Fphar-2021-734045 1..15

SYSTEMATIC REVIEW
published: 26 November 2021

doi: 10.3389/fphar.2021.734045
Polypharmacy Management in the

Older Adults: A Scoping Review of
Available Interventions
M. Kurczewska-Michalak 1*, P. Lewek 1, B. Jankowska-Polańska 2, A. Giardini 3, N. Granata 4,
M. Maffoni 4, E. Costa 5, L. Midão 5 and P. Kardas 1
1
Department of Family Medicine, Medical University of Lodz, Lodz, Poland, 2Department of Clinical Nursing, Faculty of Health
Science, Wroclaw Medical University, Wroclaw, Poland, 3IT Department, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy,
4
Psychology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Montescano Institute, Pavia, Italy, 5UCIBIO/REQUIMTE, Faculty of
Pharmacy and Porto4Ageing, University of Porto, Porto, Portugal
Background: Polypharmacy paves the way for non-adherence, adverse drug reactions,
negative health outcomes, increased use of healthcare services and rising costs. Since it is
most prevalent in the older adults, there is an urgent need for introducing effective
Edited by: strategies to prevent and manage the problem in this age group.
Fabiane Raquel Motter,
University of Sorocaba, Brazil Purpose: To perform a scoping review critically analysing the available literature referring
Reviewed by: to the issue of polypharmacy management in the older adults and provide narrative
Li-Chia Chen,
The University of Manchester,
summary.
United Kingdom
Data sources: Articles published between January 2010–March 2018 indexed in
Anthony Kar Hsing Chan,
Pfizer, Ireland CINHAL, EMBASE and PubMed addressing polypharmacy management in the older
adults.
*Correspondence:
M. Kurczewska-Michalak
Results: Our search identified 49 papers. Among the identified interventions, the most
[email protected]
often recommended ones involved various types of drug reviews based on either implicit or
Specialty section: explicit criteria. Implicit criteria-based approaches are used infrequently due to their
This article was submitted to subjectivity, and limited implementability. Most of the publications advocate the use of
Drugs Outcomes Research and
Policies, explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index
a section of the journal (MAI). However, their applicability is also limited due to long lists of potentially inappropriate
Frontiers in Pharmacology
medications covered. To overcome this obstacle, such instruments are often embedded in
Received: 30 June 2021
computerised clinical decision support systems.
Accepted: 26 October 2021
Published: 26 November 2021
Conclusion: Multiple approaches towards polypharmacy management are advised in
Citation:
current literature. They vary in terms of their complexity, applicability and usability, and no
Kurczewska-Michalak M, Lewek P,
Jankowska-Polańska B, Giardini A, “gold standard” is identifiable. For practical reasons, explicit criteria-based drug reviews
Granata N, Maffoni M, Costa E, seem to be advisable. Having in mind that in general, polypharmacy management in the
Midão L and Kardas P (2021)
Polypharmacy Management in the older adults is underused, both individual stakeholders, as well as policymakers should
Older Adults: A Scoping Review of strengthen their efforts to promote these activities more strongly.
Available Interventions.
Front. Pharmacol. 12:734045. Keywords: polypharmacy, elderly, older adults, adverse drug event, adverse drug reaction, explicit criteria,
doi: 10.3389/fphar.2021.734045 inappropriate prescribing, multimorbidity
Frontiers in Pharmacology | www.frontiersin.org 1 November 2021 | Volume 12 | Article 734045

Kurczewska-Michalak et al. Polypharmacy Management in the Older Adults
INTRODUCTION primary care physicians in England care for patients with

multimorbidity in 78% of their consultations (Salisbury et al.,
Recently, polypharmacy (also called polytherapy or 2011), whilst in several other settings, e.g., geriatrics, this
polypragmasy) became an important public health problem percentage may reach 100%.
due to its far-reaching consequences, such as possible negative Ageing and multimorbidity, i.e., two interlinked factors
effects on individual health, as well as increased use of healthcare mentioned above, are to a large extent responsible for the
services and costs (Fried et al., 2014). In particular, polypharmacy observed rapid rise in global prevalence of polypharmacy
is known to cause a higher risk of adverse drug events and drug- (Guthrie et al., 2015). However, the current paradigm of
drug interactions. It also often leads to medication non- healthcare seriously increases the chances of polypharmacy in
adherence. All these provide negative health outcomes as well the older adults as well. Undoubtedly, it is a consequence of
as increased risk of geriatric syndromes (e.g., cognitive single-disease oriented guidelines promoting pharmacotherapy
impairment, or falls). This, in turn, leads to increased risk of as a routine solution. This approach leads to undesirable effects,
hospitalization and institutionalization, as well as much greater such as difficulties in integrating care in multimorbidity cases,
health care expenditures (Maher et al., 2014). Therefore, poor communication between patients, carers and their multiple
polypharmacy is considered to be “one of the greatest care providers, and a lack of patient-focused (rather than
prescribing challenges” (Payne and Avery, 2011). condition-focused) care plans (Boyd et al., 2005; May et al.,
Obviously, polypharmacy is not limited to older adults. 2009). Unfortunately, the guidelines only seldom tend to
Nevertheless, the highest prevalence of this scenario comes address the complex nature of multimorbidity trying to
with older age. A nationwide cohort study in Sweden among address it from the patient’s perspective in order to prioritize
individuals aged ≥65 has found prevalence of polypharmacy certain conditions or treatments over the other ones, thus
reaching 44%, and prevalence of extreme polypharmacy reducing the burden of prescribed drugs (Montori et al., 2013;
(defined as taking ten drugs or more) of 11.7% (Morin et al., Farmer et al., 2016). Similarly, “defensive medicine” makes the
2018). Data from the United Kingdom highlight that 20.8% of initiation of therapy easy and always correct, contrary to a more
individuals with two clinical conditions have been prescribed four conservative approach which accepts that not every condition is
to nine medicines, whereas 10.1% of them—ten or more automatically the reason for taking a medication, thus giving both
medicines. In patients with six or more comorbidities, relevant the prescriber and the patient more freedom in making their
values were 47.7 and 41.7%, respectively, and these figures choices based on accepted priorities (Austad et al., 2016).
increased with age (Barnett et al., 2012). In Poland, Despite the significance of the problems created by
polypharmacy has been observed among 55.0% of the citizens polypharmacy in the older adults, this subject is only seldom
aged 80+ (Kardas et al., 2021). Scottish data show that around tackled in European countries in a systematic way. An extensive
35% of those aged 85 years and above receive more than ten search for polypharmacy guidance documents (both published in
medicines (Stewart et al., 2017a). A recent analysis of a large peer-reviewed journals and made available as grey literature)
European cohort has found polypharmacy (defined as concurrent performed recently across Europe has identified only five
use of five or more medications) to be present in 32.1% of citizens European countries that actually have such documents
aged 65 years or above, ranging from 26.3 to 39.9% across the targeting older patients (Stewart et al., 2017a).
studied countries (Midão et al., 2018). High prevalence of There is a variety of tools aimed at reduction of inappropriate
polypharmacy in the older adults has also been observed polypharmacy using either implicit (judgement-based) or explicit
outside Europe, e.g., in countries such as Brazil (Pereira et al., (item list-based) criteria (Kaufmann et al., 2014). Unfortunately,
2017) and United States (Quinn and Shah, 2017). their practical implementation in older adults care is very limited.
Thus, the burden of polypharmacy is a direct consequence of Recent research shows that healthcare professionals (HCPs) are
demographic challenge which, though observed worldwide, is often either unaware of such tools or disregard them as not being
particularly pronounced in Europe. According to Eurostat data, user-friendly (Mc Namara et al., 2017). For example, the use of
currently those aged 65 years or above, account for 19.2% of the various forms of drug reviews has been reported in half of 32
European Union’s population, and this proportion is expected to studied European countries only (Bulajeva et al., 2014).
rise up to 29.1% by 2080, whereas percentage of those aged over Under such circumstances, healthcare professionals should be
80 years, is expected to increase even more dramatically—from supported and motivated to implement polypharmacy targeting
the present 5.4–12.7% (Eurostat (2015). People i, 2015). interventions. Therefore, the overall aim of this paper was to
The longer citizens live, the higher are the chances of summarize available information on the methods to prevent and
multimorbidity which is defined by the World Health manage polypharmacy in the older adults. Accepting the
Organization as “the co-occurrence of two or more chronic perspective of practical approach and pragmatic guidance to
medical conditions in one person” (World Health polypharmacy management, the objective of this scoping
Organization, 2008). Prolonged life expectancy, the privilege of review was to map available interventions and more complex
people living in the 21st century, means much longer years lived strategies, and discuss their implementability. The rationale
with chronic conditions the number of which grows even more behind the approach was a common belief that there is no
with age. Current statistics estimate that over 70% of people aged “one-size-fits-all” solution for polypharmacy management in
over 65 years are affected by multimorbidity (National Guideline the older adults. Therefore, in order to help HCPs select an
Centre, 2016). It has a major impact on healthcare systems, e.g., approach that would satisfy their requirements best and increase

