Polypharmacy and deprescribing in older people

Introduction

Medicines can have a dramatic impact on people’s lives; some are curative, directly targeting the underlying cause of the condition, while others will help to enhance therapeutic outcomes, improve disease prognosis, effectively manage symptoms and enhance overall quality of life^​1​. However, as long-term conditions and comorbidities increase, the risk of inappropriate polypharmacy — where medicines begin to have a detrimental impact on a person’s health — needs to be actively managed. There is no universally agreed definition of what constitutes polypharmacy^​2​; however, it is broadly agreed that taking multiple medicines can be characterised as either appropriate (rational prescribing according to best available evidence that aligns with the patients’ values and preferences) or inappropriate (irrational prescribing in the absence of an intended therapeutic benefit)^​3​. 

Inappropriate polypharmacy becomes more problematic in older people with susceptibility to side effects and harm from medicines constituting one of the five frailty syndromes^​4​. People living with frailty often take many medicines owing to multimorbidity^​5​. Additionally, likelihood of harm increases as a result of pharmacokinetics and pharmacodynamic changes with age. Pharmacokinetic changes result in reduced renal and hepatic clearance, as well as increased elimination half-lives as a consequence of increased volume of distribution. Pharmacodynamic changes typically result in greater sensitivity to medicines^​6​. This increases the risk of falls, cognitive impairment and delirium, which in turn can lead to increased hospital admissions, morbidity and mortality^​7,8​. 

In 2017, the World Health Organization started a global initiative to reduce harm from medicines by 50% over five years, which it recognised as a major global safety challenge^​9​. This initiative focused on improving how medicines are prescribed, dispensed, administered and monitored globally. 

Published in 2021, the National Overprescribing Review identified repercussions of polypharmacy, particularly for older people^​10​. This harm was demonstrated in a recent study whereby adverse drug reactions (ADRs) accounted for 16.5% of hospital admissions with an increased mortality and cost to the health economy^​11​. Results of another study, published in 2022, have shown that each additional medicine prescribed in older people is associated with increased mortality^​12​. Much of the harm is potentially avoidable and pharmacy teams play a central role in addressing problematic polypharmacy through structured medication review (SMR) in frail people^​13​. Deprescribing is fundamental to this; one definition of deprescribing states that it “refers to a process of medication withdrawal, supervised by a healthcare professional, with the goal of managing polypharmacy and improving outcomes”^​14​.

This article will outline the risks of inappropriate polypharmacy in older people and highlight opportunities that pharmacists have to implement and carry out deprescribing in their practice to improve patient outcomes.

Risks of inappropriate polypharmacy

Inappropriate polypharmacy in older people is a growing problem, with 25% of people aged over 60 years having at least two long-term conditions and the increasing use of multiple medicines in an ageing population^​15​. Ageing and multimorbidity is associated with hospital admission. Furthermore, hospital-acquired harm (adverse events that occur during a hospital admission that were not present prior to the admission)  can have greater implications for older people, cause deconditioning, loss of functionality, infections, pressure damage, sleep disorders, depression, delirium and falls^​16​. The burden of medicines can result in ineffective treatment of conditions through non-adherence to complex regimes. It is recognised that 30–50% of medicines are not taken as intended^​17​. This can be compounded in older people owing to a multitude of factors, including cognitive impairment and ADRs^​18​.  

Risk and benefit profiles of medicines evolve over the course of the patient journey, with the likelihood of expired indications (medicines that are no longer clinically indicated or no longer having intended therapeutic benefit) being more prevalent. Additionally, the inadequate evidence base in frailty, prescribing cascades from ADRs and changing prognosis over time mean that frail patients are often exposed to inappropriate polypharmacy^​19​.  For example, optimal blood pressure control reduces the risk of cardiovascular and other complications; however, low target blood pressures can cause harm in older adults, with an increased risk of hospitalisation from falls, hypotension, syncope, acute kidney injury and electrolyte disturbances^​20​. The European Cardiology Hypertension guidelines, published in 2024, have highlighted the importance of aligning frailty level to blood pressure targets^​21​.  

Specific medication harms in frailty include falls, fractures, cognitive impairment and mortality associated with anticholinergic burden (ACB), which refers to the cumulative effect of taking medicines with anticholinergic activity^​22​.  

Recognition and intervention opportunities for pharmacists

Pharmacy teams in all settings have opportunities to recognise and make interventions to address inappropriate polypharmacy. They should be aware of reactive triggers for medication review, which include hospital admission, transfers of care, patient or clinician concerns, adherence problems or identified medication harm (e.g. falls, deranged bloods or acute kidney injury)^​23​. Additionally, pharmacy professionals should have the opportunity to proactively identify patients at risk of harm from multiple medicines, such as those with polypharmacy, high ACB, high-risk drugs, care home residents, increasing frailty and frequent hospital admissions^​22​.

Opportunities to ‘make every contact count’ can open discussions with patients about their medicines. In addition to deprescribing, pharmacist intervention often resolves prescribing omissions where clinically appropriate medicines have not been prescribed^​24​. Opportunities for pharmacists across sectors to address inappropriate polypharmacy can be seen in Table 1^{​25–31​}.

