This document provides resources to support the management of polypharmacy and deprescribing. It begins with an overview of key terms such as polypharmacy, oligopharmacy, and deprescribing. It then discusses the increase in polypharmacy among older adults and some of the risks associated with inappropriate polypharmacy. The document is structured to provide background information on polypharmacy, tools and initiatives to support practice, and references. It aims to assist healthcare professionals with medication reviews and decisions around deprescribing for patients taking multiple medications.
This power point is my attempt to address the common yet serious issue of Polypharmacy.
Polypharmacy in elderly is a necessary evil. Although it is not always inappropriate, but the “inappropriateness” should be judged on a case to case basis.
Necessary tools should be used to avoid it.
And deprescribing is recommended to correct it as soon as it is labeled as a case of “inappropriate polypharmacy”.
This presentation will cover information about polypharmacy in older populations. The presentation will allow explain the use of technology such as HomeMeds as a tool to prevent adverse reactions in older populations.
This power point is my attempt to address the common yet serious issue of Polypharmacy.
Polypharmacy in elderly is a necessary evil. Although it is not always inappropriate, but the “inappropriateness” should be judged on a case to case basis.
Necessary tools should be used to avoid it.
And deprescribing is recommended to correct it as soon as it is labeled as a case of “inappropriate polypharmacy”.
This presentation will cover information about polypharmacy in older populations. The presentation will allow explain the use of technology such as HomeMeds as a tool to prevent adverse reactions in older populations.
Pharmaceutical care concepts - clinical pharmacy ShaistaSumayya
The pharmaceutical care is defined as “the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life.”
Pharmaceutical care involves the process through which a pharmacist cooperates with a patient and other professional in designing , implementation, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
detection methods of Adverse drug reactions, postal survey method, Reporting of Adverse drug reactions, Preventability assessment, predictability assessments
This lecture slides are prepared for Refresher course for pharmacist. Essential Medicines, Rational use of drugs and Self medication, These are the topics covered in this ppt.These slides are also useful for other medical undergraduates and post graduates students.
When a psychiatric patient is diagnosed, the practitioner selects a medication therapy from a variety of therapeutic approaches and according to the severity and condition of a patient; through peer evaluation. This requires the writing of a prescription. Prescribing accounts for a large proportion of errors [1]: Medication errors, problems related to strength and frequency of medication, quantity per dose, instructions for use, total quantity to be dispensed, dosage form etc; if absent, can cause great deal of patients’ harm. Medicines are a key component of healthcare and errors relating to medication, may impact on patient’s safety [1-4].
Human errors can be understood through a lot of suggested models and frameworks but the findings vary from country to country [5,6]. Prescribing errors are harmful to the patients and in worst cases they may lead to fatality. To avoid errors in prescriptions and its amelioration at the time of writing; is the easiest way of prevention of prescription errors [6-10]
Theories of human error states that, “a series of planned actions may fail to achieve their desired outcome because the plan itself was inadequate or because the actions did not go as planned. The definition reflects this distinction, including failures both in the prescribing decision and the prescription writing process” [5]. In 2005, Department of Health in the United Kingdom planned to reduce prescribing errors by 40% [10]. Such initiatives are also required in a developing country like Pakistan. Apparently, psychiatrists know a little about prescribing errors. Irrational drug therapy can cause patient’s harm by exacerbation or prolongation of illness, distress and higher costs [8] in some cases. Irrational prescribing is a global problem and may also be regarded as "pathological" prescribing [9].
All prescriptions must include the name, address, specialty and signature of the prescriber as well as the name, sex, and age of the patient and the strength, quantity, dose, frequency, dosage form and instructions for use of the medication [11–15]. The dispensing system of Pakistan is different than some other countries. The medication is available in already packed in containers etc by the pharmaceutical industries, to be dispensed. There is no option of refill instructions to the pharmacist etc. Adherence by the physician to good quality prescribing will minimize errors and ultimately improve patient’s care. Prescribing errors can occur as a result of errors in haste, poor concentration to the patient or attendant (in case the patient is unable to deliver the correct information), decision-making or the prescription-writing process. Incorrect prescribing habits are common unfortunately [16-20].
The purpose of this study was to investigate drug prescriptions of Psychiatry for the essential elements of prescriptions mentioned above, and to study the prescribing trends in psychiatric practice in Peshawar area, Pakistan.
Polypharmacy: seeing it through patients' eyesJeremy Taylor
How do patients experience having to take multiple medications? What are the implications for policy and practice? These are slides framing a presentation at a joint Royal Pharmaceutical Society/Royal College of GPs conference on polypharmacy on 20 April 2016.
Pharmaceutical care concepts - clinical pharmacy ShaistaSumayya
The pharmaceutical care is defined as “the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life.”
Pharmaceutical care involves the process through which a pharmacist cooperates with a patient and other professional in designing , implementation, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient
Medication therapy is becoming increasingly more complex as new drugs are developed and more therapeutic targets are elucidated. In addition, polypharmacy (≥5 scheduled medications) has become exceedingly common in geriatric patients and in patients with chronic disease states. As the complexity of drug therapy and the number of medications increase, patients are at a high risk for medication errors and adverse drug events (ADEs), or injuries resulting from medication. The type of adverse events may be associated with professional practices, healthcare products, procedures, and systems including prescription, communication through instructions, drug labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring, and use. Classification and evaluation of medication errors according to their importance may constitute an important factor for process improvement in order to render the administration of medicines as safe as possible. In hospitals, medication errors occur at a rate of about one per patient per day. A dispensing error is one made by pharmacy staff when distributing medications to nursing units or directly to patients in an ambulatory-care pharmacy; the error rates for doses dispensed via the cart-filling process range from 0.87% to 2.9%. Technology has grown to be a constituent part of medicine these days. A few advantages that technology can supply are categorized as follows: the assisting of communication between clinicians; enhancing medication safety; decreasing potential medical errors and adverse events; rising access to medical information and encouraging patient-centered healthcare. The aim of this article is to provide a compendious literature review regarding Medication errors
detection methods of Adverse drug reactions, postal survey method, Reporting of Adverse drug reactions, Preventability assessment, predictability assessments
This lecture slides are prepared for Refresher course for pharmacist. Essential Medicines, Rational use of drugs and Self medication, These are the topics covered in this ppt.These slides are also useful for other medical undergraduates and post graduates students.
