Reducing harm from polypharmacy in older people

Reducing harm

from polypharmacy

in older people

Effectiveness Matters is a summary of reliable research evidence

about the effects of important interventions for practitioners and

decision makers in the NHS and public health. This issue was

produced by CRD in collaboration with the Yorkshire and Humber

AHSN Improvement Academy and Connected Yorkshire, part of

Connected Health Cities. Effectiveness Matters is extensively

peer reviewed.

August 2017

EffectivenessMatters

▀ Polypharmacy is common

among older people; it can

increase the risk of adverse drug

reactions and interactions, as

well as reduce compliance and

adherence

▀ Positive (but inconsistent) effects

of deprescribing interventions

have been observed

▀ Patient and practitioner decisions

about stopping medications are

influenced by social influences,

expected consequences, and

factors such as consultation

length

▀ Practitioners said their own

knowledge and skills, plus beliefs

about the capabilities of patients

could influence their decisions

▀ Patients said their emotions,

treatment goals, and willingness

to experiment could also

influence their decisions

▀ A multifaceted person-centred

coordinated care approach,

as advocated in NICE clinical

guidelines and by the ‘House of

Care’ model, should underpin

efforts to reduce harm from

polypharmacy in older people

Background

Polypharmacy in older people

The use of multiple medications is often referred to

as polypharmacy.

Epidemiological evidence shows

that as people age they develop a greater number of

conditions (multimorbidity), with a related increase in

polypharmacy.

NICE guidance on medicines optimisation distinguishes

between “appropriate polypharmacy” (where medicines

use has been optimised and prescribed according

to best evidence) and “problematic polypharmacy”

(where the prescribing of multiple medicines is either

inappropriate or sub-optimal).

This bulletin will focus

on approaches that aim to reduce problematic forms of

polypharmacy.

Scale of the problem

During the period 2005-2015, 60.4% of all prescription

items in England were dispensed to patients aged 60

and over,

and approximately one in ve prescriptions

to older people living in their own homes may be

inappropriate.

4,5

Among older people in care homes, up

to 91%, 74%, and 65% of residents take more than ve,

nine, and ten medications, respectively.

Consequences of polypharmacy in older people

Polypharmacy may increase risk of adverse drug

reactions, drug-drug and drug-disease interactions, and

reduce compliance and adherence (due to complexity of

drug regimens).

NICE guideline evidence suggests that polypharmacy

(ve or more drugs) is associated with increased risks

of unplanned hospital admission and mortality, with

even greater risks at higher levels of polypharmacy.

Polypharmacy (when dened as ≥13 drugs) is

associated with increased risk of admission to a care

home. No evidence was identied on how polypharmacy

inuences health-related quality of life.

Systematic review evidence has shown polypharmacy

to be associated with falls among both nursing home

residents and community-dwelling older people.

However, the potentially harmful consequences of

polypharmacy are difcult to estimate precisely.

Identifying people at risk of harm

NICE guidelines describe people who may benet

from an approach to care that takes account of

multimorbidity. This includes adults who are prescribed

15 or more regular medicines, or adults prescribed

fewer than 15 regular medicines who are at particular

risk of adverse events.

Additional reasons for re-appraising an older person’s

medication needs might include: emergence of adverse

drug effects; onset of dementia or end-stage disease;

loss of symptom control; ongoing use of high risk

medications (alone or in combination); newly available

evidence on a medication; and concerns around

intolerance or non-adherence.

Within the wider population of older adults, subgroups

at particular risk of harm from polypharmacy could

include people recently admitted to hospital, care home

residents, and those living with frailty.

Identifying frailty among older adults with

polypharmacy

NICE guidelines recommend assessing people with

multimorbidity for frailty.

Frailty can be conceptualised

and measured in a number of ways; up-to-date

information on how to recognise and manage frailty in

primary care in general is available elsewhere.

Few published studies report the relationship between

measures of frailty and subsequent inappropriate

medication use.

One recent retrospective database

study reported a signicant correlation between Frailty

Index (FI) score and both potentially inappropriate

prescribing (PIP) and adverse drug reactions (ADR) in

older hospitalised patients.

However, the use of FI

scores to reduce PIP and ADR has yet to be tested.

Evidence on interventions to reduce harm from

problematic polypharmacy

Multiple approaches to improve polypharmacy

have been proposed, including organisational (e.g.

medication review, specialist clinics, computerised

decision support, risk screening tools), professional

(e.g. educational programmes), nancial (e.g. incentive

schemes) and regulatory methods.

15,16

One Cochrane review found that complex, multi-

faceted pharmaceutical approaches for improving the

appropriate use of polypharmacy in older people led to

some benets in terms of Medication Appropriateness

Index scores and number of Beers medications (a list of

potentially inappropriate medications to be avoided in

older adults),

though evidence on hospital admissions

and medication-related problems was inconsistent.

15,16

A second Cochrane review concluded that interventions

to optimise prescribing for older people living in care

homes may lead to fewer days in hospital, a slower

decline in health-related quality of life, identication and

resolution of medication-related problems, and improved

medication appropriateness, but may make little or no

difference to adverse drug events or mortality.

Evidence on deprescribing approaches

While the Cochrane reviews evaluated prescribing

optimisation, other evaluations have focused solely on

deprescribing. This is the complex process needed to

ensure the safe and effective withdrawal (i.e. tapering or

stopping) of inappropriate medicines.

Deprescribing interventions can include: screening tools

or criteria (e.g. Beers criteria, STOPP/START tool),

specic medication- or population-specic guidelines,

or more structured frameworks for deprescribing (e.g.

