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Summary for primary care

Polypharmacy in Older People Part 1: A Guide for Healthcare Professionals

Overview

This is part 1 of our Guidelines summary on polypharmacy in older people. Recommendations included are on frailty, high-risk medication, sick day rules, reviewing patient medication adherence, the anticholinergic effect on cognition, and falls.

For recommendations on the four-step approach and practical guide to stopping medication, including tapering information and withdrawal effects for nine classes of medication, refer to part 2 of this Guidelines summary

For a complete set of recommendations, refer to the full guideline.

This summary as a whole has been reproduced with permission from the All Wales Medicines Strategy Group.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record. 

Definition 

  • Polypharmacy can be defined as appropriate polypharmacy or problematic polypharmacy:
    • appropriate polypharmacy—prescribing of multiple medications for an individual with complex conditions or for multiple conditions in circumstances where medicines use has been optimised and prescribed in accordance to best evidence
    • problematic polypharmacy—prescribing of multiple medications inappropriately or where the intended benefit of the medication is not realised. The following examples would contribute to polypharmacy being considered inappropriate:
      • use of a treatment is not evidence-based
      • risk of harm outweighs the benefits of treatment
      • drug interactions leading to unintended side effects
      • unacceptable pill burden making it difficult to achieve clinically useful medicine adherence
      • prescribing medicines to treat side effects of other prescribed medicines.

Identification

  • A pragmatic approach to identifying high-risk polypharmacy in practice has been suggested by The King’s Fund:
    • patients with 10 or more regular medicines (for example, those medicines taken every day or every week)
    • patients receiving between four and nine regular medicines who also:
      • have at least one prescribing issue that meets criteria for potentially inappropriate prescribing
      • have evidence of being at risk of a well-recognised potential drug–drug interaction or have a clinical contraindication
      • have evidence from clinical records of difficulties with taking medicines, including problems with adherence
      • have no or only one major diagnosis recorded in the clinical record (it might be expected that large numbers of medicines are unlikely to be justified in patients without multiple clinical conditions)
      • are receiving end-of-life or palliative care (where this has been explicitly recognised). 

Good Prescribing Practice in Older People

  • Use drugs that are familiar to the prescriber
  • Use the lowest effective dose and titrate up slowly
  • Prescribing should always be evidence-based for the specific age group
  • Anticipate drug interactions (including drug–drug, drug–food, drug–alcohol, and drug–herbal)
  • Be aware of and vigilant for adverse drug reactions and how pharmacology differs in older people
  • Monitor therapy (particularly high-risk medications, for example, digoxin)
  • Be aware of medications that may be prescribed via specialist clinics and therefore not on the patient’s record (for example, memory clinic)
  • Be aware of medications not prescribed, such as over-the-counter medications, herbal products, or someone else’s medication
  • Avoid the prescribing cascade:
    • optimise existing medication
    • consider introducing drugs as a trial—titrate dose and stop if ineffective
    • consider deprescribing to enable the safe and effective cessation of inappropriate medication
  • Promote adherence in collaboration with the patient:
    • undertake shared decision making with the patient and involve carers where reasonable
    • keep the medication regimen simple, taking into account pill burden and timings
    • provide clear written instructions, a dosing schedule, and information on why the medicine has been prescribed
      • avoid using the term, ‘as directed’
    • identify over-ordering/hoarding of medicines
    • consider advantages and disadvantages of compliance aids. Monitored dosage systems should not be used first line as they can have disadvantages, for example, drug stability and difficulty in following directions such as ‘when required’ or with/after food
    • don’t assume that the patient is taking medication as prescribed
  • Be aware of any transfer between care settings and changes to medication that may occur as a result. The community pharmacy discharge medicines review (DMR) service can provide support to patients recently discharged between care settings by ensuring that changes to patients’ medicines made in one care setting (for example, during a hospital admission) are enacted as intended in the community
  • Be aware of the person's culture or social beliefs of the treatment or disease
  • Be aware that people of different races and ethnicities can have varying responses to medicines. The British National Formulary (BNF) or the individual medicine’s summary of product characteristics should always be consulted
  • Be aware of potential links between overprescribing, deprivation, ethnicity, and inequalities, and the impact this has on the health of the person.

