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The BGS Pharmacy Group have assembled a list of helpful resources to guide clinicians on medicines management and deprescribing in older adults.
General polypharmacy guidance
Within this section you will find links to guidance for conducting effective polypharmacy reviews.
- Polypharmacy Guidance - NHS Scotland and The Scottish Government (2012, updated )
Including the 7 steps to medication review, realistic prescribing, numbers needed to treat information. Also available to download as app.
- PrescQIPP Polypharmacy and deprescribing toolkit
Safe and appropriate medicines use, polypharmacy and deprescribing resources.
- Health Innovation Network (previously Academic Health Science Network) Polypharmacy Programme
National polypharmacy programme aimed at creating clinical, multi-stakeholder communities of practice across England, focusing on problematic polypharmacy within local areas.
- NHS Specialist Pharmacy Services Polypharmacy Resources
Resources complied by SPS on behalf of NHS England including tools which are useful to support medication reviews.
- Canadian Medication Appropriateness and Deprescribing Network and Deprescribing.org
Deprescribing resources including tools and algorithms for specific medicine groups, patient information and educational resources.
- New South Wales Therapeutic Advisory Group Deprescribing resources
Including guidance for deprescribing specific groups of medicines and information for patients.
- Deprescribing Guidance - Primary Care Tazmania
General information on deprescribing including a flowchart and guidance on stopping specific medicines or groups of medicines.
- Greater Manchester Medicines Management Group Polypharmacy Resource Pack
Resources on polypharmacy, deprescribing and structured medication reviews including resources for specific therapeutic areas, people living with frailty and in care homes.
- Polypharmacy in older people - A guide for healthcare professionals
All Wales Therapeutics and Toxicology Centre (nhs.wales) - a really helpful practical tool for deprescribing.
Explicit tools
These provide background, context and evidence-based framework for optimal use of medicines to support safe reviews (criterion based).
- STOPP/START tool vs3 2023
STOPP/START version 3 represents an updated explicit list of potentially inappropriate medications and potential prescribing omissions aimed at optimizing medication and minimizing adverse drug reactions and events during medication review in older people, particularly those with multimorbidity and polypharmacy.
- Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2
STOPPFrail comprises 27 criteria relating to medications that are potentially inappropriate in frail older patients with limited life expectancy. STOPPFrail may assist physicians in deprescribing medications in these patients.
- STOPPFall 2020 STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs
STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review for patients who are at risk of falls.
- Beers Criteria (Updated 2019)
The American Geriatric Society “Beers” criteria, first developed in 1992, provides a list of medications and types of medications that are either potentially inappropriate or should be used with caution in older people, including people with specific health conditions or poor kidney function.
- LESS-CHRON 2017 Spain Geriatr Gerontol Int 2017; 17: 2200–2207
The “LESS-CHRON (List of Evidence-baSed depreScribing for CHRONic patients) criteria” identify clinical situations for deprescribing drugs in chronic patients with multimorbidity.
- IMPACT (Improving Medicines and Polypharmacy Appropriateness Clinical Tool)
This bulletin provides suggestions for consideration by commissioning organisations and clinicians to optimise medicines use and provide practical advice (where it is available) about how to safely stop/ discontinue/withdraw a medicine and issues to consider.
- 10 step framework for Minimizing Inappropriate Medications in Older Populations
The framework aims to reduce drug use in older patients to the minimum number of essential drugs, and its utility is demonstrated in reference to a hypothetical case study.
- The FORTA (Fit fOR The Aged) List 2021: Fourth Version of a Validated Clinical Aid for Improved Pharmacotherapy in Older Adults
FORTA list addresses both over- and undertreatment, leading to patients’ medical needs being comprehensively met, detecting both potentially inappropriate medicines and potentially omitted medicines.
Implicit tools (judgement based)
Implicit tools require judgement, which means they can be subjective and demand more time and clinical expertise.
