R15 - Introduction to Pharmaceutical Care, Medication Reviews and Polypharmacy

What is pharmaceutical care, and how has it evolved over time?

• Pharmaceutical care is the responsible provision of medication treatment to achieve positive health outcomes and improve patients' quality of life.

Now- person-centred, holistic care,medicines are safe, effective, and appropriate; clinical decisions; prescribing,med reviews,med optimisation

What is person-centred care?

• Person-centred care means placing the patient's individual needs, preferences and values at the centre of healthcare decisions.

What is medicines optimisation?

Medicines optimisation is a person-centred approach to ensuring medicines are used safely and effectively to achieve the best possible health outcomes.

How -

• Ensuring patients receive appropriate medicines.

• Reducing adverse drug reactions and prescribing errors.

• Improving adherence to treatment.

• Reviewing and stopping unnecessary medicines.

What are the four principles of medicines optimisation according to the Royal Pharmaceutical Society (RPS)?

• Understand the patient's experience – consider how medicines affect their daily life.

• Evidence-based medicine choices – prescribe treatments supported by clinical evidence.

• Ensure medicines are as safe as possible – minimise side effects, interactions and errors.

• Make medicines optimisation routine – regularly review treatment to maintain effectiveness and safety.

Why is medicines optimisation important?

Medication optimisation is important because patients may experience problems with their medicines, including:

• Non-adherence: Not taking medicines as prescribed.

• Polypharmacy: Taking multiple medicines, increasing treatment complexity.

• Adverse drug reactions (ADRs): Harmful or unwanted effects of medicines.

• Inappropriate prescribing: Medicines that are unnecessary or unsuitable.

What is polypharmacy?

Polypharmacy refers to the use of multiple medicines, commonly defined in this lecture as more than five medicines.

Related terms:

• Hyperpolypharmacy: Taking 10 or more regular medicines.

• Oligopharmacy: Intentionally minimising the number of regular medicines, for example in end-of-life care.

What is the difference between appropriate and inappropriate polypharmacy?

Appropriate polypharmacy	Inappropriate polypharmacy
All medicines are clinically needed.	Some medicines are unnecessary or unsuitable.
Benefits outweigh risks.	Risks may outweigh benefits.
Improves health outcomes and quality of life.	May cause harm or reduce quality of life.
Example: Multiple medicines needed to manage heart failure.	Example: Continuing a medicine that is no longer needed.

What are the main causes (drivers) of polypharmacy?

• Multimorbidity: Having two or more long-term health conditions.

• Ageing: Older patients are more likely to have multiple conditions requiring treatment.

• Single-disease guidelines: Following separate guidelines can lead to multiple prescriptions.

• Fragmented care: Different healthcare professionals prescribe without fully coordinating treatment.

• Prescribing cascade: A new medicine is prescribed to treat the side effect of another medicine.

What is a prescribing cascade?

A prescribing cascade occurs when the side effect of one medicine is mistaken for a new medical condition, leading to another medicine being prescribed.

What is overprescribing?

Overprescribing occurs when a medicine is prescribed despite being unnecessary, inappropriate or less suitable than an alternative.

This includes medicines that:

• Are no longer needed.

• Cause more harm than benefit.

• Have better non-pharmacological alternatives.

• Do not match the patient's preferences or circumstances.

Which patient groups are most affected by polypharmacy?

• Older adults, particularly those living with frailty.

• Patients with multimorbidity.

• Patients with cancer.

• Patients receiving end-of-life care.

• Patients with learning disabilities.

What are the clinical risks associated with polypharmacy?

Polypharmacy can increase the risk of:

• Adverse drug reactions (ADRs) – unwanted, harmful effects of medicines.

• Drug interactions – one medicine alters the effect of another.

• Medication errors – mistakes in prescribing, dispensing or administration.

• Non-adherence – difficulty following complex treatment regimens.

• Falls and cognitive impairment – particularly in older patients.

• Hospital admissions – due to medicine-related harm.

What are the social, financial and environmental impacts of polypharmacy?

• Social: Increased tablet burden, more appointments and reduced quality of life.

• Financial: Higher prescribing costs and healthcare expenses from managing adverse effects.

• Environmental: Increased medicine waste, packaging and pharmaceutical pollution.

Reducing inappropriate polypharmacy can improve patient wellbeing and healthcare sustainability.

What is medicines reconciliation, and why is it important?

Medication reconciliation is the process of obtaining an accurate list of a patient's medicines and comparing it with their current prescriptions to identify and resolve discrepancies.

It helps:

• Prevent omitted or duplicated medicines.

• Identify incorrect doses or medicines.

• Reduce medication errors during transfers of care.

What is the Discharge Medicines Service (DMS)?

The DMS is an NHS community pharmacy service supporting patients after hospital discharge.

