Resources to manage problematic polypharmacy

American Geriatrics Society Beers criteria

The 2023 Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults is a list of medicines that are either potentially inappropriate or should be used with caution in older people, including patients with specific health conditions or poor kidney function.

British Geriatric Society Comprehensive Geriatric Assessment Toolkit

This comprehensive geriatric assessment (CGA) toolkit for GPs and primary care professionals explains what CGA is, when to use it, and how to conduct it, including collaboration with social services. The toolkit also includes guides on specific medical issues affecting older patients, covering topics from bone health to end-of-life care.

CRIME criteria

The CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project makes prescribing recommendations for older complex patients. It targets those with limited life expectancy, functional or cognitive impairment, and age-related conditions like falls or malnutrition. The project focuses on managing diabetes, hypertension, heart failure, atrial fibrillation, and coronary heart disease in an older population.

Department of Health and Social Care: National Overprescribing review

The National Overprescribing review evaluates the prevalence of overprescribing in the NHS and offers recommendations for addressing this issue, particularly in primary care including medication reviews. It identifies the system and culture changes required to reduce overprescribing to make patient care better and safer, support the NHS, and reduce carbon emissions.

Health Improvement Scotland: Right Decision Service

The Right Decision Service offers polypharmacy guidance, insight and resources to support all healthcare professionals involved with the management of polypharmacy.

Health Innovation Network: polypharmacy

The Health Innovation Network polypharmacy programme is a national polypharmacy programme. It provides resources that enable healthcare professionals to identify and prioritise patients for shared decision-making structured medication reviews.

Medication appropriateness index

The medication appropriate index assesses the appropriateness of prescribing of medicines for elderly patients, using 10 criteria: indication, effectiveness, dose, correct directions, practical directions, drug-drug / drug-disease interactions, duplication, duration of therapy, cost comparison with alternatives. It is used in research studies rather than clinical practice. 

NHS England medicines optimisation: polypharmacy

The NHS England medicines optimisation polypharmacy opportunity focuses on prioritising and reviewing patients with problematic polypharmacy. It aims to do this through Structured Medication Reviews (SMRs), while promoting cultural and behavioural changes in prescribing practices.

SMRs are a key intervention to address problematic polypharmacy by prioritising and reviewing patients who are most likely to benefit.

Progress is tracked by the percentage of patients aged 75 and over on 10 or more medicines. It uses NHSBSA polypharmacy comparators at practice, ICB, regional and national level.

NHS Scotland: Polypharmacy guidance

This NHS Scotland Polypharmacy guidance (2018) provides patient centred guidance on preventing inappropriate polypharmacy using the 7 steps framework.

Key features include:

• Drug efficacy (NNT) tables: these summarise the clinical efficacy of common interventions.
• Harm reduction tools: these use cumulative toxicity and anticholinergic burden tools to reduce risks.
• Polypharmacy indicators: these standardise case finding, assess prevalence, and monitor outcomes.
• Patient app: these aid patients in shared decision-making about medicines.

NHS Wales: Polypharmacy in older people

This NHS Wales Polypharmacy in older people guide supports medicines optimisation in older patients who may have inappropriate polypharmacy.

It includes practical guides for stopping specific groups of medicines, such as:

• acid suppressants
• acetylcholinesterase inhibitors and memantine for dementia
• antidepressants
• antihypertensives
• antipsychotics for non-cognitive symptoms of dementia
• bisphosphonates
• benzodiazepines and Z-drugs
• gabapentinoids for neuropathic pain
• opioids for non-cancer pain
• oral corticosteroids
• antipsychotics for non-cognitive symptoms of dementia.

NICE: Medicines optimisation guideline

This NICE medicines optimisation guideline promotes medication reconciliation, medication review and use of patient decision aids to optimise safety and efficacy of medicines-related treatment.