Good Palliative-Geriatric Practice algorithm, CEASE

framework, The 7 Steps).

11,19,21

Several systematic reviews have evaluated the effects

of deprescribing interventions (including comprehensive

and drug-specic medication reviews, education

programmes for prescribers, and patient-specic

interventions) on the total number of prescribed or

inappropriate medications,

22-25

hospitalisation rates,

symptoms

26,27

and mortality.

22,28

While positive effects

were observed in many primary studies, reviews often

failed to draw denitive conclusions about the relative

effectiveness of different deprescribing approaches

due to the poor quality and high variability of research

evidence in this area.

In addition, interventions are often complex and it can

be unclear how best to organise and implement these to

achieve a reduction in inappropriate polypharmacy.

Evidence on barriers and enablers to

deprescribing

Three systematic reviews have synthesised qualitative

data on the perceived barriers and enablers to

deprescribing inappropriate medications in adults.

11,29-31

Much of this evidence focuses on the perceptions and

beliefs of primary care practitioners and older patients

(see online for details).

Factors identied by practitioners fell into the following

domains:

• Knowledge and skills (e.g. being unaware of

inappropriate prescribing; needing more education

in geriatric pharmacology;

11,29

lacking condence,

11,29

feeling insecure, overwhelmed or inadequately

prepared)

• Beliefs about the capabilities of others (e.g.

assuming that older patients lack health literacy or

don’t share information about their medicine intake)

• Beliefs about consequences (e.g. fears about the

possible risks of deprescribing)

11,29

• Environmental context and resources (e.g. lack

of time or remuneration;

11,29

the impact of multiple

disease guidelines;

lack of communication or clarity

about responsibilities among professional groups)

• Social inuences (e.g. patient reluctance;

professional attitudes favouring more rather than

less medication use)

11,29

Factors that might inuence a patient’s decision to

cease a medication included:

• Beliefs about consequences (e.g. perceived

effectiveness and side effects; hopes of future

benet; peace of mind from keeping medications;

scepticism about non-pharmacological

alternatives)

30,31

• Intentions (e.g. experimenting with certain

medications to understand the effect of stopping)

• Goals (e.g. prioritising treatments according to their

effects on survival, physical function, and symptom

relief)

• Environmental context and resources (e.g. lack of

consultation time, GP support or clear procedures;

dislike of medications;

30,31

distrust of the system;

perceived lack of generalist knowledge or

cooperation between specialists; concerns about

pharmaceutical industry inuence);

• Social inuences (e.g. perceived pressure from

family or health professionals;

the need for a

trusting relationship and good communication with

GP)

• Emotion (e.g. fear of worsening illness or withdrawal

reactions

)

Solutions proposed by GPs have included: relaxing

treatment targets, applying patient-centred and

patient education strategies, optimising medication

management processes and relying on IT system

support.

Implications for practitioners and

commissioners

While much of the research evidence on effectiveness is

heterogeneous and of relatively low quality, it suggests

that tools and strategies that promote appropriate

deprescribing need to be considered at both the level

of individual patient–prescriber encounters and the

systems of care.

11,29

The environmental and resource barriers identied by

patients and practitioners reect those identied in other

areas of integrated care. These include services being

focused on single condition guidelines,

insufcient

communication or coordination between professional

groups, and a lack of emotional/psychological support.

NHS England and its partners have responded to such

barriers by proposing the ‘House of Care’ model for

person-centred coordinated care (see gure 1).

Prescribers should be aware that deprescribing is

likely to be relevant to their own clinical practice and,

when done appropriately and carefully, can have

a positive and worthwhile impact. Where possible,

deprescribing methods should address prescribers’

information needs, including information about

previous prescribing decisions, and any known benet-

harm trade-offs for relevant medications or special

patient populations. NICE guideline on multimorbidity

specically recommends using its supporting database

of treatment effects

to inform medication reviews.

Polypharmacy guidance issued by NHS Scotland

also provides information on the efcacy of several

commonly prescribed medications.

This includes the

number of patients who would need to be treated with

each medication for one patient to benet on relevant

health outcomes. In addition, the NHS Business

Service Authority’s ePACT 2 includes a Polypharmacy

Figure 1.‘House of Care’ model illustrating the building blocks of high

quality person-centred coordinated care

Dashboard (incorporating a collection of polypharmacy-

related indicators), which is being rolled out across

England in the summer of 2017.

In line with existing recommendations,

37,38

deprescribing

should be patient-centred, incorporating shared

decision-making, informed patient consent, and

appropriate monitoring arrangements. Patient concerns

and beliefs about deprescribing can mirror those

of prescribers, so everyone involved in the clinical

consultation should be empowered to discuss openly

the available options, along with their possible benets

and harms. Where available, appropriate decision aids

may be used to support these discussions.

Both patients and clinicians have identied inter-

professional communication as an important inuence

on polypharmacy. NICE guidance recommends

that organisations consider a multidisciplinary team

approach to improve outcomes for people who have

long-term conditions and take multiple medicines.

This includes consideration of a structured medication

review for people taking multiple medicines, and use

of a screening tool such as STOPP/START to identify

potentially inappropriate medication in older people.

NICE guidance also recommends individualised

management plans for patients with multimorbidity

that take into account disease and treatment burden

(including the medicines they are taking), as well as

patient goals, values and priorities.

Implementation of such recommendations will require

professional awareness of the likely enablers and

barriers to success, alongside the fostering of a trusting,

patient-centred consultation style within a supportive

environment.

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