1. Polypharmacy: a pharmacy perspective
Professor Nina Barnett
Consultant Pharmacist,
Care of Older People, London North West Healthcare NHS Trust
Medicines Use and Safety Team, Specialist Pharmacy Service
Visiting Professor, Institute of Pharmaceutical Science,
Kings College London
My session will be entitled Listen to your patient: polypharmacy for older people
I will include information about the patient centred approach to managing multiple medicines, identifying risks  and how to make the best of short consultation about multiple medicines.
Facts figures – scale of the problem
What’s out there already kings fund Scottish welsh indiv CCG (not grouped) Stopp/start, clarhc deprescribing
Seven steps – how this works in practice
care homes, long term condition furosemide
What can we do:
Meds optimisation agenda – what is most important to you? realisation that there may be a gap.
GP and Pharms together practical guide to managing this – how do RPS suggest we can move it from published guide to implementation
Evidence based and patient centred prescribing (is the gap)
Clinician thinks there is a problem – pt. doesn’t
Pt thinks there is problem (ADR/ineffective meds) that clinician isn’t aware of

2. What is polypharmacy? Prescribing or taking many medicines
Numbers of medicines
More than clinically required
Appropriate
Problematic (inappropriate)
Hyperpolypharmacy/Excessive polypharmacy
Oligopharmacy/ Non polypharmacy
Deprescribing
Polypharmacy is a term that refers to either the prescribing of or taking many medicines. For many years it referred to the prescription or use of more than a certain number of medicines, at least four or five or more medicines per day (see A2). More recently it has been used in the context of prescribing or taking more medicines that are clinically required, as the number of medicines taken was of limited clinical value in interpreting individual potential problems.
Kings fund
Appropriate polypharmacy ”Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence.” Problematic polypharmacy “the prescribing of multiple [medicines] inappropriately, or where the intended benefit of the [medicines are] not realised.” (previously termed and defined in some studies as inappropriate)
Oligopharmacy seeks to promote the deliberate avoidance of polypharmacy, which if considered in terms of numbers of medicines, is the prescribing of less than or equal to 5 prescription drugs daily. (O’mahoney and O’connor
Non polypharmacy Sirpa Hartikainen Professor of Geriatric Drug Therapy Faculty of Pharmacy Kuopio Research Centre of Geriatric Care (Gerho) University of Kuopio. Nonpolypharmacy is use of 1-5 drugs
Deprescribing is the complex process required for the safe and effective cessation (withdrawal) of inappropriate medication, recognising that
much of the evidence to support stopping medicines is empirical and based on the patient’s physical functioning, co-morbidities, preferences and lifestyle. (DTB 2016;54:69-72 doi: /dtb
Excessive polypharmacy: Drugs & Aging June 2009, Volume 26, Issue 6, pp First online: 31 August 2012 Patterns of Drug Use and Factors Associated with Polypharmacy and Excessive Polypharmacy in Elderly Persons Results of the Kuopio 75+ Study: A Cross-Sectional Analysis Johanna Jyrkka et al  EPP (i.e. ≥10 drugs)
Hyperpolypharmacy is a new term referring to the prescribing of ten or more medicines and the phrase has come into use to distinguish it from polypharmacy, which is increasingly common.
O’Mahoney D and O’Connor M N, Pharmacotherapy at the end-of-life Age and Ageing 2011; 0: 1–4 doi: /ageing/afr059
Gnjidic, Danijela, Le Couteur, David G, Pearson, Sallie-Anne, McLachlan, Andrew J,  Viney, Rosalie, Hilmer, Sarah, Blyth Fiona M N, Joshy, Grace and Banks, Emily. High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level BMC Public Health 2013, 13:115  
Polypharmacy: Misleading, but manageable
Clin Interv Aging Jun; 3(2): 383–389. Reamer L Bushardt,1 Emily B Massey,1 Temple W Simpson,1 Jane C Ariail,2 and Kit N Simpson3
….. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication.The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use

3. The importance of language
Polypharmacy
“too many medicines”
the right amount for you
Deprescribing
“stopping your medicines”
trial and review
Multimorbidity......