NICE: Multimorbidity guidance

This NICE multimorbidity guideline focuses on optimising care for adults with multimorbidity by reducing treatment burden and unplanned care. It promotes shared decision-making to improve quality of life, aligning treatments with individual priorities, lifestyles, and goals. It identifies who benefits most from a multimorbidity-centered approach and outlines the necessary care.

The NICE database of treatment effects spreadsheet supports multimorbidity guidance by detailing the benefits of medicines for specific conditions and outcomes. It helps clinicians and patients discuss the harms and benefits to enable shared decision-making.

Royal College of Physicians: Acute care toolkit 17: Managing multiple medications

The Acute care toolkit 17 aims to support clinicians caring for patients with polypharmacy who are admitted to acute care setting. It outlines the key presentations and complications of polypharmacy.

Royal Pharmaceutical Society: Polypharmacy guide

This archived Royal Pharmaceutical Society Polypharmacy guide sets a vision for addressing polypharmacy. It focuses on system-wide responsibility and collaborative processes to identify and support those at risk of medication-related harm.

Prescribers are encouraged to consider the consequences of prescribing for those already taking multiple medicines and discuss these effects with patients.

When done effectively, these conversations can reduce problematic polypharmacy, increase patient satisfaction and adherence, decrease medication waste, and improve health outcomes.

The King’s Fund: Polypharmacy and medicines optimisation

The King’s Fund: Polypharmacy and medicines optimisation report proposes a pragmatic approach by defining ‘appropriate’ and ‘problematic’ polypharmacy to clarify when it can be beneficial. It explores the occurrence of polypharmacy in different care settings and makes recommendations for improving the management of complex care in older people.

World Health Organisation: Medication without harm

This World Health Organisation: Medication without harm guide set the strategic global vision of aiming to reduce the level of severe, avoidable harm related to medications by 50% over five years. It proposed local, national and global action to ensure medicines are given without harm.

Resources to support shared decision making

Choosing Wisely UK initiative

Choosing Wisely UK promotes shared-decision making conversations between clinicians and patients using BRAN questions:

• What are the Benefits?
• What are the Risks?
• What are the Alternatives?
• What if I do Nothing?

It is a collaborative process to select tests, treatments and care management or support packages, based on clinical evidence and patients’ informed preferences and values.

NHS England: Shared-decision making

This NHS England shared-decision making guide supports local implementation by:

• Defining good shared decision-making to align systems with informed individuals’ needs.
• Guiding commissioning and integration of shared decision-making in care pathways.
• Enabling providers to have better conversations, helping individuals make informed, value-based choices.

NICE: Shared decision making

This NICE shared decision making guideline explains how to involve patients in making decisions about their care and how to provide helpful information before, during, and after appointments.

Realistic Medicine

This Realistic Medicine document focuses on values-based conversations to collaboratively plan and agree care between patients and those working in health and social care. A key aim of Realistic Medicine is to empower patients and their families to engage fully in discussions about their treatment, including potential side effects or negative outcomes.

SPS resources

Understanding polypharmacy, overprescribing and deprescribing

This SPS article on understanding polypharmacy, overprescribing and deprescribing explores the causes, consequences and tools to support pharmacy professionals in managing these concerns in practice.

A person-centred approach to polypharmacy and medication review

This SPS article on a person-centred approach to polypharmacy and medication review outlines how to identify and invite patients for a structured medication review. It also includes a practical framework to manage inappropriate polypharmacy using a person-centred approach.

Tools to support medication review

This SPS article on tools to support medication review highlights tools to identify inappropriate medicines, guide deprescribing, and empower patients via shared decision making.

Training materials

Centre for Pharmacy Postgraduate Education

The Centre for Pharmacy Postgraduate Education introduction to appropriate polypharmacy course aims to increase the confidence of pharmacy professionals in addressing potentially problematic polypharmacy.

The Centre for Pharmacy Postgraduate Education introduction to overprescribing course helps pharmacy professionals identify overprescribing and empower patients in shared-decision making.

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