Polypharmacy prescribing guidance - draft: consultation

A medication review should be considered for those who experience or are at risk of falls. This may include modification/ reduction/ withdrawal, as part of a multifactorial prevention strategy. People on psychotropic medications should have their medication discontinued if possible to reduce risk of falling.

Strong recommendation

Medication reviews to reduce risk of falls should be conducted by a health-care provider with the appropriate knowledge and skills, such as a pharmacist, prescriber, or specialist.

Strong recommendation

Medication reviews should be part of multifactorial risk assessment and individual care plan.

Conditional recommendation

A medication review should be undertaken during transitions of care (admission, transfer, discharge), after a fall, when there is a significant change in condition; and when new medications are prescribed, with the aim to monitor medications with side effects known to contribute to risk of falls.

Conditional recommendation

1

A medicine review undertaken by a pharmacist can have a significant reduction on adverse drug events.

Strong recommendation

2

A medicine review undertaken by a pharmacist may help reduce the risk of falls.

Conditional recommendation

Medication review to identify medication-related problems in those receiving care at home

Healthcare professionals (HCP) and people over 65 years with frailty might want to discuss the importance of a medication review at least annually (regardless of the level of frailty).

Good practice point

Our recommendations

HCPs and people over 65 years with frailty might want to discuss the importance of the investigation of falls in the last 12 months.

Good practice point

Our recommendations

Person-centred medication review that recommends stopping inappropriate medication

HCPs and people over 65 years with frailty might want to discuss the 7-Steps process; including reviewing the medication of all older people for the purpose of potentially discontinuing, particularly in those vulnerable to adverse effects.

Conditional recommendation

Our recommendations

Prescribers should ensure there is a valid clinical indication for current medication, and consider deprescribing corresponding medicines, where appropriate.

Good practice point

Our recommendations

Prescribers and older people with frailty should discuss reducing or stopping a medication that is no longer clinically appropriate or has more harms than benefits.

Conditional recommendation

Our recommendations

Prescribers should consider discontinuing medication when appropriate, where there is a narrow window of benefit and evidence of potential harms, especially for sedative and antipsychotic medications.

Good practice point

Our recommendations

Prescribers should follow the 7-Steps process to undertake holistic medication reviews.

Strong recommendation

Our recommendations

Multidimensional interventions

Medication review may identify the need for additional medications. It is important to take a person-centred approach to ensure that medicines that are needed for symptomatic control or prevention are considered where appropriate.

Good practice point

Healthcare professionals (HCP) and older people with frailty might want to discuss the following regarding diabetes medication:

Strict avoidance of both hypoglycaemia (defined as <4.0 mmol/L) and osmotic symptoms (usually seen when glucose levels are greater than 15 mmol/L) should be a major goal of care for the frail older inpatient.

Good practice point

A higher glucose range should be considered by the care team in people with moderate to severe frailty or those with limited life expectancy.

Good practice point

The need for glycaemic control to be less rigid for frail older adults with chronic kidney disease: an HbA1c range of 59-69mmol/mol (7.5-8.5%), due to an increased risk of hypoglycaemia. Avoid tight glycaemic control (Hba1c <42mmol/mol (6%)).

Good practice point

Higher HbA1c of >69 mmol/mol (>8.5%) has been shown to be independently associated with poor muscle quality, which may lead to sarcopenia.

Good practice point

To review medication regimen post discharge, at home, or in a care facility.

Good practice point

Antihypertensive medications can reduce the risk of mortality, stroke, and heart failure in older adults. Because biological rather than chronological age can determine tolerability of, and likely benefit from medications, these individuals should not be denied treatment, or have it withdrawn simply on the basis of their chronological age. A person-centred approach should be considered.

Good Practice Point

Prescribers and people over 65 years of age with frailty might want to discuss the tolerability of, and benefits from, antihypertensive medication taking into consideration a person’s level of frailty, and independence.

