Multimorbidity & Polypharmacy
Red Flags — harms hiding in the drug list
| Red flag | Why it matters | Action |
|---|---|---|
| Falls + postural hypotension from over-treatment | Fractures, hospitalisation, loss of independence. | Review/reduce antihypertensives, sedatives, ACB; lying/standing BP; falls assessment |
| Hypoglycaemia from tight glycaemic control in frailty | Falls, confusion, harm; benefit of tight control is long-term. | Relax HbA1c target; reduce/stop sulfonylurea/insulin causing hypos |
| High anticholinergic burden → confusion/cognitive decline/falls | Reversible cognitive impairment; possible dementia association (MHRA public assessment report, July 2026: insufficient evidence of a direct causal link for bladder anticholinergics, though a small risk cannot be excluded). | Calculate ACB; deprescribe/swap antimuscarinics/sedating drugs |
| "Triple whammy" (NSAID + ACE/ARB + diuretic) / nephrotoxic combos | Acute kidney injury. | Stop/avoid NSAID; check renal function; rationalise |
| Stopping high-value medicines inappropriately (e.g. anticoagulation in AF) | Deprescribing the wrong thing causes stroke/harm. | Keep high-value treatments; deprescribe low-value/harmful ones |
| Abrupt withdrawal of dependence/rebound drugs (steroids, benzodiazepines, beta-blockers) | Withdrawal/rebound harm. | Taper gradually; never stop abruptly |
⚖️ Fewer can be better
Reframe deprescribing as good care, not giving up.
"Taking fewer tablets isn't us giving up on you — for some of these, stopping them will actually help your balance and your mind, which is exactly what you want."🤝 Her expertise
Treat her as the expert in her own life.
"You know your body and your days better than anyone — tell me which tablets feel worth it and which don't, and we'll start there together."🛡️ Keeping what matters
Reassure that the important ones stay.
"Some medicines are genuinely protecting you — like the blood-thinner for your heart rhythm, which prevents strokes — so we'll keep those. It's the ones causing more harm than good we'll tackle."👪 Involving the daughter
Include the carer with Edith's consent.
"With your agreement, it helps to have your daughter involved — she sees the falls and can help keep an eye as we make changes."Independence & living at home
Edith lives at home with some help. Two falls and a fear of a third threaten the thing she values most: staying in her own house. Ask who helps with shopping, cleaning and personal care, whether she has a pendant alarm, and whether she has had a "long lie" on the floor after a fall. A long lie is a marker of high risk and changes the urgency of the falls referral.
"If you did fall again, how would you get help — could you get up on your own, or reach a phone or an alarm?"The daughter as carer
Her daughter is anxious and increasingly involved. She may be taking on medicines support, lifts to appointments and night-time worry. Carers are entitled to a carer's assessment from the local authority (Care Act 2014), and the practice should code her as a carer. Involve her with Edith's consent, but keep Edith at the centre. The daughter's view ("Mum should take everything the doctor gave her") may be different from Edith's ("I'd rather take fewer").
"How are you coping yourself? Looking after someone you love is a lot — there's support available for you too."How the medicines are actually taken
Ask Edith to bring every box and bottle, including over-the-counter products and herbal remedies (a "brown bag" review). Many older people keep old stock, take ibuprofen from the supermarket on top of prescribed naproxen, or use St John's wort or ginkgo, which interact with anticoagulants and antidepressants. Check who fills any dosette box, whether she can open blister packs and bottles, and whether poor eyesight or arthritis in her hands gets in the way.
"Could you show me how you take them in a normal day — morning to bedtime? And is there anything you buy yourself from the chemist or health shop?"Fear of dementia & loss of self
"Keep my marbles" is a statement of fear. New forgetfulness in someone on an antimuscarinic may be partly reversible once the drug is stopped. That is a hopeful message, but don't over-promise: also plan a proper cognitive assessment once the medicines have been rationalised. Ask directly what she fears. Many older people have watched a spouse or friend decline with dementia.