overall application of polypharmacy management, the literature publication, country of origin, type of the publication,
search strategy was designed to identify the scientific publications definitions of polypharmacy used by the authors, target for
detailing a broad spectrum of interventions available for intervention (i.e., multimorbidity or individual disease typical
polypharmacy management in the older adults. In order to for elderly people), characteristics of intervention, settings,
reflect the state-of-the-art findings, the literature search was healthcare professionals involved in/suggested to deliver the
limited to items published from 2010 onward. intervention, and results of intervention implementation (for
publications assessing implementation of interventions only).
The extracted data are presented in the Supplementary
MATERIALS AND METHODS Online Material S2. Further elaboration of the extracted data
involved grouping according to the predefined criteria and a
Search Strategy statistical analysis with descriptive statistics. The final analysis of
In this review, the Preferred Reporting Items for Systematic the extracted data took the form of a narrative, descriptive
Reviews and Meta-Analyses (PRISMA) guidelines were followed summary and synthesis.
(Moher et al., 2009). The electronic databases, i.e., CINHAL,
EMBASE and PubMed, were systematically searched in
accordance with the predefined literature search strategy based RESULTS
on a various combination of keywords including “polypharmacy”
and its equivalents, terms corresponding to a systematic approach Characteristics of Selected Studies
to polypharmacy management, such as “intervention” etc., and The literature search included 244 publications. Subsequently,
various identifiers of older age. The Supplementary Online 127 duplicates were removed, and the titles and abstracts of the
Material S1 provides the combination of search terms that were remaining 117 articles were reviewed, which resulted in
used to identify relevant publications. elimination of 67 papers that did not meet the inclusion
criteria. A further detailed review of the full-text articles led to
Inclusion Criteria elimination of another paper. A final set of 49 articles that met the
Publications were included if: (A) they outlined interventions inclusion criteria was accepted for synthesis. For details of article
addressing polypharmacy (however, not implementation of screening and the exclusion process, see the PRISMA flow chart
guidelines) in the older adults in any of the following settings: in Figure 1. The identified publications originated from a variety
1) clinical practice, 2) health care systems, 3) scientific research; of European as well as non-European countries and included
and (B) they were published in the years between 2010 and 2018. original articles, reviews, systematic reviews, randomized
What is noteworthy is that the definition of an “intervention” was controlled trials and guidelines. A few papers were focused on
not explicit in order to allow for a broad spectrum of search one specific disease characteristic for older people [e.g., diabetes
results that could be of potential interest to the readers. Similarly, (Dunning, 2017), hip fracture (Komagamine and Hagane, 2017),
we accepted various definitions of the “elderly” used by the etc.], whereas a majority of the publications did not define the
authors, not limited to the traditional convention defining the type of disease. One study was focused on the patients with
“elderly” as those aged 65 years or above. (Orimo, 2006). multimorbidity (Bokhof and Junius-Walker, 2016). All the
reviewed studies were focused on elderly patients.
Exclusion Criteria
Articles were excluded if they: 1) were not peer-reviewed; 2) were Aims of Identified Interventions
written in a language other than English; 3) were not devoted to Across the reviewed literature, some attention is paid to
interventions addressing polypharmacy; or 4); did not present prevention of polypharmacy. Optimal or appropriate
intervention descriptions in full details (e.g., letters, comments, prescribing was advised as a general method of polypharmacy
conference proceedings, editorials, erratum, etc., as opposed to prevention (Kaufman, 2011; Nobili et al., 2011; Cadogan et al.,
original articles, reviews, systematic reviews, randomized 2015; Cadogan et al., 2016; Cadogan et al., 2017). This
controlled trials and guidelines). recommendation, however, was not necessarily followed by
detailed practical guidance. Only one publication provides
Study Selection recommendations on how to prevent polypharmacy in very
Studies meeting the inclusion criteria were initially selected, based specific patients, i.e., critically ill older adults who, when
on screening the titles and abstracts by one researcher (PL). staying at an intensive care unit, are at risk of developing
Copies of full-text papers considered as potentially relevant after delirium (Garpestad and Devlin, 2017). In fact, strategies of
the first screening were then fully analysed independently by two polypharmacy management identified in our search
researchers (out of the three: BJ-P, MK-M, and PL). In the case of predominantly target correction of polypharmacy. Specific
different opinions on possible inclusion of an article into the aims of relevant interventions include one or several out of
study, the third author (PK) was consulted to reach a consensus. the below-listed ones:
Data Extraction Process and Analysis 1. Reduction of polypharmacy (lowering the number of drugs
The data was extracted from each eligible paper according to the prescribed and/or used)
predefined framework which included the source, year of 2. Increasing the use of a recommended medication