When a psychiatric patient is diagnosed, the practitioner selects a medication therapy from a variety of therapeutic approaches and according to the severity and condition of a patient; through peer evaluation. This requires the writing of a prescription. Prescribing accounts for a large proportion of errors [1]: Medication errors, problems related to strength and frequency of medication, quantity per dose, instructions for use, total quantity to be dispensed, dosage form etc; if absent, can cause great deal of patients’ harm. Medicines are a key component of healthcare and errors relating to medication, may impact on patient’s safety [1-4].
Human errors can be understood through a lot of suggested models and frameworks but the findings vary from country to country [5,6]. Prescribing errors are harmful to the patients and in worst cases they may lead to fatality. To avoid errors in prescriptions and its amelioration at the time of writing; is the easiest way of prevention of prescription errors [6-10]
Theories of human error states that, “a series of planned actions may fail to achieve their desired outcome because the plan itself was inadequate or because the actions did not go as planned. The definition reflects this distinction, including failures both in the prescribing decision and the prescription writing process” [5]. In 2005, Department of Health in the United Kingdom planned to reduce prescribing errors by 40% [10]. Such initiatives are also required in a developing country like Pakistan. Apparently, psychiatrists know a little about prescribing errors. Irrational drug therapy can cause patient’s harm by exacerbation or prolongation of illness, distress and higher costs [8] in some cases. Irrational prescribing is a global problem and may also be regarded as "pathological" prescribing [9].
All prescriptions must include the name, address, specialty and signature of the prescriber as well as the name, sex, and age of the patient and the strength, quantity, dose, frequency, dosage form and instructions for use of the medication [11–15]. The dispensing system of Pakistan is different than some other countries. The medication is available in already packed in containers etc by the pharmaceutical industries, to be dispensed. There is no option of refill instructions to the pharmacist etc. Adherence by the physician to good quality prescribing will minimize errors and ultimately improve patient’s care. Prescribing errors can occur as a result of errors in haste, poor concentration to the patient or attendant (in case the patient is unable to deliver the correct information), decision-making or the prescription-writing process. Incorrect prescribing habits are common unfortunately [16-20].
The purpose of this study was to investigate drug prescriptions of Psychiatry for the essential elements of prescriptions mentioned above, and to study the prescribing trends in psychiatric practice in Peshawar area, Pakistan.
Polypharmacy: seeing it through patients' eyesJeremy Taylor
How do patients experience having to take multiple medications? What are the implications for policy and practice? These are slides framing a presentation at a joint Royal Pharmaceutical Society/Royal College of GPs conference on polypharmacy on 20 April 2016.
The Indo-American Journal of Life Sciences and Biotechnology of the journal uses recommended electronic formats for submitting articles, which helps speed up the overall process.Once an article is submitted, it undergoes an initial rapid screening by the editors of the Scopus indexing Journal.
Patient-centered pharmacovigilance represents a pivotal shift in the landscape of healthcare, emphasizing the active involvement of patients in the monitoring and reporting of adverse drug reactions. Unlike traditional pharmacovigilance, which primarily relies on healthcare professionals to identify and document adverse events, this approach recognizes patients as critical stakeholders in ensuring medication safety. By empowering patients to share their experiences, concerns, and observations regarding medication effects, whether positive or negative, healthcare systems can gain a comprehensive understanding of drug safety and efficacy in real-world settings. Patient-centered pharmacovigilance fosters a collaborative partnership between patients, healthcare providers, and regulatory agencies, promoting transparency, accountability, and ultimately, better patient outcomes. Through increased patient engagement and the utilization of patient-reported data, this approach enables healthcare systems to identify potential safety issues earlier, tailor treatment strategies to individual needs, and enhance overall drug safety surveillance efforts.
Polypharmacy and deprescribing safely: a patient-centred method, Professor Nina Barnett Consultant Pharmacist,Care of Older People, London North West Healthcare NHS Trust Medicines Use and Safety Team, Specialist Pharmacy Service
Visiting Professor, Institute of Pharmaceutical Science,
Kings College London
An Essential Drug List, also known as a core drug list or medication list, is a carefully selected inventory of medications that are deemed essential for addressing the most prevalent health conditions within a specific population or country. It serves as a key component of national drug policies and pharmaceutical programs, ensuring the availability, accessibility, and affordability of essential medicines. The list is typically developed based on rigorous criteria, taking into consideration the medications' safety, efficacy, cost-effectiveness, and suitability for primary healthcare settings.
Rational Drug Therapy refers to the systematic and evidence-based approach to prescribing medications, aiming to maximize therapeutic benefits while minimizing the risk of adverse effects. It involves following established therapeutic guidelines and clinical protocols to ensure that medications are prescribed in a manner that is appropriate for the patient's condition, taking into account factors such as age, weight, co-existing conditions, drug interactions, and individual response. Rational drug therapy promotes the use of medications based on sound scientific evidence, emphasizing the principles of efficacy, safety, and cost-effectiveness to optimize patient outcomes and improve overall healthcare quality.
V O L U M E 3 4 - N U M B E R 4 - F A L L 2 0 1 6 187FEATURE ART.docxkdennis3
V O L U M E 3 4 , N U M B E R 4 , F A L L 2 0 1 6 187
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Nurse Practitioner Perceptions of a Diabetes Risk Assessment Tool in the Retail Clinic Setting Kristen L. Marjama, JoAnn S. Oliver, and Jennifer Hayes
Diabetes is the seventh leading cause of death in the United States, burdening society with
high costs for treatment and placing increased demand on the health care system (1). According to the 2014 National Diabetes Statistics Report, an estimated 29.1 million people in the United States have diabetes, and 8.1 million of them are undiagnosed (2). The lack of screening for early identification of patients at risk for type 2 diabetes is a significant clin- ical problem. Health care providers (HCPs) need to be aware of the in- creasing diabetes burden and to pri- oritize the screening of patients who may be at risk. Screening for risk can aid in both efforts to prevent the development of diabetes and early management of the disease to reduce complications. Clinical trials have demonstrated that type 2 diabetes can be delayed or prevented through life- style modification or pharmacother- apy for people at increased risk (3).
In order to reduce risk for those at risk of developing diabetes, screen- ing is a priority that will raise patient
awareness. Many patients are not aware of their risk for type 2 dia- betes until they receive a confirmed diagnosis from their HCP. There are numerous health care settings in which screenings can be imple- mented, including but not limited to primary care practices, urgent care centers, hospital emergency depart- ments, and retail health clinics.