• Hospitals refer patients to community pharmacies.

• Pharmacists check changes made to medicines during admission.

• Patients receive advice about their medicines after discharge.

Aim: Reduce medication errors, improve understanding of treatment and prevent hospital readmissions.

What is the New Medicine Service (NMS), and who is it for?

The NMS is a community pharmacy service that supports adults starting a new medicine for certain long-term conditions.

Examples: Asthma, COPD, hypertension and diabetes.

The three stages described in your lecture are:

1. Patient engagement: Patient recruited or referred to the service.

2. Intervention: Consultation 7–14 days after engagement.

3. Follow-up: Consultation 14–21 days after the intervention.

Aim: Improve medication adherence, address concerns and help patients use their new medicine effectively.

What is a Structured Medication Review (SMR)?

An SMR is a comprehensive, evidence-based review of a patient's medicines, usually carried out in primary care.

It assesses:

• Whether medicines are still needed.

• Their effectiveness and safety.

• Potential drug interactions and side effects.

• The patient's treatment goals and preferences.

• Opportunities for deprescribing.

Aim: Optimise medicines, reduce harm and improve patient outcomes.

How are medication reviews carried out during a hospital stay?

Medication reviews occur at different stages:

1. Admission: Medication reconciliation to identify what the patient normally takes and check for discrepancies.

2. During hospital stay: Review prescriptions for correct indication, dose, route, duration, interactions and safety.

3. Discharge: Reconcile medicines, explain changes to the patient and communicate them to the GP.

Aim: Ensure safe and appropriate medicine use throughout the patient's hospital stay.

What is deprescribing, and why is it important?

Deprescribing is the planned and safe withdrawal of inappropriate or unnecessary medicines.

It is important because it can:

• Reduce adverse drug reactions and drug interactions.

• Reduce tablet burden.

• Improve quality of life.

• Minimise inappropriate polypharmacy.

Deprescribing should involve the patient and appropriate monitoring, as some medicines require gradual dose reduction.

What is the STOPP/START tool, and how is it used?

STOPP/START is a clinical tool used to support appropriate prescribing in older adults.

• STOPP (Screening Tool of Older Persons' Prescriptions): Identifies potentially inappropriate medicines that may need to be stopped.

• START (Screening Tool to Alert to Right Treatment): Identifies beneficial medicines that may have been omitted.

Aim: Reduce inappropriate prescribing while ensuring patients receive necessary treatment.

What is the Anticholinergic Burden (ACB) score?

The ACB score is a tool used to estimate a patient's cumulative exposure to medicines with anticholinergic effects.

• Anticholinergic medicines block the effects of acetylcholine.

• A higher burden is associated with increased risks of confusion, cognitive impairment, dry mouth, constipation and falls, particularly in older adults.

• Pharmacists use the score to identify medicines that may need reviewing.

What other tools and frameworks can support medication reviews and deprescribing?

Tool	Purpose
ThinkCascades	Helps identify prescribing cascades.
STOMP	Aims to stop overmedication of people with a learning disability, autism or both.
IMPACT	Supports assessment of medicines and polypharmacy appropriateness.
SPS resources	Provide professional guidance to support medication reviews.
RCP Greener Pharmacy Guides	Support more environmentally sustainable pharmacy practice.

What is social prescribing, and how does it support medicines optimisation?

Social prescribing involves referring patients to non-medical services or community activities to improve their physical and mental wellbeing.

Examples:

• Exercise and walking groups.

• Social support groups.

• Community activities.

• Nature-based activities.

Importance: It addresses social and lifestyle factors affecting health and may reduce the need for unnecessary medicines.

What are the four principles of sustainable healthcare, and how do they relate to pharmacy?

• Prevention: Prevent illness and reduce the need for treatment.

• Patient self-care: Support patients to manage their own health.

• Lean service delivery: Reduce waste and unnecessary healthcare activity.

• Low-carbon alternatives: Choose effective treatments and services with a lower environmental impact.

summary key definitions

erm	Simple definition
Pharmaceutical care	Using medicines responsibly to improve patient outcomes.
Medicines optimisation	Ensuring medicines are safe, effective and appropriate for the patient.
Polypharmacy	Taking multiple medicines, commonly five or more.
Multimorbidity	Having two or more long-term health conditions.
Hyperpolypharmacy	Taking 10 or more regular medicines.
Overprescribing	Prescribing medicines that are unnecessary or inappropriate.
Deprescribing	Safely stopping medicines that are no longer appropriate.
Medicines reconciliation	Checking and confirming an accurate list of a patient's medicines.
SMR	A comprehensive review of a patient's medicines.
ADR	An unwanted, harmful reaction to a medicine.
Non-adherence	Not taking medicines as prescribed.
Prescribing cascade	Treating a medicine's side effect with another medicine.