Polypharmacy in Home Care

Abstract

Home care grows in conjunction with the phenomenon of polypharmacy (synonymous with polymedication) while emerging in parallel with aging and frailty as a real health issue added to comorbidities. It is a situation of drug use for which we do not have an agreed definition. Some authors define polypharmacy as the concomitant ingestion of four or more drugs in the last three months, while other authors raise the number to five different drugs. Polypharmacy is often the result of the sum of appropriate prescriptions of drugs of proven effectiveness in patients with various chronic conditions. In these cases, from the point of view of compliance with clinical practice guidelines, everything would be in order. However, the reality of this situation is far more complex due to the lack of knowledge of the interactions that more than two drugs can cause in patients, in terms of kinetics or dynamics of the active principles, as well as the potentiation of their adverse effects.

1. Introduction

Longevity has been described as the main cause of increased chronicity and frailty. For this phenomenon, it is essential to enhance home healthcare. The increase in life expectancy increases the chances that, at some point, the diagnostic criteria established by the scientific community for the most prevalent chronic diseases will be met. Multimorbidity, referred to as multiple comorbidities or multiple chronic conditions, is a prevalent phenomenon that significantly amplifies the intricacies associated with patient disease management. Globally, individuals are experiencing prolonged lifespans accompanied by disabilities and the presence of multiple comorbidities, which has an important implication for global healthcare needs, and polypharmacy is a serious health issue for frail older adults.

Other factors such as lowering thresholds for diagnosis and therapeutic recommendations for some conditions involving the treatment of asymptomatic entities to prevent potentially serious complications are factors that increase the “epidemic” of chronicity that affects health systems around the world. Traditionally, what defined the disease was the presence of symptoms or signs; however, the active search for asymptomatic alterations, supported by a highly relevant technological development, increasingly broadens the field of diseases to the field of the simple alteration of parameters, today biochemical and soon genetic [1].

The sustainability of public welfare policies is threatened, especially in addressing the needs of individuals with higher levels of needs or who are at risk. It is estimated that 8% of the population is in a situation of complex health or social needs and consumes 30% of the budget. Many of these individuals are cared for in their homes (their own homes or their residential facility). Professionals should focus on identifying individuals with complex needs, adapting care to each moment and situation, and making their home an ideal place in many circumstances, often the preferred location for decompensations, but not the exclusive one [2].

Home care is growing alongside the phenomenon of polypharmacy. These are emerging in parallel with aging and frailty as a real health problem added to comorbidities. Polypharmacy describes the circumstance in which a patient utilizes multiple medications concurrently. The World Health Organization (WHO) defines polypharmacy as “the administration of many drugs at the same time or the administration of an excessive number of drugs”. Polypharmacy is a situation of drug use for which we do not have a consensus definition [2, 3]. Some authors define it as the concomitant intake of four or more drugs in the last three months, while others raise the number to five different drugs. Nevertheless, polypharmacy is typically defined as using five or more regular medications. Recently, the term “hyperpolypharmacy” has also entered the literature, defined as the consumption of 10 or more drugs [3].

Polypharmacy is a common problem in elderly patients and can increase the risk of drug interactions and side effects. It is commonly associated with adverse health outcomes. Polypharmacy is frequently linked to various adverse health repercussions, particularly among older adults with multimorbidity. These consequences encompass a heightened risk of mortality, falls, drug interactions, non-adherence, and hospitalization. Since the population with multimorbidity tends to increase with aging, the number of drug consumption increases simultaneously. The initial and crucial step in mitigating the potential adverse events related to polypharmacy involves identifying individuals who are at risk of receiving inappropriate polypharmacy treatment [4].

Home care can be bear in mind for addressing frail patients with multiple chronic conditions who often experience polypharmacy. It allows them to receive specialized medical care and supervision to reduce the risk of complications and improve their quality of life. Optimizing polypharmacy care requires effective targeting and follow-up of interventions. Pharmaceutical interventions have demonstrated a beneficial impact on addressing medication-related issues within hospital and nursing home environments, providing valuable support to nurses and physicians.