their active role in addressing polypharmacy is currently very

low (Schöpf et al., 2017).
Thus, the reviewed literature supports the use of interventions
targeting polypharmacy which are initiated by healthcare
professionals. A suggested trigger to employ such an
intervention is just presence of polypharmacy in an older
adult. This advice, however, is not easy to implement due to
current lack of common standard definition of polypharmacy. In
fact, the authors adopted various existing definitions, as
illustrated in Table 1. Among them, the most commonly used
definition of polypharmacy was taking concurrently five or more
medications. However, in some publications other threshold
values were also used, ranging from 1 to >9. Moreover, in
several papers a qualitative approach to polypharmacy
definition was preferred and the most common one was the
imprecise definition describing it as “the use of a number of
different medicines possibly prescribed by different doctors and
often filled in different pharmacies, by a patient who may have
one or several health problems” (Kaufman, 2011; Nobili et al.,
2011; Clyne et al., 2016; Dunning, 2017; Lin et al., 2018). Finally,
in nine papers the operational definition of polypharmacy was
not precisely detailed (Planton and Edlund, 2010; Sergi et al.,
2011; Mansur et al., 2012; Van der Linden et al., 2014;
Yamanouchi et al., 2014; Cadogan et al., 2016; Garpestad and
Devlin, 2017; Heaton et al., 2017; McNicholl et al., 2017) leaving it
open to individual interpretation.
Who Should Provide a Polypharmacy

Management Intervention
The reviewed literature pointed to a range of healthcare
professionals who may or should provide polypharmacy
FIGURE 1 | PRISMA flow chart of the literature search and study
addressing intervention. The most common setting in which
selection. Note: * Excluded due to not detailing interventions to manage polypharmacy management interventions were most successful
polypharmacy (56 items) or not meeting other eligibility criteria (e.g., not was primary care and they were implemented either by GPs, or by
providing the details of the intervention, 11 items in total); # excluded for primary healthcare team (Kaufman, 2011; Nobili et al., 2011;
not meeting eligibility criteria (non-English-language publication).
Sabzwari et al., 2013; Bergert et al., 2014; Kann et al., 2015; Bokhof
and Junius-Walker, 2016; Cadogan et al., 2016; Clyne et al., 2016;
Sinnige et al., 2016; Cadogan et al., 2017; Franco et al., 2017;
3. Lowering the costs (drug costs, and/or overall healthcare Schöpf et al., 2017; Tommelein et al., 2017). However, some
system expenditures) interventions were provided at community or hospital
4. Enhancing patient adherence to medication pharmacies, by pharmacists alone, in the form of
5. Increasing effectiveness of drug therapy (e.g., avoidance of pharmaceutical care, or in cooperation with a physician, e.g.,
hospitalisations, etc.) under an umbrella of collaborative physician-pharmacist
6. Securing patient safety (e.g., avoidance of adverse drug medication therapy management (MTM) program (Mansur
reactions) et al., 2012; Patterson et al., 2012; Doan et al., 2013; Cooper
et al., 2015; Jódar-Sánchez et al., 2015; Wilson et al., 2015;
Targets of Identified Interventions Cadogan et al., 2016; Chau et al., 2016; Jokanovic et al., 2017;
Although the role of patients is emphasized, and relevant Komagamine and Hagane, 2017; Malet-Larrea et al., 2017;
recommendations include better patients’ health literacy McNicholl et al., 2017; McNicholl et al., 2017; Tommelein
and awareness of their complex multiple medication et al., 2017; Lin et al., 2018). Specialists who are perfectly
regimens (Bokhof and Junius-Walker, 2016), patients are prepared to take care of polypharmacy in the older adults are
not perceived as those who actively initiate any formalised geriatricians, thus relevant interventions could be included in the
action against polypharmacy. In fact, it is also suggested that geriatric consultation (Eyigor and Kutsal, 2012; Kojima et al.,
general practitioners (GPs) might support patients by 2014; Van der Linden et al., 2014). Finally, other settings also
“inviting” their contribution to polypharmacy and allow for polypharmacy interventions which have been
medication safety, as their awareness of the significance of successfully provided in various hospital settings such as

TABLE 1 | Definition of polypharmacy used in reviewed publications.
Definition of polypharmacy
Type of definition — — References
Numerical Number of medications Number of studies —
1 1 Bokhof and Junius-Walker, (2016)

>3 1 Zelko et al. (2016)
≥4 7 Kaufman. (2011); Patterson et al. (2012); Patterson et al.
(2014); Cooper et al. (2015); Stewart et al. (2017b);
Cadogan et al. (2017); Patton et al. (2017)
>5 2 Doan et al. (2013); Kim and Parish. (2017)
≥5 17 Clyne et al. (2012); Eyigor and Kutsal (2012); Sabzwari
et al. (2013); Bergert et al. (2014); Jódar-Sánchez et al.
(2015); Kann et al. (2015); Chau et al. (2016); Sharma
et al. (2016); Sinnige et al. (2016); Urfer et al. (2016);
Franco et al. (2017); Kaufman. (2017); Komagamine and
Hagane. (2017); Malet-Larrea et al. (2017); Schöpf et al.
(2017); Tommelein et al. (2017); Lin et al. (2018)
5–9 1 Harugeri et al. (2010)
≥9 2 (Kojima et al. (2014); Jokanovic et al. (2017))
Qualitative Definition Number of studies References
1. The use of a number of different medicines possibly prescribed 5 Kaufman. (2011); Nobili et al. (2011); Clyne et al. (2016);
by different doctors and often filled in different pharmacies, by a Dunning. (2017); Lin et al. (2018)
patient who may have one or several health problems
2. The use of multiple medicines and/or more medicines than 4 Patterson et al. (2014); Wilson et al. (2015); Rodrigues
clinically indicated and Oliveira. (2016); Levy. (2017)
3. Prescribing of multiple medicines (this includes “inappropriate 1 Stewart et al. (2017a)
polypharmacy” and “appropriate polypharmacy”)
4. At risk of inappropriate prescribing and adverse drug events 1 Hughes et al. (2016)
teaching hospitals (Harugeri et al., 2010; Urfer et al., 2016; Lin many residents may require reviews more often. (National Institute
et al., 2018), acute care hospitals (Komagamine and Hagane, for Health and Clinical Excellence, 2015) Obviously, practical
2017), acute geriatric wards (Mansur et al., 2012; Van der Linden implementation of relevant interventions is limited by many
et al., 2014). It is worth emphasizing that such interventions are factors, such as the availability of qualified staff, a paradigm of
also advisable in the case of residential aged care facilities (Kojima the local healthcare system, reimbursement of the intervention, etc.
et al., 2014; Jokanovic et al., 2017). Some studies highlight the
need for an interdisciplinary approach, e.g., in order to execute Details of Identified Interventions
Comprehensive Geriatric Assessment (CGA), the authors suggest Full list of all types of interventions identified in the reviewed
an interdisciplinary team comprising nurses, occupational and studies is presented in Table 2.
physical therapists, social workers, general practitioners and For obvious reasons, effective management of polypharmacy
geriatricians (Sergi et al., 2011). should start with its prevention. Appropriate prescribing is the
method that undoubtedly satisfies this expectation. Thus, a
thorough risk–benefit analysis of each medicine should be made
How Often Should an Intervention Be whenever any drug is prescribed (Kaufman, 2011; Nobili et al., 2011;
Provided Bokhof and Junius-Walker, 2016; Cadogan et al., 2016; Cadogan et al.,
The available literature does not pay much attention to the 2017). If, however, polypharmacy is already in place, deprescribing is
question of how often interventions targeting polypharmacy another logical step to be taken, as suggested by several publications
should be repeated. According to one publication included in (Bokhof and Junius-Walker, 2016; Sharma et al., 2016; Urfer et al.,
our review, GPs should scrutinize senior people’s medications 2016; Jokanovic et al., 2017; Kaufman, 2017; Komagamine and
on each consultation whenever a patient meets the criteria of Hagane, 2017; Schöpf et al., 2017). Although not limited to, the
polypharmacy (Dunning, 2017). The recently published WHO concept, aims, and practice of deprescribing overlap much with
report on medication safety in polypharmacy generally polypharmacy management. One of its definitions describes it as
recommends that “appropriate polypharmacy should be “the process of withdrawal of an inappropriate medication, supervised
considered at every point of initiation of a new treatment for by a health professional with the goal of managing polypharmacy and
the patient, and when the patient moves across different health care improving outcomes” (Reeve et al., 2015). This broad concept has
settings.” (World Health Organization, 2019) As for residents of been supported by specific guidance, e.g., patient-centred
care homes, the NICE guidelines advise that an interval in deprescribing strategy, proposed in one of the publications
medication reviews “should be no more than 1 year” and that (Kaufman, 2017). The strategy includes five steps: 1.

