Introduction
Polypharmacy – the concurrent use of multiple medications – is increasingly common, particularly among older adults with multiple long-term conditions. While appropriate polypharmacy can be beneficial, problematic polypharmacy significantly increases the risk of adverse drug reactions (ADRs), falls, hospital admissions, and poor adherence. Mastering the principles of deprescribing elderly UKMLA candidates need is therefore a vital component of safe and effective patient care.
Deprescribing, the planned and supervised process of dose reduction or stopping of medication that might be causing harm or no longer providing benefit, is a core skill rooted in safe prescribing practices. This guide provides a structured 7-step approach to medication review and deprescribing in older adults, equipping you with the knowledge needed for UKMLA scenarios and real-world clinical practice. This complements the fundamental principles discussed in Prescribing Safely for the UKMLA & PSA.
Key Takeaways
Polypharmacy is Risky: The use of multiple medications (often defined as 5 or more) in elderly patients significantly increases the risk of adverse drug reactions (ADRs), falls, hospitalisation, and non-adherence.
Deprescribing is Essential: Actively reviewing and stopping inappropriate or unnecessary medications (deprescribing) is a key skill for improving patient safety and outcomes in older adults.
Use a Structured Approach: Employ a systematic process (like the 7 steps outlined) involving medication review, identifying targets, assessing risks/benefits, shared decision-making, and monitoring.
Prioritise High-Risk Medications: Be particularly vigilant about medications with high risks in the elderly, such as benzodiazepines, opioids, anticholinergics, NSAIDs, and drugs prone to causing postural hypotension.
Shared Decision-Making is Key: Involve the patient (and their family/carers) in the deprescribing process, explaining the rationale and agreeing on a plan together.
Why Deprescribing Elderly UKMLA Candidates Must Master
The aging population and increasing prevalence of multimorbidity mean that managing polypharmacy is a growing challenge in healthcare.
The Problem of Polypharmacy in Older Adults (Risks & Prevalence)
Elderly patients are more susceptible to ADRs due to physiological changes (pharmacokinetics and pharmacodynamics) and the sheer number of drugs often prescribed. Risks include:
Increased ADRs and drug-drug interactions.
Higher risk of falls (e.g., due to sedation, hypotension).
Cognitive impairment.
Reduced medication adherence.
Increased hospital admissions and healthcare costs.
Recognising and mitigating these risks through deprescribing is fundamental to patient safety, a core tenet relevant even when considering safeguarding vulnerable adults.
UKMLA Relevance (AKT Scenarios, CPSA Stations on Medication Review/Safety)
Both the AKT and CPSA components of the UKMLA assess your ability to manage medications safely, particularly in complex patients.
AKT: Scenarios might involve identifying potentially inappropriate medications (PIMs) in an elderly patient’s drug list, recognising ADRs linked to polypharmacy, or choosing the most appropriate medication change. Understanding these concepts is part of interpreting clinical data.
CPSA: Stations could require you to conduct a medication review for a simulated elderly patient, discuss stopping a medication using shared decision-making principles, or counsel a patient about potential side effects related to polypharmacy.
What is Deprescribing? Definition and Goals
Deprescribing is the planned, supervised process of reducing or stopping medications for which the potential harms outweigh the potential benefits within the context of an individual patient’s care goals, current level of functioning, life expectancy, values, and preferences.
The primary goals are to:
Reduce medication burden and complexity.
Minimise the risk of ADRs and drug interactions.
Improve patient adherence and quality of life.
Reduce the risk of falls, confusion, and hospitalisation.
Align medication use with current goals of care.
Understanding these concepts is clearly outlined in UK resources like the NHS Specialist Pharmacy Service (SPS) explanation.
The 7-Step Framework for Safe Deprescribing
A structured medication review is essential for effective deprescribing, often guided by national frameworks such as those recommended in NICE Guideline NG56 on Multimorbidity.
Step 1: Reconcile Medication List (Comprehensive & Accurate)
Action: Obtain the most accurate list possible of all medications the patient is currently taking. Include prescribed drugs, over-the-counter (OTC) medications, supplements, and herbal remedies.
Sources: Patient interview, GP records, hospital notes, pharmacy records, carer input.
Step 2: Review Indications & Goals of Care
Action: For each medication, ask: Why was it started? Is the original indication still present? Does it align with the patient’s current health status and goals of care (e.g., symptom control vs. long-term prevention)?
Step 3: Identify Potentially Inappropriate Medications (PIMs)
Action: Systematically screen the medication list for PIMs – drugs where risks may outweigh benefits in older adults.
Using Tools: Conceptual frameworks like the STOPP (Screening Tool of Older People’s Prescriptions) / START (Screening Tool to Alert doctors to Right Treatment) criteria can help identify common PIMs and prescribing omissions, although applying them formally requires specific training. Focus on understanding the principles.
