Polypharmacy in older people: taking many medicines safely

Polypharmacy simply means taking multiple medicines. NICE guideline NG5 on medicines optimisation uses the term for adults, children and young people taking multiple medicines, and identifies this group, people with chronic or long-term conditions, and older people as groups for whom a structured medication review may be considered.

There is no single number that defines it. NICE NG56 on multimorbidity sets thresholds for a different purpose, advising an approach to care that takes account of multimorbidity for adults of any age prescribed 15 or more regular medicines, and considering that approach for those prescribed 10 to 14 regular medicines or fewer than 10 but at particular risk of adverse events. Medicines in this context include ointments, inhalers, creams and drops as well as tablets and injections.

NICE NG56 points out that the evidence behind guidance on single conditions is regularly drawn from people without multimorbidity and taking fewer regular medicines. It also says that managing risk factors for future disease can be a major treatment burden for people with multimorbidity, so the benefits and harms of each treatment need to be considered for the individual.

NG56 lists medicines with a higher risk of adverse events, giving falls, gastrointestinal bleeding and acute kidney injury as examples. It also describes treatment burden as including the number and type of healthcare appointments, the number of medicines and how often they are taken, any harms from medicines, and effects of treatment on mental health or wellbeing.

NICE NG5 says a structured medication review should be considered when a clear purpose has been identified, and NG56 points to people prescribed 10 or more regular medicines or who are at particular risk of adverse events. If you are unsure whether a review would help, it is reasonable to ask your GP practice or pharmacist, particularly if you are finding it hard to manage your medicines or suspect a side effect.

If you have a sudden severe reaction to a medicine, such as breathing difficulty, swelling of the face or a spreading blistering rash, that is an emergency and you should call 999 rather than wait for a review.

NG5 says organisations should decide locally which health professional should carry out a structured medication review, based on their technical knowledge of medicines processes, therapeutic knowledge of medicines use and communication skills. It may be led, for example, by a pharmacist or by an appropriate health professional who is part of a multidisciplinary team.

• Your views and understanding about your medicines, and any concerns, questions or problems you have with them.

• All prescribed, over-the-counter and complementary medicines you take or use, and what they are for.

• How safe each medicine is, how well it works for you, how appropriate it is, and whether its use is in line with national guidance.

• Whether you have had or have risk factors for adverse drug reactions.

• Any monitoring that is needed.

Both NG5 and NG56 suggest considering a screening tool such as STOPP/START in older people to identify potential medicines-related safety concerns and medicines the person might benefit from but is not currently taking. NG56 also advises agreeing an individualised management plan with the person after discussing treatment burden and their goals, values and priorities.

The plan could include starting, stopping or changing medicines and non-drug treatments, prioritising appointments, arranging follow-up and review of decisions made, and deciding who coordinates care. Stopping a medicine should be a decision made with a prescriber, not on your own, because some medicines need to be reduced gradually.

Bring all your medicines, including over-the-counter products, vitamins and herbal remedies, because NG5 asks reviewers to take these into account. Write down questions, such as what each medicine is for, what would happen if it were stopped, and how long you are meant to take it. A relative or carer can help, and NG5 says family members or carers should be considered where appropriate.

Tell the reviewer what matters most to you, such as staying independent, being able to take part in social activities or avoiding hospital admission. NG56 lists these among the personal goals that should shape treatment decisions.

A review does not always result in fewer medicines. NG56 stresses that the aim is to improve quality of life by reducing treatment burden, adverse events and unplanned or uncoordinated care. Sometimes the right outcome is to keep everything, add something, or simplify the timing. Regular follow-up and review of decisions made is part of the process.

Medicines reviews are usually carried out in general practice, by practice or community pharmacists, or by hospital teams on discharge. A private consultation can also look at medicines, but the prescriber who knows your full record is often best placed to change anything. Whichever route you use, make sure your GP practice has an up-to-date list of all your medicines.