TABLE 2 | Polypharmacy interventions identified in reviewed publications.
Intervention Number of References

publications
Optimal/appropriate prescribing 5 Kaufman (2011); Nobili et al. (2011); Cadogan et al. (2015); Cadogan et al. (2016); Cadogan
et al. (2017)
Deprescribing 7 Bokhof and Junius-Walker (2016); Sharma et al. (2016); Urfer et al. (2016); Jokanovic et al.
(2017); Kaufman (2017); Komagamine and Hagane (2017); Schöpf et al. (2017)
Drug review 18 Planton and Edlund (2010); Kaufman, (2011); Nobili et al. (2011); Sergi et al. (2011); Kojima
et al. (2014); Wilson et al. (2015); Chau et al. (2016); Hughes et al. (2016); Sharma et al.
(2016); Urfer et al. (2016); Stewart et al. (2017b); Cadogan et al. (2017); Dunning (2017);
Jokanovic et al. (2017); Kaufman (2017); Komagamine and Hagane (2017); Levy (2017);
McNicholl et al. (2017)
Medication review with follow-up (MRF) 2 Jódar-Sánchez et al. (2015); Malet-Larrea et al. (2017)
Comprehensive program of polypharmacy 1 Kaufman, (2017)
management
Pharmaceutical care 3 Patterson et al. (2012); Cooper et al. (2015); Tommelein et al. (2017)
Collaborative physician—pharmacist medication 1 Lin et al. (2018)
therapy management (MTM)
Comprehensive Geriatric Assessment 4 Sergi et al. (2011); Eyigor and Kutsal (2012); Sharma et al. (2016); Pazan and Wehling
(2017)
Validated
screening tools
STOPP/START 19 Nobili et al. (2011); Sergi et al. (2011); Eyigor and Kutsal (2012); Patterson et al. (2012);
Bergert et al. (2014); Patterson et al. (2014); Cooper et al. (2015); Chau et al. (2016); Clyne
et al. (2016); Hughes et al. (2016); Rodrigues and Oliveira (2016); Sharma et al. (2016); Urfer
et al. (2016); Cadogan et al. (2017); Franco et al. (2017); Kim and Parish (2017);
Komagamine and Hagane (2017); Levy (2017); McNicholl et al. (2017)
Beers criteria 17 Planton and Edlund (2010); Nobili et al. (2011); Sergi et al. (2011); Eyigor and Kutsal (2012);
Patterson et al. (2012); Sabzwari et al. (2013); Kojima et al. (2014); Patterson et al. (2014);
Cooper et al. (2015); Clyne et al. (2016); Hughes et al. (2016); Rodrigues and Oliveira
(2016); Sharma et al. (2016); Kim and Parish (2017); Komagamine and Hagane (2017);
Levy (2017); McNicholl et al. (2017)
MAI 11 Sergi et al. (2011); Barnett et al. (2012); Eyigor and Kutsal (2012); Patterson et al. (2012);
Bergert et al. (2014); Patterson et al. (2014); Cooper et al. (2015); Rodrigues and Oliveira
(2016); Sharma et al. (2016); Cadogan et al. (2017); Patton et al. (2017)
NORGEP 3 Nobili et al. (2011); Hughes et al. (2016); Rodrigues and Oliveira (2016)
IPET 1 Eyigor and Kutsal, (2012)
McLeod 4 Nobili et al. (2011); Patterson et al. (2012); Patterson et al. (2014); Cooper et al. (2015)
PIM 5 Nobili et al. (2011); Kojima et al. (2014); Van der Linden et al. (2014); Sharma et al. (2016);
Levy (2017)
PIP 5 Stewart et al. (2017b); Franco et al. (2017); Kaufman (2017); McNicholl et al. (2017);
Tommelein et al. (2017)
PRISCUS 2 Bergert et al. (2014); Hughes et al. (2016)
MRCI 2 Mansur et al. (2012); Cadogan et al. (2017)
ARMOR 2 Planton and Edlund (2010); Levy (2017)
New screening tool
RASP 2.0 1 Van der Linden et al. (2014)
GheOPS tool 1 Tommelein et al. (2017)
multidrug cytochrome-specific 1 Doan et al. (2013)
software program
Computerised decision support 6 Eyigor and Kutsal (2012); Patterson et al. (2012); Patterson et al. (2014); Cooper et al.
(2015); Bokhof and Junius-Walker (2016); Sinnige et al. (2016)
Note: STOPP–Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions; START–Screening Tool to alert Doctors to the Right Treatment; MAI–Medication Appropriateness
Index; IPET–Inappropriate Prescribing in the Elderly Tool; NORGEP–The Norwegian General Practice criteria; McLeod–McLeod criteria; PIM–Potentially Inappropriate Medication;
PIP–Potentially Inappropriate Prescribing; PIM–Potentially Inappropriate Medications; EMR–Electronic Medical Record; MRCI–Medication Regimen Complexity Index;
PRISCUS–PhaRmaCotheRaPy In eldeRly PatIentS; ARMOR–Assess, Review, Minimize, Optimize, Reassess.
comprehensive medication history; 2. identification of potentially 1. Is it an inappropriate prescription (e.g., a case without clear
inappropriate medications; 3. determination if medication can be indication, obvious contraindications, or a consequence of
ceased and prioritisation; 4. planning and executing withdrawal; and “prescribing cascade”)?
finally, 5. monitoring, support and documentation. 2. Does the drug lead to adverse effects or interactions that
A practical implementation of the deprescribing process in outweigh symptomatic effects or potential future benefits?
older adults may be guided by four crucial questions as proposed 3. Are drugs taken for symptom relief but the symptoms are
by Page et al. (2016), i.e.: stable?