The fragmented practice of clinical care, which is common across different levels of care in all the care systems around the world, can lead to various types of duplications. This is because patients, during each of their repeated admissions and consultations at different care levels, receive numerous prescriptions from the professionals with whom they come into contact. A considerable proportion of these healthcare encounters result in the prescription of at least one additional medication, adding to the therapeutic arsenal that the patient is already taking.

2. Polypharmacy and appropriate prescribing

According to the WHO, rational use of medicines occurs when “patients receive medications that are appropriate to their clinical needs, in doses that meet their individual requirements, for an adequate duration, and at the lowest cost possible to them and the community” [5].

As the global population continues to age, the urgent need for the development of effective and safer treatments for older individuals has emerged as a critical concern in numerous countries. Managing polypharmacy, implementing measures against frailty and disability, has consequently become a significant focal point. In recent times, there has been widespread adoption of cautionary practices in prescription review and the avoidance of potentially inappropriate medications (PIM). The recognition of the detrimental effects of polypharmacy has gained considerable traction, particularly in its close association with multimorbidity. With the escalation of chronic diseases and geriatric syndromes during the aging process, there is a tendency for polypharmacy and the prescribing of potentially inappropriate medications (PIM) to rise as the severity of disability intensifies. On the other hand, in patients with more severe conditions, healthcare professionals, including physicians, may exclude stroke prevention or cardiovascular drugs based on management reviews. Addressing the specific stage at which polypharmacy and potentially inappropriate medication (PIM) pose significant challenges in older individuals with disabilities appears to be a considerable issue requiring clarification [6].

Polypharmacy is often the result of combining appropriate prescriptions of proven effective drugs in patients with various chronic conditions. In these cases, from the perspective of compliance with clinical practice guidelines, everything would be in order. However, the reality of this fact is much more complex due to the lack of knowledge about the interactions that two or more drugs can impose in patients, in terms of the kinetics or dynamics of the active pharmaceutical ingredients, as well as the potentiation of their adverse effects. Having an optimal understanding of which medications function as inducers or inhibitors of other drugs becomes crucial when devising optimal prescribing strategies for older individuals. In 2010, the WHO developed initiatives to improve the rational use of medicines through policy structures and measures, information, and education (see Table 1) [8].

Creation of national bodies to coordinate policies on the use of medicines and monitor their impact Formulation of evidence-based clinical guidelines aimed at training, supervision, and decision-making support related to medicines Development of essential medicines lists for use in procurement and reimbursement by social health insurance Establishment of drug and treatment committees to implement interventions to improve medicine use and monitor their effects Inclusion of problem-based pharmacotherapy courses in university studies Inclusion of continuing medical education as a requirement for professional practice Provision of independent and unbiased public information on medicines, both for healthcare professionals and consumers Promotion of public education on medicines Elimination of economic incentives that facilitate inappropriate prescribing, such as the profit-driven sale of medicines by prescribes, increases their income Formulation of regulations to ensure that promotional activities adhere to ethical criteria Sufficient funding to ensure the availability of medicines and healthcare personnel

Table 1.

Political and structural measures to improve the use of medicines (WHO).

Modified from World Health Organization (WHO) [7].

It is essential to understand and address non-pharmacological aspects relevant to prescription, such as placebo effects or non-specific adverse effects (nocebos), non-adherence, cost, psychological meanings (symbols, beliefs, or stigmas surrounding medications), ethical issues, and the fact that prescription can be a way for the doctor to deal with their frustration, among others. These factors can impact the doctor-patient encounter and consequently influence a change in attitude in daily prescription practices.

During the aging process, a series of physiological changes occur that modify the pharmacodynamics and pharmacokinetics of medications, leading to a diverse and heterogeneous response to illness and its treatments. Comorbidities, geriatric syndromes, decreased function of vital organs, and sensory, functional, and cognitive impairments contribute to a reduction in the effectiveness of commonly used medications and an increased predisposition to experience adverse effects. Furthermore, there are often unfavorable social conditions in frail elderly individuals, such as loneliness and institutionalization, as well as psychological circumstances affecting self-esteem and self-perception of health. All of these factors place these patients in the most vulnerable group to suffer iatrogenic effects and, therefore, make them a priority for quaternary prevention (which encompasses activities aimed at avoiding, reducing, and alleviating harm caused by medical interventions).