- Medication appropriateness index
Lists 10 criteria that evaluate various aspects of medication appropriateness (e.g. indication, effectiveness, dose).
- GARFINKEL'S PROCEDURE in Nursing Departments (drugstop.co.il)
Geriatric palliative methodology study aiming to identify and stop medication in frail patients and assessing intervention vs control group for reduction in mortality rates and referrals to acute care facilities, costs and quality of living.
- ARMOR
The ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) is an interactive tool which aims to combine recommendation from Beers’ criteria and patient’s functional state and clinical state aiming to balance evidence-based practice with altered physiological reserves.
- NO TEARS
The NO TEARS tool goes through process of medication review covering need and indication, open questions, tests and monitoring, evidence and guidelines, adverse events, risk reduction or prevention and simplification and switches.
Prescribing cascades
Prescribing cascades occur when a drug is prescribed to manage side effects of another drug, typically when a side effect is misinterpreted as a new condition.
- ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People
A nine-item consensus-based list of clinically important prescribing cascades, representing potentially inappropriate prescribing obtained via Delphi process.
- Are you the victim of a prescribing cascade? — Do I still need this medication? Is deprescribing for you? (deprescribingnetwork.ca)
Canadian website aimed at patients explaining what prescribing cascades are and how to manage them.
Shared decision making
Shared decision-making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process through which a clinician supports a patient to reach a decision about their treatment. The conversation brings togethert the clinician’s expertise (such as treatment options, evidence, risks and benefits) with what the patient knows best (their preferences, personal circumstances, goals, values and beliefs).
- Choosing Wisely
Choosing Wisely campaign aims to spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.
- Me & My Medicines, Medicines Communication Charter, It's OK to Ask
‘Me and My Medicines’ is a campaign led by patients and supported by clinical staff to help people raise concerns and use their medicines better.
- Realistic Medicine
Realistic medicine aims to encourage meaningful conversations between health and social care professionals and their service users to base care around what matters most to people, with a shared understanding of what healthcare might realistically contribute to this.
Medicines and falls resources
Medication review forms an essential part of multifactorial falls risk assessment. Below are useful resources for health care professionals undertaking this activity.
- Medicines and Falls National Falls Prevention Co-ordination Group endorsed by Royal Pharmaceutical Society
Guidance to support medication review by healthcare professionals in patients at risk of falls, created on behalf of National Falls Prevention Coordination Group.
- STEADi
STEADI-Rx was designed to improve collaboration between healthcare providers and pharmacists and is based on CDC's STEADI (Stopping Elderly Accidents, Deaths, & Injuries) initiative. STEADI-Rx provides guidance to pharmacists on how to screen pharmacy patients, assess their medications, and intervene to reduce fall risk.
- STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk to help identify and review falls risk increasing drugs)
STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review in patients at risk of falls.
- Medication and falls - PresQUIPP
This bulletin and resources highlight medicines that can increase the risk of falls in older people. Guidance is provided on deprescribing Fall-Risk-Increasing Drugs (FRIDs) and when deciding whether to initiate medicines in older people at risk of falls.
Fracture risk assessment and bone health
Fracture risk assessment and management of bone health forms an integral part of frailty care. Below are useful tools and guidance to aid decision making and treatment choice.
- FRAX ®Fracture Risk Assessment Tool
UK calculator used to estimate 10-year major osteoporotic fracture risk and hip fracture risk based upon demographic, lifestyle and clinical data.
- Clinical Guideline for the prevention and treatment of osteoporosis from National Osteoporosis Guideline Group
This guideline is used to review the assessment and diagnosis of osteoporosis, the therapeutic interventions available and the approaches for the prevention of fragility fractures, in postmenopausal women, and in men aged 50 years or older.
- Management of osteoporosis and the prevention of fragility fractures (sign.ac.uk)
This guideline provides recommendations based on current evidence for best practice in the management of osteoporosis and prevention of fractures. It addresses risk factors for fracture, commonly used tools for fracture risk assessment, approaches to targeting therapy, pharmacological and non-pharmacological treatments to reduce fracture risk in different patient groups, treatment of painful vertebral fractures and systems of care.