4. Is drug intended to prevent serious future events but the department visits and hospitalizations, improvement of quality
potential benefit is unlikely to be realised due to limited life of life of patients, and it also lowered the mean daily cost of
expectancy? prescribed medication (Jódar-Sánchez et al., 2015; Malet-Larrea
et al., 2017). In Spanish study, the cost analysis showed that MRF
If the answer to any of these questions is positive, then the saved the national health system € 97 per patient in 6 months. It
medication should be considered for deprescribing. was calculated that for every 1 euro invested in MRF a service
No matter whether deprescribing comes under its own name, returned a benefit of € 3.3 to € 6.2 (Malet-Larrea et al., 2017).
or not, it is the major aim of corrective polypharmacy addressing In practical terms, drug reviews are usually formalised, and
interventions. Perhaps, the most well-known and crucial part of driven by either implicit (judgement-based), or explicit criteria.
this process is a drug review. Due to their usefulness, explicit criteria-based screening tools are
Indeed, various forms of drug reviews and identification of used most often to help systematic assessment of drug safety and
potentially inappropriate medications were the most often appropriateness. In publications covered by this review, the tools
suggested procedures according to our literature review (see most often recommended for use in clinical practice were the
Table 2). Drug reviews might be stand-alone procedures. ones based on such criteria, i.e., STOPP/START criteria, Beers
However, they might be also embedded in more complex Criteria and MAI index. A short overview of these three
programs, being the core item of e.g., Comprehensive Geriatric instruments is presented below.
Assessment (Sergi et al., 2011; Eyigor and Kutsal, 2012; Sharma
et al., 2016; Pazan and Wehling, 2017), pharmaceutical care Beers Criteria
(Patterson et al., 2012; Cooper et al., 2015; Tommelein et al., In 1991, a geriatrician Mark H. Beers published criteria on
2017), and collaborative physician—pharmacist medication potentially inappropriate use of medication in the older adults
therapy management (Lin et al., 2018). agreed by experts (Beers, 1997). After a few updates, the last
Effective polypharmacy management with drugs reviews may version in 2019 (stewarded by the American Geriatrics Society)
require that several additional factors are taken into included not only evidence-based recommendations on drugs to
consideration, such as: be avoided, but also guidance on which medication should be
used with caution, expected to cause significant drug-drug
• Settings: hospital vs. outpatient, in the latter case: primary interactions or be reduced depending on the kidney function
care vs. specialised care (e.g., outpatient geriatric clinic). in seniors. (By the 2019 American Geri, 2019) These are the
• A healthcare professional to perform drug review (e.g., a longest running explicit criteria for potentially inappropriate
physician, pharmacist, nurse, other) medication for older patients with five updates since the first
• The purpose and related scope of the drug review publication. They are useful as a clinical, educational and public
• Criteria to guide drug review (implicit vs. explicit) health tool developed to be used in conjunction with healthcare
• A tool to base drug review on (comprehensive vs. limited in providers. However, the main disadvantage of Beers criteria is the
scope; validated vs. non-validated) fact that two large European studies have shown a lack of their
• A method used for drug review (manual vs. supported by a association with adverse drug reactions (Onder et al., 2005;
computerised clinical decision system) Laroche et al., 2007). Due to a large number of presented
drugs, it is a challenge to create a simple checklist using these
Depending on their purpose, drug reviews may have a criteria. Also, additional software is required to take full
different scope. Therefore, current literature distinguishes three advantage of its potential (Levy, 2017). It should be
types of such reviews (Shaw and Seal, 2015; Clyne et al., 2008): emphasized that being of American origin, Beers criteria may
include or miss medications used or not in Europe (O’Mahony,
• Type 1—Prescription review, performed often without the 2019).
patient, addressing technical issues relating to the
prescription (e.g., duplications, possible drug-drug STOPP/START Criteria
interactions etc.) Proposed for the first time in 2008 by an Irish geriatrician Denis
• Type 2—Concordance and compliance review, performed O’Mahony and his colleagues, it is a list of potential prescribing
most often in the patient’s presence, addressing issues omissions (underprescribed drugs) and potentially inappropriate
relating to their medicine-taking behaviour medications for seniors. In its second version published in 2015,
• Type 3—Clinical medication review, requiring the patient’s the list included revised criteria included in the first version
presence, addressing issues relating to their use of medicines divided into groups depending on the body systems approved by
in the context of their clinical conditions 19 experts from 13 European countries. (O’Mahony et al., 2015).
Its definite advantage is the evidence for correlation with
Drug reviews are advised to be undertaken by all physicians reduction of adverse drug events. (Hamilton et al., 2011). They
and particularly frequently by GPs (Kaufman, 2011). Pharmacists are endorsed and used by several European societies including the
seem to be competent to carry out drug reviews as well. The National Institute for Clinical Excellence (NICE) and the
medication review with follow-up (MRF) performed by United Kingdom Royal College of General Practitioners
pharmacists in community pharmacies provided a decreased (O’Mahony, 2019). However, these criteria (currently planned
number of prescribed medicines, reduction of emergency for 5-year periods) (O’Mahony, 2019) need updating, and just