"You mentioned your memory — is there something in particular you're worried it might be?"Autonomy, capacity & future wishes
Edith has capacity to make her own decisions; assume capacity unless there is evidence otherwise (Mental Capacity Act 2005). Her wish to take fewer tablets is legitimate even if a guideline would add more. This is also a natural time to ask whether she has thought about a Lasting Power of Attorney or advance care planning, especially if her cognition is changing. Raise it gently and don't force it into this appointment.
"Some people like to plan ahead and write down what matters to them for the future — is that something you'd like to talk about, now or another time?"Mood, loneliness & meaning
She is on an antidepressant. Is her mood now good, and was it prescribed after a bereavement years ago? Loneliness and low mood reduce motivation for exercise and self-care and increase falls risk. Social prescribing (lunch clubs, befriending, community strength and balance classes) can treat several problems at once, and is often more welcome than another tablet.
"How's your mood been lately — and how much do you get out and see people these days?"- Starting from the disease list/guidelines, not the person
- Not linking falls/confusion to drug causes (BP/ACB/hypo)
- Deprescribing high-value treatment (anticoagulation) or doing everything at once
- Ignoring adherence/treatment burden and the carer
Same day / urgent
Acute harm- Significant hypoglycaemia / AKI / bleedingAddress the cause urgently
- Injurious falls / collapseFalls assessment; reduce culprit drugs
- Dangerous combinationStop "triple whammy"/opioid+benzo
This review
Deprescribe- Falls/confusion driversOver-treated BP, ACB, sedatives, hypo risk
- Relax over-tight targetsHbA1c/BP in frailty
- Low-value preventivesTime-to-benefit > prognosis
Over reviews
Optimise- Simplify regimenReduce burden; adherence aids
- Keep high-value treatmentsAnticoagulation for AF
- Monitoring & follow-upRe-check after each change
- Changing everything at once / no prioritisation
- Missing acute harm (hypo/AKI/injurious falls)
- Not measuring lying/standing BP in falls/dizziness
- Not assessing frailty/cognition to inform deprescribing
- Deprescribing without checking renal function/monitoring
- Not using a structured tool / not quantifying ACB
🚩 Deprescribe the harmful, keep the high-value — for her goals
Edith's plan, anchored to "stay on my feet and keep my marbles": reduce/relax the over-treated BP and diabetes, lower the anticholinergic burden (stop/swap the bladder drug), discuss stopping preventives whose benefit lies years away (e.g. a primary-prevention statin), while reassessing rather than reflexively stopping bone protection given her falls, stop the NSAID (AKI/bleeding risk) and use safer OA analgesia — while KEEPING her anticoagulation (genuine stroke prevention). Change one or two things at a time, monitor, and review.
- No per-medicine benefit/burden reasoning
- Stopping high-value drugs or keeping clearly harmful ones
- Fragmented, uncoordinated changes
- Not using pharmacist/falls/frailty support
Validate — name both expectations out loud
Edith expects to come away on fewer tablets. She may also secretly expect to be told off for missing doses. Her daughter may expect more to be done: a scan, a referral or a new tablet for memory. Say both expectations back to them before explaining anything. This stops either of them feeling overruled and shows you have heard the quiet comment Edith made about wanting fewer tablets.
"Edith, I heard you say you'd rather be on fewer tablets. That's a completely reasonable thing to want, and I think we can do it. And I can see you're worried about the falls and her memory," (to the daughter) "which is exactly what I want to tackle too."Explain — link the tablets to the symptoms
Explain in plain language that some of her current medicines are probably contributing to the dizziness, falls, drowsiness and forgetfulness. Her blood pressure is now lower than it needs to be at 82, especially on standing. Her sugar is tighter than is safe and the gliclazide can cause lows. The bladder tablet (oxybutynin) is known to affect memory and balance in older people. So in her case, fewer tablets is not a compromise. It is the treatment. Also explain that some tablets are genuinely protective and will stay, especially the blood thinner for her heart rhythm.
