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410
A. R. Mair et al.
Table 18.1 Medications commonly associated with adverse drug reactions and medication-related harm in inappropriate polypharmacy
Medication group/
medication
Angiotensinconverting enzyme
inhibitors (ACEIs)/
Angiotensin receptor
blockers (ARBs)
a
Examples of individual
medications Issues/important areas to consider [7, 22]
Ramipril, enalapril, captopril,
lisinopril, perindopril, irbesartan,
losartan
• The indication for ACEIs and ARBs and the
evidence base for their use is the indication for
symptomatic management for heart failure or for
secondary prevention after myocardial infarction.
• Kidney function before starting and while titrating
the dosage.
• Can also cause a drop in BP and cause dizziness
and falls.
Antibiotics Cephalosporins (e.g. cefalexin),
penicillin (e.g. amoxicillin),
quinolones (e.g. ciprooxacin),
macrolides (e.g. azithromycin)
• Use antibiotics only when indicated and avoid
prophylactic use in care homes.
• Commonly used antibiotics, such as cephalosporins,
uoroquinolones and amoxicillin with clavulanic
acid increase the risk of C. difcile and
antimicrobial resistance.
Antidepressants Fluoxetine, paroxetine,
amitriptyline, citalopram,
venlafaxine, dosulepin
• Antidepressants have been implicated in causing
falls.
• Tricyclic antidepressants have more anticholinergic
and cardiotoxic effects than other antidepressants
and should be used with caution in patients with
cardiovascular or cognitive comorbidities.
Anti-thrombotics Antiplatelet agents (e.g. aspirin,
clopidogrel)
Oral anticoagulants (warfarin and
direct Oral anticoagulants
[DOACs], e.g. dabigatran,
edoxaban, rivaroxaban, apixaban)
• Kidney function declines as people age, which has
an impact on the dose and suitability of DOACs
• Patent factors can contribute to increased risk of
bleeding, such as age, previous bleeding or stroke,
raised blood pressure, reduced kidney/liver function
and drug–drug interactions.
• Review dual antiplatelet therapy and its intended
duration, due to the risk of gastrointestinal
haemorrhage.
Beta blockers Atenolol, propranolol, sotalol,
bisoprolol, metoprolol, carvedilol
• Adverse effects such as bradycardia and fatigue can
be exacerbated with age and by drug–drug
interactions
Digoxin • Kidney function, electrolytes and digoxin serum
concentration require monitoring.
• Drug–drug interactions can impact on digoxin
clearance and increase toxicity.
Diuretics Furosemide, bendroumethiazide,
bumetanide, spironolactone
• Potent diuretics, useful for symptomatic
management (e.g. of heart failure), require regular
review due to risk of hypotension and electrolyte
disturbances.
Hypoglycaemic
agents
Insulin, sulfonylureas (e.g.
glibenclamide, glipizide)
• Intensive glycaemic control strategies markedly
increase the risk of hypoglycaemia, associated with
increased mortality, cardiovascular events, falls and
accidents [23], especially sulfonylureas in over
75-year-old persons.
Mood stabilisers Lithium • Lithium concentrations require regular monitoring,
especially when other medicines are added or
withdrawn, or with changes to the patient’s clinical
conditions (e.g. kidney impairment, dehydration)
• Adverse effects that can develop over time and
require dosage adjustment
18 Polypharmacy andDeprescribing
Table 18.1 (continued)
Medication group/
medication
Non-steroidal
Anti-Inammatory
Drugs (NSAIDs)
Opioids Morphine, dihydrocodeine,
Psychotropic agents Benzodiazepines and hypnotics
Systemic
corticosteroids
a
Adapted from [19–21]
Examples of individual
medications Issues/important areas to consider [7, 22]
Diclofenac, ibuprofen, celecoxib,
ketoprofen, naproxen
codeine (± paracetamol) tramadol,
fentanyl
(e.g. diazepam, nitrazepam,
temazepam)
Antipsychotics (e.g. olanzapine,
clozapine, quetiapine)
Prednisolone
411
• In a landmark UK study, gastrointestinal bleeding
due to NSAIDs and antiplatelet agents was the
leading cause of drug-related hospital admissions,
accounting for approximately a third of all
drug- related admissions and half of drug-related
deaths [21]. This is exacerbated with a history of
peptic ulcer disease and the use of several
medicines, including antiplatelets, anticoagulants,
corticosteroids and selective serotonin reuptake
inhibitors.