High-Risk Classes: Be particularly alert for drug classes known to cause problems in the elderly (see detailed section below).
Step 4: Assess Risk vs. Benefit of Continuing Each PIM
Action: For each identified PIM, weigh the potential benefits of continuing against the potential harms (ADRs, interactions, burden).
Consider: Remaining life expectancy (will the patient live long enough to benefit from long-term prevention?), time until benefit for preventative drugs, risk of ADRs based on patient’s frailty and comorbidities, potential for withdrawal syndromes.
Step 5: Prioritise Medications for Deprescribing
Action: Identify which medication(s) offer the best opportunity for deprescribing first.
Prioritise: Drugs with the highest risk of harm, lowest likelihood of benefit, limited indications, or those contributing most to pill burden or complexity. Start with one or two changes at a time.
Step 6: Plan & Implement Withdrawal (Shared Decision Making)
Action: Develop a clear withdrawal plan in partnership with the patient and/or their carers.
Plan: Decide whether to stop abruptly or taper the dose gradually (essential for drugs with withdrawal potential, e.g., benzodiazepines, opioids, some antidepressants, beta-blockers). Provide clear instructions.
Shared Decision: Discuss the rationale for stopping, potential benefits (e.g., reduced side effects), and potential risks (e.g., withdrawal, symptom return). Agree on the plan together.
Step 7: Monitor, Follow-up & Document
Action: Closely monitor the patient after stopping or reducing a medication.
Monitor: Watch for withdrawal symptoms, return of the condition being treated, or improvement in ADRs (e.g., reduced confusion, fewer falls). Arrange follow-up (e.g., phone call, clinic visit).
Document: Clearly document the deprescribing decision, rationale, plan, and monitoring outcomes in the patient’s notes.
Communicate: Inform the GP, community pharmacy, and other relevant healthcare professionals of the changes made.
High-Risk Medications in the Elderly: Key Targets for Deprescribing
Certain drug classes require extra caution in older adults. Understanding these aligns with High Yield Pharmacology for UKMLA.
Benzodiazepines & Z-drugs (e.g., Diazepam, Zopiclone)
Risks: Sedation, confusion, increased falls/fracture risk, dependence, withdrawal syndromes.
Deprescribing: Often require slow tapering over weeks/months. Consider non-pharmacological approaches for insomnia/anxiety.
Opioids (e.g., Codeine, Morphine, Oxycodone)
Risks: Constipation (almost universal), sedation, confusion, respiratory depression, increased falls risk.
Deprescribing: Review indication regularly. Optimise non-opioid analgesia. Taper dose gradually if stopping chronic use. Proactive laxative prescribing is essential if continued.
Anticholinergics (e.g., Tricyclics, older Antihistamines, Oxybutynin)
Risks: Cognitive impairment/delirium, dry mouth, blurred vision, constipation, urinary retention. High anticholinergic burden (multiple drugs) is particularly problematic.
Deprescribing: Identify drugs with anticholinergic effects (many exist!). Switch to alternatives with lower burden where possible. Taper if necessary.
NSAIDs (e.g., Ibuprofen, Naproxen, Diclofenac)
Risks: GI bleeding/ulceration, acute kidney injury (AKI), fluid retention exacerbating heart failure, increased blood pressure.
Deprescribing: Avoid long-term use if possible. Use lowest effective dose for shortest duration. Consider alternatives (e.g., paracetamol). Co-prescribe PPI for GI protection if essential.
Drugs causing Postural Hypotension
Examples: Alpha-blockers (e.g., Tamsulosin, Doxazosin), Vasodilators (Nitrates, CCBs), some Antidepressants (TCAs, Trazodone), Diuretics.
Risks: Dizziness, falls, syncope.
Deprescribing: Review need for each agent. Consider dose reduction or switching. Advise patients on postural hypotension precautions (slow positional changes).
Table 1: High-Risk Drug Classes in the Elderly & Common ADRs
| Drug Class | Examples | Common High-Yield Risks in Elderly |
|---|---|---|
| Benzodiazepines / Z-drugs | Diazepam, Lorazepam, Zopiclone | Sedation, Confusion, Falls, Dependence |
| Opioids | Codeine, Tramadol, Morphine | Constipation, Sedation, Confusion, Falls, Resp. Depression |
| Anticholinergics | Amitriptyline, Chlorphenamine, Oxybutynin, Hyoscine | Cognitive Impairment, Dry Mouth, Constipation, Urinary Retention |
| NSAIDs | Ibuprofen, Naproxen, Diclofenac | GI Bleed, AKI, Fluid Retention (HF Exacerbation), Hypertension |
| Drugs Causing Postural Hypotension | Alpha-blockers, Nitrates, Diuretics, TCAs | Dizziness, Falls, Syncope |
Practical Tools and Resources for Deprescribing
While memorising lists isn’t essential, being aware of tools that guide deprescribing is useful:
STOPP/START Criteria: Widely used evidence-based criteria. STOPP lists PIMs to consider stopping, while START lists appropriate medications often omitted. Understanding the types of issues they highlight (e.g., drug-disease interactions, duplicate therapy) is valuable.