"Some of your tablets were right when they were started, but your body has changed since then. A few are now pushing your blood pressure and sugar too low, and one of them can make memory and balance worse. Easing those should help the very things you're worried about. Others, like your blood thinner, are protecting you from a stroke, so those stay."Negotiate — agree the first one or two changes today
Don't overhaul 14 medicines in one appointment. Agree the first one or two changes, the ones with the most harm and least benefit (e.g. stop oxybutynin and stop gliclazide, or stop naproxen). Book the lying and standing BP recheck and bloods. Give a written list of what has changed and what to watch for, and set a date to decide on the next step. Explain that the plan will continue over several reviews. This matches her wish for fewer tablets, deals with the daughter's safety concern, and keeps each change traceable.
"Today let's stop two tablets, the bladder one and the sugar tablet that can cause lows. I'll write down exactly what's changed. In two to four weeks we'll check your blood pressure lying and standing, see how you feel, and then decide on the next one or two together."Sarcopenia and poor balance are core parts of frailty. Progressive resistance and balance training improve lower-limb strength, gait speed and the ability to recover from a trip. This is the intervention with the strongest evidence for preventing falls in community-dwelling older people.
Refer to the community falls service or physiotherapy (NICE NG249). Many areas run evidence-based programmes such as FaME or Otago. Programmes need to be progressive and sustained; one-off advice leaflets don't prevent falls. Encourage walking with a suitable aid, and teach her how to get up from the floor.
Ageing blunts the baroreflex. Vasodilators, diuretics and dehydration reduce preload. Together these cause a drop in cerebral perfusion when she stands up. Counter-manoeuvres and adequate fluids help the body cope while the antihypertensives are being reduced.
Sit on the edge of the bed for a minute before standing. Clench calves and buttocks before walking. Avoid hot baths and large carbohydrate meals before activity. Maintain fluid intake unless she has a fluid restriction. Get up at night with a light on. Review whether the diuretic is making her rush to the toilet at night, a double hazard alongside her overactive bladder.
Bladder training gradually lengthens the intervals between voids and retrains detrusor control. Stopping the anticholinergic is safer if the symptoms it treated are managed another way. Otherwise urgency returns and she rushes to the toilet, which is itself a common cause of falls.
NICE NG123 recommends bladder training for at least 6 weeks as first line for overactive bladder. Advise moderating caffeine and fizzy drinks, avoiding large volumes of fluid late in the evening, and treating constipation. Consider a continence service referral, a commode or urinal at night, and a clear, lit route to the toilet.
Environmental hazards (rugs, poor lighting, stairs, a bath without rails) combine with drug effects to cause falls. An occupational therapist identifies and changes these and assesses her function and safety.
OT home visit, grab rails, night lights, a raised toilet seat if needed, and a pendant or telecare alarm (especially if she has had a long lie). Check vision (cataracts, varifocals on stairs) and footwear. These are simple, low-cost measures that she and her daughter usually welcome.
Weight loss and low protein intake worsen sarcopenia and frailty. Poor intake also changes drug handling: renal function falls, creatinine drops with muscle loss (so eGFR looks falsely reassuring), and hypoglycaemia risk rises. Dehydration drives postural hypotension and AKI.
Weigh her at each review (weight is also needed for Cockcroft–Gault). Screen for malnutrition, e.g. with MUST. Encourage regular meals with protein. If her dietary calcium is adequate, a vitamin D supplement alone may replace a large chewable calcium/vitamin D tablet she dislikes. Check with bone-health guidance, as she is on a bisphosphonate.
Loneliness, low mood and inactivity feed frailty. A social prescribing link worker can connect Edith to community groups, exercise classes and befriending. They can also help her daughter access a carer's assessment and respite.