Frailty

  • Frailty is a multicomponent syndrome where individuals have a reduced resilience to external stressors such as infections and adverse drug reactions
  • The multicomponent syndrome is made up of the five ‘geriatric giants’ or frailty syndromes, including:
    • falls
    • immobility
    • delirium
    • incontinence
    • susceptibility to adverse drug reactions
  • Establishing frailty in individuals can be undertaken using a range of tools such as Frailty phenotype or PRISMA-7 questionaire. There is also the clinical frailty index. However, this should only be used to quantify the extent of frailty following on from a comprehensive geriatric assessment (CGA)
    • undertaking a medication review is a beneficial intervention which forms part of the CGA
  • The STOPPFrail tool can be used to review medications as listed below in patients aged over 65 years that have ALL of the following:
    • end-stage irreversible pathology
    • poor 1-year survival prognosis (this can be gauged from the frailty score)
    • severe functional impairment and/or severe cognitive impairment
  • Symptom control is a priority over disease progression prevention.
Box 1: Medicines Highlighted for Review in Frail Patients with Limited Life Expectancy as per the STOPPFRAIL Toolkit
  • Lipid-lowering therapies
  • Antiplatelets
  • Neuroleptic antipsychotics
  • Memantine
  • PPIs
  • H2-receptor antagonists
  • Gastrointestinal antispasmodics
  • Theophyline
  • Leukotriene antagonists in COPD
  • Calcium supplementation
  • Antiresorptive medicines
  • SORMs for osteoporosis
  • Long-term NSAIDs
  • Long-term oral steroids
  • 5-alpha reductase inhibitors
  • Alpha-blockers
  • Muscarinic antagonists
  • Diabetic oral agents—aim for monotherapy
  • ACEis for diabetes
  • ARBs for diabetes
  • Systemic oestrogens for menopausal symptoms
  • Multivitamin combination supplements
  • Nutritional supplements
  • Prophylactic antibiotics

ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; COPD=chronic obstructive pulmonary disease; NSAID=nonsteroidal anti-inflammatory drug; PPI=proton pump inhibitor; SORM=selective oestrogen receptor modulator

Further detail on each of these drug classes can be found within the STOPPFRAIL toolkit.

© All Wales Medicines Strategy Group, 2023 reproduced with permission. 

  • In frail patients, other factors such as medication risk versus benefit, difficulties with medicines administration, and challenging monitoring of the medication or compliance should be taken into account when stopping or starting medication.

High-Risk Medication

The acronym APINCH highlights high-risk medicines that can cause preventable harm (see Table 1).

Table 1: APINCH Classification of High-Risk Medicines

ClassificationExplanation

A

Antimicrobials

P

Potassium and other electrolytes

I

Insulin

N

Narcotics (opioids) and other sedatives

C

Chemotherapeutic agents

H

Heparin and other anticoagulants

© All Wales Medicines Strategy Group, 2023 reproduced with permission. 

Sick Day Rules

  • Patients who become unwell and are unable to maintain adequate hydration are at risk of dehydration. Continuing to take certain medications when dehydration occurs can increase the risk of harm to the patient. It is therefore suggested to consider sick day rules. The following medications should be temporarily stopped during an illness that can result in dehydration (acronym SADMANS):
    • sulphonylurea
    • angiotensin-converting enzyme inhibitors (ACEis)
    • diuretics
    • metformin
    • angiotensin receptor blockers (ARBs)
    • nonsteroidal anti-inflammatory drugs (NSAIDs)
    • sodium–glucose cotransporter-2 inhibitors (SGLT-2is)
  • It is important to weigh up the risks and benefits of withholding these medications for each individual
  • Patients should be advised to withhold these medications if they develop severe vomiting, diarrhoea, or fever, and to restart taking the medication 24–48 hours after this has resolved. Refer to individual health board guidance for advice
  • In addition to the above, patients receiving steroids should receive a dose escalation dependent on the steroid and indication for use during acute illness, trauma, or surgery.

Reviewing Patient Medication Adherence

Patient Assessment

As part of each patient assessment, the following questions should be addressed:

  • Who is responsible for administering medication?
    • for example, self-administration, family, healthcare support worker (HCSW), social care worker
  • If medication is administered by social care workers or HCSWs:
    • do administration times align with planned care calls?
    • when required (prn) medicines?
      • state reason (for example, pain, constipation)
      • specify dose (that is, avoid terms such as ‘one or two to be taken’)
  • How does the patient access their community pharmacy and/or GP to arrange order for delivery of medication?
  • Is the patient unable to manage their medication? For example, due to:
    • complex dosage regimen
    • over-ordering/hoarding of medication
    • forgetful/diagnosis of dementia
    • chaotic lifestyle
    • swallowing difficulties
    • poor dexterity
    • poor mobility
    • poor sight
    • unable to hear, read, or understand directions
    • unable to use medication device (for example, inhalers, eye drops)
  • Is the patient intentionally poorly adherent? For example, due to:
    • medication no longer needed (particularly when required drugs), for example, ongoing use of proton pump inhibitors (PPIs) once long-term NSAIDs have stopped, painkillers
    • ineffective medication
    • lack of understanding of indication/importance of treatment
    • patient beliefs surrounding their medication
    • lack of immediate visible effects/benefits (for example, for hypertension)
    • unpleasant side effects
    • directions unclear
    • complex administration instructions (for example, bisphosphonates, warfarin)
  • Is the patient taking any over the counter or herbal medicines?