- QFracture
You can use this calculator to work out your risk of developing any osteoporotic (i.e. hip, wrist, shoulder or spine) fracture or hip fracture alone by answering some simple questions intended for use in the UK.
End of life
Preparing for the end of life and jointly making decisions about treatment choices are important aspects of care of the older person. The following resources may be useful when undertaking this task.
- Medication Review and Rationalisation of Medicines for Adult Patients with a Limited Prognosis
This guidance is intended for use by healthcare professionals in any care setting when conducting a structured medication review and optimising medication for patients with a limited prognosis (days to short years) due to advanced age, frailty, comorbidity and/or disease, where the goals of care are moving towards optimising symptoms and quality of life rather than prolonging survival.
Opioid review
Historically, opioids have been prescribed to manage chronic pain; however, the clinical evidence shows limited effectiveness and patient safety concerns due to the risks associated with long-term use of opioids such as fractures and falls, endocrine abnormalities, immunomodulation, opioid induced hyperalgesia and dependence.
- NHS Greater Manchester Integrated Care - Opioid Prescribing for Chronic Pain: Resource Pack
This document brings together several resources clinicians can use to support the appropriate use and review of opioids used for chronic pain. The information in this document does not apply to palliative care and end of life care where use of opioids should follow the World Health Organisation (WHO) pain ladder and relevant guidance.
- Live Well with Pain
Resources aimed at patients who are living with pain and clinical practitioners managing those living with pain.
- Improving the management of non cancer pain – reducing harm from opioids
Management of ‘chronic non-cancer pain’ requires personalised care and shared decision making at its core with patients requiring a mixture of biopsychosocial support. A whole system approach is proposed to support people to live well with their ‘chronic non-cancer pain’ - this website shares impact and outcomes.
Reviewing antipsychotics
In some people antipsychotics can eliminate or reduce the intensity of certain symptoms. However, they also have serious side effects for people living with dementia. There is concern over the high rates of antipsychotic prescribing in people with dementia due to the associated risks often outweighing the benefits. As such, antipsychotics should only be considered as a last resort in dementia.
- Guidance for reviewing antipsychotics in people living with dementia
This toolkit provides expert, evidence-based practical advice and guidance on risk reduction when using antipsychotic medication in patients with dementia and support with deprescribing where appropriate.
Reviewing antidepressants
Antidepressants have an important role in the therapeutic management of depression and anxiety, when used appropriately in line with the NICE guidelines. However, antidepressant use can become inappropriate which may lead to patient harm from problematic polypharmacy, adverse-effects, or both.
- Deprescribing of antidepressants for depression and anxiety – Specialist Pharmacy Service
Useful resources that are available free-of-charge to help plan and support deprescribing of antidepressants in practice.
- Guidance for safe withdrawal of antidepressants
Pharmaceutical Journal article presenting a case of safe antidepressant withdrawal.
- Stopping antidepressants (rcpsych.ac.uk)
Guidance from the Royal College of Psychiatrists.
Supporting adherence
Resources aimed at healthcare professionals to help them discuss options for medicines management (to support adherence) with patients.
- Managing medication - a guide to assist health and social care workers in conversations with people
A guide to assist health and social care practitioners in conversations around medicines management.
- Getting the most from your medicines - Age UK
Age UK summary on how to get the most from your medicines and what pharmacy services are available to support patients with safe medication management.
- Defining and understanding medication adherence – SPS - Specialist Pharmacy Service
Definitions, evidence and the importance of effective consultations, with tools and interventions to facilitate medication adherence.
- MCA Stability Tool
Medicines in Compliance Aids Stability Tool
Anticholinergic burden
Many of the medications that we commonly prescribe have anticholinergic properties. In patients over 65 years of age these can cause adverse events, such as confusion, dizziness and falls.