• Consider, gastroprotection (usually with a proton
pump inhibitor if unavoidable, which approximately
halves the risk of gastrointestinal bleeding) in those
at highest risk
• Cardiovascular risk associated with many of the
NSAIDs
• Opioids are rarely indicated for long-term use for
chronic, noncancer pain
• Adverse effects such as respiratory and cognitive
dysfunction are exacerbated with drug–drug
interactions and altered pharmacodynamics in older
persons.
• Long-term use of hypnotics and anxiolytics in
general practice is not appropriate, maximum
duration for most patients is three to four weeks [24].
• Long-term use is associated with numerous risks,
including drowsiness and falls, forgetfulness,
confusion, depression, irritability, aggression,
impulsivity, digestive problems and dependence.
• Antipsychotics are frequently prescribed to reduce
symptoms of stress and distress in people with
dementia. However, these drugs have (time) limited
benets, and older patients are particularly
vulnerable to their adverse effects [25]. They should
therefore be used as the last resource.
• Long-term use is associated with cerebrovascular
events and death in people with dementia [26].
• Require ongoing review to wean or use the lowest,
effective dose
• Adverse effects with long-term use necessitate
management, such as osteoporosis and glaucoma.
3.1 Anticholinergic Burden
It is also important to consider the anticholinergic
symptoms that are caused by multiple medications that have anticholinergic side effects. These
include impaired cognition, increased risk of
falls, functional decline, cardiovascular events
and mortality. Sensitivity varies across individuals and are dose-dependent [27–31]. This is why
it is essential to take a person-centred approach
when reviewing medications with anticholinergic
side effects, as the impact will vary depending on
individual sensitivity, although at the time of
writing this chapter, there is currently not a com-
412
Percentage of populaon
Age band
Percentage dispensed 10+ Brish Naonal Formulary paragraphs + high risk drug
A. R. Mair et al.
monly accepted measure of cumulative anticholinergic burden [32]. However, several tools have
been developed to estimate the anticholinergic
load of an individual’s medicine regimen, including the Drug Burden Index (DBI) [33] and the
Anticholinergic Risk Score (ARS) [34].
4 People Most Aected by
Polypharmacy
People prescribed multiple concurrent medicines
are at risk of medication-related harm, as polypharmacy increases the chances of experiencing
ADRs, poor medication adherence and drug–drug
interactions [35]. The major risk factors for medication-related harm include old age, polypharmacy, comorbidities, those visiting multiple
prescribers [36, 37] and those living with cognitive impairment, including Alzheimer’s and
related dementias [38]. One study found that for
those people admitted to hospital with a PIM,
there was at least three further readmissions [39].
Deprivation can have an impact on the numbers of medicines that people take, as multimorbidity occurs earlier for those in more deprived
communities [40]. Figure 18.1 illustrates this for
the Scottish population, where the Scottish Index
of multiple deprivation (SIMD) shows that those
from more deprived communities will take medications at an earlier age and may need more support to manage their medication and medication
review to prevent harm [41].
The gure supports that people from more
deprived populations are taking more medications in each age group. This is in line with multimorbidity also presenting earlier in life in those
from more deprived communities, so that people
from more deprived backgrounds experience
polypharmacy at an earlier age and are potentially at increased risk of medication-related
harm.
4.1 Tools to Identify People at
Risk of Potentially
Inappropriate Polypharmacy
Inappropriate prescribing is also a major risk factor for medication-related harm [42]. There are
several screening tools that have been developed
to help identify PIMs and appropriate prescribing, in an effort to improve medication prescribing practices. Some examples of these screening
tools, typically used to assess older adults, are
presented in Table 18.2.