Retail clinics are located in retail supermarket and pharmacy chains to provide high-quality, affordable, and easily accessible health care services for communities. A true measure of quality in retail clinics is their degree of adherence to several measures iden- tified in the Healthcare Effectiveness Data and Information Set (4). Services in this type of setting may include treatment of acute episodic conditions, physical examinations, vaccinations, health screenings, and prevention and management of chronic conditions (5). Retail clinics provide services to patients with or without insurance or a primary care “home.†Patients’ visits to a retail clinic afford the opportunity to assess
■IN BRIEF This article describes a study to gain insight into the utility and perceived feasibility of the American Diabetes Association’s Diabetes Risk Test (DRT) implemented by nurse practitioners (NPs) in the retail clinic setting. The DRT is intended for those without a known risk for diabetes. Researchers invited 1,097 NPs working in the retail clinics of a nationwide company to participate voluntarily in an online questionnaire. Of the 248 NPs who sent in complete responses, 114 (46%) indicated that they used the DRT in the clinic. Overall mean responses from these NPs indicated that they perceive the DRT as a feasible tool in the retail cli.
Global Medical Cures™ | Responding to America's Prescription Drug Abuse CrisisGlobal Medical Cures™
Global Medical Cures™ | Responding to America's Prescription Drug Abuse Crisis
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
Consumer health: time for a regulatory re-think? is a report by RB in association with PAGB, written by the Economist Intelligence Unit. It looks at the changing healthcare environment and the role self-care plays and efforts at regulatory harmonisation, the barriers they have encountered, and prospects for the future.
Similar to Polypharmacy resource_JAN 15_NINA BARNETT (20)
1. East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Medicines Use and Safety
Winner: RPS Pharmaceutical Care Award 2013
Finalist: HSJ Patient safety award in primary care 2013; Winner: UKCPA/Guild Conference Best Poster award 2013
Winner: UKCPA Pain award 2012; Winner: UKCPA Respiratory award 2012
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Resources to support local delivery
http://www.publicdomainpictures.net/view-image.php?image=8211
Polypharmacy, oligopharmacy & deprescribing:
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Introduction
At least one third of over 75’s in the UK take four or more medicines regularly and this increases to an average of eight medications per person
per day in nursing homes. The number of medicines taken by older people has been steadily increasing for the last three decades. There are a
number of factors affecting this including; the advent of evidence based medicine; increase in multiple morbidity and longevity; promotion of
age-independent access to the increasing number of treatments and the increasing expectations for treatment from patients and their families.
These have made polypharmacy the “rule” rather than the “exception” for many patients.
Medicines are the most common intervention to improve health and concerns about the risks of polypharmacy in primary and secondary care are
growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased health care
costs and non-adherence (see section A: A1,A4). This has led to the suggestion that “ Polypharmacy itself should be conceptually perceived as a
“disease” with potentially more serious complications than those of the diseases these different drugs have been prescribed for”1
. Recent
attention has been focussed on Medicines Optimisation and management of polypharmacy is an integral part of this. The Five Year Forward
View2
recognises the need for integration of services and equity of care for patients across hospital and community settings and implementation
is supported by the Better care fund3
. Improved cross sector communication is key to continuing management of appropriate prescribing and
monitoring of polypharmacy. Improving integration of teams and encouraging multidisciplinary professional working will all support medicines
optimisation and reduction of inappropriate polypharmacy in all sectors of care.
Background: polypharmacy, oligopharmacy and deprescribing
There are number of terms which have come into use over recent years to describe multiple medicines use:
Polypharmacy refers to either the prescribing or taking many medicines. For many years it referred to the prescription or use of more than a
certain number of medicines, at least four or five or more medicines per day (see A2). More recently it has been used in the context of
prescribing or taking more medicines that are clinically required, as the number of medicines taken was of limited clinical value in interpreting
individual potential problems.
The Kings fund (see A4) divides the definition into “appropriate” and “problematic” polypharmacy which is a helpful distinction in practice:
Appropriate polypharmacy ”Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines
use has been optimised and where the medicines are prescribed according to best evidence.”
Problematic polypharmacy “the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not
realised.”
1
Garfinkel D and Mangin D ARCH INTERN MED/ VOL 170 (NO. 18), OCT 11, 2010 https://www.leg.bc.ca/cmt/39thparl/session-
4/health/submissions/Garfinkel_Feasibility_Study_of_a_Systemic_Approach_2010.pdf
2
http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
3
http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/
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Oligopharmacy seeks to promote the deliberate avoidance of polypharmacy, which if considered in terms of numbers of medicines, is the
prescribing of less than 5 prescription drugs daily4
Deprescribing is the complex process required for the safe and effective cessation (withdrawal) of inappropriate medication, recognising that
much of the evidence to support stopping medicines is empirical and based on the patient’s physical functioning, co-morbidities, preferences and
lifestyle.
Hyperpolypharmacy is a new term referring to the prescribing of ten or more medicines and the phrase has come into use to distinguish it from
polypharmacy, which is increasingly common5
The increase in polypharmacy can largely be attributed to the greater availability of evidence-based treatments promoted through therapeutic
guidelines. However these are written for management of single disease states and patients with long term conditions, especially older people,
commonly suffer from a number of conditions and these guidelines are designed for single condition treatment. In addition, each condition is
often treated by separate clinicians and the lack of a contemporaneous medication record, available to all health care providers and patients in
the UK, means that polypharmacy often ensues. With the increase in number of medicines available for purchase without prescription and the
poor co-ordination and communication of clinicians managing medicines, accurate medication review is often a challenge. Prescribers caring for
patients with multiple morbidities are further challenged by the absence of evidence based national guidance, incorporating the patient
perspective, around reducing and stopping medication. Polypharmacy is associated with an increased risk of adverse effects, falls, drug
interactions, drug disease interactions, drug errors and poor medicines adherence. This document has been created to assist with medication
review and decisions around deprescribing in the context of polypharmacy.
What does this mean for pharmacists?
This resource supports pharmacists in getting the best outcome for patients through evidence based medication review. It contributes to pharmacy
roles in supporting GPs and hospital doctors and encourages consideration of the ongoing benefit of prescribing medicines at every contact between
prescriber and patient. In pharmacy consultations, pharmacists have a crucial role in reviewing the balance or benefits and risk directly with the patient,
referring for or undertaking patient focused medication reviews when prescribing new drugs and regular medication review. Pharmacists can contribute
to Directly Enhanced Services or other GP performance indicators as well as GP care plans to apply current evidence to the patient situation to initiate
deprescribing where appropriate, eliminate inappropriate polypharmacy, and promote oligopharmacy.