Refer to the PCN social prescribing link worker. Code the daughter as a carer and signpost her to the local carers' centre and a Care Act 2014 carer's assessment. If mood stays low once medicines are adjusted, psychological therapy (NHS Talking Therapies is open to older adults) may be more acceptable than an increased antidepressant dose.
- During vomiting, diarrhoea or fever with poor fluid intake, some medicines raise the risk of AKI, lactic acidosis or hypoglycaemia. They are often remembered by the mnemonic SADMANS: sulfonylureas, ACE inhibitors, diuretics, metformin, ARBs, NSAIDs, SGLT2 inhibitors.
- The Think Kidneys programme (NHS England/UK Renal Registry) advises that sick-day guidance is reasonable for patients judged at high risk of AKI after individual assessment. The evidence base is limited, so give it thoughtfully and in writing.
- Write a restart trigger for each drug (no blanket 24–48-hour rule), with U&E after restarting the ACE inhibitor or diuretic if the illness was significant. Advise Edith (and her daughter) to seek review if she is not recovering within a day or two.
- Do not include apixaban or bisoprolol in "stop when unwell" advice unless directed by a clinician.
- NICE NG5 (medicines optimisation, 2015) includes over-the-counter and complementary medicines in medicines reconciliation.
- OTC NSAIDs (ibuprofen) undo the naproxen withdrawal and restore triple-whammy and bleeding risk.
- Sedating antihistamines (e.g. chlorphenamine, promethazine and "night-time" cold or sleep remedies) add anticholinergic burden and falls risk.
- St John's wort is an enzyme inducer. It reduces DOAC and warfarin levels (risk of stroke) and interacts with SSRIs (serotonin toxicity), so it should be avoided with apixaban.
- Ginkgo, high-dose fish oil and turmeric may add to bleeding risk with anticoagulants. Advise checking with the pharmacist before buying anything new.
"This bladder tablet works by blocking a chemical messenger in the body, and that same messenger helps memory and balance. At your age the brain is more sensitive to it. We'll stop it, use bladder training instead, and see whether your head feels clearer over the next few weeks."
SCA: name the anticholinergic mechanism in plain words and link it to her symptoms (forgetfulness, drowsiness, falls). Offer the non-drug alternative, not just "stop it".
"Your sugar is actually a bit too well controlled for safety. This tablet can push it too low, and in older people that can show up as dizziness, muddle or a fall rather than the usual shakes. Stopping it should make lows much less likely. If you get very thirsty or are passing a lot of water, let us know."
SCA: "very well controlled" HbA1c in a frail faller is a red flag for over-treatment, not a success. Relaxing the target is a NICE NG28 recommendation, so it is not a lower standard of care.
"This is the one tablet I really want you to keep taking. It prevents the kind of stroke that heart rhythms like yours cause. If you have a fall and bang your head, you need to be seen the same day, because the blood thinner means we have to check for bleeding."
SCA: stopping a DOAC because someone "falls a lot" is a classic deduction. Instead, make it safer: correct dose, remove NSAIDs, reduce falls risk, and give a head-injury safety-net.
"This stomach tablet was mainly there to protect you from the anti-inflammatory. Now that's stopped, we can try a lower dose. For a couple of weeks you might get some heartburn as the stomach adjusts. That usually settles, and you can take an antacid if you need it."
SCA: show you know why each drug was started. PPIs are often a "prescribing cascade" that outlives its reason.
"Because you've had falls, your bones need protecting more than ever, so I'd suggest keeping the weekly bone tablet for now. If taking it standing up on an empty stomach is a struggle, tell me, because there's a once-a-year drip alternative."
SCA: in a faller, bone protection may be one of the more valuable preventives. Show you have weighed it rather than stopping "all the preventives".
"This tablet may still be helping your mood, so I don't want to stop it today. Once we've sorted the others, we can talk about whether you still need it. If you decide to stop, we'll do it slowly over weeks so you don't get withdrawal symptoms."
