Polypharmacy

•    Defined as use of ≥5 medications, though can also refer to inappropriate or unnecessary use regardless of number.

•    Problematic polypharmacy:

o    When the potential harm outweighs benefit

o    Contributes to medication-related morbidity and hospital admissions

STOPP/START Criteria

STOPP (Screening Tool of Older Persons’ Prescriptions)

•    Identifies potentially inappropriate medications in older adults

•    Examples:

o    Long-term benzodiazepines → increased risk of falls, cognitive impairment

o    NSAIDs in patients with heart failure or chronic kidney disease

o    Anticholinergics in patients with dementia

START (Screening Tool to Alert doctors to Right Treatment)

•    Identifies beneficial medications omitted from a patient’s regimen

•    Examples:

o    Statins in patients with known vascular disease

o    Bisphosphonates in osteoporosis with fracture risk

o    ACE inhibitors in heart failure

High-Risk Medications

•    NSAIDs

o    GI bleeding, peptic ulcer disease

o    AKI, especially with concomitant ACE inhibitors ("triple whammy" with diuretics)

o    Fluid retention, worsening heart failure

•    Sedatives (e.g., benzodiazepines, z-drugs)

o    Falls, fractures

o    Confusion, cognitive decline

o    Daytime sedation, dependence

•    Anticholinergics

o    Delirium, confusion

o    Urinary retention

o    Constipation

o    Worsening glaucoma

•    Hypoglycaemics

o    Risk of hypoglycaemia, particularly sulfonylureas in frail older adults

•    Antihypertensives

o    Postural hypotension → falls

o    Over-treatment risk if strict BP targets

Risks of Polypharmacy

•    Falls and fractures

o    Often multifactorial; medications are a major contributor

•    Delirium

o    Frequently precipitated by sedatives, anticholinergics, polypharmacy

•    Functional decline

o    Reduced mobility, reduced independence

•    Medication cascade

o    New medications prescribed to treat side effects of others

Deprescribing

•    Process of systematic medication review and withdrawal, guided by:

o    Current evidence

o    Goals of care

o    Functional and cognitive status

o    Patient and carer preferences

Steps

1.    Identify medications with no clear indication

2.    Assess benefit-risk balance

3.    Prioritise stopping drugs most likely to cause harm

4.    Taper slowly if required (e.g., steroids, benzodiazepines)

5.    Monitor for withdrawal effects or symptom recurrence

Extra Revision Pearls

•    Anticholinergic burden scales can help quantify cumulative risk

•    Always involve patients in shared decision-making — consider goals (e.g., quality of life vs disease prevention)

•    Regular medication review recommended at least annually in older adults

•    Check for "prescribing cascades" — e.g., anticholinergic for incontinence causing delirium, then antipsychotic started unnecessarily