How is the resource structured?
Section A: Overview of key papers Section B Tools and Initiatives to support practice Section C: Useful references
4
O’Mahoney D and O’Connor M N, Pharmacotherapy at the end-of-life Age and Ageing 2011; 0: 1–4 doi: 10.1093/ageing/afr059
5
Gnjidic, Danijela, Le Couteur, David G, Pearson, Sallie-Anne, McLachlan, Andrew J, Viney, Rosalie, Hilmer, Sarah, Blyth Fiona M N, Joshy, Grace and Banks, Emily. High risk prescribing in older adults:
prevalence, clinical and economic implications and potential for intervention at the population level BMC Public Health 2013, 13:115 http://www.biomedcentral.com/1471-2458/13/115
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Who is the resource for?
This resource supports all sectors of the pharmacy profession, in acute, mental health primary and community care with appropriate management of
polypharmacy. Commissioners can use this as a basis for commissioning enhanced services to support medicines optimisation, to provide them with assurance that
medicines are being reviewed and patient are being supported to achieve optimal outcomes from their medicines. The section which includes examples of resources
can guide commissioners to ensure that providers work to best practice and services meet best practice standard. Education and training leads may find this useful
for their staff in developing and implementing strategies for reducing medicines, as well as individuals using it to support continuing professional development. It is also
useful for any health professionals who work or liaise with patients to support optimising medicines: through access to key papers, knowledge, skills development
and information on training.
Putting it into practice
This resource will be supplemented by an additional publication in February 2015, Seven steps to managing polypharmacy: an algorithm. The algorithm has been
created to assist with medication review and decisions around deprescribing in the context of polypharmacy and aims to address polypharmacy as part of overall
medicines optimisation strategies. It can be used in successive consultations to address one or a small number of polypharmacy issues at a time. While it likely to be
most applicable in community settings, the principles can be applied to all patient care settings. Developed by Nina Barnett and Lelly Oboh, Consultant Pharmacists
working with Older People, Medicines Use and Safety Team, NHS Specialist Pharmacy Service, and Katie Smith, Regional Medicines Information Director, East
Anglia Medicines Information Service, it is based on published evidence and current practice and has been reviewed by clinicians who work directly with patients. A list
of key reference documents with content summary is provided following the algorithm together with references for further reading.
We thank all the contributors for sharing their tools with us and the practitioners who have commented on this document in the context of their practice.
Practitioners should seek permission from the authors should they wish to use or adapt any of the tools. The relative paucity of secondary care tools is a reflection of
the challenges in that setting. Due to the rapidly developing evidence base, please note that this resource cannot be comprehensive.
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Section A: Overview resources
A1 Organisation: NHS Scotland and The Scottish Government
Organisation’s Website: http://www.healthscotland.com/ http://www.scotland.gov.uk/
Title: Polypharmacy Guidance October 2012
Overview: This comprehensive and robust 47 page document is presented in three sections. The first outlines the rationale for addressing
polypharmacy, identifies patient groups who may benefit from polypharmacy related medicines review and the general content of the review. While the
document recommends using SPARRA (Scottish Patients at Risk of Readmission and Admission) prediction tool data to identify local high risk groups,
this concept is readily transferable to other localities where different tools are used. The second section gives clinical information using evidence based
sources to support conducting a review explaining the meaning of and including numbers needed to treat (NNT) and numbers needed to harm (NNH)
for individual drugs and drug groups. . The drug review process described is clinically focussed and supports practitioners with the clinical information
needed to conduct an effective review. Risk from high risk medication is discussed individually and by BNF categories, as well as identification of
clinical conditions of patients which can increase the risks from polypharmacy. Primary references are given. The final section on administrative
consideration includes useful information on how to conduct reviews however embedded documents are not available directly through the link.
See http://www.central.knowledge.scot.nhs.uk/upload/Polypharmacy%20full%20guidance%20v2.pdf
A2 Organisation: NHS Wales Health Board
Organisation’s Website: http://www.wales.nhs.uk/
Title : Polypharmacy: Guidance for Prescribing in Frail Adults Practical guide, with full guidance, BNF sections to target
Overview: An excellent summary of a practical introduction for practitioners who are interested in implementing polypharmacy reviews in their
workplace. The document covers similar ground to the Scottish guidance and presents the information in one page flow –chart based summaries of
background; drug review process; high risk medication; frailty and shortened life expectancy, ending with useful links.
The more detailed full guidance is also available which describes key considerations around polypharmacy, provides a medicines effectiveness
summary table (with numbers needed to treat for specified conditions) and explains the practicalities for stopping specific groups of medicines. The
appendices contain an example medicines review leaflet for patients and a list of helpful resources as well as references.
The supplementary guidance is set out in BNF order and describes key risks for each drug group and points for consideration during medication review
to reduce inappropriate polypharmacy. Links to relevant guidelines including NICE are given together with advice on deprescribing and follow
up/monitoring.
See practical guide http://www.wales.nhs.uk/sites3/documents/814/PrescribingForFrailAdults-ABHBpracticalGuidance%5BMay2013%5D.pdf
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Full guidance http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20-%20Guidance%20for%20Prescribing%20in%20Frail%20Adults.pdf
BNF guidance http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20Supplementary%20Guidance%20-
%20BNF%20Sections%20to%20Target.pdf
A3 Organisation: PrescQIPP NHS Programme
Organisation’s Website: http://www.prescqipp.info/
Title: Polypharmacy and Deprescribing
Overview: PrescQIPP has produced a number of resources to support practitioners in reducing polypharmacy. The current web pages outline the
background to this area and describe the current work of the project, including a landscape review of polypharmacy and deprescribing. PresQIPP has
also produced a bulletin on this subject and an audit as support for GP practices to identify patients at risk. These resources can help with creation of
local tools to support improved practice.