- Canadian Medication Appropriateness and Deprescribing Network - do I still need this medicine (anticholinergics)
Canadian website aimed at patients explaining what anticholinergics are and how to address the risk if you are taking these medicines.
- ACB Calculator (calculates total anticholinergic burden including peripheral effects)
ABC Calculator allows end user to calculate total anticholinergic burden including peripheral effects and was created using the German Anticholinergic Burden score and the Anticholinergic Cognitive Burden scale.
- Anticholinergic Effect on Cognition Tool (calculates central anticholinergic burden)
Medicheck Calculator allows end user to calculate central anticholinergic burden and provides information on QTc prolongation, hyponatraemia, bleeding, dizziness, drowsiness and constipation.
Monitoring specific medicines/groups of medicines
As part of effective medicines optimisation care, it is important to note monitoring requirements and in particular how these may change in older patients. The following resources provide further information on this subject.
- Specialist Pharmacy - Service Drug monitoring
Summarised recommendations and guidance for medication requiring monitoring with drug specific advice.
- Care of the elderly – SPS - Specialist Pharmacy Service – Management of specific conditions in older patients
Condition-specific guidance focused on the needs of older patients for multiple cardiovascular conditions and polypharmacy documents including taking a person-centred approach to managing polypharmacy.
- NICE BNF Medicines guidance - Prescribing in the elderly
BNF summary on safe prescribing advice in older patients including discussion on forms, adverse drug reactions, pharmacokinetics and particular groups of drugs associated with harm.
- Drug Interactions Flockhart Table ™
This table is designed as a teaching and reference tool for health care providers and researchers interested in drug interactions that are mediated by cytochrome P450 enzymes.
- Renal Drug Database
The Renal Drug Database is a digital tool for pharmacists, clinicians, and other healthcare professionals prescribing for patients with renal disease and who receive renal replacement therapy. (Requires subscription to access).
- CredibleMeds
QT Drugs List: This portal includes QTdrugs.org, a list of drugs categorized by their potential to cause QT prolongation and/or Torsades de pointes (TdP).
Cardiovascular risk and medication
Useful references when assessing cardiovascular risk and considering polypharmacy in frailty patients is listed below.
- QRISK®3-2018 risk calculator
This site estimates a person's risk of developing a heart attack or stroke over the next 10 years.
- Statin Intolerance Pathway - NHS England
Pathway for managing patients at high risk of CVD events who report statin intolerance.
- SPARCtool
Link to calculators which allow patients and clinicians to estimate cardiac events risk.
- U-prevent
Link to calculators which allow patients and clinicians to estimate cardiac events risk.
- ‘Frailty’ in Care of the elderly – SPS - Specialist Pharmacy Service
Guidance on management of cardiovascular conditions in frail patients.
Swallowing difficulties
Patients who have swallowing difficulties are commonly encountered in frailty. Resources below offer advice on managing medication in this cohort.
- Swallowing difficulties – SPS - Specialist Pharmacy Service
Series of articles on swallowing difficulties including choosing the correct formulation, preparing and administering medicines, examples of treatment modification in certain conditions, thickeners and enteral tubes.
Enteral feeding
Use of enteral feeding and administration of medicines via enteral tubes resources.
- Enteral feeding and medicines administration - CQC
CQC advice on considerations to note with regards to medicines administration via enteral tubes.
- Handbook of Drug Administration via Enteral Feeding Tubes
The information provided in this resource is intended to support healthcare professionals in the safe and effective prescribing and administration of drugs via enteral feeding tubes. It is a comprehensive guide covering the legal, practical and technical aspects that healthcare professionals should consider before attempting to prescribe or administer drugs via an enteral feeding tube.
- Rosemont
Catalogue of liquid medication available including licenced and special preparations.
Inhalers
Multiple inhaler options and combinations are available for treatment of respiratory conditions – the following are useful resources for patients and prescribers.