like other explicit criteria (e.g., Beers) they cannot evaluate drug ARMOR (Assess, Review, Minimize, Optimize, Reassess) and
therapy omission, adherence, life expectancy, issues related to Beers criteria, along with the recommendation to avoid drugs
comorbidities or patient preferences. Some studies show that they covering side effects of other drugs (i.e., the so-called “prescribing
ignore a majority of drug-related problems in seniors (Verdoorn cascade”), whereas another one suggested the use of two explicit-
et al., 2015). based approaches, i.e., Beers and STOPP criteria (Levy, 2017).
Drug reviews can be further facilitated by implementing
Medication Appropriateness Index specific computerised decision support systems and mobile
In 1992, a clinical pharmacist Joseph Hanlon and a geriatrician applications which most often use one or many validated
Kenneth Schmader proposed criteria in a form of ten questions screening tools, at first those based on explicit criteria. Such
enabling assessment of drugs taken by a patient. (Hanlon et al., an approach proved to be an effective element of primary care
1992) By providing an answer to each question based on a three- and pharmaceutical care, leading to reductions in inappropriate
point scale (“A” being appropriate, “B” being marginally prescribing (Patterson et al., 2012; Cooper et al., 2015).
appropriate, and “C” being inappropriate), appropriateness Multidimensional geriatric assessment could be also improved
index can be calculated for each drug. A weighting system for by dedicated IT solutions providing on-line access to information
each MAI question has also been developed. In order to obtain a on patients, alerts indicating inappropriate drugs prescribed,
total MAI score per person, the scores for individual drugs were assessment of the effects of accompanying diseases, reviewing
summed up (Hanlon et al., 1992). This method was quite easy to potential drug-drug interactions, etc. (Eyigor and Kutsal, 2012).
perform; therefore, it was employed in multiple studies. It also
considered drug-drug or drug-disease interactions. However, its Comprehensive Strategies
main disadvantage was the time needed for answering the Our search revealed comprehensive strategies described in
questions. It took 10 minutes per drug, which (Hanlon et al., dedicated guidelines. One of these, focused on geriatric
1992) made it impossible to use MAI in a busy outpatient clinic patients on multimedication (Bergert et al., 2014), was
without application of computer software. Moreover, patient designed especially for GPs. They identified eight key steps as
medication adherence was not included. The MAI score did components of appropriate prescription process:
not help the clinician to prioritize which drugs should be
changed, neither did it provide assistance in how to modify Step 1. Patient evaluation and collecting information
drug regimens to avoid adverse drug withdrawal events that Step 2. Medication review
could occur in older adults. (Hanlon and Schmader, 2013). Step 3. Agreeing with patients on treatment objectives
Step 4. Prescription decision
Along with the validated reliable instruments, we have Step 5. Communication and obtaining patient agreement
identified three studies based on the development and/or Step 6. Drug dispensing
testing of new screening tools (Doan et al., 2013; Van der Step 7. Medication usage
Linden et al., 2014; Tommelein et al., 2017). One of them was Step 8. Monitoring and assessment
focused on development and validation of RASP checklist to
systematically identify Potentially Inappropriate Medications As for medication review in Step 2, these guidelines suggest the
(PIMs) in the older adults (Van der Linden et al., 2014). The use of several instruments, including MAI, STOPP/START and
second study used GheOP³S tool for identification of potentially PRISCUS. It is noteworthy that, in Step 3, after agreeing overall
inappropriate prescribing (PIP) in community-dwelling older objectives of the treatment with the patient, along with their
people on polypharmacy (Tommelein et al., 2017). The third expectations for a pharmaceutical treatment, a GP is supposed to
one analysed CYP-mediated patients’ drug-drug interactions prescribe a drug (Step 4), communicate this to the patient, and
(Doan et al., 2013). Detailed characteristics of these studies are obtain their agreement (Step 5).
provided in the Supplementary Online Material S3. Being one of only very few well-organized polypharmacy
Implicit criteria-based approaches are usually employed by management programs in Europe (Stewart et al., 2017a), the
more complex strategies, such as comprehensive geriatric NHS Scotland Polypharmacy Guidance (Wilson et al., 2015)
assessment (CGA). Typically, CGA includes a drug review, offers probably the most complete guidance to polypharmacy
performed with the involvement of interdisciplinary team management, as evaluated by our search. This guidance accepts a
comprising nurses, occupational and physical therapists, social patient-centred approach to ensuring safe and appropriate use of
workers, general practitioners and geriatricians (Sergi et al., medicines in polypharmacy. Therefore, it advocates a drug review
2011). With the use of several evaluation tools exploring process that should be focused on the patient as a whole rather
cognitive, clinical, nutritional, functional and social than a jigsaw of conditions. The updated third edition of the
parameters, the team conducts a global assessment of an older guidance, published in 2018, provides a holistic model of care
adult with the primary aim of drug therapy optimisation and based on a comprehensive approach to medication review and
correction of medications used for untreated or under-treated provides healthcare professionals with practical tips to improve
conditions (Sergi et al., 2011). prescribing in polypharmacy and make it less problematic
It is noteworthy that some publications advised concurrent use (Scottish Government Polyp, 2018). This approach may be
of more than one screening tool. For example, one review easily adopted to the need of polypharmacy management in
(Planton and Edlund, 2010) suggested the use of both the older adults (Wilson et al., 2015). It recommends that

TABLE 3 | An overview of key considerations of 7 Steps of NHS Scotland Polypharmacy Guidance, 3rd edition [from (Wilson et al., 2015), with modifications].
Domain Steps Process
Aims 1. Identify objectives of drug therapy Review diagnoses and identify therapeutic objectives with respect to
• Management of existing health problems
• Prevention of future health problems
Need 2. Identify essential drug therapy Identify essential drugs (not to be stopped without specialist advice)
• Drugs that have essential replacement functions (e.g., thyroxine)
• Drugs to prevent rapid symptomatic decline (e.g., drugs for Parkinson’s
disease, heart failure)
3. Does the patient take unnecessary drug therapy Identify and review the (continued) need for drugs
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit in general or the indication they are used for
• with limited benefit in the patient under review
Effectiveness 4. Are therapeutic objectives being achieved? Identify the need for adding/intensifying drug therapy in order to achieve
therapeutic objectives
• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
Safety 5. Does the patient have adverse drug reactions or is at risk Identify patient safety risks by checking for
of adverse drug reactions? • drug-disease interactions
• drug-drug interactions
• robustness of monitoring mechanisms for high-risk drugs and for high-risk
drug-drug and drug-disease interactions
• risk of accidental overdosing
Identify adverse drug effects by checking for
• specific symptoms/laboratory markers
• cumulative adverse drug effects
• drugs that may be used to treat ADRs caused by other drugs
Costeffectiveness 6. Is drug therapy costeffective? Identify unnecessarily costly drug therapy by
• Considering more cost-effective alternatives (but balance against
effectiveness, safety, convenience)
Adherence/ 7. Is the patient willing and able to take drug therapy as Identify risks to patient non-adherence by considering
Patientcenteredness intended? • Is the medicine in a form that the patient can take?
• Is the dosing schedule convenient?
• Is the patient able to take medicines as intended?
• Is the patient’s pharmacist informed of changes to regimen?
Ensure drug therapy changes are tailored to patient preferences by
• Discuss with the patient/carer/or welfare proxy therapeutic objectives and
treatment priorities
• Decide with the patient/carer/or welfare proxies what medicines have an
effect of sufficient magnitude to consider continuation/discontinuation
clinicians step back from the usual process of chronic condition health care settings. It should be emphasized that this model is
management to specifically consider the challenges of not based on any specific explicit criteria-based tools. Instead, it
multimorbidity. They should realize that patients need a uses its own set of potentially unnecessary drugs.
“multimorbidity focus” and initiate a process that enables This approach is well-designed and based on strong evidence,
patients to prioritize their own care needs. however, it is also time—consuming. List of medications that
In practical terms, the guidance is composed of seven steps to should be considered by healthcare professionals following
follow (see Table 3). It starts with establishing treatment Steps from 2 to 7 includes almost 100 drugs, groups of drugs
objectives in cooperation with the patient (Step 1), and it is and scenarios. This might be a serious disadvantage, especially
followed by identification of essential (Step 2) and unnecessary in primary care settings. Busy practitioners may not necessarily
drugs (Step 3). Then, it is checked whether therapeutic objectives be able to manage that big load of data. To overcome this
have been achieved (Step 4), which is followed by identification of limitation, in Scotland, since 2013 pharmacists have been
potential or actual adverse drug reactions (Step 5). At the end of funded to work in general practice and support appropriate
the process it is verified whether therapy costs can be minimized polypharmacy management (Mair et al., 2019). Recently, an
(Step 6) and checked if the patient is willing and able to receive application has also been made available for clinicians to help
drug therapy as planned (Step 7). This model provides a cohesive practical realization of this process, along with a toolkit for
structure for a polypharmacy management process that is holistic, patients taking multiple medicines, as well as their carers to
patient-centred and applicable to older adults across a range of support self-management and shared decision-making during

