What is polypharmacy and how would you prevent it?

No single agreed definition. Polypharmacy has been defined in about 24 different ways, which has made it hard to measure and to compare studies (Pathy, Ch. 10).

Numerical definition. The most widely used cut-off is the concurrent use of five or more medications; hyperpolypharmacy is ten or more. The five-drug threshold identifies community-dwelling older men at risk of adverse outcomes.

Qualitative (and more accurate) definition. The most precise definition is "the use of multiple medications, and more than are medically necessary". This allows the essential distinction between appropriate polypharmacy (many drugs, all indicated, e.g. in heart failure) and inappropriate polypharmacy.

Regulatory definition. The Omnibus Budget Reconciliation Act (OBRA) 1987 in the USA first brought polypharmacy in nursing homes under regulatory scrutiny.

Rising everywhere. In Scotland, use of ≥5 drugs rose from ~11% to 20% between 1995 and 2010, and ≥10 drugs from ~1.5% to almost 6%; by 2010, 13% of older patients were exposed to a potentially serious drug interaction.

Comparable trends elsewhere: Sweden 18% → 42% (1992–2002); Italy 43% → 53% (2000–2010).

Indian context. Polypharmacy in India is driven by multimorbidity in a rapidly ageing population (LASI), fragmented care across multiple prescribers, unrestricted OTC sales, concurrent AYUSH and home remedies, and the absence of a shared electronic medication record. NPHCE geriatric clinics are the logical place to embed structured medication review.

Patient factors: multimorbidity, chronic disease, under-reporting of symptoms, expectation of a prescription, OTC and supplement use.

Prescriber factors: treating symptoms rather than evaluating them, single-disease guideline adherence in a multimorbid patient, prescribing inertia, and failure to review.

System factors: multiple doctors each prescribing without a complete list, transitions of care, direct-to-consumer advertising, and pressure from patients or families.

The prescribing cascade — an ADR is misread as a new disease and treated with another drug — is the single most important self-perpetuating mechanism.

Clinical: ADRs, drug–drug and drug–disease interactions (notably CYP450-mediated), falls, frailty, disability, cognitive impairment and delirium, malnutrition, urinary incontinence, sarcopenia and increased mortality.

Practical: reduced adherence, greater treatment burden, higher cost, more hospital admissions and readmissions, and more medication errors — the incidence of medication error in UK nursing home residents has been reported as high as 69.5% (Pathy, Ch. 11).

Prevent at the point of prescribing. Apply the rational prescribing sequence (Q2): correct diagnosis → non-drug options first → lowest effective dose → explicit review date. Each time a drug is added, consider whether one can be stopped.

Obtain an accurate, complete medication list. "Brown-bag" review at first assessment; include OTC, herbal and traditional preparations; maintain and update the record at every visit; reconcile medicines at admission, transfer and discharge.

Screen with a validated tool — Beers, STOPP/START, MAI, Pill Pruner, DBI or FORTA. Be proficient in at least one.

Deprescribe systematically. Deprescribing is "a patient-centred, systematic optimisation of a person's medication list through the reduction, tapering or stopping of medications that are not indicated or are causing real or potential harm" (Scott et al.). Scott's five-step protocol: (i) compile a complete, accurate medication list; (ii) assess overall risk of drug-induced harm; (iii) determine each drug's discontinuation potential; (iv) prioritise drugs for discontinuation; (v) establish a monitoring plan. Barnett's seven steps begin with the patient's needs and goals and end with a long-term communication and monitoring plan. The Deprescribing Rainbow places the patient at the centre and considers clinical, psychological, social, financial and physical determinants.

Taper, do not stop abruptly, for benzodiazepines, opioids, SSRIs, beta-blockers, corticosteroids, levodopa and antiepileptics — abrupt withdrawal causes adverse drug withdrawal events.

Avoid under-prescribing at the same time. Use START criteria so that deprescribing does not become age-based rationing; apply ERASE to remove unnecessary diagnoses.

Work as a team and educate. Clinical pharmacists, nurses, family caregivers and structured patient education are the interventions most consistently shown to work. Documented benefits of systematic deprescribing include fewer falls, improved cognitive and psychomotor function, reduced mortality and reduced healthcare utilisation, without an increase in adverse outcomes.