# Polypharmacy and Deprescribing in Older Adults

## Introduction

**Polypharmacy**, commonly defined as the concurrent use of five or more medications, affects over 40% of older adults and is a major driver of adverse drug events, hospitalizations, and functional decline. **Deprescribing** is the systematic process of identifying and discontinuing medications when existing or potential harms outweigh benefits, guided by the patient's goals of care and life expectancy.

## Epidemiology and Impact of Polypharmacy

- Approximately **65% of adults aged 65 and older** take five or more medications daily
- Polypharmacy increases the risk of **adverse drug reactions (ADRs)** exponentially; patients on 5+ medications have a 50% risk of ADR
- Drug-drug interactions, falls, cognitive impairment, and hospitalization are common consequences
- Medication non-adherence increases with regimen complexity
- Annual medication costs are significantly higher in polypharmacy patients

## Identifying Potentially Inappropriate Medications

### Beers Criteria

- Published by the **American Geriatrics Society (AGS)**, updated regularly
- Lists medications that are potentially inappropriate for older adults due to high risk of adverse effects
- Categories include medications to **avoid**, to **use with caution**, and **drug-disease interactions**
- Common offenders: **benzodiazepines**, anticholinergics, long-acting sulfonylureas, NSAIDs, and first-generation antihistamines

### STOPP/START Criteria

- **STOPP (Screening Tool of Older Persons' Prescriptions)**: identifies potentially inappropriate prescriptions
- **START (Screening Tool to Alert to Right Treatment)**: identifies potential prescribing omissions
- More clinically oriented and organized by organ system compared to Beers Criteria
- Useful as a complementary tool alongside the Beers list

![Beers Criteria high-risk medication categories for older adults](images/beers-criteria-categories.png)

## The Anticholinergic Burden

- **Anticholinergic burden** refers to the cumulative effect of taking one or more medications with anticholinergic properties
- Measured using scales such as the **Anticholinergic Cognitive Burden (ACB) Scale**
- Common culprits: diphenhydramine, oxybutynin, tricyclic antidepressants, paroxetine, promethazine
- Effects include **dry mouth, constipation, urinary retention, confusion, delirium**, and increased dementia risk
- Reducing anticholinergic burden is a priority in medication optimization

## The Deprescribing Process

### Stepwise Approach

1. **Compile** a complete medication list including OTC and supplements
2. **Identify** potentially inappropriate or unnecessary medications using validated tools
3. **Determine** whether each medication has a current indication and whether benefits outweigh risks
4. **Prioritize** which medications to discontinue first based on harm potential
5. **Plan** a gradual taper when appropriate (e.g., benzodiazepines, beta-blockers, corticosteroids, SSRIs)
6. **Monitor** for withdrawal symptoms, disease recurrence, or improved outcomes

### Medications Commonly Targeted for Deprescribing

| Medication Class | Deprescribing Consideration | Taper Strategy |
|-----------------|---------------------------|----------------|
| Proton pump inhibitors | No ongoing indication; >8 weeks use | Step down to H2 blocker, then stop |
| Benzodiazepines / Z-drugs | Fall risk, cognitive impairment | Slow taper (10-25% every 1-2 weeks) |
| Statins | Life expectancy <1-2 years, no active CVD | Can stop abruptly |
| Antihypertensives | Symptomatic hypotension, limited prognosis | Gradual dose reduction |
| Cholinesterase inhibitors | Advanced dementia, no perceived benefit | Taper over 4 weeks; monitor for decline |
| Bisphosphonates | >5 years use, low fracture risk | Drug holiday (stop and reassess) |

- **Proton pump inhibitors (PPIs)**: often continued beyond recommended duration; step down to H2 blockers
- **Benzodiazepines and Z-drugs**: taper slowly over weeks to months
- **Statins**: limited benefit in patients with life expectancy < 1-2 years and no active cardiovascular event
- **Antihypertensives**: consider reducing if symptomatic hypotension or limited life expectancy
- **Cholinesterase inhibitors**: reassess in advanced dementia with no perceived benefit

![Five-step deprescribing protocol flowchart](images/deprescribing-protocol.png)

## Barriers to Deprescribing

- **Prescriber inertia**: reluctance to change medications prescribed by another provider
- **Patient and caregiver resistance**: fear of disease progression or symptom return
- **Fragmented care**: multiple prescribers without coordinated medication review
- **Lack of evidence**: limited trial data on deprescribing in specific populations
- Effective **communication and shared decision-making** are essential to overcoming these barriers

## Tools and Resources

- **MedStopper** (medstopper.com): ranks medications by deprescribing priority
- **Deprescribing.org**: evidence-based deprescribing guidelines and algorithms
- **Medication reconciliation** at every care transition is a critical safety practice
- Pharmacist-led medication reviews have demonstrated reductions in polypharmacy and ADRs

![Deprescribing conversation guide for clinicians](images/deprescribing-conversation.png)

## Goals of Care Integration

- Deprescribing decisions should align with the patient's **goals, values, and prognosis**
- In palliative and end-of-life care, aggressive deprescribing of preventive medications is appropriate
- Focus shifts to **symptom management and quality of life**
- Time-to-benefit analysis helps determine whether continuing a preventive medication is warranted

## Key Clinical Pearls

- Polypharmacy is a modifiable risk factor for adverse drug events, falls, and cognitive decline in older adults.
- Use the Beers Criteria and STOPP/START tools systematically at least annually to identify inappropriate medications.
- Deprescribe one medication at a time when possible, with gradual tapering and close monitoring.
- Reducing anticholinergic burden can improve cognition and reduce delirium risk.
- Engage patients and caregivers as partners in the deprescribing process using shared decision-making.

## References

1. American Geriatrics Society Beers Criteria Update Expert Panel. Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. *Journal of the American Geriatrics Society*. 2023;71(7):2052-2081.
2. Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. *JAMA Internal Medicine*. 2015;175(5):827-834.
3. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START Criteria for Potentially Inappropriate Prescribing in Older People: Version 3. *European Geriatric Medicine*. 2023;14(4):625-632.
4. Reeve E, Shakib S, Hendrix I, et al. Review of Deprescribing Processes and Development of an Evidence-Based, Patient-Centred Deprescribing Process. *British Journal of Clinical Pharmacology*. 2014;78(4):738-747.