consultation and medicine reviews (The Scottish Government into account along the whole cycle of polypharmacy
Polypharmacy, 2018). management, most of other publications reserve a much less
It is noteworthy that from the interventions described above, important role for the patient making them an object rather than
several ones were analysed and checked in order to confirm their a subject of relevant interventions. In the light of current limited
effectiveness in clinical outcomes in randomized controlled trials, use of available tools by healthcare professionals, this paradigm
interventional or prospective studies. They included several perhaps needs to be changed. Being provided with necessary
interventions, e.g., assessment of appropriateness of knowledge, even an older adult may be an important ally for
polypharmacy (Komagamine and Hagane, 2017; Lin et al., HCPs in adoption of polypharmacy management interventions.
2018), drug reviews (Jódar-Sánchez et al., 2015; Malet-Larrea In absence of patients’ pressure to get involved in
et al., 2017; McNicholl et al., 2017) or checklists improving quality polypharmacy issues, healthcare professionals are expected to
of drug prescription (Urfer et al., 2016). A complex intervention self-initiate relevant activities. Here again, available literature
to be used in a nursing home (covering a drug list review, does not help much, not providing a clear message on when
identification of potentially inappropriate medications using to consider such an activity, and how often to include it in routine
the Beers criteria, potential drug-drug interactions and care. Perhaps, the most frustrating problem is current lack of
contraindicated medications using the Epocrates online drug- uniform definition of polypharmacy, which not only hinders
drug interaction program) has been assessed in a prospective implementation of available interventions, but also makes their
study which demonstrated a decrease in potentially inappropriate benchmarking much more elusive (Masnoon et al., 2017).
medications, contraindicated drugs, and medication costs. The most common operational definitions of polypharmacy,
(Kojima et al., 2014) Characteristics of the studies providing applied in the reviewed publications, were based on the number
evidence of effectiveness for selected interventions that have been of concurrently prescribed and/or used drugs, with five and more
identified in our search are presented in the Supplementary being the most frequent option. This, however, deserves a
Online Material S4. comment. Although polypharmacy has numerous negative
consequences, in some cases is desirable. Perhaps, for every
patient there is an optimal number of drugs to be used (e.g.,
DISCUSSION for hypertension to be controlled according to certain
recommended levels, often two or more medications are
Our review clearly shows that current scientific literature devotes required). It results from a rational compromise between the
a lot of attention to polypharmacy, not only in its general aspect, benefits of providing evidence-based therapies for particular
but particularly focusing on older adults. Consequently, various conditions, and the negative consequences of using too many
potentially useful approaches to polypharmacy management have drugs at the same time. Thus, “appropriate polypharmacy” or
been described, ranging from narrow-focused screening tools up “optimal polypharmacy” should be distinguished from
to comprehensive programs and complex strategies. This large inappropriate one (Rankin et al., 2018). Unfortunately, this
variety of solutions enables healthcare professionals to adopt distinction is subject to case-by-case approach. Therefore, it
polypharmacy-addressing interventions that suit their needs may cause confusion, as it cannot be concluded with a simple
and preferences, taking into account specificity of the clinical uniform threshold that would be suitable for everyone, which
scenario. On the other hand, it may lead to obvious confusion in dichotomizes the number of drugs used concurrently to be either
less experienced medical staff who, in their busy daily practice, acceptable or too high (Masnoon et al., 2017).
may not find enough time or motivation to learn and implement a Our findings undoubtedly show that available interventions
new service which might be certainly time-consuming. Indeed, might be successfully implemented by a range of healthcare
there is evidence that the uptake of available strategies is more professionals, first of all GPs, pharmacists, and geriatricians.
than limited (Mc Namara et al., 2017). Some tools are dedicated or are most suitable for each out of
Theoretically, the most effective polypharmacy strategy could these groups [e.g., recommendations for treating adult and
be appropriate prescribing. If each and every drug initiated in a geriatric patients on multimedication designed by and for GPs
patient satisfied the criteria of appropriate prescribing, the (Bergert et al., 2014)], whereas others are much more generic, and
multidrug therapies could be avoided, and the prevalence of might be implemented across different settings [e.g. STOPP/
polypharmacy would reduce. Unfortunately, the current START (O’Mahony et al., 2015)].
fragmented architecture of the healthcare systems, and single Our results show that various forms of drug reviews are
disease-oriented clinical guidelines do not help practical particularly often used for polypharmacy management in the
implementation of this concept (Farmer et al., 2016). older adults. However, despite an obvious value of drug reviews,
Instruments designed to promote appropriate prescribing are they are not necessarily employed routinely in clinical practice.
mostly based on implicit criteria and thus not easy to implement, On the contrary, in Europe, various forms of these reviews were
particularly in the digital version. reported in only 16 out of 32 studied countries (Bulajeva et al.,
A very interesting finding of our review was that current 2014). Most often, medication reviews were reported to be carried
literature does not perceive the patients as those who take care of out in hospital settings (14 countries), followed by 13 countries
their therapies in terms of initiating activities aimed at reduction reporting implementation of such a procedure in community
of inappropriate polypharmacy. Apart from the NHS Scotland settings, and only six in nursing homes. In community settings,
Polypharmacy Guidance, which takes the patient’s perspective those were mostly reviews targeting prescription and verifications