SCA: acknowledge that the antidepressant might still be doing good. Deprescribing psychotropics is staged and never abrupt.
(To a family member) "This medicine can calm distress, but in people with dementia it also raises the risk of stroke and falls. So we use it only when really needed, at the smallest dose, and check every few weeks whether we can reduce or stop it."
SCA care-home variant: explore the cause of the behaviour first (pain, constipation, infection, environment) before prescribing, and set a documented review date.
Driving & the DVLA
Ask whether Edith still drives. Drivers must renew their licence at 70 and every 3 years after that, declaring fitness themselves. Falls from postural hypotension, hypoglycaemia on a sulfonylurea, sedation, and cognitive change can all affect safe driving. Follow DVLA "Assessing fitness to drive" guidance on hypoglycaemia, and remind her that it is illegal to drive if impaired by medicines. Stopping gliclazide and the anticholinergic may make driving safer. If cognition is a concern, discuss it openly and document.
"Do you still drive? Some of these tablets can affect alertness and blood sugar, so I want to make sure you're safe behind the wheel."The daughter-carer relationship
The daughter's anxiety may lead her to take over ("I'll do Mum's tablets now"). This can protect Edith but can also erode her autonomy. Agree roles with Edith's consent. Offer the daughter a copy of the medicines plan and a named contact. Signpost a carer's assessment (Care Act 2014) and local carers' support. Carer burnout is a common reason older people move into care homes.
"Would it help if I wrote the changes down for both of you, so you're working from the same list?"Identity: "patient" or person?
Being defined by a pill list is demoralising. Edith was a mother, a worker and a neighbour before she was "on 14 medicines". Framing the review around what she wants to do (gardening, the grandchildren, church, getting to the shops) restores agency and gives practical measures of success that mean more than a blood pressure reading.
"What would you like to be able to do in six months' time that's hard at the moment?"Practical burden: packs, deliveries & appointments
Multi-compartment compliance aids ("blister packs") are not a default solution. NICE NG67 (medicines support in social care) and the Royal Pharmaceutical Society prefer original packs with a proper assessment of need, because compliance aids can't hold some medicines and hide which tablet is which. Consider synchronising repeat dates, once-daily regimens, a community pharmacy New Medicine Service or delivery, and combining reviews into one longer appointment instead of several short ones.
"Would it be easier if all your tablets were due on the same day each month, and we did your reviews together in one visit?"If Edith moves into a care home
A move to a care home is a high-risk transition for medication errors. Social care guideline SC1 (Managing medicines in care homes, 2014) covers medicines reconciliation on admission, care-home medication reviews, homely remedies and covert administration (which needs a best-interests decision under the Mental Capacity Act). Enhanced Health in Care Homes arrangements provide a named clinical lead and structured medication reviews for residents.
"If you ever need more support at home or move somewhere with care, we'll make sure your medicines list goes with you and is checked."Time, prognosis & what's worth it
Talking about time-to-benefit means gently acknowledging that time is limited. Many older people welcome this honesty: "I don't want pills for 10 years from now, I want to enjoy now." Others want everything continued. Both are valid choices under NICE NG197. Record her preferences so future clinicians don't restart what she chose to stop.
"Some tablets work over many years and others help you now. Which matters more to you at this stage of life?"Today — Shared plan, first 1–2 changes, bloods
Agree Edith's goals and the first changes (e.g. stop oxybutynin and gliclazide; stop naproxen and switch to a topical NSAID). Give a written, updated medication list to Edith and her daughter. Arrange U&E with sodium, creatinine for CrCl, weight, FBC, LFT, HbA1c, B12 and bone profile. Refer to the falls service/physio and OT. Tell the community pharmacy about the changes so stopped items are removed from repeats.