……?
“the presence of two or more long-term health conditions”
The guide supports the use of the process in practice. It describes the purpose behind each of the seven steps and gives guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely. Although patients with polypharmacy often have multiple medicines-related issues, the guide allows the practitioner to prioritise the issues based on the importance to the patient, risks, benefits and current evidence and then focus on one or a small number of key concerns rather than trying to solve all the problems at once. The guide emphasises the need for effective communication with the patient, their family/carers and other healthcare professionals at all seven steps of the process to ensure any changes made are actioned and followed up
MULTIMORBIDITY (From prescriber article Barnett Payne and Rutherford)
Firstly, NICE have taken a relatively straightforward approach to defining multimorbidity as “the presence of two or more long-term health conditions”. This includes physical and mental health problems, and other conditions arguably not readily classified as either, such as learning disability or symptom complexes (e.g. frailty).
The guidance advocates tailoring care for those multimorbid individuals who have difficulties with day-to-day activities, those who receive care from multiple services, and those with both physical and mental health problems. It also recommends considering tailored care for those patients identified through factors such as frailty, use of frequent unplanned or emergency care, or the prescription of multiple medicines. Patients should be identified either opportunistically during routine care, or proactively using electronic records, and the guidance suggests the use of approaches such as validated frailty or admission risk assessment tools, or numbers of regular medications prescribed. In general, the guideline does not differentiate management in primary and secondary care, although does specifically recommend a comprehensive assessment of older people with complex needs at the point of hospital admission.

4. What’s the problem?
More than one third of over 75’s take four or more medicines regularly
Compare to today to 1980’s
Evidence of polypharmacy associated with
Increased ADE’s
Hospital admissions
Increased healthcare costs
Poor medicines adherence
“As people get older, their use of medicines tends to increase. Four in five people over 75 take at least one prescribed medicine, with 36% taking four or more medicines”
NSF for older people 2001 quotes Health Survey for England Volume 1: Findings
According to one study, people aged 75 years and older take an average of 7.9 drugs per day. Marinker M, Blenkinsopp A, Bond C, et al. From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. London, UK: Royal Pharmaceutical Society of Great Britain; 1997.
Clinical Consequences of Polypharmacy in Elderly
Robert L. Maher, Jr, PharmD, Assistant Professor, Joseph T. Hanlon, PharmD, MS, Professor of Geriatric Medicine, and Emily R. Hajjar, PharmD, Associate Professor
3.0 Consequences of Polypharmacy
Unfortunately, there are many negative consequences associated with polypharmacy. , Specifically, the burden of taking multiple medications has been associated with greater health care costs and an increased risk of adverse drug events (ADEs), drug-interactions, medication non-adherence, reduced functional capacity and multiple geriatric syndromes.
3.1 Increased Healthcare Costs
Polypharmacy contributes to health care costs to both the patient and the healthcare system. A retrospective cohort study found that polypharmacy was associated with an increased risk of taking a potentially inappropriate medication and an increased risk of outpatient visits, and hospitalization with an approximate 30% increase in medical costs [10]. Another study conducted in Sweden reported that those taking 5 or more medications had a 6.2% increase in prescription drug expenditure and those taking 10 or more medications had a 7.3% increase [11].
3.2 Adverse Drug Events
In 2005, it was estimated that over 4.3 million health care visits were attributed to an ADE [12]. It has been reported that up to 35% of outpatients and 40% of hospitalized elderly experience an ADE. Furthermore, approximately 10% of emergency room visits are attributed to an ADE [13]. In a population based study, outpatients taking 5 or more medications had an 88% increased risk of experiencing an ADE compared to those who were taking fewer medications [12]. In nursing home residents, rates of ADEs have been noted to be twice as high in patients taking 9 or more medications compared to those taking less [14]. Another study evaluating unplanned hospitalizations in older veterans found that a patient taking more than 5 medications was almost 4 times as likely to be hospitalized from ADE [15]. As one might expect, common drug classes associated with ADEs include anticoagulants, NSAIDs, cardiovascular medications, diuretics, antibiotics, anticonvulsants, benzodiazepines, and hypoglycemic medications [13,15,16].