Beers Criteria: An American equivalent to STOPP/START, also listing PIMs for older adults.
Medication Appropriateness Index (MAI): A questionnaire-based tool assessing appropriateness based on indication, effectiveness, dosage, interactions, etc.
Putting It All Together: 2 UKMLA-Style Clinical Scenarios
Case 1: Medication Review for a Frail Nursing Home Resident
Vignette: You are reviewing Mrs. Higgins, an 88-year-old nursing home resident with dementia, osteoarthritis, hypertension, and insomnia. She takes Ramipril, Amlodipine, Paracetamol, Zopiclone (long-term), and Donepezil. She has had 2 falls in the last month and often seems drowsy during the day.
Deprescribing Process:
List: Confirm current meds.
Indications: All seem appropriate except long-term Zopiclone for insomnia. Goals are comfort, function, safety.
PIMs: Zopiclone (benzodiazepine receptor agonist) is a major falls/sedation risk. Amlodipine can cause postural hypotension/falls.
Risk/Benefit: Zopiclone’s risks (falls, sedation) likely outweigh benefits for sleep now. Amlodipine benefit for BP needs weighing against falls risk.
Prioritise: Target Zopiclone first.
Plan: Discuss with patient/family/GP about slowly tapering Zopiclone (e.g., reduce dose over several weeks) and exploring non-drug sleep strategies. Monitor BP and consider reducing Amlodipine if appropriate.
Monitor: Track falls, sedation levels, sleep quality, BP during taper. Document plan. This scenario involves principles relevant to General Practice Essentials for UKMLA.
Concise Shared Decision Script (Stopping Zopiclone):
“Mrs. Higgins (or relative), I’ve reviewed your medications. The Zopiclone sleeping tablet might be contributing to your recent falls and daytime drowsiness. While it helps sleep initially, long-term use in older adults carries risks.
I recommend we try gradually reducing and stopping it over a few weeks, while trying other ways to help your sleep. We’ll monitor you closely. How do you feel about trying this?”
Case 2: Post-Hospital Discharge Medication Reconciliation
Vignette: Mr. Khan, 75, is discharged after admission for delirium secondary to a UTI. His new discharge list includes Ciprofloxacin (7 days), Ramipril, Bisoprolol, Furosemide, Atorvastatin, Omeprazole, Amitriptyline (low dose, for pain), and Lorazepam (started inpatient for agitation).
Deprescribing Process:
List: Confirm discharge list vs. pre-admission meds.
Indications: Cipro course is finite. Lorazepam was for acute delirium (now resolved). Amitriptyline indication needs clarity (neuropathic pain? depression?). Others are long-term.
PIMs: Lorazepam (benzo – sedation, falls), Amitriptyline (TCA – anticholinergic, sedation, falls). Polypharmacy increases overall risk.
Risk/Benefit: Lorazepam has no ongoing indication. Amitriptyline risks need weighing against benefit for pain/mood.
Prioritise: Stop Lorazepam. Clarify/review Amitriptyline.
Plan: Advise immediate stop of Lorazepam (short inpatient course unlikely to need taper). Contact GP to clarify Amitriptyline indication/dose/necessity, suggesting review or switch to safer alternative if possible.
Monitor: Check for recurrent delirium/agitation off Lorazepam. Ensure GP follows up Amitriptyline. Document communication.
Table 2: The 7-Step Deprescribing Process Checklist
| Step | Key Action |
|---|---|
| 1. Reconcile List | Get accurate list of ALL current medications (inc. OTC/supplements). |
| 2. Review Indications/Goals | Why is each drug taken? Does it match current goals? |
| 3. Identify PIMs | Screen for drugs potentially inappropriate for elderly (use tools/knowledge). |
| 4. Assess Risk vs. Benefit | Weigh potential harms against benefits for each PIM in this patient. |
| 5. Prioritise for Deprescribing | Select 1-2 drugs to target first (highest risk/lowest benefit). |
| 6. Plan & Implement (Shared Decision) | Decide stop vs. taper. Agree plan with patient/carers. Give clear instructions. |
| 7. Monitor, Follow-up & Document | Watch for withdrawal/symptom return/ADR improvement. Follow up. Document & communicate. |
Frequently Asked Questions (FAQ) about Deprescribing in the Elderly
While there’s no single universal definition, polypharmacy is most commonly defined as the regular use of 5 or more medications. Some definitions use higher numbers (e.g., 10 or more for “major” polypharmacy) or focus on the appropriateness rather than just the number of drugs. For clinical purposes, using 5+ as a trigger to conduct a careful medication review is a reasonable starting point.