The Safe and Appropriate Medicines Bulletin briefing 671 June 2013 outlines ten therapeutic areas/ drug classes where cost of therapy versus clinical
benefit may be in question. . The Safe and Appropriate Medicines Bulletin 159 June 2013 uses BNF classes to highlight potential clinical and cost
issues with medication to support medicines optimisation and reduce polypharmacy. There is a useful patient information leaflet provided as an
appendix and a poster which summaries the work undertaken. The most recent addition to these resources is the ‘landscape review’, a survey of CCGs
and CSUs systems and tools used, meaning of and attitudes to polypharmacy and deprescribing, local projects and challenges to implementation. Key
findings include the difficulty of the terminology for patients and the need for public education and the desire for sharing resources
See http://www.prescqipp.info/projects/polypharmacy-and-deprescribing
http://www.prescqipp.info/safe-appropriate-medicines-use-deprescribing/viewcategory/190-safe-and-appropriate-medicines-use (four documents)
A4 Organisation: Kings Fund
Organisation’s Website www.kingsfund.org.uk/
Title: Polypharmacy and medicines optimisation : Making it safe and sound
Overview: This 68 page 2013 report is a detailed look at how polypharmacy manifests in different care settings, key issues and areas for
development. It introduces the concept of appropriate and problematic polypharmacy. It highlights both the benefits of appropriate polypharmacy and
the risks of problematic polypharmacy in clinical and patient-centred term and both medicines waste and poor adherence to treatment are included in
the problems of problematic polypharmacy. Recognising that most evidence for use of medicines is for single conditions it identifies the gap in multi-
morbidity guidelines (which is currently being addressed by NICE). Recommendations for practice are given regarding shortened life expectancy and
managing long term conditions, including the importance of overview by one clinical team of all long term conditions. The need for clinician training in
multimorbidity is highlighted. The document specifically addresses polypharmacy and use of monitored dose systems, polypharmacy in care homes
and discusses issues around stopping medicines
See http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf
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Section B: Tools and Initiatives to support practice
B1
Primary
Care
Organisation: NHS Harrow
Organisation’s Website: http://www.harrowccg.nhs.uk/
Title: Review of patients with 10 or more items on repeat prescription
Overview: This document was produced as part of a local improvement scheme. It describes the rationale for reviewing patients in this group and
provides a standard operating procedure for “level 2” medication review (without the patient) in GP practices as a five step process. The appendices
include a medication review template, checklist for medication review, action planning form and two worked case examples.
See link:
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/NHS%20HARROW%2010+%20medications%20PSD%2
0Harrow%20CCG%20LIS%20July%202014.pdf
B2
Primary
Care
Organisation: NHS Lambeth Clinical Commissioning Group
Organisation’s Website: http://www.lambethccg.nhs.uk/Pages/Home.aspx
Title: Polypharmacy and Medicines Adherence Review.
Overview: This is a comprehensive document which supports full medication review with the patient, based in primary care. The tool contains protocols
for medicines review and adherence support and requires the clinician to have completed the Kings College on line ‘FutureLearn’ course on medicines
adherence. The five step protocol identifies patients prescribed eight or more repeat medicines, prioritising those with recent hospital attendances. The
protocol includes instructions for comprehensive medication review and provides appendices to support and document the review. The final step of the
protocol outlines patient and prescriber responsibilities post review. A summary flow chart with links to relevant documents is provided. The appendices
include a medicines review proforma, medicines adherence questionnaire (patient survey) for patient completion prior to the consultation and detailed
suggestions to support practitioners in working with patients who are challenged by unintentional or intentional non-adherence issues. An EMIS web
template for standardising medication reviews and, searches to identify appropriate patients are also available for interested practitioners.
See link:
http://nww.lambethccg.nhs.uk/Directorates/ICA/MedicinesManagement/Medicines%20adherence/Polypharmacy%20and%20Adherence%20tool%20FIN
AL%204.pdf
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B3
Primary
Care
Organisation: North West London Commissioning Support Unit
Organisation’s Website: www.nwlcsu.nhs.uk
Title: Toolkit for managing poly-pharmacy in clinically complex patients
Overview: This document focusses on providing detailed guidance to GP practice based pharmacists to undertake medication review clinics focussing
on reducing inappropriate polypharmacy. Targeting patients on 10 or more medicines or with other risk factors, the procedure outlined allows
practitioners to identify patients, set up and run medication review clinics in practices, work with patients to address polypharmacy issues and therefore
reduce inappropriate polypharmacy to improve patient care in a concordant way. The appendices provide excellent support for undertaking these
reviews including a flow chart of the process, a variety of template letters to engage GP practices and patients, an outline of the drug review process
and of the medicines related consultation framework as well as an aide memoire for use in the consultation. The appendices also contain evaluation
and patient survey paperwork. Practitioners who undertake these reviews have undertaken skill development around adherence.
See link:
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/Medication%20Review%20toolkit%20updated%20Sep%2
014v2.pdf
B4
Primary
Care
Organisation: NHS Cumbria and NHS Brent Clinical Commissioning group/
Organisation’s Website: http://www.cumbria.nhs.uk/ www.brentccg.nhs.uk/
Title: Tools to support prescribers in optimising benefit from medication review
Overview: These resources support medication review in practice with the aim of using evidence from STOPP START to support reduction of
polypharmacy.
The Medication Review Practice Guides include a description of what is and what is not a medication review and a checklist as well as outlining
principles of medication review, who to review, high risk groups and targeting reviews. It provides detail on the process for reviewing each drug and
gives guidance regarding implementation, documentation and follow up of recommendations. Appendices include a simple screening tool to use with
patients, sample patient information leaflet and NNT data to support review of commonly used medicines, classified by BNF chapter. The linked
document, STOPP START Toolkit provides a clear introduction to the rationale for medication review and, using simple colour coding, classifies
medicines for consideration according to the STOPP, START or NICE/local guidance.
The Brent document was produced with the help of resources from the NHS Cumbria Medicines Management Team.
Cumbria:
http://www.networks.nhs.uk/nhs-networks/nhs-cumbria-ccg/medicines-management/guidelines-and-other-
publications/Medication%20Review%20practice%20guide%202013.pdf/at_download/file
or
http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/MedicationReview-PracticeGuide2011.pdf
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Brent:
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/STOPP%20START%20Toolkit.pdf
or
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/Medication%20Review%20Practice%20Guide%202014.p
df
B5
Primary
Care
Organisation: NHS Lambeth CCG
Organisation’s Website: http://www.lambethccg.nhs.uk/Pages/Home.aspx
Title: In-depth Medication Assessment Form
Overview: This document aims to support practitioners to identify and record the medicines related risks and needs of an individual and evaluate the
impact on daily living and quality of life, so that appropriate action can be planned to improve patient outcomes by reducing inappropriate polypharmacy,
engaging with the patient, improving adherence and reducing risks.
