Polypharmacy in the Elderly: Medication Review

Clinical Scenario

Margaret Wilson, 78, has a telephone consultation booked for a medication review. She has type 2 diabetes, hypertension, osteoarthritis, depression, COPD, previous MI (3 years ago), and osteoporosis. She is currently on 14 medications including dual antiplatelet therapy, codeine, a loop diuretic, a PPI, and an anticholinergic. She has been having falls, is constipated, and reports feeling drowsy during the day. Her daughter is concerned she is taking too many tablets and not coping.

What This Case Tests

Conducting a structured medication review using STOPP/START criteria; identifying potentially inappropriate prescribing in older adults; deprescribing safely with clear rationale; balancing multimorbidity management with quality of life; communicating medication changes to a patient who may be attached to her current regimen.

Common Mistakes Trainees Make

The three most common mistakes are: reviewing each medication in isolation rather than assessing the overall burden and interactions (the polypharmacy itself is the problem), failing to identify that several of Margaret's symptoms — falls, constipation, drowsiness — are likely medication side effects rather than new conditions, and being too cautious about stopping medications (trainees often add medications but rarely remove them).

The Consultation Challenge

Margaret is on 14 medications and her symptoms — falls, constipation, drowsiness — are almost certainly iatrogenic. The consultation tests whether you can see the medications as the cause of her problems rather than adding more medications to treat the side effects.

Start by understanding her current experience. How is she managing her tablets? Is she taking them all? What symptoms bother her most? The daughter's concern about coping is a crucial signal — medication non-adherence in elderly patients on complex regimens is extremely common and dangerous.

Now conduct a systematic STOPP/START review. STOPP (Screening Tool of Older Persons' Prescriptions) identifies potentially inappropriate medications. In Margaret's case, several red flags should jump out: dual antiplatelet therapy (aspirin plus clopidogrel) more than 12 months post-MI without ongoing indication, codeine in an elderly patient (causing constipation, falls risk, cognitive impairment), a PPI without clear ongoing indication (increased fracture risk in a patient with osteoporosis), and any anticholinergic medications contributing to confusion and falls.

Link her symptoms to her medications. The falls are likely multifactorial: antihypertensive-related postural hypotension (ramipril plus amlodipine plus furosemide), codeine-related sedation, and potential anticholinergic effects on balance. The constipation is almost certainly codeine-related. The drowsiness could be codeine, amitriptyline, or anticholinergic load.

Develop a deprescribing plan. Prioritise stopping the medications with the worst risk-benefit ratio: codeine should be the first to go (causing constipation, falls, drowsiness — switch to regular paracetamol), review the dual antiplatelet therapy with cardiology input, consider stepping down the PPI, and assess whether the furosemide has a clear indication.

Present changes collaboratively. Patients on long-term medications are often reluctant to stop them. Frame deprescribing as optimisation: "I think some of your tablets might actually be causing the problems you're experiencing. By removing the ones that are doing more harm than good, I think you'll feel significantly better."

Time check: Spend the first 3 minutes understanding Margaret's experience with her medications. By minute 6, identify the key medications to review using STOPP criteria. Use minutes 7-10 for the deprescribing plan with clear rationale for each change. Reserve the final 2 minutes for communicating the plan, safety netting, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you take a structured medication history covering adherence, side effects, and functional impact. They look for whether you identify the link between Margaret's symptoms (falls, constipation, drowsiness) and her medications, review each medication's ongoing indication, and assess the anticholinergic burden. A trainee who treats the falls as a new problem requiring investigation rather than recognising the iatrogenic cause will miss the point.

Clinical Management and Medical Complexity: Heavily weighted. Examiners expect application of STOPP/START criteria with specific medications identified for deprescribing. They look for a prioritised plan (which medication to stop first), safe deprescribing advice (gradual reduction where needed, not abrupt cessation), and awareness of interactions. Demonstrating that you can remove medications — not just add them — is the key skill being tested.