by age group and 2020 SIMD quinle, Scotland. Jul - Dec 2021
35%
30%
25%
20%
15%
10%
5%
0%
Fig. 18.1 The number of people taking multiple medications by age and deprivation
SIMD 1 (Most deprived)
SIMD 2
SIMD 3
SIMD 4
SIMD 5 (Least Deprived)
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
18 Polypharmacy andDeprescribing
413
Table 18.2
propriate prescribing
Name of tool/instrument Contents of tool/instrument
Tools used in community settings
Beers Updated Criteria for
Potentially Inappropriate
Medication (PIMs) use in Older
Adults [43]
STOPP/START criteria [44] Screening Tool for Older People’s
FORTA (Fit fOR The Aged) tool
[45]
Medication Appropriateness
Index (MAI) [46]
PRIME (Prospective study to
develop a model to stratify the
RIsk of Medication-related
harm in hospitalised Elderly
patients) tool [47]
Scottish Polypharmacy Case
nding indicators [7]
Goal-directed Medication
review Electronic Decision
Support System (G-MEDSS)
[48]
Tools used for frail older persons
Screening Tool of Older Persons
Prescriptions in Frail adults with
limited life expectancy
(STOPPFrail_v2) [50]
Norwegian General Practice
Nursing Home (NORGEP-NH)
[51]
Examples of screening tools developed to help identify potentially inappropriate medications and inap-
An explicit list of PIMs to avoid in older
adults or in certain circumstances
Potentially Inappropriate Prescriptions
(STOPP)
Screening Tool to Alert Doctors to the
Right Treatment (START)
FORTA is a validated tool based on a drug
list approach
MAI is a valid and reliable measure of
potentially inappropriate prescribing
based on the following 10 criteria: (i)
indication, (ii) effectiveness, (iii) dosage,
(iv) correct directions, (v) practical
directions, (vi) drug–drug interactions,
(vii) drug–disease interactions, (viii)
duplication, (ix) duration and (x) expense.
The PRIME tool includes a combination
of demographic (age, female gender),
medication-specic (number of
medicines, antiplatelet drug, antidiabetic
drug, past ADR), biochemical (sodium
level) and social predictors (living alone)
This is a suite of 68 case nding
indicators that prioritise patients using
diagnosis, examination signs and
laboratory data. Composite indicators will
prioritise on, for example, falls risk,
bleeding risk as well as age and frailty
This provides clinical decision support for
healthcare practitioners conducting
medication reviews for older people with
and without dementia, to tailor care to
meet the person’s goals and preferences.
Emphasises the importance of shared
decision-making in deprescribing
medicines for older persons approaching
end-of-life.
A list of 34 explicit criteria for PIM use. Suitable for use in aged care residents
Where has the tool/instrument been
used?
In acute and community settings
These tools/instruments have been
used in a variety of settings and to
identify potentially inappropriate
prescribing in older adults
(≥65years).
PRIME is a prediction tool used to
identify high-risk medication-related
harm requiring healthcare within
8weeks post discharge from hospital.
Patients taking 10 or more medicines
are prioritised where there are limited
resources considering:
1. Age >75years
2. Frailty
3. High-risk medication
Tool is used across Scotland and has
also been piloted in the Republic of
Ireland
In clinical practice, mainly by
pharmacists, during medication
reviews in their homes and aged care
residences [49].
Used also to identify older people
approaching the end-of-life, e.g. in
residential aged care, and the
deprescribing criteria for
antihypertensive agents, anti-anginal
medicines and vitamin D.
to reduce concomitant PIMs, risk of
falls, acute infection, dehydration.
(continued)
414
A. R. Mair et al.
T
able 18.2
Name of tool/instrument Contents of tool/instrument
Tools used in hospital settings
Shed-MEDS [52] Shed-Meds considers patient and
MedSafer [53] MedSafer is an electronic decision
PADR-EC (Prediction of
Hospitalization due to Adverse
Drug Reactions in Elderly
Community-Dwelling Patients)
score [57, 58]
Brighton Adverse Reactions
Risk (BADRI) score which has
been used to assess the risk of
older adults experiencing an
ADR while in hospital [59].
Prediction of Adverse Drug
Reactions in Older Inpatients
(PADROI) Risk Assessment
Tool [60]
(continued)
disease-related factors, life expectancy,
goals of care, appropriate treatment
targets and the duration of treatment
required.
support tool for deprescribing, based on
the Beers Screening Tool for Older
People’s Potentially Inappropriate
Prescriptions (STOPP) [44] and the
‘Choosing Wisely’ lists from Canada
[54–56].
Variables included in the PADR-EC are:
≥4 comorbid conditions, heart failure,
liver disease, number of medications (≤5,
5–7, ≥8), previous ADR, renal failure.
The BADRI score is based on the
following ve clinical variables: (i)
taking eight or more medications, (ii)
hyperlipidaemia, (iii) raised white cell
count, (iv) taking antidiabetic
medications and (v) length of stay
≥12days.
The PADROI risk assessment tool is
based on the following eight predictors:
(i) age 60–75years, (ii) ADR in the
previous 12months, (iii) PIMs, (iv)
polypharmacy (≥5 medications), (v)
Charlson Comorbidity Index Score ≥6,
(vi) heart failure, (vii) kidney disease and
(viii) hospital stay ≥11days
Where has the tool/instrument been
used?
