eye drops in the medication list and treat the bradycardia per protocol. Ophthalmic drugs can have systemic effects, so they cannot be dismissed. Timolol slows rather than speeds the heart. Glaucoma itself does not cause bradycardia.

11. An 80-year-old on high-dose simvastatin was started on clarithromycin 5 days ago. She now has diffuse muscle pain, weakness, and dark brown urine. You should suspect:

    1. A. A urinary infection that the antibiotic missed
    2. B. Normal muscle aches from a viral illness
    3. C. Dehydration from the antibiotic's side effects
    4. D. Muscle breakdown from a drug interaction
    Show answer

    Answer: D. Muscle breakdown from a drug interaction

    Clarithromycin blocks the enzyme that clears simvastatin, so statin levels rise and can cause rhabdomyolysis, with muscle pain, weakness, and dark urine from myoglobin. It can lead to kidney failure and high potassium, so give IV fluid, monitor the ECG, and bring the medication list.

12. An 81-year-old has two pill bottles: one labeled Lopressor and one labeled metoprolol tartrate. She takes a tablet from each every morning. Her pulse is 46. The most likely problem is:

    1. A. The two drugs are canceling each other out
    2. B. She has missed doses of her blood pressure pill
    3. C. She is taking a double dose of the same drug
    4. D. Lopressor is a vitamin with no heart effect
    Show answer

    Answer: C. She is taking a double dose of the same drug

    Lopressor is the brand name of metoprolol tartrate, so she is taking the same beta blocker twice, a common error when a pharmacy switches to a generic or a new prescriber reorders the drug under another name; bradycardia results. Bring both bottles and point out the duplication at handoff. Two bottles of one drug add, not cancel. Missed doses would cause a fast, not slow, pulse. Lopressor is a prescription beta blocker, not a vitamin.

13. Regular use of NSAIDs such as ibuprofen in older adults increases the risk of:

    1. A. Hypoglycemia and seizures
    2. B. GI bleeding and kidney injury
    3. C. Bradycardia and complete heart block
    4. D. Hypothermia and shivering
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    Answer: B. GI bleeding and kidney injury

    NSAIDs injure the gastric lining and reduce renal blood flow, and they worsen heart failure and hypertension; older adults are especially vulnerable. They do not cause heart block.

14. An 80-year-old taking citalopram was started on azithromycin. She fainted, and the monitor now shows a long QT interval with brief runs of twisting, polymorphic VT. The most likely cause is:

    1. A. Two drugs that each lengthen the QT interval
    2. B. An allergic reaction to the new antibiotic
    3. C. Low blood sugar from poor intake while she is ill
    4. D. A stroke that is causing a heart rhythm problem
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    Answer: A. Two drugs that each lengthen the QT interval

    Many drugs prolong the QT interval, including citalopram and macrolide antibiotics, and older adults on several of them are at risk of torsades de pointes. Magnesium is the treatment for torsades. An allergic reaction would cause hives, wheezing, or hypotension, not a long QT.

15. A 74-year-old has rapidly swelling lips and tongue without hives. He has taken lisinopril for 6 years and says it 'can't be the pills.' You should know that ACE-inhibitor angioedema:

    1. A. Stops being a risk after the first month
    2. B. Is caused by an allergy that worsens slowly
    3. C. Can first appear after years of safe use
    4. D. Is ruled out because there are no hives
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    Answer: C. Can first appear after years of safe use

    ACE-inhibitor angioedema is bradykinin-mediated and unpredictable; although it is most common in the first months, it can first occur after many years on the drug, and older adults are frequently affected because so many take these drugs. Protect the airway, anticipate a difficult intubation, and transport; epinephrine may help less than in allergic reactions. The risk does not end after the first weeks or months. It is not an IgE allergy that builds gradually. Absent hives is typical of the bradykinin type and argues for, not against, the diagnosis.

16. Staff at a memory care unit ask why the doctor stopped the antipsychotic used to keep a resident with dementia calm. The best explanation is that in older adults with dementia these drugs:

    1. A. Raise the risk of stroke and death
    2. B. Lead to addiction like opioids do
    3. C. Cause dangerously high blood pressure
    4. D. Mostly damage the kidneys over time
    Show answer

    Answer: A. Raise the risk of stroke and death

    Antipsychotics carry an FDA boxed warning for increased mortality (from stroke, heart events, and infections) in older adults with dementia-related psychosis, and the Beers Criteria advise avoiding them for behavioral symptoms unless nondrug measures fail and the patient is a danger to self or others; they also cause sedation, falls, and parkinsonism. They do not cause addiction the way opioids do. They tend to lower blood pressure and cause orthostasis rather than raise it. Kidney damage is not the reason for the boxed warning.

17. Long-acting benzodiazepines are a concern in older adults mainly because they:

    1. A. Cause severe hypertension
    2. B. Raise blood glucose levels
    3. C. Speed up renal clearance
    4. D. Raise the risk of falls
    Show answer

    Answer: D. Raise the risk of falls

    Benzodiazepines accumulate in older adults' larger fat stores and cause prolonged sedation, ataxia, and confusion, leading to falls and fractures. They lower, rather than raise, blood pressure when they affect it at all.