Deprescribing can present challenges to prescribers of all disciplines owing to cultural and systemic barriers^​32​. Pharmacological treatments are often favoured over other approaches in today’s health systems^​10​. Time pressures, challenges with digital systems and lack of support for clinicians also contribute to overprescribing, particularly in minority ethnic and deprived communities and those who are vulnerable through older age and frailty. Feedback from patients demonstrates that problematic polypharmacy and inequality in healthcare is more prevalent in these vulnerable groups^​10​. 

In 2019, the British Geriatrics Society stated that “judicious review of medications, their indications, side effects, benefits and interactions can cause significant and rapid improvements in a patient’s condition”^​33​. Similarly, studies have concluded that reducing inappropriate polypharmacy can reduce ADRs, healthcare resource utilisation and improve patient quality of life^​32​. Some examples of UK projects that have previously addressed inappropriate polypharmacy can be seen in the Box below.

Medication reviews 

A medication review should determine the indication for use, duplication of therapy and whether the medicine is effective for the condition based on clinical monitoring, observations and blood results^​38​. Checks for correct dosage and directions based on weight, renal function and hepatic impairment are also crucial in older frail patients^​31​. It is important to assess an individual’s level of frailty to understand their functional reserve, which is affected by the cumulative decline in multiple physiological systems. This will impact decision making on how appropriate treatments are which have longitudinal goals of prevention (i.e. treating holistically to reduce the likelihood of becoming ill or dying prematurely)^​39​. 

Person-centred considerations are equally important, such as ease of dosage regime, willingness to take medicines and use of a compliance aid^​31​.

The BGS and SPS both have useful resources to assist clinicians in reviewing medicines and deprescribing (‘Older adult pharmacy resources’ and ‘Tools to support medication review’, respectively).

Table 2 outlines what should be included in a medication review and any additional considerations^{​31,38,39​}.

Literature suggests that SMRs should be underpinned by shared decision making and a multidisciplinary approach^​29,40​. Additionally, a holistic approach is required in frailty, with a move away from single condition reviews. Patients should be given information to support them to prepare for a medication review (see ‘Useful resources’). Assessing a patients’ clinical frailty score, alongside a discussion about their values and wishes and realistic expectations of outcomes, are crucial to unlocking an effective and productive SMR.

What action can be taken to address inappropriate polypharmacy? 

Much of the evidence to support stopping medicines is empirical and based on the patient’s physical functioning, comorbidities, preferences and lifestyle^​41​. Therefore, addressing inappropriate polypharmacy through deprescribing requires a structured and cautious approach. A trial without medication before complete cessation is often better received by patients and carers. Communication and follow-up are vital, as is gaining trust of patients/carers and team members^​38​.

Once it has been identified that a patient may benefit from deprescribing, the following approaches can be considered:

• Can multiple daily dose regimens be adapted? E.g. oral iron taken once daily; 
• Is it safe to stop medicines completely?
• Consider trial without the medicine for two to four weeks;
• Deprescribe one at a time if clinically appropriate;
• Taper doses; the regime used will depend on the medicine. Generic information on dose tapering can be found here;
• Signpost the patient to resources to support them (see ‘Useful resources’); 
• Communicate with other clinicians and the wider MDT, ensuring documentation regarding medicine changes and ongoing monitoring is clear in patient notes and on discharge/clinic letters. This should include details of and reasons for the medicine change and any follow up or ongoing monitoring. 

Communication with patients 

When communicating with patients about medicine changes, pharmacists should:

• Be clear and concise;
  • Tailor the information to the patient’s needs (e.g. written, large font);
  • Share changes with the patient, relatives, carers and all relevant healthcare professionals involved in their care, include communication to the community pharmacy via Discharge Medicines Service;
  • Clearly document information in notes and care plans in real time to ensure everyone is updated in a timely manner;
  • Give patients the opportunity to ask questions; 
  • Check that the patient understands and that any language barriers are addressed and health literacy is accounted for.  

The following resources can help patients with changes to their medicines: 

• Medication passport: NHS England ‘Health and care passport’;
• NHS medicine reminder chart;
• The Health Innovation Network’s ‘Me and my medicines’ resources aimed support patients undertaking a SMR.

Monitoring

Effective safety netting advice needs to be provided — ensure the patient knows what effects to look out for and to present promptly to GP or A&E if red-flag symptoms occur after medicine changes, such as chest pain, shortness of breath, signs of bleeding and confusion.

Review for benefit/harm in two to four weeks, which may be done remotely or face to face, depending on the complexity of the changes and patient factors, such as communication difficulties or cognitive impairment.

Arrange relevant blood tests and observations where appropriate. Careful consideration is needed as to whether severely frail patients can tolerate investigations and whether the result of the investigation would change the decision or outcome.

Conclusion

Despite the challenges, there are many opportunities to optimise medicines and improve outcomes for frail patients taking multiple medicines. This requires open communication, collaborative working and the building of relationships, based on trust, with patients and healthcare professionals. Lack of knowledge and training must be addressed through the education of patients and clinicians. Opportunities to identify those most at risk from harm and time for follow-up after medication reviews needs to be prioritised^​29​.