Reasoned drug selection requires time, knowledge, and analytical capacity (see Figure 1). The reasoned selection of drugs is complex due to the lack of a filter for published information, publication bias (positive results are more likely to be published than negative ones), and the wide array of available therapeutic options. The assessment of polypharmacy often relies on arbitrary numeric thresholds, which, despite their limitations, do not fully encompass the appropriateness of drug usage. Therefore, it is necessary to employ more sophisticated approaches that take into account the clinical context. Adverse events related to medications in primary care contribute significantly to hospital admissions and mortality rates. Such events can arise from individuals experiencing adverse drug reactions, which are typically not preventable, or from medication errors, which are often preventable [9, 10].

Figure 1.

Reasoned selection of medications.

For all these reasons there are needed conditions to consider for polypharmacy to make sense beyond clinical practice guidelines [9]. Implicit indicators of the adequacy of polypharmacy have been described [11]. The following criteria are considered when evaluating medication usage:

1. The indication for the drug is documented in the patient’s medical record.

2. Non-pharmacological alternatives, if available, have been assessed and found ineffective.

3. The selected drug aligns with established clinical practice.

4. There are no clinically significant drug-drug interactions, including avoiding duplicate therapy.

5. If the drug is contraindicated, the prescriber provides a valid reason.

6. The drug is deemed effective for the patient’s specific indication.

7. The prescribed drug, in its current form, is unlikely to be subtherapeutic or toxic, taking into account the patient’s age, renal and hepatic status, as well as the dose, route, and dosing interval.

8. The drug regimen cannot be simplified further.

9. The patient or caregiver possesses a clear understanding of the prescribed drug regimen.

10. The patient adheres to the prescribed drug schedule.

11. An appropriate clinician reviews the drug treatment at least once a year or more frequently based on best clinical practice.

12. If an adverse drug reaction occurs, the details of the reaction are documented, and follow-up recommendations are provided in the patient’s medical record.

The concept of appropriate polypharmacy recognizes that patients can benefit from multiple medications as long as the prescription is based on evidence, reflects patients’ clinical conditions, and considers potential drug interactions. Rather than relying on arbitrary numerical thresholds to define polypharmacy, it is essential to promote the adoption of this concept, which encompasses a comprehensive evaluation of medication appropriateness and clinical context. Polypharmacy should be viewed as potentially problematic rather than inherently inappropriate. Therefore, assessments of prescription appropriateness should go beyond simply counting the number of drugs prescribed. Alternatively, they should take into account the presence of coexisting medical conditions to differentiate between a reasonable number of medications and an excessive amount [11].

The concept of inappropriate prescription should be supported by two essential considerations: respect for the common good (including implications and familial and social aspects) and respect for the patient’s preferences and perspective [8]. By employing such a measure as an initial step, healthcare providers can identify patients who may be at risk of receiving inappropriate prescriptions. This measurement can then facilitate focused discussions with patients, allowing for an exploration of their perspectives on the suitability of their existing medication regimen. Prescription appropriateness assessments need to shift their focus away from solely considering the quantity of drugs prescribed. Ideally, they should prioritize evaluating the presence of multiple conditions when distinguishing between “appropriate polypharmacy” (indicative of managing multiple conditions effectively) and “inappropriate polypharmacy” (associated with an excessive number of medications).

“Appropriate polypharmacy” recognizes the necessity and potential benefits of multiple medications for patients, given that the prescribing process adheres to evidence-based practices, mitigates interactions and adverse events, and aligns with the patient’s clinical conditions. Simultaneously, when aiming to achieve appropriate polypharmacy, the inclusion of additional medications should be approached cautiously, considering the need for adequate monitoring of disease control. Regular reviews by healthcare professionals are essential in ensuring optimal medication management. Population-level research has demonstrated that when employed appropriately, polypharmacy can yield beneficial outcomes for patients [12].

