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420
A. R. Mair et al.
patients transition between providers [13]. Fear
of potential for harm when stopping a medicine
and a lack of knowledge of methods for optimal
tapering or stopping are among other barriers
given to deprescribing medicines that are no longer appropriate [80, 81].
In addition to barriers, there are a number of
facilitators which need to be recognised to
reviewing polypharmacy and commencing deprescribing when appropriate, as discussed throughout this chapter. These include shared
decision-making, delivering person-centred care,
judicious prescribing, improved communication
and collaboration between patient and prescribers across different healthcare settings [78, 79].
Other facilitators include the availability of evidence-based tools and resources, formal training/
teaching, an increased awareness of potential
harms with continuation or benets of stopping a
medication, as well as discussions about goals of
care and treatment preferences [78]. Another
important facilitator of reducing or ceasing medicines includes the availability and acceptability
of non-pharmacological alternatives [79]. Nonpharmacological options are not consistently
considered rst-line or continued once pharmacological treatments are initiated [82]. It is
important that prescribers consider and recommend non-pharmacological options if appropriate. For example, heat/cold applications, massage
therapy and relaxation techniques should be considered for the management of pain.
Trust between the prescriber and patient plays
a complex role, as both a barrier and a facilitator
[83]. Trust is necessary because of the complexity and uncertainty of decisions about changing
medication regimens and is dependent on several
factors such as length of time that the patient has
been seeing the prescriber, repeated positive
experiences of care and the perceived medical
expertise of the prescriber [83]. Patients themselves can also act as either barriers and facilitators to deprescribing by unintentionally
withholding information about adverse drug
events and reporting their symptoms to specialists or nurses rather than their GPs, who may be
mainly responsible for overall medication management [13]. Some patients are also reluctant to
stop familiar medications and may not under-
stand the need for deprescribing because of their
level of education, health literacy, cognitive
impairment and functional dependency [13].
The challenges of addressing inappropriate
polypharmacy, especially in older people with
multimorbidity and frailty, are complex and
require a person-centred approach, as described.
These challenges are often compounded by the
involvement of several healthcare providers from
different specialties, who prescribe medicines
based on disease-specic guidelines which do
not contain evidence on the older, frailer and
multimorbid patient population [13]. It is therefore evident that an interdisciplinary approach to
the treatment of these older patients needs to be
implemented, ensuring that they are treated holistically. There is a growing body of evidence suggesting that deprescribing interventions led by
pharmacists [84, 85] and interdisciplinary teams
have successfully reduced the number of medicines, including inappropriate medicines, prescribed in older people [86]. It could be argued
therefore, that for deprescribing and addressing
inappropriate polypharmacy to be successfully
achieved, it is essential that prescribers collaborate between themselves and with interdisciplinary team members, which include nurses,
pharmacists, social workers and others [87].
Other strategies which can be used to address
inappropriate polypharmacy include public
involvement in changing and designing policy
[88]. In addition, application of the nudge theory
such as clinical decision support may help change
behaviour, and there is some emerging evidence
to support this [89–91]. Consideration of human
factors, together with change management strategies that are scalable, is important to deliver a
sustainable solution across the whole healthcare
system [92].
7 Implementing Programs to
Address Inappropriate
Polypharmacy and Impact
The EU-funded SIMPATHY (Stimulating
Innovation Management of Polypharmacy and
Adherence in the Elderly) project spent 2years
studying polypharmacy management in Europe
18 Polypharmacy andDeprescribing
421
[92]. Case studies in nine EU countries were used
to determine how programs to manage polypharmacy and adherence were implemented using
change-management tools such as Kotter’s eight
steps, PESTEL (Political, Economic, Social,
Technological, Environmental and Legal), model
and SWOT (Strengths, Weakness, Opportunity
and Strength) analysis. In addition to a literature
review, a benchmarking survey across the EU and
a modied Delphi approach were used to establish an EU-wide consensus on how to address
polypharmacy and a recommendation on what
should be measured to demonstrate improvement
[93–95]. From the modied Delphi approach, the
key areas of consensus were around potential
gain arising from polypharmacy management,
strategic development, strategic change management, indicator measures, awareness raising and
person-centred polypharmacy reviews. Notably,
no consensus was achieved in relation to statements relating to the need to alter legislation in
areas of healthcare delivery, remuneration and
practitioner scope of practice [93].