3.3 Drug-Interactions
Older adults with polypharmacy are predisposed to drug- interactions [17]. In a prospective cohort study of older hospitalized adults taking 5 or more medications, the prevalence of a potential hepatic cytochrome enzyme-mediated, drug-drug interaction was 80%. The probability of a drug-drug interaction increased with the number of medications. Specifically, a patient taking 5-9 medications had a 50% probability whereas the risk increased to 100% when a patient was found to be taking 20 or more medications [18]. In a study of community-dwelling elderly adults, almost 50% of patients had a potential drug-drug interaction [19]. Drug-drug interactions are a frequent cause of preventable ADEs and medication-related hospitalizations [16,20]. , Thus practitioners should keep the possibility of a drug-drug interaction in mind when prescribing any new medications.
Studies have reported the prevalence of drug-disease interactions to be 15-40% in frail elderly patients. Risk of drug-disease interactions has been shown to increase with increased numbers of medications [21,22]. With patients living longer with more chronic disease states requiring drug therapy, the risk of drug-disease interactions should be a concern for healthcare providers.
3.4 Medication Non-adherence
Non-adherence with drugs in older adults has been associated with complicated medication regimens and polypharmacy [23-27]. Non-adherence rates in community dwelling elderly adults has been reported to be between % [24,25]. The large variance in the non-adherence rates may be attributed to different methods, tools, and thresholds for categorizing adherence as well as the variety of populations studied. In one study, the rate of patient non-adherence was 35% when a patient was taking 4 or more medications [28]. Medication non-adherence is associated with potential disease progression, treatment failure, hospitalization, and ADEs, all of which could be life-threatening [24,27,28].
3.5 Functional Status
Polypharmacy has been associated with functional decline in older patients. In a prospective study of community-dwelling older adults, increased prescription medication use was associated with diminished ability to perform instrumental activities of daily living (IADLs) and decreased physical functioning [29]. A study using data from the conducted aWomen's Health and Aging Study, found that use of 5 or more medication was associated with a reduced ability to perform IADLs [30]. A prospective cohort of approximately 300 older adults found that patients taking 10 or more medications had diminished functional capacity and trouble performing daily tasks [31]. As part of the Women's Health Initiative Observational study, polypharmacy was associated with incident disability in older women [32]. In patients who have reported falling in the past year, higher medication use was found to be associated with functional decline [33]. Prescribers should be aware of the risk of functional decline in patients taking multiple medications.
3.6 Cognitive Impairment
Cognitive impairment, seen with both delirium and dementia, has been associated with polypharmacy. A study in hospitalized older adults reported that the number of medications was a risk factor for delirium [34]. In a prospective cohort study of 294 elders, 22% percent of patients taking 5 or less medications were found to have impaired cognition as opposed to 33% of patients taking 6-9 medications and 54% in patients taking 10 or more medications [31].
3.7 Falls
Falls are associated with increased morbidity and mortality in older adults and may be precipitated by certain medications. A study comparing patients who have not fallen compared to those who have fallen once and those multiple times , reported that the number of medications was associated with an increased risk of falls [35]. A study in older adult outpatients asas the number of medications increased, the falls risk index score increased and the duration of the one-leg standing test duration decreased [36]. In a prospective cohort study, the use of 4 or more medications was associated with increased risk of falling and the risk of recurrent falls [37]. A study in elderly patients with dementia reported that those patients who reported a fall had an increased prevalence of polypharmacy [38]. In a study of institutionalized older adults the risk of experiencing a fall within the previous 30 days was by 7% for each additional medication [39]. Given the serious consequences of falls in older adults, caution should be used in prescribing new medications to those who are at risk of falling.
3.8 Urinary Incontinence
Urinary incontinence is yet another problem that is associated with the use of multiple medications. In a population-based, longitudinal study of women aged 70 years and older, polypharmacy was associated with an increased risk of lower urinary tract symptoms [40]. Many medications are known to exacerbate urinary incontinence, so a medication review should be performed to evaluate both the number of medications as well as the specific types of medications a patient is taking.
