Medicines have made a significant contribution to the health of the population and their use is on the rise (Royal Pharmaceutical Society (RPS), 2019). This increase is escalating concerns about polypharmacy, which is a challenge for general practice and primary care (Guthrie et al, 2015; Swinglehurst and Fudge, 2017).
Polypharmacy is associated with increasing age, the presence of multi-morbidities, and a culture of single condition, guideline-based prescribing (Burt et al, 2018; Slater et al, 2018). Polypharmacy is also associated with obesity and lower wealth, and its prevalence is likely to become more pronounced as the obesity epidemic continues and the gap in UK health inequalities widens (Slater et al, 2018). The Scottish Government Polypharmacy Model of Care Group (2018) has highlighted the need to address polypharmacy management as a public health issue, because multi-morbidities affect a broader population than the older community alone. They pointed out that 29% of patients with multi-morbidities are under the age of 65 and come from the most deprived communities (Scottish Government Polypharmacy Model of Care Group, 2018).
Polypharmacy is often clinically indicated and beneficial in specific conditions (Cadogan et al, 2016). However, polypharmacy can be problematic when the risk of harm to the patient outweighs the benefits of treatment (Archer 2018). Polypharmacy is associated with adverse outcomes, including adverse drug reactions (ADRSs), falls, increased length of stay in hospital, and mortality (Masnoon et al, 2017).
This article will discuss some of the challenges associated with polypharmacy. Definitions of the term will be discussed, including appropriate and problematic polypharmacy. Medication reviews and deprescribing will be considered, alongside proposals in the NHS Long Term Plan (NHS, 2019) to improve medicine safety in primary care.
Defining polypharmacy
One of the challenges in discussing polypharmacy, and the related medication safety implications, is that the term lacks a universally accepted definition (Cadogan et al, 2016). The term ‘polypharmacy’ first appeared in medical literature more than 150 years ago, and originally referred to issues associated with the consumption of multiple drugs and excessive drug use (Mortazavi et al, 2016). Polypharmacy is commonly defined as the prescribing of multiple medicines (Cadogan et al, 2016). It is typically measured using numerical counts (five or more medications) or numerical counts that incorporate a duration of therapy (the use of five to nine medications for 90 days or more) (Masnoon et al, 2017). The problem for prescribers is that there is no agreed safe limit for the number of drugs taken daily (O'Mahony and Curtin, 2018). However, drug-related problems, such as ADRs, high-risk prescribing, medication errors, and poor adherence to treatment, increase with the number of medicines prescribed (Duncan et al, 2019).
The term polypharmacy can also have a dual meaning – it can refer to the prescribing of ‘many drugs’ or ‘too many drugs’ (Cadogan et al, 2016). The term ‘too many drugs’ has negative connotations, and polypharmacy is often viewed negatively and seen as inappropriate drug therapy (Cadogan et al, 2016). The term ‘inappropriate medication’ describes the use of medications where the potential risks outweigh the potential benefits. This includes medications which present a high risk of harm, as well as medications that are ineffective or unnecessary (Reeve et al, 2017).
Cadogan et al (2016) contended that polypharmacy should be interpreted as the prescribing of multiple medicines; however, rather than using a numerical count and quantifying the term, more emphasis should be placed on qualifying the term. This should be based on whether the combination of medicines is clinically appropriate for the individual patient.
Appropriate polypharmacy
The notion of ‘appropriate polypharmacy’ recognises that patients can benefit from taking a number of medications, provided that prescribing reflects the clinical needs of the patient and is evidence-based (Cadogan et al, 2016).
The term ‘appropriate polypharmacy’ emerged from a report published by The King's Fund and is defined as ‘prescribing for an individual with complex or multiple conditions where medicines use has been optimised, and prescribing is in accordance with best evidence’ (Duerden et al, 2013). ‘Medicines optimisation’ is an umbrella term for all aspects of the selection, procurement, delivery, prescription, administration, and review of medicines (Duerden and Payne, 2015). However, from a clinical perspective, understanding the patient experience and patient engagement are central to medicine optimisation and achieving appropriate polypharmacy.