1–2 weeks — Phone check (GP or clinical pharmacist)
Any urgency or incontinence since stopping oxybutynin? Any thirst, polyuria or high glucose readings since stopping gliclazide? Falls, dizziness, drowsiness? Review results. If sodium is low, prioritise stopping indapamide. Confirm the apixaban dose against CrCl, weight and age. Reinforce the safety-net.
2–4 weeks — Lying/standing BP; next change
Repeat lying and standing BP. If the postural drop persists, reduce the next antihypertensive (e.g. stop indapamide, then review amlodipine). Assess cognition and drowsiness now the anticholinergic is gone. Agree the next one or two changes (e.g. PPI step-down now that the NSAID has stopped). Check she is attending the falls service.
~3 months — Structured medication review
HbA1c against the relaxed target; renal function; weight. Discuss the statin (primary or secondary prevention; her wishes) and the bisphosphonate (fracture-risk reassessment; technique). Mood review (PHQ-9) and a decision on the sertraline taper. Formal cognitive assessment if concerns persist once anticholinergics are cleared. Update the eFI or Clinical Frailty Scale. Document her preferences.
6–12 months, then at least annually — Ongoing review
At least annual structured medication review (the GP contract expects one for people with severe frailty). Repeat the falls assessment if she falls again. Check DOAC monitoring (renal function, FBC). Rereview whenever there is a hospital discharge, a new specialist drug or a care-setting change. Consider advance care planning as her priorities evolve.
Memory rule — "FAB-KS" after every deprescribing step
Falls and function (any falls, gait, confidence); Anticholinergic symptoms and cognition (drowsiness, confusion, dry mouth, constipation); BP lying and standing, and Blood glucose control against the agreed target; Kidneys (creatinine, CrCl, potassium, sodium), which decide DOAC and metformin dosing; Symptoms returning (urgency, reflux, pain, mood), which tell you whether a withdrawn medicine was still needed.
| Medicine / area | Parameter | Timing | Action threshold |
|---|---|---|---|
| Antihypertensive reduction | Lying and standing BP (1 and 3 min); symptoms | 2–4 weeks after each change | Persistent drop ≥20/10 or symptoms → reduce the next agent. Standing BP consistently above target (NICE NG136: <150/90 clinic at ≥80) → reconsider. |
| Sulfonylurea stopped | Symptoms of hyperglycaemia; HbA1c | Symptoms at 1–2 weeks; HbA1c at ~3 months | Osmotic symptoms or HbA1c well above the agreed individualised target → review; consider an agent with low hypoglycaemia risk. |
| Antimuscarinic stopped | Bladder diary; cognition; drowsiness | 2–4 weeks | Urgency returns despite bladder training → continence review; consider mirabegron (check BP). Cognition not improving → formal assessment. |
| DOAC (apixaban) | Weight, creatinine, CrCl (Cockcroft–Gault), FBC, LFT | Baseline; at least annually; more often if CrCl is falling or the patient is unwell | Crosses a dose-adjustment criterion → change dose per SmPC/SPC. Unexplained Hb fall → look for bleeding. |
| ACE inhibitor / diuretic | U&E, sodium, potassium | 1–2 weeks after any change; during intercurrent illness | Sodium falling (SSRI + thiazide-like diuretic) → stop the diuretic first. Creatinine rise → apply sick-day guidance; review for AKI. |
| Metformin | eGFR, B12 | At least annually; B12 if symptoms or risk factors (MHRA, June 2022) | Reduced renal function → adjust dose per SPC. Low B12 → replace; consider neuropathy as a falls contributor. |
| PPI step-down | Dyspepsia symptoms; alarm features | 2–4 weeks | Rebound only → alginate or as-needed PPI. Alarm features → urgent assessment per NICE NG12. |
| SSRI taper | Withdrawal symptoms; mood (PHQ-9) | At each step (NICE NG222) | Troublesome withdrawal → slow the taper or return to the previous dose. Relapse → restart and review. |
| Frailty & falls | eFI/CFS; falls diary; weight | Each review; annually at minimum | Worsening frailty → comprehensive geriatric assessment; re-weigh time-to-benefit of all preventives. |
⚠ Three scenario-specific safety-nets: use these (almost) verbatim
What to document
- Stopping many drugs at once / abrupt withdrawal of taper drugs
- No monitoring/safety-net/review; not simplifying
- Imposing changes rather than shared decisions
Who you are
Edith Hargreaves, 82, here with your daughter. You take 14 medicines (for blood pressure, type 2 diabetes, atrial fibrillation, osteoporosis, depression, an overactive bladder, reflux, arthritis and cholesterol). You've become frailer, had two falls, feel light-headed standing up, drowsy in the day, and a bit forgetful. You've been told your diabetes is "very well controlled" and your blood pressure runs low (you feel dizzy). You find the tablets a burden, don't always take them all, and would rather be on fewer. Your priority is to "stay on my feet and keep my marbles". Your daughter is anxious about the falls and memory.
