Dr Melanie Wroth ( left ) Geriatrician at Royal Prince Alfred Hospital , chief clinical advisor , Aged Care Quality and Safety Commission , Sydney , NSW .

Associate Professor Juanita

Breen ( right ) Accredited pharmacist and aged care medication researcher ; consults for the pharmacy unit at the Aged Care Quality and Safety Commission ; associate of the Wicking Dementia Centre at the University of Tasmania , Hobart , Tasmania .

First published online on 10 March 2023

WHAT IS POLYPHARMACY ?

THE term polypharmacy is widely

used , and we intuitively know what it means , though definitions vary . The number of medications a person is taking to term it polypharmacy is subject to opinion and appears arbitrary , with polypharmacy referring to the total number of medicines being taken . The inclusion of topical , complementary and supplementary agents is also a point of difference .

What is not debated is that polypharmacy is common , and the number of people impacted is growing . It is estimated that more than a third of older Australians , almost one million people , are using five or more medications . 1 In residential aged care facilities ( RACFs ) the average number of regular medications is nine . 2

Patients understand the concept in terms of “ I ’ m taking lots of

drugs ”, or “ I struggle to afford them all ” ( see figure 1 ).

It is widely acknowledged that much of this prescribing may not be appropriate and the risks and burdens are clear ; polypharmacy and potentially inappropriate medication ( PIM ) use are associated with increased hospital admissions , falls , non-adherence , adverse drug reactions , death and reduced quality of life . 3 , 4 A ‘ PIM ’ is defined as a medication in which the risk of an adverse event outweighs its clinical benefit , particularly when there is a safer or more effective alternative therapy for the same condition . 5

Polypharmacy is not wrong , per se , if the risk – benefit ratio for each medication is considered for the individual and the overall regimen is reviewed . 6 In those with multiple complex chronic medical problems where there is a justifiable value , taking multiple medications is often

appropriate . However , the risks are magnified because of the potential for drug interactions , potentiation of effects , increasing risk of adverse effects and increased risk of medication errors . It may also be more difficult to review individual medications in people with a long list .

This How to Treat considers the issue of polypharmacy in older people and offers practical suggestions on how to recognise opportunities to deprescribe . It aims to ensure GPs can appropriately review and adjust medications based on current patient goals , needs and risks .

WHAT CONTRIBUTES TO POLYPHARMACY ?

Culture and history

PHARMACEUTICAL technology

and marketing are important and extremely influential in our culture ; we are all susceptible to messaging .

Despite the advances and development of pharmaceutical substances having contributed to better health and longevity , this has at times resulted in over-reliance on medications and a belief they are better than they sometimes are . Many medications have exaggerated expectations of their efficacy , number to treat , evidence for benefit over placebo and , crucially , a failure to consider their harms .

Humans have always sought to treat illness rather than to succumb , leading to the expectation that there is “ a pill for every ill ”. Treatment has included spiritual and religious activity , witchcraft , alchemy , herbalism and scientific investigation . Forms of traditional healing have evolved and incorporate belief and trust with physical , psychological and pharmacological cures . Money may drive deception , fraud and ‘ snake-oil ’ cures .