Patient experience includes relational elements, such as empathic two-way communication, shared decision-making, respect for patient preferences, and the provision of clear information (Doyle et al, 2013). These relational elements are important if patients are to become more involved in decision-making and better informed so that they can have greater ownership of their medicines (Doyle et al, 2013).
While The King's Fund definition of appropriate polypharmacy is helpful, a measure of clinically appropriate polypharmacy would be beneficial for clinical practice. Burt et al (2018) argued that there is a need for a measure of polypharmacy that considers both the number of medicines someone is prescribed, and whether the medicines are clinically appropriate.
To develop a valid and reliable means of measuring polypharmacy that takes account of clinical appropriateness, Burt et al (2018) carried out a systematic review of the literature and identified existing approaches to defining and measuring appropriate polypharmacy. They carried out an expert consensus study which involved a panel of ten clinical experts reviewing the identified indicators. This resulted in the development of a short but comprehensive list of 12 indicators (Table 1) relevant to assess prescribing appropriateness in a patient with polypharmacy.
Table 1. Indicators suitable to assess prescribing appropriateness in a patient with polypharmacy
| For this specific drug: |
|---|
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The indicators are a helpful guide to prescribing appropriateness, but Burt et al (2018) acknowledged that further work was necessary to explore the acceptability and use of the indicators in clinical practice.
Problematic polypharmacy
A report from The Kings' Fund (Duerden, 2013) differentiated between appropriate polypharmacy and problematic polypharmacy, which arises when ‘multiple medicines are prescribed inappropriately, or where the intended benefit of the medication is not realised’. Patients at the highest risk of inappropriate polypharmacy are those with the greatest frailty, taking the most drugs, and on high-risk medicines.
Polypharmacy guidance published by the Scottish Government Polypharmacy Model of Care Group (2018) listed high-risk medicines that were first identified in a study carried out by Pirmohamed et al (2004) into the burden of ADRs on hospital admissions. The study acknowledged that these drugs had proven benefits for patients, but they also presented a potential harm (Pirmohamed et al, 2004).
The challenge of achieving appropriate polypharmacy
Achieving appropriate polypharmacy is not straightforward, and there are considerable challenges in enabling its practical use by practitioners (Cadogan et al, 2016). An important first step is being vigilant about the key aspects of safer prescribing to minimise the risks of inappropriate polypharmacy (Duerden and Payne, 2015). This includes:
- Having an up-to-date knowledge of therapeutics, and particularly the drugs regularly prescribed, including their side effects and interactions
- Having all the information about the patient's health before prescribing, including comorbidities and allergies
- Checking computerised alerts to ensure that important interactions or drug allergies are not missed
- Sometimes the risks of prescribing outweigh the benefits, therefore carefully reflecting on the need to prescribe a particular drug is important
- Ensure that patients have laboratory test monitoring as required for the drugs they are taking, and are followed up at appropriate intervals
- Involve patients in prescribing decisions, and ensure they have the information required to take their medicines as prescribed, to recognise important side-effects and that they know when to return for monitoring and review.
Medication review
Guidance published by the Royal Pharmaceutical Society (2019) and endorsed by the Royal College of Nursing reminded prescribers of the need to address polypharmacy directly with patients under their care. Undertaking structured medication reviews is one way to address issues with polypharmacy and enhance the management of patients on multiple medicines (Duerden and Payne, 2015).
Medication reviews can be conducted by a range of health professionals such as nurses, doctors and pharmacists, provided they have the appropriate knowledge, skills, and experience (Morris, 2013). Burt et al (2018) contended that regular medication reviews are of particular importance for patients with polypharmacy, and without access to regular reviews, patients are at greater risk of harm. However, knowing which patients to target for a medication review is also an important consideration. Following a comprehensive review, the Scottish Government Polypharmacy Model of Care Group (2018) published a set of criteria that are helpful in prioritising patients who may benefit the most from a polypharmacy review (Table 2). The National Institute for Health and Care Excellence (NICE) (2015) defined a structured medication review as ‘a critical examination of a person's medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems, and reducing waste’.