Shed-Meds is a person-centred
deprescribing tool initiated in hospital
and continued in post-acute care
facilities
MedSafer is especially useful in
deprescribing antipsychotics and high
dose iron salt medications in an acute
care setting.
PADR-EC is used to help identify
older adults at increased risk of
adverse drug reactions (ADRs) in
hospital and among communitydwelling older adults at risk of
hospitalisation due to ADRs, which
include inappropriate medications,
anticholinergic medications and
antihypertensive medications
BADRI is used to assess the risk of
older adults experiencing an ADR
while in hospital
PADROI is used to assess older adults
experiencing ADRs while in hospital
These screening tools are recommended to
identify those high-risk medicines (as shown in
Table 18.1) which require monitoring to reduce
the risk of adverse events, as well as high-risk
situations that place patients at greater risk of
harm. However, using screening tools may
generate many more patients than can practically be reviewed, and in these cases, organisations may use additional criteria to prioritise
those eligible for a comprehensive medication
review [7, 61].
Once people are prioritised, it is then important to use a process of review using a personcentred approach, which the next section will
consider. This process should be one that can
be used by all healthcare professionals and
involve shared decision-making with the
patient.
18 Polypharmacy andDeprescribing
415
5 A Person-Centred Approach
to Address Polypharmacy
Strategies used to address medication-related
harm that include a person-centred approach to
address polypharmacy will be considered as these
have been shown to reduce harm by up to 15% [2].
5.1 7-Step Approach to
Appropriate Polypharmacy
One method to apply a person-centred attitude to
review polypharmacy is the ‘7-step approach’,
which starts by matching therapeutic objectives
to current life priorities with the patient. This is
illustrated in Fig. 18.2. This initial discussion
guides decision-making in subsequent steps that
consider medication need, effectiveness and
safety before a therapeutic plan and follow-up
strategy are agreed upon. Applying the seven
steps as part of a holistic medication review has
the potential to address all six dimensions of
quality in healthcare: efcacy, safety, efciency,
timeliness, equity and acceptability [7]. Although
the seven-step approach was primarily designed
to be applied at the point of medication review to
correct inappropriate prescribing, its principles
may equally be applied when initiating new medicines, to prevent inappropriate prescribing or
when a patient moves across transitions of care.
This may result in reducing the dose or stopping
a medication completely, although this should
not be the primary objective of a medication
review. Addressing unmet needs may include
starting new medications.
The actions undertaken in each step are summarised and begin with asking ‘what matters to
the patient?’
• Step 1: sets the context within which all fur-
ther decisions are made, namely establishing
what matters to the patient
• Step 2: identify essential treatment
• Step 3: determine if the patient is taking unn-
ecessary treatment
• Step 4: identify whether therapeutic objec-
tives that matter to the patient are achieved
• Step 5: assess if any medicines are too risky or
cause unacceptable adverse effects
• Step 6: consider which medicines are costeffective and environmentally sustainable
• Step 7: determine whether the patient is willing and able to manage their medicines in a
way that avoids harm and maximises benet.
Please refer to Case 1 and Case 2 in Sect. 9
to better understand the use of the 7-step
approach to appropriate polypharmacy.
5.2 Sick Day Guidance
Dehydration can be a signicant risk for people taking certain medicines. ‘Medicine Sick Day guidance’ provides information on medicines that
should be temporarily stopped during illness that
can result in dehydration (vomiting, diarrhoea and
fever). This advice does not apply to minor sickness
or diarrhoea, which is dened as a single episode.
Some key medicines and contexts are:
• Diuretics can cause dehydration or make
dehydration more likely in an ill patient.
• In a dehydrated patient, ACE inhibitors, ARBs
and non-steroidal anti-inammatory drugs
(NSAIDs) may impair kidney function which
can reduce elimination of other medicines such
as DOACs or could lead to kidney failure
• Dehydration increases the risk of lactic acidosis, a serious and potentially life-threatening
side effect of metformin.
Prescribers should discuss with the patient
which of their medicines might cause harm if
they are dehydrated and provide appropriate
guidance. An example of ‘sick day guidance’ is
for people with diabetes and the changes required
to medicines during a bout of illness [62].