3.9 Nutrition
Polypharmacy has also been reported to affect a patient's nutritional status. A prospective cohort study found that 50% of those taking 10 or more medications were found to be malnourished or at risk of malnourishment [31]. A survey of community-dwelling elders older adults found that polypharmacy was associated with a reduced intake of fiber, fat-soluble and B vitamins, and minerals as well as an increased intake of cholesterol, glucose, and sodium [41].

5. Risk of guideline based prescribing
Dumbreck et al. BMJ 2015;350:bmj.h949
Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines – Dumbreck et al. BMJ 2015;350:bmj.h949 incl Bruce Guthrie, professor of primary care medicine
Abstract
Objective To identify the number of drug-disease and drug-drug interactions for exemplar index conditions within National Institute of Health and Care Excellence (NICE) clinical guidelines.
Design Systematic identification, quantification, and classification of potentially serious drug-disease and drug-drug interactions for drugs recommended by NICE clinical guidelines for type 2 diabetes, heart failure, and depression in relation to 11 other common conditions and drugs recommended by NICE guidelines for those conditions.
Setting NICE clinical guidelines for type 2 diabetes, heart failure, and depression
Main outcome measures Potentially serious drug-disease and drug-drug interactions.
Results Following recommendations for prescription in 12 national clinical guidelines would result in several potentially serious drug interactions. There were 32 potentially serious drug-disease interactions between drugs recommended in the guideline for type 2 diabetes and the 11 other conditions compared with six for drugs recommended in the guideline for depression and 10 for drugs recommended in the guideline for heart failure. Of these drug-disease interactions, 27 (84%) in the type 2 diabetes guideline and all of those in the two other guidelines were between the recommended drug and chronic kidney disease. More potentially serious drug-drug interactions were identified between drugs recommended by guidelines for each of the three index conditions and drugs recommended by the guidelines for the 11 other conditions: 133 drug-drug interactions for drugs recommended in the type 2 diabetes guideline, 89 for depression, and 111 for heart failure. Few of these drug-disease or drug-drug interactions were highlighted in the guidelines for the three index conditions.
Conclusions Drug-disease interactions were relatively uncommon with the exception of interactions when a patient also has chronic kidney disease. Guideline developers could consider a more systematic approach regarding the potential for drug-disease interactions, based on epidemiological knowledge of the comorbidities of people with the disease the guideline is focused on, and should particularly consider whether chronic kidney disease is common in the target population. In contrast, potentially serious drug-drug interactions between recommended drugs for different conditions were common. The extensive number of potentially serious interactions requires innovative interactive approaches to the production and dissemination of guidelines to allow clinicians and patients with multimorbidity to make informed decisions about drug selection.

6. Number of medicines
The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010
Abstract
Background
The escalating use of prescribed drugs has increasingly raised concerns about polypharmacy. This study aims to examine changes in rates of polypharmacy and potentially serious drug-drug interactions in a stable geographical population between 1995 and 2010.
Methods
This is a repeated cross-sectional analysis of community-dispensed prescribing data for all 310,000 adults resident in the Tayside region of Scotland in 1995 and The number of drug classes dispensed and the number of potentially serious drug-drug interactions (DDIs) in the previous 84 days were calculated, and age-sex standardised rates in 1995 and 2010 compared. Patient characteristics associated with receipt of ≥10 drugs and with the presence of one or more DDIs were examined using multilevel logistic regression to account for clustering of patients within primary care practices.
Results
Between 1995 and 2010, the proportion of adults dispensed ≥5 drugs doubled to 20.8%, and the proportion dispensed ≥10 tripled to 5.8%. Receipt of ≥10 drugs was strongly associated with increasing age (20–29 years, 0.3%; ≥80 years, 24.0%; adjusted OR, 118.3; 95% CI, 99.5–140.7) but was also independently more common in people living in more deprived areas (adjusted OR most vs. least deprived quintile, 2.36; 95% CI, 2.22–2.51), and in people resident in a care home (adjusted OR, 2.88; 95% CI, 2.65–3.13). The proportion with potentially serious drug-drug interactions more than doubled to 13% of adults in 2010, and the number of drugs dispensed was the characteristic most strongly associated with this (10.9% if dispensed 2–4 drugs vs. 80.8% if dispensed ≥15 drugs; adjusted OR, 26.8; 95% CI 24.5–29.3).