Stopping medication can indeed carry risks, such as withdrawal syndromes (e.g., from benzodiazepines, opioids, beta-blockers, antidepressants) or the return/worsening of the condition being treated. This is why deprescribing must be a planned, supervised process involving careful risk-benefit assessment, shared decision-making, a clear withdrawal plan (often gradual tapering), and close monitoring during and after the change. The potential risks of continuing an inappropriate medication must also be considered.
The prescribing cascade occurs when a new medication is prescribed to treat the side effects of another medication, often without recognising the side effect as drug-induced. For example, prescribing an anticholinergic for urinary symptoms caused by a cholinesterase inhibitor used for dementia, or prescribing laxatives for opioid-induced constipation (though this is often necessary). Identifying and interrupting these cascades by treating the initial side effect or stopping the culprit drug is a key goal of medication review.
STOPP/START criteria are evidence-based screening tools developed to help clinicians identify potentially inappropriate prescribing (STOPP – Screening Tool of Older People’s Prescriptions) and potential prescribing omissions (START – Screening Tool to Alert doctors to Right Treatment) in older adults. They list specific scenarios where certain drugs should generally be avoided (STOPP) or considered (START) based on diagnoses, interacting drugs, or physiological parameters. While useful guides, they require clinical judgement for individual application.
Patient (and carer) involvement through shared decision-making is absolutely crucial for successful deprescribing. Patients may be hesitant to stop medications they’ve taken for a long time or may fear symptom return. It’s essential to explore their beliefs and concerns, clearly explain the rationale for considering deprescribing (e.g., reducing side effects, falls risk), discuss the potential benefits and risks of stopping versus continuing, and agree on a plan together. This improves adherence to the plan and patient satisfaction.
Many medications that affect the central nervous system or cardiovascular system require gradual tapering to avoid withdrawal syndromes or rebound effects. Key examples include: benzodiazepines, opioids, antidepressants (especially SSRIs and SNRIs), beta-blockers, proton pump inhibitors (PPIs) (rebound hyperacidity), and long-term corticosteroids. The tapering schedule depends on the drug, dose, and duration of use, and should be individualised.
Yes, definitely. OTC medications (like NSAIDs, older antihistamines with anticholinergic effects, cough/cold remedies) and supplements (herbal remedies) can cause significant side effects and interact with prescribed drugs. It’s vital to ask specifically about their use during medication reconciliation, as patients often don’t consider them ‘real medicine’.
Pharmacists play a key role in identifying patients suitable for medication review, performing structured reviews (especially clinical pharmacists in primary care or hospitals), identifying PIMs and interactions, advising on withdrawal strategies, and counselling patients. Collaborative work between doctors, pharmacists, and nurses is essential for effective deprescribing.
Anticholinergic effects result from blocking the neurotransmitter acetylcholine. Many medications have these effects (e.g., older antihistamines, tricyclic antidepressants, some antipsychotics, bladder antispasmodics). In elderly patients, these effects are often exaggerated, leading to side effects like cognitive impairment (confusion, memory problems), delirium, dry mouth, blurred vision, constipation, and urinary retention. Accumulating anticholinergic burden from multiple drugs significantly increases these risks, including falls.
The NICE guideline NG56 on Multimorbidity provides key recommendations on structured medication reviews, considering polypharmacy, and using shared decision-making. NHS resources, such as those from the Specialist Pharmacy Service (SPS), offer practical guidance and explain the concepts within the UK healthcare context. Local NHS formularies and medicines management guidelines also often contain specific advice.
Conclusion
Tackling polypharmacy through structured medication review and safe deprescribing is a core competency for doctors caring for older adults. Mastering deprescribing elderly UKMLA principles involves recognising high-risk situations, applying a systematic 7-step approach, understanding the risks associated with specific drug classes, and prioritising shared decision-making with patients.
By integrating regular medication reviews into your practice and using a patient-centred approach, you can significantly reduce the burden of inappropriate polypharmacy, improve patient safety, enhance quality of life, and demonstrate key competencies required for the UKMLA and beyond.
Your Next Steps
Memorise the 7 Steps: Internalise the framework for structured medication review and deprescribing.
Learn High-Risk Drugs: Be able to identify common drug classes particularly problematic in the elderly (Table 1).
Practice Risk/Benefit Assessment: In clinical scenarios (real or simulated), practice weighing the pros and cons of continuing specific medications in frail older patients.
Develop Communication Skills: Practice explaining the rationale for deprescribing and engaging in shared decision-making with patients/carers.
Consult Guidelines: Familiarise yourself with the principles in NICE NG56 and resources like the SPS guidance.
