Polypharmacy and Deprescribing – Comprehensive Study Notes

Knowledge
- Describe polypharmacy and its impact on patients.
- Identify situations warranting exploration of polypharmacy and deprescribing.
Skills
- Confidently sign-post patients for medication reviews.
- Apply a structured framework for ongoing medication use.
- Facilitate shared decision-making in prescription management with older adults.
Attitudes
- Promote public awareness of harms from inappropriate polypharmacy.
- Support the cultural shift that “more drugs ≠ better care” in later life.

Simply: concurrent use of multiple medications.
Numerical thresholds have evolved as prescribing volumes rise:
- Historically: $\ge 4\text{–}5$ drugs.
- NICE NG56 (multimorbidity):
- Always take a multimorbidity approach if patient has $\ge 15$ regular drugs.
- Consider if taking $10\text{–}14$ or < $10$ plus high ADR risk.
Key distinction: appropriate vs inappropriate / problematic polypharmacy—not just pill counts.
- Example of appropriate: vigorous older adult post-MI + heart failure on 7–8 evidence-based agents.

Average prescriptions per person ↑ 54 % in 10 years.
UK projections (2018): 3 million people managed via polypharmacy for long-term conditions.
Proportion on $\ge 10$ drugs: 1.9 % → 5.6 % (1995–2010).
One-third of ≥75-year-olds take ≥6 medicines.

Taking $\ge 10$ medicines ⇒ 3× higher hospital admission risk.
Adverse drug reactions (ADRs) cause 6.5 % of all UK hospital admissions, occupying 4 % of beds.
Prescription workload: 3 chronic diseases → 6–13 different daily drugs; 6 diseases → 18 drugs/day.

Drug–Drug: e.g. cholinesterase inhibitors + anticholinergics (delirium episode 1.02).
Drug–Disease: e.g. NSAIDs worsening hypertension.
Multimorbidity multiplies interactions: analysis of 12 NICE guidelines found in diabetes guidance:
- 133 serious drug–drug interactions; 25 (19 %) involved 1st-line agents.
- 32 serious drug–disease interactions across 11 other conditions.

New drug started to treat ADR of another drug.
- Classic: amlodipine-induced oedema → furosemide prescription.
Visualised in OliviaSDON cartoon (Twitter link).

Note: drugs provoking subtle presentations (frailty crises, vague malaise) likely under-recognised.

Absorption
- ↑ Gastric pH (H!!\text{+}↓) from atrophic gastritis / PPIs.
- ↓ Gastric emptying.
Distribution
- ↑ Body fat, ↓ total body water.
- Fat-soluble drugs (benzodiazepines) ⇒ ↑ volume of distribution ⇒ prolonged $t_{1/2}$ .
- Water-soluble drugs (digoxin) ⇒ ↓ Vd ⇒ need lower loading dose.
- Blood–brain barrier permeability ↑ ⇒ greater CNS ADRs.
Metabolism
- ↓ Hepatic blood flow ⇒ impaired clearance of high-extraction drugs (e.g. amitriptyline).
- Polypharmacy ⇒ higher likelihood of CYP450 induction / inhibition.
Elimination
- Renal mass & flow ↓; $eGFR \downarrow 0.5\%$ per year after age 20.
- Accumulation risk: diuretics, digoxin, NSAIDs.

Older, frail, cognitively impaired, multimorbid adults & care-home residents are under-represented; included elders usually “healthy”.

20–50 % of older adults receive ≥1 anticholinergic drug.
Effects: dry mouth/eyes, constipation, urinary retention, blurred vision, tachycardia; plus sedation, confusion, hallucinations, functional/cognitive decline.
23 % of dementia patients prescribed anticholinergics.
Systematic review: strong negative impact on cognition & physical function; delirium & mortality data limited.
ACB Scale
- Literature 1966–2007 scanned for drugs with anticholinergic activity + cognitive harm.
- Inter-disciplinary panel scored each drug (mild-moderate-severe).
- Resources: printable PDF link provided in transcript.

Frail patients may not live long enough to realise preventive drug benefits (e.g. statins).
Continue meds giving day-to-day symptomatic relief (analgesia, anti-anginals).
Do not stop essential control drugs (antiepileptics, antiparkinsonian) without specialist input.

Ascertain All Drugs & indications (include prescriptions, OTC, CAM).
Clarify Actual Use
- Ask about missed doses in a specific recent period.
- Explore daily habits without blame.
Pharmacy Collaboration
- Medication reconciliation, pill counts, contacting community pharmacy.
Risk Stratification for Harm
- Key predictors: total drug count, past toxicity, >65 yrs, dementia, multimorbidity, multiple prescribers, non-adherence, renal impairment, substance misuse, end-of-life.

Tool	Purpose & Highlights
STOPP/START	Screening Tool of Older Person’s Prescriptions / to Alert doctors to Right Treatment. Delphi consensus. Use ↓ inappropriate scripts (ARR $35.7\%$ , NNS $=2.8$ ) & ↓ undertreatment (ARR $21.2\%$ ).
STOPPFrail	27 criteria for frail elders with limited life expectancy. Facilitates deprescribing of longevity-focused meds.
Beers Criteria (AGS 2015)	US list of PIMs in older adults; originated with 11-member panel (1991).
NO TEARS	6-point mnemonic for 10-min GP review: Need, Open questions, Tests, Evidence, Adverse events, Risk reduction, Simplification.
Consultant Pharmacy Services Factsheets	Bite-sized deprescribing guides (allopurinol, antihypertensives, antiplatelets, BZDs, bisphosphonates, PPIs, statins, etc.).
Scottish Polypharmacy App	Mobile decision support.
NNT.com	Quantifies absolute benefits / harms to aid shared decisions.

Shift from disease-centric to person-centred care prioritising quality of life.
Engage patients/public via campaigns & shared decision aids.
Importance of interdisciplinary teamwork (GP, geriatrician, pharmacist, nurse, caregiver).

NHS KSF: Communication (Lvl 3–4), PPD (Lvl 1–3), Service Improvement (Lvl 1–2).
Foundation Curriculum: Safe prescribing, frailty, multimorbidity.
Core Medical / GP VTS / Geriatric Medicine: therapeutics, patient-centred care, long-term conditions, palliative aspects.
Dementia Core Skills Framework: Tier 2 pharmacological interventions.