The tool utilises a personalised, co-ordinated and outcome focused approach based on the principles of Medicines Optimisation, the Single Assessment
Process and Common Assessment Framework for older people which originated from work around the National Service Framework for Older People
(2001) and local experience of the past ten years. It presents an opportunity to ensure better integration of medicines related needs within overall
patient assessment and care planning process. The tool and process are designed to consider the whole range of patient’s medicines needs and feed
into overall patient care to prevent duplication and encourage information sharing. Completion of the tool results in a personalised care plan that meets
the specific needs identified rather than providing a service or undertaking a task. Adequate training of staff using the tool, supervision and support is
considered vital for safe, effective patient care.
This tool facilitates comprehensive documentation of medication review and can be used in its entirety or in specific section. The document includes
demographic data and checklists for high risk medicines, access, compliance and day-to-day medication management issues, patient knowledge of,
attitude and ability to take meds as well as an assessment of patient’s ability to agree to actions around medication taking. The paperwork includes a
short pharmaceutical care plan and details for follow up.
See link: http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/Assessment%20tool.pdf
B6
Primary
Care
Organisation: West Hampshire CCG
Organisation’s Website: http://www.westhampshireccg.nhs.uk/
Title: Medicines optimisation detail aid: Medicines Optimisation LES 2013/4 Intervention 12 Polypharmacy
Overview:
This concise document outlines rationale, evidence and a process for medication review of older people taking multiple medications.
The three page summary is supported by a detailed appendices including a list of medicines to consider for review, a falls risk table for medicines, a
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medication review template and a checklist for practice.
See link: http://www.westhampshireccg.nhs.uk/documents/doc_view/364-12-polypharmacy-detail-aid-amended-11-sep-13
B7
Primary
Care
Organisation: NHS West Hampshire Clinical Commissioning Group
Organisation’s Website: www.westhampshireccg.nhs.uk
Title: Use of web-based mortality indices to support medicines optimisation and reduce polypharmacy
Overview
This easy to use web based tool utilises accurate estimates of longevity using mortality indices (eg, see http://eprognosis.ucsf.edu) to support reviews
to minimise the use of drugs that are unlikely to prevent disease events within the patient's remaining life span. It identifies when, rather than how much
benefit drugs aimed at preventing future disease events (such as statins and bisphosphonates), may confer. If the time until benefit exceeds the
patient's estimated life span, no benefit will result, while the adverse drug event risk is constant and immediate. Undertaking such reconciliations is
facilitated by accurate estimation of longevity and drug-specific time until benefit using trial-based time-to-event data.
Email: liz.corteville@nhs.net
B8
Primary
Care
Organisation: New Devon CCG
Organisation’s Website: : n/a
Title of initiative/tool:
Using STOPP/START tool when undertaking clinical medication reviews for care home patients.
Brief overview: Reviews are conducted for patients with polypharmacy issues in care home. Pharmacists undertaking clinical medication reviews in
care homes using STOPP/START tool. Recommendations are reviewed with GP afterwards. While the STOPP/START tool is currently being used,
Devon CCG have a group looking at whether to create a local version including links to formulary etc.
Contact: gail.foreshew@nhs.net
B9
Primary
Care
Organisation: Somerset CCG
Organisation’s Website: : n/a
Title: Eclipse Live tool
Overview: Somerset is one of a number of CCGs which have commissioned the Eclipse Live tool which enables use of predefined or locally defined
algorithms to identify and stratify risky polypharmacy. More importantly it also allows risky (non polypharmacy) prescribing to be identified by looking at
outcomes ie the effect the prescribing is having on patient’s blood tests etc .
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Contact Shaun.Green@somersetccg.nhs.uk
B10
Care
Homes
Organisation : Leeds North CCG
Organisation’s Website: : n/a
Title of initiative/tool: Pharmacist Care Homes Medication review for residential and nursing homes – System 1 (S1) and Egton Medical Information
Systems (EMISweb) templates
Brief overview: Leeds North CCG have developed an aide-memoire template for use on GP systems that can be followed when carrying out and
recording medication reviews to ensure that all relevant areas of the resident’s medication use and relevant health information are identified and
addressed. There is particular reference to considering whether specific medications can or should be stopped, or patients can undergo a trial of
stopping the medication. Once the information has been entered into the template it forms part of the patient’s GP medical record and is visible to all
healthcare professionals at that practice. Changed medications are automatically updated on the NHS Spine. Both S1 and EMISweb versions of this
template are given in the links below.
A more generic version of this template has also been developed to apply to the general population and it can be further amended to be applicable to
other larger cohorts or at-risk groups requiring medication review. Versions are available for both S1 and EMISweb and an update to the EMIS version
in response to in-use feedback is planned. The Data Quality Team at the Commissioning Support Unit are in the process of developing reporting tools
to allow data collection on the interventions made and recorded using these templates.
Contact: ellywakeling@nhs.net
See links: Link 1, Link 2, Link 3, Link 4a, Link 4b, Link 5
B11
Care
Homes
Organisation: NHS Lanarkshire
Organisation’s Web-site: http://www.nhslanarkshire.org.uk/Pages/default.aspx
Title: NHS Lanarkshire Care Homes Protocol Group. Prescribing and Polypharmacy Guidelines 2013
Overview: This guidance addresses polypharmacy as part of the overall pharmacy service to care homes. It includes guidance on medication review
(full or NPC level3 for polypharmacy reviews), end of life care and general care home pharmacy prescribing support as well as polypharmacy guidance.
It is intended for use in GP practices to support practitioners in providing an evidence based, rational approach to prescribing and deprescribing. It
includes lists of high risk combinations of drugs, drugs commonly causing hospital admission, drugs that are high risk in older people including
consideration of hypotension, diabetes, antipsychotic treatment, laxatives and drugs with additive adverse effects. There is also a section specifically
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devoted to management of polypharmacy in patients with limited life expectancy including patients with dementia and frailty. Suggestions around drug
groups to review, what drugs are associated with symptomatic decline and use of liquids.
This document is useful for care of patients in care homes and in their own homes as the principles that apply are broadly similar.