Relating to Others: Examiners assess whether you communicate medication changes collaboratively, address the patient's potential attachment to her medications, involve the daughter's concerns constructively, and frame deprescribing as improving quality of life rather than withdrawing treatment. The patient should feel that her medication burden is being lightened, not that her care is being reduced.

Example Opening

Strong opening: "Hello Margaret, I'd like to have a good look at all your medications today. Sometimes when people are on a lot of tablets, some of them can start causing problems rather than helping. How have you been finding things — are you managing to take everything, and how are you feeling generally?"

When linking symptoms to medications: "I think the falls, the constipation, and the drowsiness you've been having are actually being caused by some of your tablets. The codeine in particular can cause all three of those things. If we take that away and switch to something gentler for your pain, I think you'll notice a real difference."

Avoid: "You're on too many medications." (Implies previous prescribers made mistakes, which undermines trust).

How This Appears in the SCA

Polypharmacy medication review is an increasingly examined SCA topic given the ageing population. Examiners assess whether you can apply STOPP/START criteria, identify iatrogenic symptoms, deprescribe safely, and communicate changes to the patient. This case specifically tests whether you recognise that the patient's symptoms are medication side effects.

Key Statistic

Polypharmacy (5+ medications) affects approximately 50% of people over 65, and 10% take 10 or more medications. Adverse drug reactions cause approximately 6.5% of hospital admissions, rising to 17% in the over-65s. Up to 50% of these are preventable through medication review.

Relevant Guidelines

• NICE NG5: Medicines optimisation
• STOPP/START criteria for potentially inappropriate prescribing in older adults
• NICE multimorbidity guideline (NG56).

Frequently Asked Questions

What are the STOPP/START criteria and how do I apply them in the SCA?

STOPP (Screening Tool of Older Persons' Prescriptions) identifies medications that are potentially inappropriate in older adults — for example, long-term PPIs without indication, anticholinergics in patients with cognitive impairment, or benzodiazepines in fall-prone patients. START (Screening Tool to Alert to Right Treatment) identifies medications that should be prescribed but are missing — for example, calcium and vitamin D in osteoporosis. Applying both systematically demonstrates structured medication review skills.

How do I identify iatrogenic symptoms in an elderly patient?

The key principle: when an elderly patient develops new symptoms, always ask "could this be a medication side effect?" before investigating for new pathology. Common iatrogenic presentations include: falls (antihypertensives, sedatives, anticholinergics), constipation (opioids, anticholinergics, calcium channel blockers), confusion (anticholinergics, benzodiazepines, opioids), and drowsiness (opioids, antidepressants, antihistamines). Mapping symptoms to the medication list is a high-scoring skill.

How do I deprescribe safely?

Not all medications can be stopped abruptly. Gradual reduction is needed for: benzodiazepines, opioids, antidepressants, beta-blockers, and corticosteroids. For other medications (PPIs, statins in very elderly, duplicate therapies), stopping can be more straightforward. Always deprescribe one medication at a time so you can assess the impact. Arrange follow-up within 1-2 weeks of any change and provide clear safety netting.

How do I communicate deprescribing to a reluctant patient?

Frame it as optimisation, not withdrawal. "I think some of these tablets might be causing more problems than they're solving — if we can simplify things, you should feel better and have fewer side effects." Acknowledge that stopping a long-term medication can feel unsettling. Emphasise that you will monitor closely and can restart if needed. Involving family members (with the patient's consent) provides additional support.

When should dual antiplatelet therapy be reviewed post-MI?

NICE recommends dual antiplatelet therapy (aspirin plus a second agent like clopidogrel or ticagrelor) for 12 months following acute coronary syndrome. After 12 months, the evidence supports stepping down to single antiplatelet therapy in most patients. Continuing dual therapy beyond 12 months increases bleeding risk without proportionate benefit. In Margaret's case — 3 years post-MI — review with cardiology input is appropriate before stopping.