How should I approach the management of polypharmacy in elderly patients to minimize adverse drug reactions?

To manage polypharmacy in elderly patients effectively and minimize adverse drug reactions (ADRs), a comprehensive, patient-centred approach is essential. This involves regular, systematic medication reviews focusing on the necessity, effectiveness, and safety of each drug, particularly in those prescribed 10 or more regular medicines or at high risk of ADRs NICE NG56.

Key steps include:

• Engage a pharmacist with relevant clinical expertise to support medicines optimisation and strategic decision-making about medicines use NICE NG5.
• Assess the patient's frailty and multimorbidity status, as these increase susceptibility to ADRs due to altered pharmacokinetics and pharmacodynamics in older adults NICE CKS,NICE NG56.
• Review all medications, including prescription, over-the-counter, and herbal remedies, to identify potential drug–drug interactions and inappropriate prescribing, which are common contributors to ADRs in the elderly NICE CKS,NICE CKS,NICE NG67.
• Consider deprescribing where appropriate, especially psychotropic drugs and those with anticholinergic effects, to reduce cognitive impairment, falls risk, and other ADRs NICE CG185,NICE CKS.
• Involve the patient in shared decision-making, taking into account their preferences, treatment goals, and quality of life to balance benefits and risks of polypharmacy NICE NG5,NICE NG56.
• Monitor closely for ADRs, including rare or delayed effects, and adjust treatment accordingly NICE CKS,NICE CKS.
• Implement multifactorial interventions, including medication review as part of falls risk assessment and management, to reduce adverse outcomes NICE CKS.

This approach aligns with the concept of polypharmacy stewardship, which emphasises coordinated, multidisciplinary efforts to optimise medication regimens and reduce harm in older adults Daunt et al. 2023. Medication-related problems in older people often arise from complex regimens and physiological changes with age, necessitating tailored management strategies Wong 2020. Pharmacotherapy in elderly patients, such as those with heart failure, requires vigilance for adverse events and dose adjustments Rich 2012.

In summary, minimizing ADRs in elderly patients with polypharmacy requires regular, multidisciplinary medication reviews, frailty and multimorbidity assessment, deprescribing when appropriate, patient-centred care, and vigilant monitoring for interactions and side effects NICE CKS,NICE NG5,NICE NG56,NICE NG67 Daunt et al. 2023Wong 2020Rich 2012.