The EU project made six key recommendations to implement programs to improve medication safety, of which polypharmacy is an essential
element: (1) Use a systems approach that has
multidisciplinary clinical and policy leadership;
(2) nurture a culture that encourages and prioritizes the safety and quality of prescribing; (3)
ensure that patients are integral to the decisions
made about their medicines and are empowered
and supported to do so; (4) use data to drive
change and measure outcomes; (5) adopt an evidence-based approach with a bias towards action
and (6) utilize, develop and share tools to support
implementation.
Evidence for the outcomes of reviews and
economic impact of addressing inappropriate
polypharmacy is important when developing
programmes to address this emerging research
area. Many programmes have shown a reduction
in the number of PIMs that are prescribed; however, evidence for the impact on other patient
outcomes is mixed [96]. Sustainability of programmes to address inappropriate polypharmacy in the health service will be dependent on
cost-effectiveness of the programs. While the
economic impact of the polypharmacy reviews
is mixed, some consider the savings from medicines that are stopped and others the possible
indirect benets of the review such as prevented
hospital admission or ADRs avoided, against
the costs of the reviews. One systematic review
found evidence that an adequate system for
managing, prescribing, monitoring and evaluating the use of medications is effective in reducing polypharmacy and improving adherence to
medications, while decreasing drug costs, medication errors, drug-related problems, ADRs,
drug–drug interactions, drug-related negative
health outcomes, and hospital admissions [97].
Another systematic review looking at the economic evaluation found limited evidence for the
benet of the intervention to optimise medication outweighing implementation costs [98].
The authors recommended that there is a need to
address and identify barriers when scaling up
implementation.
The Scottish national polypharmacy programme implemented the learnings from programmes such as SIMPATHY [92], pharmacist-led
information technology intervention for medication errors (PINCER) [99] and Data-Driven
Quality Improvement in Primary Care (DQIP)
[100]. The Scottish national polypharmacy programme resulted in one to two medicines reduced
per patient, as well as an improvement in safety
and quality indicators. The priority population
were those over the age of 75years old, chosen to
prioritise the available resources which generated
an average net saving of 150 euros per patient per
annum, even after taking into account the cost of
staff for the reviews [92]. There were additional
indirect benets in the form of cost avoidance due
to fewer ADRs and hospital admissions.
Another example of a program to address inappropriate polypharmacy is the study conducted in
the Basque region by Etxeberria et al. [101] This
study used the multidisciplinary SIMPATHY
methodology to minimise inappropriate polypharmacy in a population of 360,000 citizens.
This approach, including pharmacists and physicians reviewing patients with ve PIMs, resulted
in statistically signicant reductions in potentially
inappropriate polypharmacy across primary and
secondary care settings [102]. iSIMPATHY
(implementing Stimulating Innovation in the
422
A. R. Mair et al.
Management of Polypharmacy and Adherence
Through the Years) sought to implement the
SIMPATHY ndings in Scotland, Northern
Ireland and Ireland. The approach centred around
patient partnership, “what matters to me” and
shared decision-making in medicines reviews
using the 7-step approach. The project demonstrated the feasibility of embedding a standardised
approach to medicines review in Northern Ireland
and Ireland and scaling up the Scottish work for
6,481 patients engaged in reviews in primary care,
secondary care, outpatient clinics and care homes.