Good Practice Point

A general treatment target of systolic blood pressure (SBP) below 140 mmHg, and diastolic blood pressure (DBP) below 80 mmHg is recommended for adults under 80 years with or without T2DM. For those over 65 years of age with frailty, this might not be achievable. While a higher target is acceptable, if lower blood pressure is sought, a slower timeline for reductions will be required in frail old or very old patients; it is important to recognise that this might not be achievable.

Conditional recommendation

BP targets should be balanced with the greater risk of harms, falls and acute kidney injury.

Good Practice Point

Prescribers and older people with frailty might want to discuss reducing or stopping a statin because the evidence does not indicate:

Reduction in morbidity/mortality in primary prevention

A change in the frequency of admission to long-term care, or reduced frequency of admission to hospital

Good practice point

Prescribers and older people with frailty may wish to discuss what effect taking a statin has on treatment burden, or quality of life. Within the polypharmacy manage medicines app prescribers and patients may wish to use shared decision-making tools, such as NNT charts or gates plots to help visualise potential magnitude of benefit of medication for this intervention.

Good practice point

Antidepressants should only be started if non-pharmacological interventions are insufficient due to lack of evidence of benefit and increased side effects.

Conditional recommendation

If antidepressants are started for frail older adults over 65 years, the person should be reassessed after 8-12 weeks due to lack of evidence of benefit and increased risk of side effects.

Conditional recommendation

Prescribers and people over 65 years with frailty and Alzheimer’s dementia should discuss the benefits of taking AChEIs (fewer deaths and cognitive benefits), compared to the risk of adverse GI and neurological effects (agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, dizziness).

Conditional recommendation

The risks and benefits of deprescribing AChEIs for Alzheimer’s dementia should be considered carefully. Stopping established treatment with may lead to loss of cognition or function which may not be regained if the medication is restarted.

Conditional recommendation

Prescribers and people over 65 years with frailty should balance the limited benefits of prescribing anticonvulsants for agitation and aggressive behaviour in people with Alzheimer’s disease against the considerable neurological adverse effects (agitation, tremor, confusion, depression, aggression, vertigo, abnormal gait, dizziness). The evidence for the use of anticonvulsants to reduce agitation and aggressive behaviour in people with Alzheimer’s disease is limited.

Conditional recommendation

Prescribers and people over 65 years with frailty should be cautious when considering the prescription of antipsychotic medication for stress and distress in dementia. They have a considerable number of adverse effects, particularly neurological, cardiovascular and metabolic. There is an increased risk of death for those over 65 years on these medications. The evidence for the use of antipsychotic medication in stress and distress in dementia is limited.

Conditional recommendation

People taking antidepressants, anticonvulsants or antipsychotics should have the prescribing of these medicines reviewed regularly.

Conditional recommendation

Prescribers should practice caution when prescribing medicines with ACB, prescribing only the minimum needed, especially for older adults, people with frailty, or people with complex multimorbidities. This is due to the association between ACB and mortality and increased risk of cognitive impairment, dementia, and delirium.

Strong recommendation

A person-centred approach should be taken when assessing the impact of harm of anticholinergic medication and the benefits when discontinuing anticholinergic drugs.

Strong recommendation

Prescribers should carefully consider if the benefits of prescribing a drug with ACB are greater than the risks

Conditional recommendation

Prescribers might want to consider minimising prescribing of drugs with ACB as part of assessment of falls risk for those people with the highest level of ACB (e.g. ACBS⩾4), which might be indicative of the greatest risk of falls

Conditional recommendation

There is some evidence that a pharmacist undertaking patient medication review and then feeding back to the prescriber can lead to a significant reduction in ACB.

Conditional recommendation

In patients with dementia, perform a medication review to minimise medicines that may adversely affect cognitive function. Avoid prescribing of anticholinergics with acetylcholinesterase inhibitors. As part of the review, a MMSE may be helpful to assess impact of medication.

Strong recommendation