Polypharmacy and Deprescribing
Polypharmacy is the concurrent use of multiple medications, commonly defined as 5 or more regular drugs, with deprescribing being the planned, supervised withdrawal of inappropriate medications to improve outcomes.
Key Facts
Polypharmacy (≥5 medications) affects approximately 50% of people >65 and >70% of care home residents in the UK Appropriate polypharmacy is necessary for multimorbidity; problematic polypharmacy occurs when the risks outweigh benefits Adverse drug reactions (ADRs) account for 6-7% of hospital admissions in older adults STOPP/START criteria (v2, 2015): evidence-based screening tool for potentially inappropriate medications (STOPP) and potential prescribing omissions (START) Beers Criteria: American Geriatrics Society list of potentially inappropriate medications in older adults Anticholinergic burden: cumulative effect of anticholinergic drugs increases falls, delirium, and cognitive impairment risk NICE NG56: recommends structured medication review for all people with multimorbidity, especially those on ≥10 medications Deprescribing should be gradual, patient-centred, and monitored for withdrawal effects
Overview
Key Facts
Medication review and deprescribing are essential components of managing older adults with multimorbidity. The goal is to optimise medications, reduce harm, and improve quality of life.
Epidemiology
- 50% of >65s take ≥5 medications; 20% take ≥10
- ADRs cause 6-7% of hospital admissions in older adults (preventable in ~50%)
- Falls related to polypharmacy: 1.5-2× increased risk
- Care home residents: average 7-8 regular medications
Aetiology
- Multimorbidity: multiple conditions requiring multiple treatments
- Prescribing cascades: drug side effect treated with another drug (e.g. NSAID → hypertension → antihypertensive)
- Failure to review: medications continued beyond indicated duration
- Multiple prescribers: lack of coordination between specialists and GP
- Patient expectations: reluctance to stop medications
Pathophysiology
- Pharmacokinetic changes with ageing: reduced hepatic metabolism (CYP450), reduced renal clearance (GFR declines ~1ml/min/year after 40), increased body fat (lipophilic drug accumulation), reduced plasma albumin (increased free drug)
- Pharmacodynamic changes: increased sensitivity to CNS depressants, reduced baroreceptor sensitivity (postural hypotension), reduced homeostatic reserve
- Drug-drug interactions: exponential increase with number of drugs
- Anticholinergic burden: cumulative anticholinergic effect → dry mouth, constipation, urinary retention, confusion, falls
Clinical Presentation
Indicators of Problematic Polypharmacy
- ≥10 regular medications (hyperpolypharmacy)
- Recurrent falls
- Adverse drug reactions
- Poor medication adherence
- Drug-drug interactions
- Drugs prescribed without clear indication
- Drugs continued beyond recommended duration
- Prescribing cascades
Common ADRs in Older Adults
- Falls (sedatives, antihypertensives, anticholinergics)
- GI bleeding (NSAIDs, anticoagulants, SSRIs)
- Delirium (opioids, anticholinergics, benzodiazepines)
- Hypoglycaemia (sulfonylureas, insulin)
- Renal impairment (NSAIDs, ACEi, diuretics)
- Electrolyte disturbance (diuretics, PPIs)
Red Flags
- New symptom that could be an ADR (always consider "could this be a drug side effect?")
- Anticholinergic burden score ≥3
- Falling while on high-risk medications
- Delirium in a patient on multiple CNS-active drugs
- Renal function decline on nephrotoxic drugs
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| ADR causing symptoms | Temporal relationship to drug initiation | Medication review, drug levels |
| Disease progression | Worsening of known condition | Clinical assessment |
| Drug-drug interaction | Symptoms after adding new drug | Interaction check |
| Non-adherence | Treatment failure, erratic drug levels | Medication history, adherence tools |
| Drug withdrawal | Symptoms after stopping medication | Clinical history |
Diagnosis / Investigation
Bedside
- Comprehensive medication review (include OTC, herbal, supplements)
- Medication reconciliation (compare different drug lists)
- Adherence assessment (ask patient, pill count, dosette box review)
- Lying and standing BP (postural hypotension from drugs)
Bloods
- U&Es (renal function for dose adjustment)
- LFTs (hepatic function)
- Drug levels where appropriate (digoxin, lithium, phenytoin, aminoglycosides)
- HbA1c (diabetes management review)
Imaging
- Not routine for polypharmacy itself
Special Tests
- STOPP/START screening: systematic review using criteria
- Anticholinergic Burden Calculator: score anticholinergic load
- Beers Criteria: alternative screening tool
- NO TEARS tool: Need, Open questions, Tests/monitoring, Evidence, ADRs, Risk, Simplification
- GFR estimation (CKD-EPI) for dose adjustment
Management
Non-pharmacological
- Structured medication review (NICE NG56): at least annually; more frequently if on ≥10 drugs, after hospital discharge, or after ADR
- Patient involvement: shared decision-making; discuss goals, preferences, and life expectancy
- Simplify regimens: reduce dose frequency, use combination preparations
- Use compliance aids: dosette boxes, blister packs (consider with pharmacy)
Pharmacological (Deprescribing)
- Apply STOPP/START criteria:
- STOPP examples: PPI >8 weeks without clear indication; benzodiazepines >4 weeks; anticholinergics in dementia; long-acting sulfonylureas in >65
- START examples: statin in diabetes with CVD risk; ACEi in heart failure; calcium + vitamin D in osteoporosis
- Deprescribing approach:
- Identify potentially inappropriate medications
- Assess risk of withdrawal vs continuation
- Prioritise which to stop first (highest risk of harm)
- Reduce gradually (especially benzodiazepines, opioids, antidepressants, beta-blockers, corticosteroids)
- Monitor for withdrawal or disease relapse
- High-priority for deprescribing: PPIs, benzodiazepines/Z-drugs, anticholinergics, opioids for non-cancer pain, statins (if limited life expectancy)
Surgical/Interventional
- Not applicable
Referral Criteria
- Complex polypharmacy: clinical pharmacist review, geriatric medicine
- Suspected ADR causing hospital admission: medicines optimisation team
- Specialist medications: liaise with relevant specialist before stopping
Prognosis
- Medication review and deprescribing reduces inappropriate prescribing, ADRs, and falls
- Structured reviews can reduce number of medications by 2-3 in care home residents
- 50% of ADR-related admissions are preventable
- Deprescribing is safe when done gradually with monitoring
- No consistent evidence of increased mortality from appropriate deprescribing
- Patient satisfaction and quality of life often improve after deprescribing
Other Relevant Information
Selected STOPP Criteria (v2)
| Drug | Stop If |
|---|---|
| PPI | >8 weeks at full dose without clear indication |
| Benzodiazepine | >4 weeks (fall risk, dependence) |
| NSAID | >3 months; with CKD, HF, peptic ulcer |
| Anticholinergic | In patients with dementia or delirium |
| Long-acting sulfonylurea (glibenclamide) | In >65 (hypoglycaemia risk) |
| Loop diuretic | For ankle oedema without heart failure |
| Duplicate drugs | Two drugs from same class |
Selected START Criteria (v2)
| Drug | Start If |
|---|---|
| Statin | In diabetes with ≥1 CVD risk factor |
| ACEi/ARB | In heart failure with reduced EF |
| Inhaled corticosteroid | In moderate-severe asthma/COPD |
| Calcium + vitamin D | In known osteoporosis |
| Metformin | First-line in type 2 diabetes |
| Anticoagulant | In atrial fibrillation with CHA2DS2-VASc ≥2 |