- How to use a pMDI inhaler with a spacer – tidal breathing | Asthma + Lung UK (asthmaandlung.org.uk)
Asthma UK guide on correct use methodology for inhalers with a spacer.
- RightBreathe
There are over 120 inhaler device & drug combinations licensed for the treatment of respiratory disease in the UK and it can be challenging for clinicians and patients to identify the product which best meets individual needs. RightBreathe is a web-based resource which provides detailed information on all UK-licensed inhaler products. It is designed to support joint decision-making about product choice and to facilitate appropriate prescribing.
Medication withdrawal
Useful references to aid shared decision making when deprescribing in frailty.
- DePrescribing in Frailty
A summary of deprescribing advice based around therapeutic areas and clinical frailty from Gloucestershire Medicines Management team.
- Deprescribing in People Living with Frailty, Multimorbidity and Polypharmacy
Review article of best practice for clinical teams undertaking deprescribing activities.
Sleep
Sleep problems are commonly reported by patients. Below is a list of resources aimed at healthcare professionals and patients on addressing insomnia.
- Sleepio to treat insomnia and insomnia symptoms - NICE
NICE Medical Technology Guidance for using Sleepio in primary care. See also Onboarding Sleep Test - Sleepio.
- Material to support appropriate prescribing of hypnotics and anxiolytics across Wales - All Wales Therapeutics and Toxicology Centre (nhs.wales)
This educational pack aims to support the appropriate prescribing of hypnotics and anxiolytics across Wales by providing key health professionals with a practical approach for the initiation and review of hypnotic and anxiolytic prescribing. It includes examples of support material which can be used or adapted for this purpose.
- Sleep problems and insomnia self-help guide - NHS inform
Work through a self-help guide that uses cognitive behavioural therapy (CBT) and expert advice to manage sleep problems.
- Fall asleep faster and sleep better - Every Mind Matters - NHS
Resource aimed at patients with advice on ways to help sleep, including sleep hygiene, and expert video advice from a professor of sleep medicine at the University of Oxford.
Medication podcasts on care of the older adult
Podcasts are available discussing issues of polypharmacy, deprescribing and care of older patients.
- Medication – The Hearing Aid Podcasts
MD Tea Podcasts focused on pain control, polypharmacy and describing a day in the life of pharmacist.
- Humanising Healthcare podcast - Personalising the use of medicines in older people | Feature from King's College London (kcl.ac.uk)
Manasi is joined by Dr Jennifer Stevenson, Lead Pharmacist Older Adults/Honorary Senior Lecturer and Dr Carly Welch, Clinical Senior Lecturer on the episode ‘Personalising the use of medicines in older people.’ They discussed polypharmacy, the move towards ‘deprescribing’ medicine, and how ageing can affect the way the body absorbs medicines.
- The Aural Apothecary
An authentic yet lighthearted take on the world of medicines and healthcare in the UK.
Treatment targets
Treatment targets in guidelines do not always account for frailty state and how diminished reserves affect response to treatment. The following articles provide some guidance around treatment targets in frailty.
- Hypertension management in frail older people - SPS – Specialist Pharmacy Services
Guidance on targets for blood pressure in frailty.
- 2024 ESC Guidelines for the management of elevated blood pressure and hypertension
European Guidelines with advice for adjustment in frailty.
- Managing frailty and associated comorbidities in older adults with diabetes: Position Statement on behalf of the Association of British Clinical Diabetologists (ABCD)
The Association of British Clinical Diabetologists has produced this Position Statement in order for its recommendations to be implemented within the NHS in the UK, to promote improved quality care for older people with diabetes and frailty, as well as guidance on managing the inevitable comorbidities that are present.
- Inpatient Care of the Frail Older Adult with Diabetes - JBDS
JBDS has produced this guideline in order for its recommendations to be implemented within the NHS in the United Kingdom to promote improved quality care for older inpatients with diabetes and frailty, since evidence is emerging that frailty has a significant impact on inpatients in terms of increased adverse outcomes and reduced survival.