Potential Solutions

After the patient has been assessed, the following solutions to common issues may be considered:

  • Can the regimen be simplified?
    • consider call times if the patient receives a package of care
  • Is there any therapeutic duplication?
    • any drugs of limited clinical value, or drugs where long-term benefit is unlikely to be realised due to life expectancy?
  • Would they benefit from a further discussion with a community pharmacy professional?
    • assess options and support required, for example, compliance aids, reminder charts, alarms, dexterity aids
    • The Equality Act 2010 requires the healthcare professional to assess patients with ‘disabilities’ and make ‘reasonable adjustments’ to support adherence with their medicine, without introducing additional risks. The final decision on which adjustment is required to the way that prescribed medicines are supplied will be the responsibility of the supplying pharmacist (or dispensing doctor)
  • What support is available?
    • under the discretion of the supplying pharmacy, this may include:
      • child-resistant/wing-topped bottles, devices to aid popping tablets from blisters, devices to aid administration of eye drops/inhalers, large print labels/patient information leaflets, reminder charts, text alerts
      • monitored dosage systems (MDSs) are an option but should not be used first line. It is important to note that there is no contractual requirement to supply an MDS to a care facility. Providing care workers are suitably trained, the supply of medicines in original packs should be promoted as standard. For more information on the risks and benefits associated with an MDS, please refer to the full guideline
  • Link with GP and community pharmacy to explore options for delivery and/or ordering of medicines
    • it is worth noting that if a patient has medicines delivered, in an instance where they could have collected them themselves, they would miss potential opportunities for interactions with a community pharmacy professional
  • Address reasons for intentional poor adherence. For example:
    • with permission from the patient or carer, remove medication that is no longer needed or is now ineffective
    • utilise shared decision making through the use of patient decision aids
    • counsel patients appropriately
    • consider switching/stopping drugs with unpleasant side effects
  • If the patient has swallowing difficulties, would a liquid or soluble preparation be more appropriate?
    • consider cost implications, product licence
    • be aware of unlicensed specials
  • If tablets or capsules are being crushed/opened, consider the impact on product licence, stability, pharmacokinetics of the drug, and coating.

Anticholinergic Effect on Cognition

  • The long-term use of anticholinergic drugs in older people is associated with an increased risk of cognitive decline, dementia, and all-cause mortality, as well as adverse effects such as constipation, urinary retention, sedation, and falls
    • the anticholinergic effect on cognition (AEC) scale assigns a score from 0–3 for each medication—the higher the number the stronger the anticholinergic effect (see Table 2)
    • medications with a score of two or three should be reviewed, especially in older people with cognitive impairment, delirium, or dementia
    • total scores of three or above should be reviewed
    • it is recommended to review medications with the aim to reduce the AEC score
    • where possible, minimise the use of anticholinergics
    • in patients with suspected or diagnosed dementia, NICE recommends minimising anticholinergic use and looking for alternative treatments with less anticholinergic activity
    • avoid prescribing anticholinergics with acetylcholinesterase (AChE) inhibitors (for example, donepezil, rivastigmine) as this can worsen cognitive impairment
    • monitor at regular intervals for efficacy and tolerance
    • if concern arises about anticholinergic-induced impaired cognition, conduct a mental state examination and consider switching or stopping medications if clinically appropriate
    • any changes should be discussed with the patient or carer as well as the risks and benefits.

Table 2: AEC Scores of Prescribed Medications

Drugs with AEC Score of 0Drugs with AEC score of 1Drugs with AEC Score of 2Drigs with AEC Score of 3

Alprazolam

Lorazepam 

Lithium 

Pimozide 

Doxepin 

Amlodipine

Losartan

Mirtazepine

Prochlorperazine

Hyoscine hydrobromide

Amoxicillin

Lovastatin

Perphenazine

Promazine

Imipramine

Aspirin

Lurasidone

Prednisolone

Propantheline

Lofepramine

Atenolol

Meloxicam

Quinidine

Quetiapine

Nortriptyline

Atorvastatin

Metoclopramide

Sertindole

Tolterodine

Orphenadrine

Bupropion

Metopralol

Sertraline

Trifluoperazine

Oxybutynin

Cephalexin

Moclobemide

Solifenacin

 

Procyclidine

Cetirizine

Morphine

Temazepam

 

Promethazine

Chlordiazepoxide

Naproxen

 

 

Trihexyphenidryl (benzhexol)

Cimetidine

Omeprazole

 

