Residency · Residency · Family Medicine

Polypharmacy and Deprescribing in Older Adults

Introduction

Polypharmacy, commonly defined as the concurrent use of five or more medications, affects approximately 40% of adults aged 65 and older. While some patients require multiple medications for legitimate indications, polypharmacy increases the risk of adverse drug events, drug interactions, falls, cognitive impairment, and hospitalization. Deprescribing is the systematic process of identifying and discontinuing medications where harms outweigh benefits.

Scope of the Problem

Adults aged 65 and older consume approximately 30% of all prescriptions despite representing 16% of the population. Adverse drug events account for approximately 10% of emergency department visits and 5 to 10% of hospital admissions in older adults. Drug-drug interactions increase exponentially with the number of medications: the risk is 13% with two drugs and 82% with seven or more. Medication nonadherence is more common with complex regimens, paradoxically worsening outcomes.

Risk Factors for Problematic Polypharmacy

Risk factors include multiple prescribers without shared medication records, prescribing cascades (where a new drug is prescribed to treat the side effect of another drug), transitions of care (hospital to home, facility to home), over-the-counter medications and supplements not captured in the medical record, continuation of time-limited therapies beyond their intended duration, and inappropriate application of disease-specific guidelines developed for younger populations.

Identifying Potentially Inappropriate Medications

Beers Criteria

The Beers Criteria, published by the American Geriatrics Society and updated every three years, lists medications that are potentially inappropriate in older adults due to an unfavorable risk-benefit ratio. Key categories include anticholinergics (first-generation antihistamines such as diphenhydramine, tricyclic antidepressants, and bladder antimuscarinics such as oxybutynin), benzodiazepines and Z-drugs (increased fall risk, cognitive impairment, and delirium), NSAIDs (GI bleeding, renal injury, and cardiovascular risk with long-term use), proton pump inhibitors beyond recommended duration (fracture risk, C. difficile, and hypomagnesemia), and sulfonylureas such as glyburide (hypoglycemia risk).

STOPP/START Criteria

The STOPP (Screening Tool of Older People's Prescriptions) criteria identify medications to potentially stop, while the START (Screening Tool to Alert to Right Treatment) criteria identify undertreated conditions. These criteria are complementary to the Beers Criteria and are more commonly used in European practice.

Anticholinergic Burden

The Anticholinergic Cognitive Burden (ACB) Scale quantifies cumulative anticholinergic load. A cumulative ACB score of 3 or more is associated with increased cognitive decline, falls, and mortality. Common contributors include diphenhydramine, oxybutynin, paroxetine, amitriptyline, and promethazine.

The Deprescribing Process

Step 1: Comprehensive Medication Review

A brown bag review should be conducted, asking patients to bring all medications including over-the-counter drugs, supplements, and herbal products. Each medication's indication, dose, duration, and prescriber should be verified. Pharmacy records should be reconciled to identify discrepancies. Adherence should be assessed, including medications the patient may have already self-discontinued.

Step 2: Identify Deprescribing Targets

Targets include medications with no current indication, medications whose original indication has resolved, medications causing or likely causing adverse effects, medications on the Beers or STOPP lists without compelling indications, duplicate therapies, and medications with minimal benefit given limited life expectancy or changed goals of care.

Step 3: Prioritize

The medication most likely to be causing harm should be deprescribed first. Patient preferences and concerns should be considered. One to two medications should be addressed per visit to avoid overwhelming the patient.

Step 4: Plan the Taper

Many medications require gradual tapering to avoid withdrawal or rebound. | Drug Class | Taper Strategy | Withdrawal/Rebound Risk |

Benzodiazepines should be reduced by 10 to 25% every one to two weeks. SSRIs and SNRIs should be tapered over weeks to months, with discontinuation syndrome being common with paroxetine and venlafaxine. Beta-blockers should be tapered to avoid rebound tachycardia and hypertension. Opioids should be reduced by 10% per week or month depending on duration of use. Proton pump inhibitors can be stepped down to an H2 blocker or half dose, then discontinued, with awareness that rebound hyperacidity may occur. Some medications can be stopped abruptly, including statins, vitamins, and certain supplements.

Step 5: Monitor and Follow Up

Follow-up should be scheduled within two to four weeks to assess for withdrawal effects, return of symptoms, or improvement. Patient function, symptom burden, and medication adherence should be reassessed. Clinicians should be prepared to restart a medication if the condition recurs or the patient experiences significant decline.

Evidence-Based Deprescribing Guidelines

Proton Pump Inhibitors

Long-term PPI use is appropriate only for Barrett esophagus, severe erosive esophagitis (LA grade C/D), or ongoing NSAID use in high-risk patients. A trial of dose reduction or discontinuation is appropriate after four to eight weeks for uncomplicated GERD or empiric treatment.

Antipsychotics for Behavioral Symptoms of Dementia

The need for antipsychotics should be reassessed every three months. Gradual taper should be attempted after three to six months of behavioral stability. Non-pharmacologic approaches should be optimized before and during taper.

Statins in Limited Life Expectancy

Deprescribing should be considered when life expectancy is less than one to two years or when the patient shifts to comfort-focused goals. The number needed to treat increases substantially in very old, frail patients for primary prevention.

Cholinesterase Inhibitors

These agents provide modest benefit in mild-to-moderate dementia. Discontinuation should be considered in advanced dementia when no measurable benefit is observed. Tapering should be gradual, with monitoring for behavioral or cognitive decline over four to six weeks.

Shared Decision-Making

Patients and caregivers should be engaged in deprescribing conversations. The emotional attachment some patients have to their medications should be acknowledged. Deprescribing should be framed as a positive, proactive step: "optimizing your medications" rather than "taking things away." Written instructions and a clear plan for each change should be provided. Decision aids such as the Bruyere deprescribing algorithms should be used when available.

Systems-Level Strategies

Medication reconciliation should be implemented at every transition of care. Electronic health record alerts for Beers Criteria medications and drug interactions should be used. Clinical pharmacist collaboration for comprehensive medication reviews is valuable. Deprescribing should be established as a standing agenda item in geriatric care and chronic disease management visits.

Clinical Pearls

Every medication added should have a clear indication, a planned duration, and a documented discussion of risks and benefits. Prescribing cascades are one of the most common and preventable causes of polypharmacy; always ask "Could this new symptom be a drug side effect?" before prescribing another medication. Deprescribing one medication at a time allows attribution of any changes in symptoms to a specific intervention. The best time to deprescribe is during goals-of-care conversations, transitions of care, and after hospitalizations. Frailty, falls, and cognitive decline should prompt an urgent, thorough medication review.

References

1. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
2. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 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. Eur Geriatr Med. 2023;14(4):625-632.
4. Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations. Eur J Intern Med. 2017;38:8-17.

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