Among patients with extensive multimorbidity (defined as having six or more conditions), there was no increased likelihood of unplanned admissions for those taking four to six medications compared to those taking fewer medications (one to three). The available evidence indicates that polypharmacy, solely defined by a numerical threshold, should no longer be regarded as inherently harmful. The decision-making process regarding medication usage should include recognition of the clinical context and the extent of multimorbidity [12]. Emphasis should be placed on appropriate prescribing practices and effective disease management. Balancing the need for multiple medications while minimizing the risk of adverse events presents a significant challenge in everyday clinical practice. Acknowledging this need, guidance has been provided to healthcare professionals to navigate this complex task effectively.

The National Institute for Health and Care Excellence (NICE) has provided comprehensive guidance on the clinical assessment and management of multimorbidity [13]. The guidance prominently emphasizes the utilization of medicines, necessitating thorough medication reviews, the exploration of potential pharmacological or non-pharmacological treatment options to initiate or discontinue, and engaging in discussions with patients about disease management approaches and their treatment preferences.

A Cochrane review published in 2018 (and currently undergoing updates) revealed limited evidence regarding the strategies for achieving appropriate polypharmacy. The reviewed studies exhibited inadequate details regarding the development and content of the interventions employed [14]. To maximize the potential impact of assessed interventions, it is crucial to take into account their effect on outcomes that hold significance for patients, healthcare providers, and policymakers. This approach ensures that interventions are evaluated in a manner that allows for the synthesis of similar studies, thereby reinforcing the strength of the evidence and broadening the scope of their applicability. A review of systematic reviews investigating interventions targeting polypharmacy revealed that interventions emphasizing appropriate prescribing within the context of polypharmacy demonstrated some beneficial effects. However, consistent evidence regarding other outcomes such as healthcare application, morbidity, or mortality is lacking [15].

While clinical practice guidelines offer general principles to guide healthcare practice, the ultimate objective should be the individualization of treatment plans to suit the unique needs and circumstances of each patient. This indicates that a “one-size-fits-all” approach is not aligned with this guidance, necessitating a different approach that requires both time and appropriate skills to tailor treatment plans effectively. There is a growing trend to view decision-making processes, such as prescribing, through a behavioral lens. By employing behavioral insights, strategies can be developed to enhance prescribing practices.

Polypharmacy has long been recognized as a complex issue in prescribing and is expected to persist as the population ages and multimorbidity becomes more prevalent. Medications will continue to play a central role in disease management despite these challenges. While advancements in drug formulations, such as the Polypill that combines multiple drugs into a single dosage unit, may arise, prescribers and patients will still face the responsibility of striking the delicate balance between an appropriate number of medications (polypharmacy) and an excessive amount (inappropriate or problematic polypharmacy).

3. Polypharmacy and home care

The number of homebound elders has risen dramatically in the last decade, an increase that was accelerated by the Sars-Cov-2 COVID-19 pandemic. Individuals in this category typically experience the presence of five or more chronic conditions, requiring the use of six or more medications. As a result, they face an increased risk of functional decline. Polypharmacy represents a significant burden for these individuals, elevating the likelihood of medication nonadherence, errors, and interactions, while also diminishing their overall quality of life [8]. Guidelines are progressively acknowledging the necessity of using multiple drugs for the management of chronic conditions like diabetes. However, it is noteworthy that many clinical trials often exclude older individuals with multimorbidity and polypharmacy, leading to a lack of evidence in this specific population. Consequently, there exists an evidence gap in understanding the optimal treatment approaches for individuals with multiple chronic conditions and polypharmacy.

Home care refers to a range of health and social services provided to patients in their own homes. It involves the provision of medical care, personal assistance, and support services to patients who may have health conditions, disabilities, or who are recovering from an illness or injury. Home care services can include medical treatments, medication management, assistance with daily activities, nursing care, physical therapy, occupational therapy, and emotional support. The goal of home care is to enable patients to remain in their homes while receiving the necessary care and support to maintain their health and well-being [16].