See link: http://www.nhslanarkshire.org.uk/Services/CareHomeLiaison/Documents/Prescribing-and-Polypharmacy-Guidelines-Final-
090212.pdf
B12
Care
Homes
Organisation: NHS Enfield CCG
Organisation’s Web-site: http://www.enfieldccg.nhs.uk/
Title: Reducing polypharmacy and safeguarding medicines use in care homes
Overview: This presentation and summary outlines how a care home pharmacist, working with the local authority, implemented a care home service
aimed at improving the quality of healthcare provision to frail elderly residents of care homes within the borough of Enfield. The pharmacist worked with
the multidisciplinary care home assessment team. The pharmacist provided clinical medication reviews which included reduction of polypharmacy
together with reducing waste and optimising overall prescribing and processes in the homes. The presentation outlines the process and provides case
examples and top tips for initiating this services. A reference list is included in the presentation.
Contact: Zeshan.Ahmed@enfieldccg.nhs.uk
See links:
http://www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=778421
also
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/Retrospective%20outline%20of%20care%20ho
mes%20post.pdf
B13
Secondary
Care
Organisation: Gloucestershire Hospitals NHSFT
Organisation’s Web-site: www.gloshospitals.nhs.uk and www.gloucestershireccg.nhs.uk
Title: PIDE (Potentially Inappropriate Drugs in the Elderly)
Brief overview: This document summaries both the Beers Criteria and the STOPP/START tool in a one page table format including the classes of
drugs which were often inappropriate in frail older people. Criteria for review of antihypertensive and anti-diabetic medication were included following
work with Stroke, Endocrinology and General and Old Age Medicine consultants, These reviews are conducted working with the Older Persons'
Assessment and Liaison Team (OPAL) . The tool has been circulated to CCG and Gloucester Care Services Trust for use across sectors by doctors,
nurses and pharmacists working in this field. It is being piloted on the Acute Care Unit at Cheltenham General Hospital from October 2014 and data is
being collected on reasons for stopping medicines and cost avoidance. The CCG is supporting this pilot project. The aim of this work is to educate
prescribers within the Trust and guide medication review using pharmacist prescribers alongside doctors.
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Contacts: Pamela.Adams@glos.nhs.uk
See link:
http://www.medicinesresources.nhs.uk/upload/documents/Communities/SPS_E_SE_England/PIDE%20table%20final.pdf
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Section C
C1 Polypharmacy review methods publications
Baqir W., Campbell. I, D Jones T and Blair S. Reducing the ‘pill burden’ - complex multidisciplinary medication reviews
International Journal of Pharmacy Practice. 2012 20 (suppl 2) p 91
Gallagher PF, O'Connor M.N., and O'Mahony D. (2011) Prevention of potentially inappropriate prescribing for elderly patients: a randomized
controlled trial using STOPP/START criteria. Clinical Pharmacology & Therapeutics 89 (6): 845-854
Garfinkel, Doron, MD; Mangin Derelie Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults
Addressing Polypharmacy , MBChB Arch Intern Med. 2010;170(18):1648-1654
Garfinkel, Doron MD1, Zur-Gil,Sarah MA2 and Ben-Israel, Joshua MD3 The war against Polypharmacy: A New Cost-Effective Geriatric-Palliative
Approach for Improving Drug Therapy in Disabled Elderly People 1Department of Evaluation & Rehabilitation, 2Pharmacy, and 3Directorate,
Shoham Geriatric Medical Center, Pardes Hana, Israel Israel Medical Association Journal 2007;9:430–434 • Vol 9 • June 2007 Resolving
Polypharmacy in the Disabled Elderly
Hilmer Sarah N., Gnjidic Danijela., Le Couteur David G. Thinking through the medication list Appropriate prescribing and deprescribing in
robust and frail older patients Reprinted from Australian Family Physician Vol. 41, No. 12, December 2012 924
Krska J, Cromarty JA, Arris F, et al. (2011) Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary
care. BMC Health Services Research 11:4
O’Mahoney D and O’Connor M N, Pharmacotherapy at the end-of-life Age and Ageing 2011; 0: 1–4 doi: 10.1093/ageing/afr059
Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC Interventions to improve the appropriate use of polypharmacy for older people
(Review) The Cochrane Library 2012, Issue 5 http://www.thecochranelibrary.com
Runganga, Maureen., Peel, Nancye M. and Hubbard Ruth E. Multiple medication use in older patients in post-acute transitional care: a
prospective cohort study Clinical Interventions in Aging 2014:9 1453–1462
Schiff Gordon D., MD; Galanter William L., MD, PhD; Duhig Jay, MA; Lodolce Amy E., PharmD, BCPS; Koronkowski Michael J., PharmD; Lambert,
Bruce L. PhD Principles of Conservative Prescribing Arch Intern Med. 2011;171(16):1433-1440. Published online June 13,
2011.doi:10.1001/archinternmed.2011.256
Scott, Ian A. MBBS, MHA, MEd.' Gray, Leonard., MBBS, MMed, PhD.". Martin, Jennifer H. MBChB, MA (Oxon), PhD,'
Charles A. Mitchell, MBBS· Minimizing Inappropriate Medications in Older Populations: A lO-step Conceptual Framework The American
Journal of Medicine (2012) 125. 529-537
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Scott Ian A, Anderson Kristen, Freeman Christopher R and Stowasser Danielle A. First do no harm: a real need to deprescribe in older patients
Med J Aust 2014; 201 (7): 390-392. https://www.mja.com.au/journal/2014/201/7/first-do-no-harm-real-need-deprescribe-older-patients
Scott Ian A.,. Gray, Leonard C, Martin, Jennifer H. and. Mitchell, Charles A . Effects of a Drug Minimization Guide on Prescribing Intentions in
Elderly Persons with Polypharmacy Drugs Aging 2012; 29 (8): 659-667 1170-229X/12/0008-0659/$49.95/0
Scott Ian A., Gray, Leonard C, Martin, Jennifer H., Pillans Peter I, Mitchell Charles A Deciding when to stop: towards evidence-based
deprescribing of drugs in older populations Evid Based Med August 2013 | volume 18 | number 4 | 121-124
Vinks TH, Egberts TC, de Lange TM, et al. (2009) Pharmacist-based medication review
reduces potential drug-related problems in the elderly: the SMOG controlled trial. Drugs & Aging 26(2): 123-33
Zermansky AG, Alldred DP, Petty DR, et al. (2006) Clinical medication review by a pharmacist of elderly people living in care homes--
randomised controlled trial. Age & Ageing 35(6): 586-91
Zermansky AG, Petty DR, Raynor DK, et al. (2001) Randomised controlled trial of clinical medication review by a pharmacist of elderly
patients receiving repeat prescriptions in general practice. BMJ 323(7325): 1340-43
C2 Qualitative work publications
Straand, Jerund and Sandvick, Hogne Stopping long-term drug therapy in general practice> How well do Physicians and patients agree.