5.3 Numbers Needed to Treat (NNT)
In the context of multimorbidity and assessing if
therapeutic objectives are likely to be achieved,
the numbers needed to treat (NNT) can be used
as an aid to assess medication benet in assessing
416
A. R. Mair et al.
Fig. 18.2 7 steps to appropriate polypharmacy
Reproduced with permission from Scottish Government, The Scottish Polypharmacy Guidance, 2018 [7]
appropriateness of polypharmacy. The NNT is
the reciprocal of the absolute risk reduction of the
respective treatment versus a control (usually
placebo) and is dened as the average number of
patients that need to be treated for one patient to
benet. The NNT also considers the period of
time required to gain benet. A list of NNTs has
been provided in the Scottish guidance [7].
18 Polypharmacy andDeprescribing
417
Therefore, comparing the NNT for different
medicines can support discussions between clinicians and patients when prioritising medicines
for continuation. However, when interpreting
NNTs, several questions should be considered:
• First, what is the outcome being avoided?
Death is more signicant than a vertebral frac-
ture, but the importance assigned to different
outcomes may vary between individuals.
• Second, over what period does the benet
accrue? Two drugs may have the same NNT,
but a drug achieving the same benet over a
shorter period will be superior.
• Third, what is the likelihood and severity of
harm caused by the drug? If a medicine saves
the life of 1 in 25 patients but causes debilitat-
ing adverse effects for the rest, the harm it
causes may outweigh the drug’s benets.
• And fourth, how applicable are the trial data
to individual adults? The more similar an
individual is to trial populations, the more
likely it is that similar benets will be
achieved.
5.4 Shared Decision-Making
In order to take a person-centred approach, it is
important to ensure that shared decision-making is
in place and that resources can be shared with the
patient to support this action. This is particularly
important when decisions are made about the risks
and benets of medicines. Involving patients in
shared decision-making around deprescribing is
enabled by specic tools, such as those provided
by deprescribing networks [63]. Another example
is in the patient and carer tool kit which is part of
the Polypharmacy Manage Medicine app [64].
The example below, in Fig. 18.3, shows how this
can be set out to consider risks and benets of benzodiazepine use. This pictorial representation can
be used to illustrate the benet an individual will
get from medicines. The studies show that for
every 13 people who receive a benzodiazepine,
one will see an improvement in their insomnia. For
every 6 people who receive a benzodiazepine, one
will experience an adverse effect, e.g. memory
loss, confusion, disorientation, loss of balance or
falls and morning hangover effects.
The hypnotic makes no difference to
what happens to these 12 people.
Their sleep improves, or doesn’t
improve, just as if they had taken
placebo
The hypnotic makes no difference to
what happens to these 11 people.
They have adverse events, or don’t
have adverse events, just as if they
had taken placebo
Fig. 18.3 Risks and benets of benzodiazepine use—a shared decision-making tool. (Reproduced with permission
from Effective Prescribing and Therapeutics Division – Scottish Government) [65]
This person finds his/her sleep
improves, who would not have
done had he or she taken the
placebo
These 2 people have an
adverse event, who would not
have done had they taken the
placebo
418
A. R. Mair et al.
5.5 Adherence
When people take multiple medications, as well as
the burden of treatment, medication adherence is
an important factor to consider. Non-adherence to
prescribed medicines is intricately related to multimorbidity and polypharmacy. Adherence to longterm therapy for chronic illnesses in developed
countries averages 50%, while in developing
countries, the rates are even lower [66]. Nonadherence has been estimated to be responsible for
48% of asthma deaths, an 80% increased risk of
death in diabetes and a 3.8-fold increased risk of
death following a heart attack [67]. Non-adherence
might be intentional or non-intentional and agreeing, and sharing the plan to manage medications
will help to ensure that goals are agreed and
shared, resulting in improved adherence.
5.6 Teach Back
The teach back method is a useful way to conrm
that the information you provide is being understood by getting people to ‘teach back’ what has
been discussed and what instruction has been
given. This is more than saying ‘do you understand?’ and is more a check of how you have
explained things than the patient/client understanding [68, 69]. Patients should understand that
this is not a test for them. This would be useful as
part of a patient sharing and agreeing with the
plan and would also address where there are
potential problems in understanding dosage
instructions that may affect adherence.
A similar tool can be used when showing people how to carry out actions, such as where/how
to apply a cream or where to give a needle. This
is called ‘show me’.
5.7 Deprescribing as Part of a
Person-Centred Approach
As a result of reviewing medication, some medicines may be identied as no longer being
appropriate and these should be stopped. This is
often referred to as ‘deprescribing’, which is
dened as the ‘planned and supervised process
of dose reduction or stopping of medication that
might be causing harm, or no longer be of benet’ [70].