It involved application of change management
methodology and shared decision-making as part
of a person-centred approach to pharmacist-led
medicines use review delivery in multiple
healthcare settings, with multidisciplinary team
collaboration. An average of 11 interventions
were made per patient, with 82% classied as
clinically signicant and 4% potentially prevent-
ing major organ failure or similar; 94% of interventions were accepted. The average number of
medications reduced from 12 to 11 and 92% of
reviews resulted in more appropriate medication
use. Economic evaluation identied a positive
return on investment as well as a reduction in carbon footprint of both admissions and wastage of
medicines, and patient-reported outcome measures indicated improved understanding, adherence and reduced adverse effects. Together this
showed a QALY gain of 7.4 per 100 patients
reviewed. The iSIMPATHY [102] approach is
transferable and the evidence produced supports
robust policy development and recommends that
barriers such as competing priorities and workforce capacity must be addressed effectively
through the change management tools, and that
patient awareness and empowerment to be active
participants in the review is crucial. An overview
of the ndings is included in the Fig. 18.5 [102].
Fig. 18.5 An overview of ndings from iSIMPATHY-Evaluation report
18 Polypharmacy andDeprescribing
8 Summary and Conclusions
This chapter has described what constitutes
inappropriate and appropriate polypharmacy
and discussed strategies that are available to
reduce medication-related harm focusing on a
person-centred approach. The chapter also discussed which medicines have been identied to
cause most harm and which patient populations are most likely to experience medicationrelated harm. New approaches to improving
safety were discussed and include deprescribing as an outcome of medication reviews, with
the most signicant positive outcomes achieved
with programs which include interdisciplinary
teams. Some of the strategies listed are applicable to larger organisations; however, there
are approaches described in the chapter and
cases worked through that demonstrate how
each healthcare provider at all points of the
medication management pathway can reduce
the risk of medication-related harm for the
individual.
Research evidence are emerging in the eld
of polypharmacy and deprescribing on programmes that reduce inappropriate polypharmacy, but further work is needed to show
impact on patient outcomes and the sustainability of national programmes across health
systems. Evidence is also needed to support the
review and prioritisation of medication use for
people with multimorbidity. More data is also
needed to show that reducing and stopping these
medications that were being used to manage multimorbidity do not result in patient harm.
9 Case Studies
9.1 Case Study 1: Case Example of
Polypharmacy
Consider the case of a resident in a care home
with multimorbidity and polypharmacy (Ms
AK), Box 18.5, keeping in mind particularly the
denitions of appropriate and inappropriate
polypharmacy.
423
Box 18.5 Case 1—Ms AK
Case summary: AK
Background (age, sex, occupation, baseline
function)
• Ms AK is a 60-year-old female smoker,
with heart failure following a myocardial
infarction 5years previously. Retired.
History of presentation/reason for review
• Staff at the home tell you Ms AK is a bit
breathless. She is thought to have an
airways condition, due to her history, and
she has been started on a salbutamol
inhaler. Staff also tell you she’s a bit
sleepier during the day since commencing
zopiclone.
• Until 2years ago, she worked in a bakery.
She is a resident in a care home as she has
developed early onset dementia.
Current medical history and relevant
comorbidities
• Angina, hypertension, high cholesterol, type
2 diabetes mellitus, osteoarthritis.
Current medications and drug allergies
obtained from Ms AKinclude items obtained
over the counter (OTC) and herbal or
complementary medicines.
• Simvastatin 40mg daily
• Aspirin (low dose) daily
• Bisoprolol 2.5mg daily
• Ramipril 2.5mg daily
• Salbutamol inhaler
• Paracetamol 1000mg, when required for
pain.
She has also been recently prescribed:
• Zopiclone 3.75mg, one to two tablets at
night, for insomnia
Ms AK is living in a care home, and it would
be important to assess her capacity to understand the information which is being provided
to her. Due to her cognitive impairment, the clinician may need to discuss medication-related
matters with the person legally responsible for
making decisions about her care. Reviewing
AK, the rst point would be to consider ‘what is
important to AK?’ The response is that she is
breathless and that she is sleepier during the day
(Box 18.6).
Taking a person-centred 7-steps approach to
review Ms AK’s medication, the following
actions can be taken (Box 18.7).
424
Box 18.6 Case 1—Ms AK Continued
Lifestyle and current function, alcohol/smoking/diet/exercise
• Smoker with 20 pack year history; recently cut back to 4 pack years. She was walking but nds this hard
due to breathlessness.