Conclusions
Drug regimens are increasingly complex and potentially harmful, and people with polypharmacy need regular review and prescribing optimisation. Research is needed to better understand the impact of multiple interacting drugs as used in real-world practice and to evaluate the effect of medicine optimisation interventions on quality of life and mortality. 4
Guthrie et al. BMC Medicine (2015) 13:7 DOI /s

7. What’s out there to help?
NHS Scotland and The Scottish Government 2012, updated 2015 : Polypharmacy Guidance, update 2017…
Kings Fund 2013: Polypharmacy and medicines optimisation : Making it safe & sound
NHS Wales Health Board 2013: Polypharmacy: Guidance for Prescribing in Frail Adults Practical guide, full guidance, BNF sections to target
PrescQIPP NHS Programme 201: Polypharmacy & Deprescribing webkit, Improving Medicines and Polypharmacy Appropriateness Clinical Tool (IMPACT)
Organisation: NHS Scotland and The Scottish Government
Website:
Title: Polypharmacy Guidance October  
Overview: This is a comprehensive and robust 47 page document is presented in three sections. The first outlines the rationale for addressing polypharmacy, identifies patient groups who may benefit from polypharmacy related medicines review and the general content of the review. While the document recommends using SPARRA (Scottish Patients at Risk of Readmission and Admission) prediction tool data to identify local high risk groups, this concept is readily transferable to other localities where different tools are used. The second section gives clinical information using evidence based sources to support conducting a review explaining the meaning of and including numbers needed for to treat (NNT) and numbers needed to harm (NNH) for individual drugs and drug groups. . The drug review process described is clinically focussed and supports practitioner with the clinical information needed to conduct an effective review. Risk from high risk medication is discussed individually and by BNF categories, as well as identification of clinical conditions of patients which can increase the risks from polypharmacy. Primary references are given. The final section on administrative consideration includes useful information on how to conduct reviews however embedded documents are not available directly through the link.
See
Update March 2015
The new guidance provides additional background information about the interplay between polypharmacy, frailty and multimorbidity. More detail on populations to target when identifying high risk groups is given and there is a new approach to polypharmacy medication review in the form of a seven steps approach to managing medication.
This is useful method of considering each medication in terms of the benefit and risk to an individual patient, including an evidence based approach and while it discusses a patient centered approach to polypharmacy, the seven steps are written from a clinician perpspective.
The updated guide also includes key issues for medication review on a drug by drug and drug class basis listed by BNF categories A new addition to the guidance is the 'hot topics' section which highlights key conditions and drugs which merit special attention, such as review of antipsychotic medication, falls risks with medication etc.
The Numbers needed to treat information has stayed in and as with the first version, the guide is beautifully presented and well referenced.
While one of the methods of identifying high risk populations is based on Scottish data, this is easily transferable for use with local tools eg PARR, BIRT 2
Organisation: NHS Wales Health Board
Website:
Title : Polypharmacy: Guidance for Prescribing in Frail Adults Practical guide, full guidance, BNF sections to target
Overview: An excellent summary is a practical introduction to practitioners who are interested in implementing polypharmacy reviews in their workplace. The document covers similar ground to the Scottish guidance and presents the information in one page flow –chart based summaries of background; drug review process; high risk medication; Frailty and shortened life expectancy, ending with useful links.
The more detailed full guidance is also available which describes key considerations around polypharmacy, provides a medicines effectiveness summary table (with numbers needed to treat for specified conditions) and gives explains the practicalities for stopping specific groups of medicines. The appendices contain an example medicines review leaflet for patients and a list of helpful resources as well as references.
The supplementary guidance is set out in BNF order and describes key risks for each drug group and points for consideration during medication review to reduce inappropriate polypharmacy. Links to relevant guidelines including NICE are given together with advice on deprescribing and follow up/monitoring.