The organization and portfolio of services provided at home are key to value-added health and social care. Many patients prefer to be treated at home instead of in the hospital, as they are more satisfied and experience fewer complications. The lower mortality rate in conditions that can be managed at home compared to the hospital is also a significant aspect, as well as the lower cost of anything that can be done outside of the hospital.

A change is taking place in hospitals toward reducing conventional hospitalization through the development of short-stay units, day hospitals, or home hospitalization. These units are designed with the philosophy of reducing costs, preventing complications and, of course, ensuring that the patient feels comfortable in their own environment. However, adequate communication and coordination mechanisms with primary care are needed to make the system efficient and ensure patient safety during the transition between levels.

Not all iatrogenic pathology can be prevented, and yet efforts should be made to prevent a significant proportion from being due to inappropriate drug selection or dosing. For many adverse effects, patients at high risk of experiencing them can be identified. Often, these are the patients with whom extra caution should always be exercised: the elderly, children, pregnant women, and patients with kidney or liver disease. Most of them are included in home care programs.

The phrase “Better health for the dollar spent,” coined by Michael Porter, encapsulates the essence of the present emphasis on clinical management. The veteran Harvard professor, an expert in business competitiveness, had an experience with the health system and from his own observations wrote a book that went so far as to say: “I see them obsessed by the effectiveness of their actions and not focused enough on the effectiveness derived from them.” Synthetically, Porter’s contribution to clinical management is summarized in his three pillars: (a) define health goals that are valuable for each patient, (b) know how to measure the health value that is provided with every clinical act and (c) reorder care services according to the process needs of each illness [17].

The care delivery value chain is a tool that can help design care strategies for patients receiving home care who are polypharmacy. It is a tool proposed by Porter [18] that focuses efforts on achieving outcomes. Within this framework, a homogeneous group of patients is defined as those who are cared for at home and chronically consume 5 or more drugs per day. Based on the latest available evidence, the following aspects should be defined:

1. Health outcomes to achieve.

2. Strategies for patient and family empowerment.

3. Implementation of multidisciplinary teamwork.

4. Additional aspects to consider in order to achieve objectives.

3.1 Health outcomes to achieve

When healthcare practice is fragmented, patients feel more overwhelmed by the burden of treatment than by the weight of the diseases they suffer from. Therefore, the burden of treatment should be acknowledged and recognized.

By basing value on outcomes that genuinely reflect patients’ priorities, a conducive environment is established, aligning incentives among all healthcare stakeholders to generate value for patients.

The main outcomes that should be focused on are the following, according to the methodology proposed by Porter [18]:

1. Health status that is achieved or, retained:

   1. Survival. While maximizing survival duration is not necessarily the paramount outcome, particularly for older patients, who may prioritize other outcomes more significantly.

   2. Degree of health or recovery achieved or retained at the peak or steady state. Relevant aspects of functional status.

2. Recovery process:

   1. Time required to achieve recovery and return to normal or best attainable function. Cycle time is a critical outcome for patients.

   2. The negative impact of the care or treatment process, such as discomfort, the need for retreatment, short-term complications, and errors, along with their subsequent consequences.

3. Health sustainability:

   1. Recurrences of the initial disease or the emergence of long-term complications.

   2. New health issues arise as a result of the treatment.

The mission of the International Consortium for Health Outcomes Measurement (ICHOM) is to unlock the potential of value-based healthcare by defining what matters most to patients and encouraging the adoption and reporting of these measures worldwide to make life better for all. Through the establishment of a standardized list of outcomes that align with the patient’s priorities, alongside the development of appropriate measurement instruments and time points, the healthcare system can effectively maintain patient-centered care [19].

Usually, we tend to measure intermediate results and we focus little on the outcomes that are more complex to measure. Through ICHOM it is possible to advance in the definition of outcomes.

International organizations have provided support to patients, clinicians, and experts from diverse regions in determining the key dimensions of health that should be taken into account when evaluating the added value of services for adults, particularly in the context of public and primary healthcare. These organizations have also assisted in defining the appropriate measurement approaches for assessing these aspects of health. Gangannagaripalli et al. have introduced a minimum standard outcome set for overall adult health with the aim of facilitating the implementation of value-based healthcare. This outcome set enables the tracking, comparison, and enhancement of overall healthcare outcomes in adult populations across various conditions, offering specific relevance to primary care and public health settings [20]. This could be a good first step toward the health objectives that must be gained in patients that use five or more medicines. Table 2 shows the value-based patient-centered outcomes of overall health in adults by domain.