• 20units per week of alcohol
‘What matters to me’ (patient ideas, concerns and expectations of treatment)
• What is important to Ms AK is the breathlessness and drowsiness during the day.
Results, e.g. biochemistry, other relevant investigations or monitoring
• Cholesterol, kidney function and electrolytes are within normal range.
• HbA1c is 48mmol/Mol (6.5%)
Most recent relevant consultations
• Breathlessness raised by staff at the care home; early onset dementia
Box 18.7 Case 1—Taking the 7-Step Approach to Reviewing Ms AK‘s Medicines
Domain Steps Process Person-specic issues to consider
Aims
Need 2. Identify
1. What matters to
Ms AK?
essential drug
therapy.
Review diagnoses and
identify therapeutic
objectives with respect to:
– Identify objectives of
therapy
– Manage existing health
problems
– Prevent future health
concerns
Identify essential drugs (not
to be stopped without
specialist advice)
– Drugs that have essential
replacement functions
(e.g. thyroxine)
– Drugs to prevent
symptomatic decline (e.g.
drugs for Parkinson’s
disease, heart failure)
– Breathlessness and daytime
drowsiness
– Deterioration of dementia
– Essential medications are
bisoprolol and ramipril,
prescribed for heart failure
A. R. Mair et al.
18 Polypharmacy andDeprescribing
Domain Steps Process Person-specic issues to consider
3. Does the patient
take
unnecessary
drug therapy?
Effectiveness 4. Are therapeutic
objectives being
achieved?
Safety 5. Does Ms AK
have adverse drug
reactions (ADRs) or
is at risk of ADRs?
What is medication for?
Identify and review the
(continued) need for drugs:
– with temporary indications
– with higher than usual
maintenance doses
– with limited benet/
evidence of its use in
general
– with limited benet for the
patient under review
(consider numbers needed
to treat) [7]
Identify the need for adding/
intensifying drug therapy to
achieve therapeutic
objectives:
– to achieve symptom
control
– to achieve biochemical/
clinical targets
– to prevent disease
progression/exacerbation
Is there more appropriate
therapy that would help achieve
goals?
Identify patient safety risks
by checking:
– are the targets set for the
individual appropriate?
– drug–disease interactions
– drug–drug interactions
– monitoring mechanisms
for high-risk drugs
– risk of accidental
overdosing
Identify adverse drug effects
by checking for:
– specic signs/symptoms/
laboratory markers (e.g.
hypokalaemia)
– cumulative adverse drug
effects
– drugs that may be used to
treat side effects caused by
other drugs
– Zopiclone is unnecessary
– The dose may need to be
weaned gradually if Ms AK
has been taking these
>4weeks.
– Consider if her insomnia been
caused by pain?
– The indication for salbutamol
is unclear and likely to be
inappropriate as
breathlessness is probably
due to heart failure. This can
be stopped.
– Consider smoking history:
Advise spirometry as
smoking history and previous
occupation may predispose
Ms AK to chronic obstructive
pulmonary disease (COPD)
– Simvastatin is currently
appropriate, however as
dementia progresses and
becomes severe, it would be
important to review its
ongoing benets
– Review doses of ACEI
(ramipril) and beta blocker
(bisoprolol) and titrate to
manage heart failure.
– Ms AK would benet from
dose titration.
– Ensure kidney function,
electrolytes and BP are
monitored.
– Consider the different NNTs
here for symptom
management compared to
progression.
– Ensure Ms AK is not
experiencing any
gastrointestinal ADRs from
aspirin
– Zopiclone is likely to be
causing drowsiness the next
day
– Check her weight to ensure
appropriate dose of
paracetamol and discuss with
care home staff
425
426
Domain Steps Process Person-specic issues to consider
Does Ms AK or the
care home personnel
know what to do if ill
with a period of acute
dehydrating illness?
Sustainability 6. Is drug therapy
cost-effective and
environmentally
sustainable?
Personcentred care
Key concepts in this case (AK)
• This patient was incorrectly diagnosed with breathing problems that were managed with salbutamol
• Although both the beta blocker (bisoprolol) and ACEI (ramipril) can be considered high-risk medicines,
they are recommended to be increased to provide symptomatic relief of heart failure.
