Centre for Reviews and Dissemination
The use of multiple medications is often referred to as polypharmacy.1 Epidemiological evidence shows that as people age they develop a greater number of conditions (multimorbidity), with a related increase in polypharmacy.
NICE guidance on medicines optimisation distinguishes between “appropriate polypharmacy” (where medicines use has been optimised and prescribed according to best evidence) and “problematic polypharmacy” (where the prescribing of multiple medicines is either inappropriate or sub-optimal).2 This bulletin will focus on approaches that aim to reduce problematic forms of polypharmacy.
During the period 2005-2015, 60.4% of all prescription items in England were dispensed to patients aged 60 and over,3 and approximately one in five prescriptions to older people living in their own homes may be inappropriate.4,5 Among older people in care homes, up to 91%, 74%, and 65% of residents take more than five, nine, and ten medications, respectively.6
Polypharmacy may increase risk of adverse drugreactions, drug-drug and drug-disease interactions, and reduce compliance and adherence (due to complexity of drug regimens).7
NICE guideline evidence suggests that polypharmacy (five or more drugs) is associated with increased risks of unplanned hospital admission and mortality, with even greater risks at higher levels of polypharmacy. Polypharmacy (when defined as ≥13 drugs) is associated with increased risk of admission to a care home. No evidence was identified on how polypharmacy influences health-related quality of life.8
Systematic review evidence has shown polypharmacy to be associated with falls among both nursing home residents and community-dwelling older people.9 However, the potentially harmful consequences of polypharmacy are difficult to estimate precisely.10
NICE guidelines describe people who may benefit from an approach to care that takes account of multimorbidity. This includes adults who are prescribed 15 or more regular medicines, or adults prescribed fewer than 15 regular medicines who are at particular risk of adverse events.8
Additional reasons for re-appraising an older person’s medication needs might include: emergence of adverse drug effects; onset of dementia or end-stage disease; loss of symptom control; ongoing use of high risk medications (alone or in combination); newly available evidence on a medication; and concerns around intolerance or non-adherence.11
Within the wider population of older adults, subgroups at particular risk of harm from polypharmacy could include people recently admitted to hospital, care home residents, and those living with frailty.
NICE guidelines recommend assessing people with multimorbidity for frailty.8 Frailty can be conceptualised and measured in a number of ways; up-to-date information on how to recognise and manage frailty in primary care in general is available elsewhere.12
Few published studies report the relationship between measures of frailty and subsequent inappropriate medication use.13 One recent retrospective database study reported a significant correlation between Frailty Index (FI) score and both potentially inappropriate prescribing (PIP) and adverse drug reactions (ADR) in older hospitalised patients.14 However, the use of FI scores to reduce PIP and ADR has yet to be tested.
Multiple approaches to improve polypharmacy have been proposed, including organisational (e.g. medication review, specialist clinics, computerised decision support, risk screening tools), professional (e.g. educational programmes), financial (e.g. incentive schemes) and regulatory methods.15,16
One Cochrane review found that complex, multifaceted pharmaceutical approaches for improving the appropriate use of polypharmacy in older people led to some benefits in terms of Medication Appropriateness Index scores and number of Beers medications (a list of potentially inappropriate medications to be avoided in older adults),17 though evidence on hospital admissions and medication-related problems was inconsistent.15,16
A second Cochrane review concluded that interventions to optimise prescribing for older people living in care homes may lead to fewer days in hospital, a slower decline in health-related quality of life, identification and resolution of medication-related problems, and improved medication appropriateness, but may make little or no difference to adverse drug events or mortality.18
While the Cochrane reviews evaluated prescribing optimisation, other evaluations have focused solely on deprescribing. This is the complex process needed to ensure the safe and effective withdrawal (i.e. tapering or stopping) of inappropriate medicines.19
Deprescribing interventions can include: screening tools or criteria (e.g. Beers criteria, STOPP/START tool), specific medication- or population-specific guidelines,20 or more structured frameworks for deprescribing (e.g. Good Palliative-Geriatric Practice algorithm, CEASE framework, The 7 Steps).11,19,21
Several systematic reviews have evaluated the effects of deprescribing interventions (including comprehensive and drug-specific medication reviews, education programmes for prescribers, and patient-specific interventions) on the total number of prescribed or inappropriate medications,22-25 hospitalisation rates,22 symptoms26,27 and mortality.22,28 While positive effects were observed in many primary studies, reviews often failed to draw definitive conclusions about the relative effectiveness of different deprescribing approaches due to the poor quality and high variability of research evidence in this area.
In addition, interventions are often complex and it can be unclear how best to organise and implement these to achieve a reduction in inappropriate polypharmacy.22
Three systematic reviews have synthesised qualitative data on the perceived barriers and enablers to deprescribing inappropriate medications in adults.11,29-31 Much of this evidence focuses on the perceptions and beliefs of primary care practitioners and older patients (see online for details).32
Factors identified by practitioners fell into the following domains:
Factors that might influence a patient’s decision to cease a medication included:
Figure 1.‘House of Care’ model illustrating the building blocks of high quality person-centred coordinated care
Solutions proposed by GPs have included: relaxing treatment targets, applying patient-centred and patient education strategies, optimising medication management processes and relying on IT system support.31
While much of the research evidence on effectiveness is heterogeneous and of relatively low quality, it suggests that tools and strategies that promote appropriate deprescribing need to be considered at both the level of individual patient–prescriber encounters and the systems of care.11,29
The environmental and resource barriers identified by patients and practitioners reflect those identified in other areas of integrated care. These include services being focused on single condition guidelines,8 insufficient communication or coordination between professional groups, and a lack of emotional/psychological support. NHS England and its partners have responded to such barriers by proposing the ‘House of Care’ model for person-centred coordinated care (see figure 1).33
Prescribers should be aware that deprescribing is likely to be relevant to their own clinical practice and, when done appropriately and carefully, can have a positive and worthwhile impact. Where possible, deprescribing methods should address prescribers’ information needs, including information about previous prescribing decisions, and any known benefitharm trade-offs for relevant medications or special patient populations. NICE guideline on multimorbidity specifically recommends using its supporting database of treatment effects34 to inform medication reviews. Polypharmacy guidance issued by NHS Scotland also provides information on the efficacy of several commonly prescribed medications.35 This includes the number of patients who would need to be treated with each medication for one patient to benefit on relevant health outcomes. In addition, the NHS Business Service Authority’s ePACT 2 includes a Polypharmacy Dashboard (incorporating a collection of polypharmacyrelated indicators), which is being rolled out across England in the summer of 2017.36
In line with existing recommendations,37,38 deprescribing should be patient-centred, incorporating shared decision-making, informed patient consent, and appropriate monitoring arrangements. Patient concerns and beliefs about deprescribing can mirror those of prescribers, so everyone involved in the clinical consultation should be empowered to discuss openly the available options, along with their possible benefits and harms. Where available, appropriate decision aids may be used to support these discussions.
Both patients and clinicians have identified interprofessional communication as an important influence on polypharmacy. NICE guidance recommends that organisations consider a multidisciplinary team approach to improve outcomes for people who have long-term conditions and take multiple medicines.2 This includes consideration of a structured medication review for people taking multiple medicines, and use of a screening tool such as STOPP/START to identify potentially inappropriate medication in older people.2
NICE guidance also recommends individualised management plans for patients with multimorbidity that take into account disease and treatment burden (including the medicines they are taking), as well as patient goals, values and priorities.8
Implementation of such recommendations will require professional awareness of the likely enablers and barriers to success, alongside the fostering of a trusting, patient-centred consultation style within a supportive environment.