Domain	Outcome
Physical health	General physical health; Physical functioning; Mobility; Fatigue; Pain; Seeing; Hearing
Mental health	General mental health; Vitality; Symptoms of depression; Symptoms of anxiety; Sleeping
Social health	General social health; Interpersonal functioning; Work

Table 2.

Value-based patient-centered outcomes of overall health in adults.

Adapted from Gangannagaripalli et al. [20].

3.2 Strategies for patient and family empowerment

Training strategies for professionals in motivational interviewing should be considered, in order to improve adherence, and shared decision-making dynamics. In addition, support materials (decision aids) will be used or developed as facilitators of patient-centered care. The main objective is the empowerment of the patient so that he/she can manage the clinical situation with maximum autonomy.

3.3 Implementation of multidisciplinary teamwork

Elements of multidisciplinary teamwork must be implemented. These proposals can be relatively simple, such as face-to-face, telephone, or online consultations between primary care professionals and the hospital, or the scheduling of extensive sessions with the participation of social workers, nurses, family doctors, and other specialists involved; or more complex, such as the constitution of cross-sectional clinical management units with full-time professionals assigned to them. Professionals who can add value to the process are primary care physicians, nurses, health technicians, pharmacists (primary care, hospitals, and pharmacies), social workers, and other social assets that can reduce the burden of treatment.

3.4 Additional aspects

The value chain must also contemplate circuit analysis to reduce the burdens that complex therapeutic plans inflict on people, many of them with low levels of understanding, so it is recommended to use participatory methodologies such as lean or design thinking that can make the contact of patients with the health system as less uncomfortable as possible and, if considered appropriate, e-health support elements should be tested.

In health systems around the world, care practice is often fragmented. The fragmentation of healthcare systems favors polypharmacy and its harmful effects on the health of patients. Therefore, patients feel more overwhelmed by the burden of treatment than by the weight of the diseases they suffer from. Accordingly, the burden of treatment must be known and recognized.

4. Deprescribing

Deprescribing refers to the systematic process of discontinuing or reducing unnecessary or potentially harmful medications in order to optimize a patient’s medication regimen. It involves a comprehensive evaluation of the patient’s medication, taking into account factors such as appropriateness, effectiveness, safety, and patient preferences. The goal of deprescribing is to minimize medication-related harm, improve patient outcomes, and enhance the overall quality of medication use [21].

Limited randomized controlled trials (RCTs) exist that assess the advantages and drawbacks of deprescribing, although some therapeutic areas, such as hypertension, dementia, and osteoporosis, have seen some examples. Nonetheless, in situations where a comparator trial is unattainable, impractical, or ethically challenging, the quality of observational research can be enhanced through target trial emulation. This approach involves defining all elements of the target trial, including eligibility criteria, treatment allocation, follow-up duration, and outcome measures, and applying design principles from RCTs to the analysis of observational data.

The process of deprescribing is primarily structured around the following concepts:

• Evidence supporting each drug indication.

• Patient’s life expectancy.

• Prioritization of health problems affecting the patient.

• Patient’s opinion and adherence characteristics expressed.

• Individual assessment of benefits and risks of each drug.

• Non-pharmacological alternatives to address specific problems.

• Development of a gradual and monitorable deprescribing plan.

It is necessary to create spaces where the options, advantages, and disadvantages of deprescribing can be discussed with the patient or their caregivers, with a strategic and proactive vision (looking toward the future and anticipating events) and making it clear that no decision is irreversible.

There are several methods and approaches to deprescribing, which may vary depending on the individual patient’s situation and medication regimen. Some common deprescribing methods include:

1. Medication review: conducting a comprehensive review of the patient’s current medication, including assessing their appropriateness, potential risks, and benefits.