 

Trimipramine

Ciprofloxacin

Paracetamol

 

 

 

Clopidogrel

Pantoprazole 

 

 

 

Darifenacin

Pravastatin

 

 

 

Diclofenac

Propranolol

 

 

 

Diltiazem

Rabeprazole

 

 

 

Enalapril

Ranitidine

 

 

 

Entacapone

Risperidone

 

 

 

Fexofenadine

Rosiglitazone

 

 

 

Fluvoxamine

Simvastatin

 

 

 

Furosemide

Theophylline

 

 

 

Gabapentin

Thyroxine (levothyroxine)

 

 

 

Gliclazide

Tramadol

 

 

 

Haloperidol

Trazodone

 

 

 

Ibuprofen

Trimethoprim

 

 

 

Ketorolac

Trospium

 

 

 

Lamotrigine

Venlafaxine

 

 

 

Levadopa 

Valproate

 

 

 

Lisinopril

Warfarin

 

 

 

Loperamide

Ziprasidone

 

 

 

Loratadine

Zolpidem

 

 

 

© All Wales Medicines Strategy Group, 2023 reproduced with permission. 

Falls

  • As advised by NICE, individuals who are at risk of falling, have had recurrent falls in the past year, or have presented for medical attention due to a fall should have a multifactorial assessment including a medication review
  • Medicines can cause falls due to several reasons, including:
    • sedation/drowsiness
    • hypoglycaemia
    • confusion
    • vestibular damage
    • impaired postural stability
    • orthostatic hypotension
    • dehydration
    • hypothermia
    • visual impairment
    • drug-induced Parkinsonism
  • Recent changes in medicines can cause falls, but long-term medicines that have not been reviewed are often one of the main causes
  • Osteoporosis risk should also be assessed as part of the multifactorial assessment, with the relevant treatment commenced as per the NOGG guidance, if appropriate
  • See Table 3 for a list of medications that can increase the risk of falls, which should be taken into consideration when undertaking a medication review and/or when prescribing new medicines.

Table 3: Medicines that can Increase the Risk of Falls

Medication and Risk

Red (High Risk)[A]

Alpha blockers: alfluzosin, doxazosin, indoramin, prazosin, tamsulosin, terazosin

ACEis: captopril, enalapril, lisinopril, perindopril, rampiril, trandolapril

Antianginals: glyceryl trinitrate, isosorbide mononitrate, nicorandil

Antiepileptics: carbamazepine, phenobarbitone, phenytoin

Antipsychotics: chlorpromazine, fluphenazine, haloperidol, olanzapine, quetiapine, risperidone

Benzodiazepines

Beta blockers: atenolol, bisoprolol, carvedilol, metoprolol, propranolol, sotalol, timolol eye drops

Centrally-acting alpha 2 receptor agonists: clonidine, moxonidine

Dopamine agonists:[B] pramipexole, ropinirole

Monoamine oxidase inhibitors: isocarboxazid, phenelzine, tranylcypromine

Monoamine oxidase B inhibitors:[B] selegiline

Opioids

Sedating antidepressants: amitriptyline, clomipramine, dosulepin, doxepin, imipramine, lofepramine, mianserin, mirtazapine, nortriptyline, trazodone, trimipramine

SRIs: duloxetine, venlafaxine

Thiazide diuretics: bendroflumethiazide, chlorthalidone, metolazone

Z drugs: zopiclone/zolpidem

Orange (Medium Risk)[A]

Angiotensin receptor blockers: candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

Antidysrhythmics: amiodarone, digoxin, flecanide

Antiepileptics: gabapentin, sodium valproate

Calcium channel blockers: amlodipine, diltiazem, felodipine, lercanidipine, nifedipine, verapamil

Loop diuretics: bumetanide, furosemide

Muscle relaxants: baclofen, dantrolene

SSRIs: citalopram, fluoxetine, paroxetine, sertraline

Yellow (Possible Risk)[A]

Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine

Antiepileptics: lamotrigine, levetiracetam, pregabalin, topiramate

Antipsychotics: prochlorperazine

Antihistamines: cinnarazine, chlorphenamine, hydroxyzine, promethazine, trimeprazine

Anticholinergics: oxybutynin, solifenacin, tolterodine

[A] This is not a fully comprehensive list. It is intended to raise awareness of the types of drugs that cause falls. Other drugs may cause falls in certain circumstances in certain patients

[B] Do not change these Parkinson’s medications without the advice of a specialist.

ACEi=angiotensin-converting enzyme inhibitor; SRI=serotonin reuptake inhibitor; SSRI=selective serotonin reuptake inhibitor

© All Wales Medicines Strategy Group, 2023 reproduced with permission. 


References


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