18. An 82-year-old started zolpidem for sleep a week ago. Her family found her cooking at 3 a.m. with no memory of it, and last night she fell. The drug most likely caused:

    1. A. An allergic reaction to the new sleep medicine
    2. B. Complex sleep behaviors and impaired balance
    3. C. A stroke that started during the night
    4. D. Low blood sugar from skipping her supper
    Show answer

    Answer: B. Complex sleep behaviors and impaired balance

    Zolpidem and similar sleep drugs can cause sleepwalking-type behaviors such as cooking or driving without memory, and in older adults they raise the risk of confusion and falls. They are on the Beers Criteria list. Bring the bottle and report the new drug; check glucose and stroke signs as well.

19. An 82-year-old with heart failure has worsening edema. Her pill bottles were filled 3 months ago and are still nearly full. The most likely factor is:

    1. A. A diuretic dose set too low by her doctor
    2. B. Too much salt in her recent meals
    3. C. Missed doses of her medications
    4. D. An overdose of her diuretic
    Show answer

    Answer: C. Missed doses of her medications

    Nearly full bottles long after filling suggest nonadherence, which may stem from cost, confusion, poor vision, or side effects, and is a common cause of decompensation. An underdosed diuretic or a salty diet can worsen heart failure, but neither explains bottles that are still nearly full 3 months after filling. An overdose would leave bottles emptier, not fuller, and would dry her out rather than cause edema.

20. A 'prescribing cascade' occurs when:

    1. A. A patient fills prescriptions at several stores
    2. B. A side effect is treated with another drug
    3. C. A drug dose is gradually tapered to zero
    4. D. A generic drug replaces the brand name
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    Answer: B. A side effect is treated with another drug

    For example, ankle edema from amlodipine may be treated with a diuretic, which then causes falls or electrolyte problems. Recognizing new symptoms as possible side effects can stop the cascade; using several pharmacies is a different risk.

21. A 77-year-old on warfarin bruises easily and has had nosebleeds since starting a supplement. Which supplement most likely increases bleeding?

    1. A. Calcium carbonate
    2. B. Vitamin D
    3. C. Melatonin
    4. D. Ginkgo biloba
    Show answer

    Answer: D. Ginkgo biloba

    Ginkgo has reported antiplatelet effects, and NCCIH warns it may increase bleeding risk with anticoagulants such as warfarin; controlled studies of a direct interaction are mixed, but case reports of bleeding make it the most likely culprit here (garlic, fish oil, and vitamin E raise similar concerns). Calcium carbonate and vitamin D do not affect clotting. Melatonin is not known to cause bleeding. Always ask about supplements, which patients often do not think of as medications.

22. An 82-year-old with worsening kidney disease has had several low glucose readings on the same insulin dose she has used for years. The most likely reason is that:

    1. A. Her kidneys clear less insulin than before
    2. B. Her kidneys now make insulin of their own
    3. C. Kidney disease raises the body's need for insulin
    4. D. Her insulin has lost potency in the refrigerator
    Show answer

    Answer: A. Her kidneys clear less insulin than before

    The kidneys clear a large share of circulating insulin, so as kidney function falls each dose acts longer and stronger, and poor intake from uremia adds to the risk; older adults with CKD often need lower doses. Treat the hypoglycemia, and advise follow-up for dose adjustment. Kidneys do not make insulin. Declining kidney function lowers, rather than raises, insulin requirements. Insulin stored in a refrigerator stays potent; loss of potency would cause high, not low, readings.

23. An 80-year-old with 3 days of vomiting and diarrhea kept taking lisinopril and furosemide. She is weak, dizzy, and has made little urine. The combination most directly risks:

    1. A. Fluid overload causing acute pulmonary edema
    2. B. A sudden rise in her blood pressure
    3. C. Acute kidney injury from low renal perfusion
    4. D. Increased urine output from both drugs
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    Answer: C. Acute kidney injury from low renal perfusion

    Volume loss lowers kidney perfusion, and the diuretic worsens the deficit while the ACE inhibitor removes the kidney's ability to constrict the efferent arteriole and maintain filtration, so prerenal acute kidney injury and hyperkalemia follow; many prescribers advise holding these drugs on 'sick days.' Give fluid with reassessment and transport. She is dry, not overloaded. Dehydration with these drugs lowers rather than raises blood pressure. Urine output falls, as in this patient, rather than rises.

24. When transporting an older adult who takes many medications, the best practice is to:

    1. A. Bring every bottle, including OTC products
    2. B. Bring the prescribed heart and blood pressure pills
    3. C. Leave the bottles so none are lost
    4. D. Bring the medications taken today
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    Answer: A. Bring every bottle, including OTC products

    A complete set of containers, including OTC drugs, eye drops, inhalers, patches, and supplements, lets the hospital reconcile medications and spot errors. Bringing only cardiac drugs misses common culprits such as sleep aids and NSAIDs.

25. A 79-year-old with Alzheimer disease recently started donepezil and has had two fainting spells. Her pulse is 46. The drug most likely contributed by:

    1. A. Blocking beta receptors
    2. B. Increasing vagal tone
    3. C. Lowering blood glucose
    4. D. Causing heavy sweating
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    Answer: B. Increasing vagal tone

    Cholinesterase inhibitors such as donepezil raise acetylcholine levels, which increases vagal tone and can cause bradycardia, heart block, and syncope. They have no beta-blocking action.