Table 2. Patients who should be prioritised for a medication review
| A | Aged 50 years and older and residents in care homes, regardless of the number of medicines prescribed |
| B | Approaching the end of their lives: adults of any age, approaching the end of their life due to any cause, are likely to have different medication needs, and risk versus benefit discussions will often differ from healthy adults with longer expected life spans – consider a frailty score |
| C | Prescribed 10 or more medicines (this will identify those from deprived communities where the average age is lower when taking 10 or more medications) |
| D | On high-risk medications, regardless of the number of medications taken |
Medication reviews should consider a number of factors that include ‘clinical efficacy, risk/benefit ratio of the treatment, potential for drug interactions, adverse effects, drug monitoring, and patient adherence’ (Duerden and Payne, 2015: 40). To guide the process of reviewing medicines, NICE (2015) set out the key components of a structured medication review. Guidance from the Scottish Government Polypharmacy Model of Care Group (2018) also included a framework for medicines reviews that involved a structured, seven-step approach. The guidance is comprehensive and particularly helpful for prescribers. Avery (2019) commended the guidance for its strong focus on what matters to individual patients, and its emphasis on empowerment and support for patients in their decision-making around medicines.
Deprescribing
The Scottish Government Polypharmacy Model of Care Group (2018) suggested that one benefit of a holistic polypharmacy review is it can result in deprescribing.
Deprescribing has been defined as:
‘[T]he process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes.’
Dose reduction and changing to safer medications are also considered deprescribing strategies (Reeve et al, 2017). The deprescribing process can be applied in practice using a five-step approach (Table 3).
Table 3. A five-step approach to deprescribing
| Step 1 | Consider all medications currently taken and the indication for each medication |
| Step 2 | Evaluate the overall risk of medication-induced harm in an individual person |
| Step 3 | Assess each medication for its potential to be deprescribed |
| Step 4 | Sort medications by the order of priority to deprescribe |
| Step 5 | Implement and monitor a deprescribing regimen |
Numerous studies of polypharmacy or deprescribing have shown that interventions by pharmacists, doctors, and multidisciplinary teams can lead to modest reductions in the number of medicines that patients take, and the prevalence of potentially inappropriate prescribing (Avery, 2019). Research on the clinical outcomes of deprescribing is growing and overall, it appears to be safe (Avery, 2019). Duerden and Payne (2015) pointed out that during a medication review, the potential to deprescribe should not be overlooked. However, Avery (2019) highlighted the importance of recognising that deprescribing is a complex process that demands careful judgement to ensure that the risk and benefits of withdrawing medicines are balanced. Consequently, it is important to find ways of ensuring that sufficient time is given to medication reviews and that a discussion about medicines does not get squeezed into the final minutes of a consultation (Duerden and Payne, 2015).
This is important in the light of findings from a recent study (Duncan et al, 2019) that explored GP and pharmacist perspectives on conducting medication reviews in general practice. Duncan et al (2019) reported that medication reviews were often undertaken during consultations that also dealt with other problems:
‘For some GPs medication reviews were done in the quickest way possible to say that it was done, reflecting time constraints, and competing priorities.’
Furthermore, findings from the study indicated that GPs and pharmacists recognised the importance of involving patients in medication reviews; however, in reality, because of workload pressures, reviews were done quickly with minimal patient participation or they were conducted outside the consultation with no patient involvement.
Challenges in optimising polypharmacy
Medication reviews are time consuming and benefits are unlikely to be achieved in the short consultations typical of general practice appointments in the UK. Investment is required to enable health professionals to do this work and additional investment in primary care services was proposed in the NHS Long Term Plan (Avery, 2019; NHS, 2019). A key component of the plan is the development of primary care networks, which will bring general practices together to work at scale. The networks will be a key vehicle for providing a wider range of services to patients involving a wider set of staff roles (Baird, 2019). It is proposed that some of the extra funding promised in the plan will be used to substantially increase the number of clinical pharmacists, who will take on an expanded role in local primary care networks. A key focus of their work will involve structured medication reviews, improving medicine safety and advising on the potential for stopping or reducing medicines (NHS England, 2019).