See  practical guide
Full guidance
BNF guidance
Organisation: PrescQIPP NHS Programme
Website:
Title: Polypharmacy and Deprescribing
Overview: PrescQIPP has produced a number of resources in a web kit to support practitioners in reducing polypharmacy. The current web pages outline the background to this area and describe the current work of the project, including a landscape review of polypharmacy and deprescribing, a review of the evidence for medication reviews to understand and address not only patients' beliefs and behaviours, but also those of their healthcare professionals and their carers, such as family or friends, who help support them, production of a bulletin about how to withdraw medicines, support for GP practice audit to identify patients at risk and tools to support improved practice.
The original ‘Optimising Safe and Appropriate Medicines Use’ (OSAMU) bulletin from 2011 and 2013 used BNF classes to highlight potential clinical and cost issues with medication to support medicines optimisation and reduce polypharmacy. Following a review in 2016, the bulletin has been updated and relaunched as the ‘Improving Medicines and Polypharmacy Appropriateness Clinical Tool’ (IMPACT). A ‘landscape review’ in 2014 surveyed CCGs and CSUs about the systems and tools used for deprescribing, meaning of and attitudes to polypharmacy and deprescribing, local projects and challenges to implementation. Key findings include the difficulty of the terminology for patients and the need for public education and the desire for sharing resources.
See
Organisation: Kings Fund
Website
Title: Polypharmacy and medicines optimisation : Making it safe and sound
Overview: This 68 page 2013 report is a detailed look at how polypharmacy manifests in different care settings, key issues and areas for development. It introduces the concept of appropriate and problematic polypharmacy. It highlights both the benefits of appropriate polypharmacy and the risks of problematic polypharmacy in clinical and patient-centred term and both medicines waste and poor adherence to treatment are included in the problems of problematic polypharmacy. Recognising that most evidence for use of medicines is for single conditions it identifies the gap in multi-morbidity guidelines (which is currently being addressed by NICE). Recommendations for practice are given regarding shortened life expectancy and managing long term conditions, including the importance of overview by one clinical team of all long term conditions. The need for clinician training in multimorbidity is highlighted. The document specifically addresses polypharmacy and use of monitored dose systems, polypharmacy in care homes and discusses issues around stopping medicines
See

8. What tools are available?
Beers criteria
(explicit, US)
Medication appropriateness
index (implicit)
STOPP/START tool
(recently revised)
Medstopper
RxISK Polypharmacy Index
Mark H Beers 1991 Geriatrician - used delphi method to create AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2012 List of drugs to avoid in older people
Drugs Aging Nov;30(11): doi: /s JT Hanlon et al PharmD
The medication appropriateness index at 20: where it started, where it has been, and where it may be going.
The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults. Score each drug and get summated score ‘implicit’
STOPP/START criteria for potentially inappropriate prescribing in older people: version /5 (vs ) Denis 0’Mahoney Cristin Ryan Stephen Byrne Paul Gallagher
STOPP: Screening Tool of Older People’s potentially inappropriate Prescriptions. START: Screening Tool to Alert doctors to Right
i.e. appropriate, indicated Treatments.
List of medicines adapted by many ccgs as a guide eg nhs cumbriahttp://
Screening Tool for Older People’s Inappropriate Treatments (STOPIT) Abdul Saheb, Barry Jubraj, Vanessa Marvin etc. Adapted from ImPE tool
• It is anticipated that at least 72% patients will take fewer medications as a result of this work • Each medication review saves the NHS £250 per year in medication costs alone • Prompt cards for medication review were developed and are being distributed to doctors and pharmacists • Rollout of a patient held Medication Passport as part of an initiative across Northwest London to provide patients with more accurate personalised information about their medicines in a format they can use easily with any healthcare professional
metabolic disturbance, falls, bleeding, constipation, sedation, confusion – drugs associated with these
Linked to deprescribing and bottom up approach – we can link to this
Medstopper is a tool to help clinicians and patients make decisions about reducing or stopping medications. By entering the list of medications a patient is receiving, Medstopper sequences the drugs from "more likely to stop" to "less likely to stop", based on three key criteria: the potential of the drug to improve symptoms, its potential to reduce the risk of future illness and its likelihood of causing harm. Suggestions for how to taper the medication are also provided. See also
RxISK Polypharmacy Index
Could you be on too many drugs?
