Residency · Residency · Internal Medicine

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

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

• 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

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

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.

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