Family Practice Vol 18 no 6 p 597-600
Kouladjian Lisa,Gnjidic Danijela, Chen Timothy F, Mangoni Arduino A and Hilmer Sarah N Drug Burden Index in older adults: theoretical and
practical issues Clinical Interventions in Aging 2014:9 1503–1515
Shakib, I Hendrix, MS Roberts, MD Wiese .Development and validation of the patients' attitudes towards deprescribing (PATD) questionnaire
International Journal of Clinical Pharmacy Feb 2013;35(1):51-56
Schuling Jan, Gebben Henkjan, Veehof Leonardus Johannes Gerardus and Haaijer-Ruskamp Flora Marcia .Deprescribing medication in very
elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study Schuling et al. BMC Family Practice 2012, 13:56
http://www.biomedcentral.com/1471-2296/13/56
Ridgeway Jennifer L, Egginton Jason S, Tiedje Kristina ,Mark Linzer Boehm Deborah, Poplau Sara, de Oliveira Djenane Ramalho, Odell Laura Sara,
Montori Victor M.and Eton David T 1,2 Factors that lessen the burden of treatment in complex patients with chronic conditions: a qualitative
study Patient Preference and Adherence 2014:8 339–351
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C3 Narrative/review articles
Anon. Describing deprescribing doi: 10.1136/dtb.2014.3.0238 DTB published online March 6, 2014 DOI: 10.1136/dtb.2014.3.0238 Vol 52 | No 3 |
March 2014 Drug and Therapeutics Bulletin
Anon Prescribe but also know how to “deprescribe” Translated from Rev Prescrire April 2013;33 (354) 306-307. Prescrire International July 2013
vol 22 no 140 page 192
Aronson J. Polypharmacy appropriate and inappropriate Br Jour Gen Pract 2006. 56; 484-485
Routledge, PA, O'Mahony MS and Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol, 2004; 57(2): 121–126.
Barber ND, Alldred DP, Raynor DK et al 2009.The Care Homes’ Use of Medicines Study: prevalence, causes and potential harm of medication
errors in care homes for older people. Quality and Safety in Health Care 18, pp.341-6.
Cochrane Collaboration 2012 Interventions to improve the appropriate use of polypharmacy for older people.
Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, et al. 2009.8 Adverse drug reactions in hospital in-patients: a prospective
analysis of 3695 patient-episodes
Garfinkel D. Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adult. Arch internal
med. 2010 170(18) 1648-1654
Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool
to Alert Doctors to Right Treatment):Consensus Validation. Int J Clin Pharmacol Ther 2008; 46(2): 72 – 83.
NHS Highland. Polypharmacy: Guidance for prescribing in frail adults. 2011
Gnjidic D, Le Couteur DG and Hilmer SN. Discontining drug treatments. British Medical Journal 2014;349:g7103
Gnjidic, D, Le Couteur David G, Kouladjian Lisa, and Hilmer, Sarah N. Deprescribing Trials:Methods to Reduce Polypharmacy and the Impact
on Prescribing and Clinical Outcomes Clin Geriatr Med 28 (2012) Gorard D.A. Escalating polypharmacy From Wycombe Hospital, High
Wycombe, UK Q J Med doi:10.1093/qjmed/hcl109 237–253
Hanlon JT, Schmader KE, Samsa GP et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45: 1045–1051
Canadian Medical Association Journal News August 12, 2013 Introducing deprescribing into culture of medication DOI:10.1503/cmaj.109-4554
WaiSum S, Salima S. and Farrell B.Drug-related problems in the frail elderly Canadian Family Physician • Le Médecin de famille canadien | Vol
57: february p168• février 2011
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Introduction
At least one third of over 75’s in the UK take four or more medicines regularly and this increases to an average of eight medications per person
per day in nursing homes. The number of medicines taken by older people has been steadily increasing for the last three decades. There are a
number of factors affecting this including; the advent of evidence based medicine; increase in multiple morbidity and longevity; promotion of
age-independent access to the increasing number of treatments and the increasing expectations for treatment from patients and their families.
These have made polypharmacy the “rule” rather than the “exception” for many patients.
Medicines are the most common intervention to improve health and concerns about the risks of polypharmacy in primary and secondary care are
growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased health care
costs and non-adherence (see section A: A1,A4). This has led to the suggestion that “ Polypharmacy itself should be conceptually perceived as a
“disease” with potentially more serious complications than those of the diseases these different drugs have been prescribed for”1
. Recent
attention has been focussed on Medicines Optimisation and management of polypharmacy is an integral part of this. The Five Year Forward
View2
recognises the need for integration of services and equity of care for patients across hospital and community settings and implementation
is supported by the Better care fund3
. Improved cross sector communication is key to continuing management of appropriate prescribing and
monitoring of polypharmacy. Improving integration of teams and encouraging multidisciplinary professional working will all support medicines
optimisation and reduction of inappropriate polypharmacy in all sectors of care.
Background: polypharmacy, oligopharmacy and deprescribing
There are number of terms which have come into use over recent years to describe multiple medicines use:
Polypharmacy refers to either the prescribing or taking many medicines. For many years it referred to the prescription or use of more than a
certain number of medicines, at least four or five or more medicines per day (see A2). More recently it has been used in the context of
prescribing or taking more medicines that are clinically required, as the number of medicines taken was of limited clinical value in interpreting
individual potential problems.
The Kings fund (see A4) divides the definition into “appropriate” and “problematic” polypharmacy which is a helpful distinction in practice:
Appropriate polypharmacy ”Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines
use has been optimised and where the medicines are prescribed according to best evidence.”
Problematic polypharmacy “the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not
realised.”
1
Garfinkel D and Mangin D ARCH INTERN MED/ VOL 170 (NO. 18), OCT 11, 2010 https://www.leg.bc.ca/cmt/39thparl/session-
4/health/submissions/Garfinkel_Feasibility_Study_of_a_Systemic_Approach_2010.pdf
2
http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
3
http://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)