2. Patient-centered discussions (shared decision-making): engaging in open and honest conversations with the patient about their medication, including discussing the goals of treatment, potential risks, and the possibility of reducing or discontinuing certain medications. Collaborating with the patient in the decision-making process, considering their preferences, values, and goals, and involving them in the choices regarding medication changes.

3. Gradual tapering: when reducing or discontinuing medications, a gradual tapering approach may be used to minimize withdrawal symptoms or potential rebound effects.

4. Therapeutic substitution: considering alternative drugs or non-pharmacological approaches to address the patient’s health condition, potentially replacing a drug with a safer or more appropriate option.

5. Monitoring and follow-up: regularly monitoring the patient’s response to medication changes, evaluating their symptoms, and providing ongoing support and follow-up care.

It is important for deprescribing to be conducted in a systematic and individualized manner, involving healthcare professionals, patients, and caregivers working together to optimize the use of medicines and promote patient well-being.

There are several tools and resources available to support the process of deprescribing [22]. These tools are designed to assist healthcare professionals in making informed decisions about reducing or discontinuing medications. Some commonly used deprescribing tools include:

1. Beers criteria: the Beers criteria for potentially inappropriate medication use in older adults is a widely recognized tool that provides guidance on medications that may be potentially inappropriate or have a high risk of adverse effects in older adults.

2. STOPP/START Criteria: STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria are evidence-based tools used to identify potentially inappropriate and potential prescription omissions in older adults.

3. Medication appropriateness tools: various medication appropriateness tools, such as the Medication Appropriateness Index (MAI) and the Screening Tool to Alert to Right Treatment (START), can help assess the appropriateness of medication based on specific criteria.

4. Deprescribing guidelines: national or international guidelines, such as the Deprescribing Guidelines in the Elderly, provide recommendations and evidence-based strategies for reducing or stopping medications in older adults.

5. Electronic decision support systems: electronic tools and systems integrated into electronic health records (EHRs) can provide prompts, alerts, and recommendations to healthcare professionals regarding medication appropriateness and potential deprescribing opportunities.

It is important to note that these tools are meant to assist healthcare professionals in making informed decisions, but they should be used in conjunction with clinical judgment and individual patient considerations.

An illustration of this is the STOPP/START criteria (Screening Tool of Older Person’s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right, i.e., appropriate, indicated Treatment), which in its third version, allows for the identification of potentially inappropriate prescribing (PIP) at an individual level. Through four rounds of Delphi validation, the panel achieved consensus on 133 STOPP criteria, and 57 START criteria, totaling 190 STOPP/START criteria [23]. This signifies a significant increase of 66.7% in the number of criteria compared to the second version of STOPP/START published in 2015.

5. Conclusions

Polypharmacy, also known as polymedication, is a situation of drug consumption for which we do not have a consensus definition, because of this, assessments of prescribing appropriateness need to extend beyond the number of drugs prescribed and consider coexisting medical conditions.

Polymedication is frequently produced by the combination of effective prescriptions in a context of multimorbidity, chronicity, and complexity in which there is insufficient evidence. For this reason, it is necessary to differentiate “many drugs” (appropriate polypharmacy) from “too many drugs” (inappropriate polypharmacy).

The reasoned selection of pharmacological treatments requires time, knowledge, analytical skills, and individualization based on available evidence and the values and preferences of the patient. Appropriate polypharmacy can benefit patients with multimorbidity, provided that adverse effects and interactions are taken into account.

The home environment, with healthcare provided primarily by primary care professionals, is a setting with a high prevalence of patients with polypharmacy. It is a conducive environment for reflection on appropriate prescribing in situations of multimorbidity and chronicity.

To practice value-based healthcare, the care delivery value chain, which focuses on the health outcomes relevant to the patient, can be a useful tool. Throughout the process of rationalizing pharmacological treatments, different profiles of healthcare professionals working in a multidisciplinary manner are key to improvement.

Finally, it is important to note that when there is medication overload, deprescribing tools and methodologies are very useful and help ease the burden of treatment on patients.

Conflict of interest

The authors declare no conflict of interest.