• 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 (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
o GI bleeding, peptic ulcer disease
o AKI, especially with concomitant ACE inhibitors ("triple whammy" with diuretics)
o Fluid retention, worsening heart failure
o Falls, fractures
o Confusion, cognitive decline
o Daytime sedation, dependence
o Delirium, confusion
o Urinary retention
o Constipation
o Worsening glaucoma
o Risk of hypoglycaemia, particularly sulfonylureas in frail older adults
o Postural hypotension → falls
o Over-treatment risk if strict BP targets
• 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
• 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
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