Answer the following 10 questions to assess the risk of your taking a mixture of drugs that is of more harm than benefit to you. We will you a record of your answers along with your RxISK Polypharmacy Index.
The higher the number, the more important it is that you have a conversation with your doctor.

9. Patient-centred polypharmacy process
The right amount of medicines for you
To provide practical support for clinicians in embedding medicines optimisation into everyday practice through patient centred, safe, evidence based medication review in the management of polypharmacy
The guide supports the use of the process in practice. It describes the purpose behind each of the seven steps and gives guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely. Although patients with polypharmacy often have multiple medicines-related issues, the guide allows the practitioner to prioritise the issues based on the importance to the patient, risks, benefits and current evidence and then focus on one or a small number of key concerns rather than trying to solve all the problems at once. The guide emphasises the need for effective communication with the patient, their family/carers and other healthcare professionals at all seven steps of the process to ensure any changes made are actioned and followed up.
© N Barnett L Oboh K Smith EJHP: 23 December

10. Focus on the patient perspective
Where is the gap?
Polypharmacy resources provide
Background and context for the issues
Evidence for optimal use of medicines
Tools to support safe review
Focus on the patient perspective

11. Link to medicines optimisation…..
Aim to understand the patient’s experience
Evidence based choice of medicines
Ensure medicines use is as safe as possible
Make medicines optimisation part of routine practice
The four guiding principles of medicines optimisation Principle 1. Aim to understand the patient’s experience To ensure the best possible outcomes from medicines, there is an ongoing, open dialogue with the patient and/or their carer about the patient’s choice and experience of using medicines to manage their condition; recognising that the patient’s experience may change over time even if the medicines do not.
Principle 2. Evidence based choice of medicines Ensure that the most appropriate choice of clinically and cost effective medicines (informed by the best available evidence base) are made that can best meet the needs of the patient.
Principle 3. Ensure medicines use is as safe as possible The safe use of medicines is the responsibility of all professionals, healthcare organisations and patients, and should be discussed with patients and/or their carers. Safety covers all aspects of medicines usage, including unwanted effects, interactions, safe processes and systems, and effective communication between professionals
Make medicines optimisation part of routine practice Health professionals routinely discuss with each other and with patients and/or their carers how to get the best outcomes from medicines throughout the patient’s care.
NICE
1.1 Systems for identifying, reporting and learning from medicines‑related patient safety incidents
1.2 Medicines-related communication systems when patients move from one care setting to another
1.3 Medicines reconciliation
1.4 Medication review
1.5 Self-management plans
1.6 Patient decision aids used in consultations involving medicines
1.7 Clinical decision support
1.8 Medicines-related models of organisational and cross-sector working
NHS England MO dashboard
The dashboard is presented to allow local NHS organisations to highlight variation in local practice and provoke discussion on the appropriateness of local care. It is not intended as a performance measurement tool and there are no targets.   The primary aim of the programme is to improve patient outcomes, quality and value from medicine use, guided by the principles of medicines optimisation, and to create a clinical pull to accelerate the optimal use of innovative, clinical and cost effective medicines which maximises the benefits of the PPRS Agreement.

12. Things to think about Measuring polypharmacy – focus on problematic
Promoting appropriate polypharmacy
Link between medicines adherence and polypharmacy
Overlap between Polypharmacy/frailty/multimorbidity
Polypharmacy review: balancing patient centred and evidence based (Sackett et al
Deprescribing – evidence, tools, attitudes of both clinician and patient
Evidence based medicine: what it is and what it isn't
It's about integrating individual clinical expertise and the best external evidence
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire
through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients‘ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic,
rehabilitative, and preventive regimens.
BMJ VOLUME 312 JAN 1996 p71
DAVID L SACKETT R&D NHS for EBM Oxford
WILLIAM C ROSENBERG Nuffield Oxford
J A MUIR GRAY R&D Oxford RHA
R BRIAN HAYNES Ontario
W SCOTT RICHARDSON NYC

13. Thank you