The Royal Pharmaceutical Society (2019) pointed out that taking action to address the problems caused by polypharmacy is considered everyone's responsibility. The scale of the problem will not be addressed by relying on any one health profession to conduct medication reviews. Robinson (2015) highlighted the potential for collaborative working between nurses and pharmacists in primary care. These professionals bring different knowledge and skills to the management of patients, and by combining their expertise, there is the potential to improve care. However, designing and implementing systems to make this happen is reliant on funding and an adequate workforce. Medicines optimisation in polypharmacy may also require specific education and training for health professionals (Duerden and Payne, 2015).
GPNs recognise the importance of medical reviews and how deprescribing can be a significant role in patient care
The proposals for an increased workforce and more funding in the NHS Long Term Plan (NHS, 2019) may provide the solution; however, it remains to be seen whether the planned transformation of primary care will come to fruition. There is scepticism regarding the management of workforce shortages, reductions in funding for continuing professional development, and a workforce implementation plan has not been published (Wickware, 2019). Being vigilant and consistently reflecting on safe practice is a key responsibility for prescribers; however, both individual prescribers and the systems in which they work are accountable for improving safe medicine use in polypharmacy, but these accountabilities need to be balanced (Aveling et al, 2016).
For general practice nurses
Nurses working in general practice who care for patients with polypharmacy can play an important role in identifying issues related to the use of multiple medicines. This includes nurses with prescribing authority but equally nurses who are not prescribers have a role in communicating patients' needs and concerns about medicines to prescribing colleagues. Nurses frequently witness the unacceptable treatment burden associated with taking multiple medicines (Naughton and Hayes, 2017). The application of a number of single disease-specific guidelines in patients who have comorbidities (Marengoni and Onder, 2015) can result in complex drug regimens that may include harmful combinations of drugs (Dumbreck et al, 2015). Asking patients about their medicines, and listening to any concerns they may have is important to identify problems with treatment so the best way forward can be negotiated (Kaufman, 2016).
It is suggested that nurses tend to leave decisions about medicines and deprescribing to other members of the multidisciplinary team, and they may not recognise the important observations and insights they can contribute to inform a deprescribing pathway (Naughton and Hayes, 2017). Multidisciplinary interventions are observed as the most effective at reducing polypharmacy and inappropriate medication use, and many patients are comfortable with the involvement of a nurse or pharmacist in the deprescribing process (Reeve et al, 2017). Therefore, the involvement of both professions is important in enhancing deprescribing (Reeve et al, 2017) and managing polypharmacy.
Conclusion
The increasing use of medicines is escalating concerns about polypharmacy, which is a challenge for primary care. Undertaking structured medication reviews is a process that can be used to determine whether polypharmacy is appropriate or problematic, and offers the opportunity to deprescribe. However, undertaking medication reviews is a time consuming and complex process. Investment is needed to ensure an adequate primary care workforce is available with the appropriate knowledge and skills to address polypharmacy and medicine optimisation.
The NHS Long Term Plan (NHS, 2019) promised investment, but it remains to be seen whether the aspirations in the plan will be realised. Both individual prescribers and the systems in which they work are accountable for improving safe medicines use in polypharmacy.
KEY POINTS
- Polypharmacy is defined as the prescription of multiple medicines but emphasis should also be placed on whether the combination of medicines is clinically appropriate for the individual patient
- Polypharmacy is associated with increasing age, the presence of multi-morbidities, a culture of single condition guideline-based prescribing, obesity, and lower wealth
- Undertaking structured medication reviews and deprescribing are considered important strategies in managing polypharmacy and enhancing the care of patients on multiple medicines
- Undertaking structured medication reviews and deprescribing is time consuming and complex, and requires investment if the benefits are to be realised
- Increased investment to transform primary care services and address medication safety is promised as part of the NHS Long Term Plan, but workforce shortages and funding cuts for continuing professional development may hinder its implementation
- It is important that individual prescribers are vigilant about safe practice in prescribing to minimise the risks of inappropriate polypharmacy, but that the systems in which they work are also accountable