• Electrolytes and kidney function should be monitored.
• Zopiclone should be weaned and should only have been prescribed for short-term use.
• Consider non-pharmacological management, for instance, of insomnia
7. Is Ms AK
willing and able to
take medicines as
intended?
See Sick day guidance – It may be appropriate to stop
ACEI (ramipril) if Ms AK
becomes acutely unwell. The
care home staff would need
training on how this is done.
Identify unnecessarily costly
drug therapy:
– Consider more cost-
effective alternatives.
More sustainable options
would be the use of dry
powder inhalers rather
than propellant based
inhalers where these are
indicated
Does the patient understand
the outcomes of the review?
– Consider ‘Teach Back’
Ensure drug therapy changes
are tailored to patient
preferences:
– Is the medication in a
form the patient can take?
– Is the dose schedule
convenient?
– Is the patient able to take
medicines as intended?
Consider what assistance the
patient might need and when
this is available
Agree and communicate plan:
– Discuss with the patient/
carer/welfare proxy
objectives and priorities
– Decide what medicines
have an effect of sufcient
magnitude to consider
continuation or
discontinuation
– Inform relevant carers about
changes in treatments
– Balance against effectiveness,
safety, convenience
– Ensure the care staff and Ms
AK understand why the
medicines are being titrated
up and that the inhaler is
unlikely to be needed, and
why zopiclone is to be
weaned off
A. R. Mair et al.
18 Polypharmacy andDeprescribing
9.2 Case Study 2: Polypharmacy
and Prescribing Cascade
Consider a case of a person living in the community
with multimorbidity and polypharmacy (Mr PC),
Boxes 18.8 and 18.9, particularly keeping in mind
the denitions of appropriate and inappropriate
polypharmacy, and for this case, the prescribing
cascade.
For the second case of Mr PC, living in the
community, each of the steps is set out using the
7-step process below (Box 18.10).
427
Box 18.8 Case 2—Mr PC
Case summary: Mr PC
Background (age, sex, occupation, baseline
function)
• 76-year-old male, with type 2 diabetes
mellitus. Retired. Previous football player.
History of presentation/reason for review
• Feeling light-headed and dizzy; has annoying
heart burn.
Current medical history and relevant
comorbidities
• Angina, hypertension, high cholesterol, type
2 diabetes mellitus, osteoarthritis.
Current medications and drug allergies,
obtained from PC.Includes items obtained
over the counter (OTC) and herbal or
complementary medicines.
• Amlodipine 10mg daily. The dose has been
recently increased from 5mg daily.
• Bendroumethiazide 5mg in the morning,
recently commenced.
• Glibenclamide 15mg daily
• Diclofenac 75mg twice a day
• Simvastatin 40mg at night
• Ramipril 2.5mg in the morning
Mr PC has recently purchased Omeprazole
10mg, which he takes daily.
Box 18.9 Case 2—Mr PC Continued
Lifestyle and current function, alcohol/smoking/diet/exercise
• Little exercise due to joint pain
• Social alcohol consumption: 4–5units per week
• Non-smoker
‘What matters to me’ (patient ideas, concerns and expectations of treatment)
• Feeling light-headed and dizzy at times. Gets annoying heart burn
• Has not had a heart attack and understands his medicines may help prevent one, so he takes his
medicines
• His swollen ankles are annoying
Results, e.g. biochemistry, other relevant investigations or monitoring
• BP before amlodipine dose was increased: 155/70 (sitting)
• Most recent HbA1C was 61mmol/Mol (7.7%), and fasting blood glucose level (BGL) was
5.1mmol/L.He does not check his own BGL via capillary (nger-prick) testing
• Kidney function is stable, although reduced (eGFR 50mL/min/1.73m2) with microalbuminuria. Records
have not been updated since recent additions of bendroumethiazide and diclofenac
Most recent relevant consultations
• Community pharmacy request for relief of heartburn and discussion of symptoms. Referred for
medication review.