of patients’ medicine-taking behaviours (reported in nine and 11 Complex and time-consuming nature of polypharmacy
countries, respectively), and much less often, medication reviews management encourages the use of various decision-support
in the context of patients’ clinical conditions (reported in six systems. Indeed, a rising number of computer decision-
countries only). Another important question is which approach support systems and dedicated applications is available to help
to choose to guide the drug review. A systematic review of tools to clinicians manage polytherapy in real life conditions of busy
assess potentially inappropriate prescribing found that out of 46 practice (Eyigor and Kutsal, 2012; Patterson et al., 2012; Patterson
different instruments identified, 39 did not have any validation in et al., 2014; Cooper et al., 2015; Bokhof and Junius-Walker, 2016;
clinical settings (Kaufmann et al., 2014). Sinnige et al., 2016). Of course, such solutions possess some
From a practical point of view, the core assumption on a disadvantages also: they produce dozens of alerts, of which some
strategy used for drug review is very important. According to the are of low clinical usefulness, and therefore, subject to overriding
applied criteria, approaches may be divided into two different (Knight et al., 2019).
categories, i.e., those based on implicit and explicit criteria. Unfortunately, even the availability of such enablers does not
Strategies based on implicit criteria involve highly guarantee frequent implementation of polypharmacy
individualized clinicians’ assessments relying mostly on their management mechanisms. A good illustration of the problem
experience. These strategies are designed usually as protocols, is the case of the German FORTA (“Fit fOR The Aged”)
algorithms or concepts examples of which are ARMOR (Haque, guidelines. Originally released in Germany in 2008 as a tool
2009) or the Prescribing Optimization Method (Drenth-van for aiding physicians in screening for unnecessary, inappropriate
Maanen et al., 2009). Implicit criteria are usually short and or harmful medications and drug omissions in older patients in
concise. However, since they depend on clinicians’ knowledge an everyday clinical setting (Wehling, 2009), it was validated in a
and experience, they are highly subjective and thus, of limited clinical trial (Wehling et al., 2016), and turned into the
applicability across patient populations, or in benchmarking application (Pazan and Wehling, 2017). However, a study
(Levy, 2017). Last but not least, implementation of these conducted in 2018 in general practitioners in Baden-
strategies is very limited by the fact that they are extremely Württemberg, Germany revealed that out of 872 surveyed
time-consuming. For example, comprehensive geriatric GPs, 39 knew the FORTA list, and 15 declared to use the
assessment has proved effective in reducing the number of FORTA App only (Meyer and Wehling, 2020).
prescriptions and daily drug doses (Sergi et al., 2011). On the This scoping review possesses several limitations. First of
other hand, it takes a lot of time, particularly when performed all, it was limited to English language publications, and thus,
face-to-face with the patient (Martin-Khan et al., 2016). For all articles published in other languages were excluded.
these reasons, this approach is not often used in clinical practice. Moreover, among a number of approaches available for
The other type of strategies aimed at reducing polypharmacy is polypharmacy management, we were not able to prioritise
based on explicit criteria. These are much easier to use, one over the other, due to the lack of objective benchmarking
straightforward criteria which allow for objective elimination of criteria. Nevertheless, we believe that comprehensive review
inappropriate drugs, consisting mostly of lists of medications to of available methods provided in this paper will help
be excluded from a patient’s treatment regimen. Most well-known interested stakeholders make their own choices, and thus,
examples of such an approach illustrated by our review are Beers (By meet the aim of this exercise.
the 2019 American Geri, 2019) and STOPP/START criteria
(O’Mahony et al., 2015). It is noteworthy that explicit criteria are
those which can be particularly well embedded in computer decision CONCLUSION
support systems and relevant applications. Interestingly, our findings
show that explicit STOPP/START and Beers criteria are the validated This scoping review showed a variety of approaches being
tools most often used in polypharmacy management in the older suggested for and/or employed for the management of
adults. However, even these criteria are not generally accepted as a polypharmacy in the older adults. These approaches vary in
“golden standard”. On the contrary, they are criticized for not listing their replicability, complexity, and applicability. The most
a relevant number of drug-related problems (Verdoorn et al., 2015) often recommended ones were various types of drug reviews,
and a limited clinical value (Parekh et al., 2019). Some authors guided by either implicit or explicit criteria. Of these, implicit
suggest that they should be used in a complementary fashion to criteria based approaches are used infrequently due to their
improve detection of adverse drug reactions (Brown et al., 2016). subjectivity, and limited practical implementability. To the
Actually, some decision support systems use both these sets of criteria contrary, most of the reviewed publications advocated the use
in parallel (Monteiro et al., 20192019). Moreover, practical use of of explicit criteria-based approaches. However, their practical
these criteria might be difficult. A recent systematic review on applicability is somehow limited due to very long lists of
identifying potentially inappropriate prescribing in older people potentially inappropriate medications covered. To overcome
with dementia found that out of 15 studies using the Beers this, that sort of criteria are often embedded in clinical
criteria, as many as 13 did not use the full tool (Hukins et al., decision support systems.
2019). Due to the large number of potentially contraindicated Our results show that currently, no gold standard exists for
medications listed (114 recommendations in the START/STOPP polypharmacy management in older adults, and various
and 90 in the Beers), the use of these criteria is particularly limited in approaches are used in parallel. Depending on the purpose of
primary care (Croke, 2020). drug review, its settings, and available time, the users are free to

employ one of existing interventions and/or tools. For practical FUNDING

purposes, employing a drug review based on one of the available
explicit criteria seem to be the best choice. Having in mind that in This work was partially funded by the Erasmus + Programme of
general, polypharmacy management in the older adults is the European Union, under the Skills4Adherence project (Grant
underused, both individual stakeholders, as well as number 2017-1-PL01-KA202-038672). KP received speaker’s
policymakers should strengthen their efforts to promote these honoraria from Aflofarm, Fresenius, Polpharma and Sandoz,
activities more strongly. outside this work. KP, M-KM, LP got funding from a grant
from The European Commission ERASMUS + Project
Skills4Adherence (Grant Agreement Number: 2017-1-PL01-
DATA AVAILABILITY STATEMENT KA202-038672). Several authors got funding from a grant
from European Union’s Horizon 2020 for GATEKEEPER
The original contributions presented in the study are included in project (grant agreement No 857223) (KP and LP), and
the article/Supplementary Material, further inquiries can be European Union’s Health Programme for SIMPATHY project
directed to the corresponding author. (663082) (KP and LP), outside this work.
AUTHOR CONTRIBUTIONS SUPPLEMENTARY MATERIAL

Contribution of each author is equal regarding preparing the The Supplementary Material for this article can be found online at:
manuscript. BJ-P, PK, MK-M and PL performed the search of the https://www.frontiersin.org/articles/10.3389/fphar.2021.734045/
literature. full#supplementary-material
Cadogan, C. A., Ryan, C., Francis, J. J., Gormley, G. J., Passmore, P., Kerse, N., et al.
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SYSTEMATIC REVIEW

published: 26 November 2021

Polypharmacy Management in the

Frontiers in Pharmacology | www.frontiersin.org 1 November 2021 | Volume 12 | Article 734045

INTRODUCTION primary care physicians in England care for patients with

Frontiers in Pharmacology | www.frontiersin.org 2 November 2021 | Volume 12 | Article 734045

Frontiers in Pharmacology | www.frontiersin.org 3 November 2021 | Volume 12 | Article 734045

their active role in addressing polypharmacy is currently very

Who Should Provide a Polypharmacy

Frontiers in Pharmacology | www.frontiersin.org 4 November 2021 | Volume 12 | Article 734045

TABLE 1 | Deﬁnition of polypharmacy used in reviewed publications.

1 1 Bokhof and Junius-Walker, (2016)

Qualitative Deﬁnition Number of studies References

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TABLE 2 | Polypharmacy interventions identiﬁed in reviewed publications.

Intervention Number of References

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Domain Steps Process

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employ one of existing interventions and/or tools. For practical FUNDING

AUTHOR CONTRIBUTIONS SUPPLEMENTARY MATERIAL

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