Hidden concerns (reveal if explored)
Wants fewer tablets (main): the burden bothers you; you've quietly skipped some.
Fear of falls/dementia: the falls and forgetfulness frighten you and your daughter.
Worry about stopping the "wrong" one: you don't want anything bad to happen — reassurance that important ones stay helps.
Clinical details if asked
- 14 medicines; falls ×2; postural dizziness; daytime drowsiness; mild new forgetfulness; dry mouth
- HbA1c "very well controlled"; BP runs low; bladder antimuscarinic + antidepressant among the drugs; on an anticoagulant for AF; on an NSAID for arthritis
- Doesn't always take them all; finds the regimen a burden; some dexterity difficulty
- Lives at home with some help; daughter nearby and involved
Reactions at key moments
- If the doctor goes through diseases/guidelines without asking what matters: you feel unheard.
- On "what matters to you?": relieved; you say you want fewer tablets, no falls, keep your mind.
- On easing BP/bladder tablets: pleased, a little cautious.
- On keeping the blood-thinner: reassured it's important and stays.
- Challenge line: "Can't you just stop most of them? But you won't stop anything important and cause a stroke, will you?"
Resolution: Edith is well served if the GP: (1) begins with "what matters to you" and builds the review around her goals (fewer tablets, avoid falls, preserve cognition); (2) links her falls/dizziness, drowsiness and forgetfulness to likely drug causes (over-treated BP/postural drop, anticholinergic burden, hypo risk) and assesses objectively (lying/standing BP, cognition, frailty); (3) weighs benefit vs burden per medicine — reducing/relaxing the over-treated BP and diabetes, lowering anticholinergic burden, discussing stopping low-value preventives (e.g. a primary-prevention statin, by shared decision) while reassessing fracture risk and usually continuing the bisphosphonate given her age and falls, stopping the NSAID — while KEEPING her anticoagulation; (4) deprescribes deliberately, one change at a time, with shared decisions, monitoring, simplification, carer involvement and continuity. She feels unheard if the GP works through diseases/guidelines, changes everything at once, or stops a high-value medicine.
Start with "what matters to you". Structured medication review per drug: indication valid? effective? wanted? safe (interactions/monitoring/renal)? duplicated? evidence in THIS person? Weigh benefit vs treatment burden & harm. Use STOPP/START + anticholinergic burden score. In frailty, consider time-to-benefit vs prognosis for preventives.
Target: falls/confusion drivers (over-treated BP/postural drop, ACB, sedatives, hypo risk), high-risk combos (triple whammy → AKI; opioid+benzo), low-value preventives. Relax over-tight HbA1c/BP. Keep high-value (anticoagulation in AF). How: shared decision, one change at a time, taper where needed (steroids/benzos/beta-blockers), monitor, simplify, safety-net, review; coordinate (pharmacist, falls, frailty MDT, continuity GP).