A UK-based national programme found that
when taking this approach, on average 1–2 medicines were stopped per patient per review, and
the rates of polypharmacy decreased [71, 72]. A
Canadian multicentre study investigated a systematic intervention to deprescribe PIMs in
6000 older adults, across 11 hospitals, using
MedSafer decision support [53, 73]. In this
study, compared with the usual care of medication reconciliation, there was a substantial difference in the number of PIMs deprescribed in
the intervention participants, from approximately 30% to over 50%, without changes to
patient-reported measures such as sleep or quality of life [73].
5.8 Medication Safety Indicators
In terms of measuring for appropriate prescribing, the use of medication safety indicators is
more appropriate. For example, in 2019, for the
rst time, the Organisation for Economic
Co-operation and Development collected comparable international data on polypharmacy
rates, measuring the proportion of older people
chronically taking ve or more medications. It
was found that polypharmacy rates among older
people varied more than 11-fold across 14 countries, with Turkey reporting the lowest and
Luxembourg the highest rates of medication prescribing [74]. This is the rst step towards
benchmarking internationally which takes into
account the use of safety indicators and is moving away from numbers of medications to consider appropriateness.
Twelve core quality and safety indicators were
identied in a systematic review considering medication appropriateness. These included drug reactions, contraindications, drug–drug interactions and
the conduct of medication reviews [75]. Countries
can adopt or adapt a set of these indicators based on
the context, priorities and resources available to
measure inappropriate polypharmacy. Several
Acute Kidney Injury: number of people aged ≥65 years co-prescribed a NSAID and an ACE
Source: Precribing Information System Scotland, PHS, NSS.
ARDS
18 Polypharmacy andDeprescribing
419
countries have adopted indicators: one example is
an indicator to identify the ‘triple whammy’, where
the combination of an angiotensin-converting
enzyme inhibitor (ACEI) or ARB plus a diuretic
and a NSAID is to be avoided because of its potential to cause acute kidney injury [7].
Scottish polypharmacy guideline uses a suite
of 17 quality and safety indicators to monitor
appropriateness of polypharmacy nationally [7].
Figure 18.4 shows the number of people aged
65 years or older co-prescribed a NSAID, an
ACE inhibitor or ARB and a diuretic, as a percentage of all people aged 65years or older prescribed an ARB and a diuretic. Across Scotland,
there are 14 different regions providing healthcare.
These are known as NHS boards. This chart helps
one board to benchmark against the Scottish average but also see how they are positioned against
the other regional or board areas.
Canada has identied their own suite, which
also include indicators related to appropriate polypharmacy, such as ensuring that people discharged
from hospital after an myocardial infarction are on
appropriate secondary prevention medications
[76]. Similarly, Sweden has also had a suite of indi-
cators which has been in place since 2004. The
Swedish indicators include polypharmacy and covering the rational, irrational and hazardous drug use
in common disorders in older people [77].
6 Barriers and Enablers to
Address Inappropriate
Polypharmacy
There are a number of challenges which act as
barriers to actioning change from medication
reviews, particularly for deprescribing which can
be complex and can occur at an individual level
(i.e. patient and healthcare provider), an organisational level (i.e. healthcare system and policy
level) or at a cultural level, in terms of maintaining the status quo [78]. Cultural and organisational barriers identied in a recent systematic
review of 40 studies across 14 countries consisted
of the culture of diagnosing and prescribing; a
lack of evidence-based guidelines and resources,
especially for older people with multimorbidity;
and a lack of shared communication with access
to decision-making systems and resources [79].
The deprescribing process is considered an
essential component of medication reconciliation
and review [14], where inappropriate medicines
which can be discontinued are identied.
The interpersonal and individual barriers
included differences in professional practice;
fragmented care; prescribers’ and patients’ reservations and fears about deprescribing; and a lack
of tailored approaches to person-centred care
[79]. There is often miscommunication when
inhibitor/angiotension receptor blocker and a diuretic as a percentage of all people aged ≥65 years
1
0.8
0.6
0.4
0.2
Percentage of patients (%)
0
Mar
2018
Fig. 18.4 Indicator to show the percentage of people prescribed the triple whammy combination known to cause
acute kidney injury across different regions across
prescribed an ACE inhibitor/angiotensin receptor blocker and a diuretic
Sep
2018
Mar
2019
Sep
2019
Mar
2020
Sep
2020
Mar
2021
Scotland (source accessed 29.05.2023). National therapeutic indicators data visualisation—Data to September
2022—Publications—Public Health Scotland
Sep
2021
Mar
2022
NHS BO
SCOTLAND
Sep
2022
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