428
Box 18.10 Case 2—Taking the 7-Steps Approach to Reviewing Mr PC’s Medicines
Domain Steps Process Person-specic issues to consider
Aims
Need
1. What matters to
PC?
2. Identify
essential drug
therapy
3. Does PC take
unnecessary
therapy?
Review diagnoses and
identify therapeutic
objectives with respect
to:
– Identify objectives of
therapy
– Manage existing
health problems
– Prevent future health
concerns
Identify essential drugs
(not to be stopped
without specialist advice)
– Drugs that have
essential replacement
functions (e.g.
thyroxine)
– Drugs to prevent
symptomatic decline
(e.g. drugs for
Parkinson’s disease,
heart failure)
What is medication for?
Identify and review the
(continued) need for
drugs:
– with temporary
indications
– with higher than
usual maintenance
doses
– with limited benet/
evidence of its use in
general
– with limited benet
for the patient under
review, consider
number needed to
treat (NNT) [7]
– Investigate possible medication-
related causes for symptoms
– Avoiding future heart disease or
stroke is important
– Prescribed medicines are for
long-term prevention of
cardiovascular complications
– Diclofenac is for managing symptoms
but should be reviewed due to risk of
cardiovascular complications
Reconsider diuretic:
– commenced for ankle oedema, most
likely from amlodipine and not for BP
management
– has potential to reduce kidney
function
Reason for OTC omeprazole:
– possibly to manage ADRs
experienced from diclofenac or
amlodipine.
Review diclofenac and amlodipine,
considering deprescribing, with ongoing
monitoring of BP.
A. R. Mair et al.
18 Polypharmacy andDeprescribing
Domain Steps Process Person-specic issues to consider
Effectiveness 4. Are therapeutic
objectives being
achieved?
Safety 5. Does the patient
have adverse
drug reactions
(ADRs) or is at
risk of ADRs?
Does PC know what
to do if ill with a
period of acute
dehydrating illness?
Identify the need for
adding/intensifying drug
therapy to achieve
therapeutic objectives:
– to achieve symptom
control
– to achieve
biochemical/clinical
targets
– to prevent disease
progression/
exacerbation
Is there more appropriate
therapy that would help
achieve goals?
Identify patient safety
risks by checking:
– whether the targets
set for the individual
appropriate?
– drug–disease
interactions
– drug–drug
interactions
(monitoring
mechanisms for
high-risk drugs)
– risk of accidental
overdosing
Identify adverse drug
effects by checking for:
– specic signs/
symptoms/laboratory
markers (e.g.
hypokalaemia),
– cumulative adverse
drug effects
drugs that may be used to
treat side effects caused by
other drugs
See Sick day guidance
Investigate/exclude possible causes of
heartburn
– consider medication causes:
amlodipine±diclofenac
– consider dose reduction of these or
stopping, if appropriate
– H. pylori eradication (if identied)
– prescribe proton pump inhibitor/
eradication therapy, if appropriate,
with view to ‘step-down’ after initial
management.
Add aspirin for secondary prevention of
cardiovascular disease, after completing
the steps above to manage heartburn
– Intensify non-drug management for
arthritis; use paracetamol and topical
therapies; consider strict ‘as required’
dosing of NSAID with safer
cardiovascular risk prole.
– Dizziness and light-headedness are
non-specic symptoms: could be due
to postural hypotension or low blood
glucose.
– if possible, check sitting and standing
BP and fBGL at time of symptoms
– Glibenclamide is a sulphonylurea
derivative and a Potentially
Inappropriate Medicine (PIM) for an
older person with reduced kidney
function, due to the risk of
hypoglycaemia
– Less stringent targets for HbA1c and
fBGL are acceptable for older people
with multimorbidity
– Change to safer medicine, such as
metformin with dose appropriate for
kidney function.
– Check kidney function and
electrolytes (drug-drug interaction:
diclofenac + bendroumethiazide)
– Drug–drug interaction: amlodipine
and simvastatin. PC has maximum
simvastatin dose. There are no recent
cholesterol results recorded for PC.
– Monitor with potential to review or
reduce simvastatin dose with time.
429
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