General Practice · Full case
Multimorbidity & Polypharmacy
Multimorbidity & Polypharmacy · Clinical Reasoning Framework v2
GP & SCA · NICE NG56 · what matters to the person · structured medication review · STOPP/START · anticholinergic burden · deprescribing · treatment burden vs benefit
Start with "what matters to you"NICE NG56: an individualised approach built around the person's priorities, values and goals — not a disease-by-disease, guideline-by-guideline stack. In multimorbidity, single-disease guidelines can conflict, add burden, and harm. Ask what matters most to them
Treatment burden is realMultiple medicines, appointments, monitoring and self-care impose a "treatment burden" that can outweigh benefit, especially with limited life expectancy or frailty. Weigh benefit vs burden and harm for EACH medicine, in THIS person, now — not in the average trial patient
The structured medication reviewA structured medication review (SMR) systematically checks: indication still valid? still effective? still wanted? safe (interactions, monitoring, renal/hepatic)? duplicated? evidence in this person? Use tools (STOPP/START) and the person's own experience and adherence
Deprescribe deliberatelyStopping or reducing medicines that are no longer needed, not working, causing harm, or unwanted is active, planned care — agreed with the patient, one change at a time, with monitoring and a safety-net. Don't deprescribe abruptly where withdrawal effects occur (e.g. steroids, benzodiazepines, beta-blockers)
Anticholinergic burden & fallsHigh anticholinergic burden (ACB) — many drugs (some antidepressants, bladder antimuscarinics, antihistamines, antipsychotics) — causes confusion, falls and cognitive decline in older people. Sedatives, antihypertensives and hypoglycaemics also drive falls. Review the falls-risk and ACB drugs
Watch the high-risk combinationsNSAID + ACE/ARB + diuretic ("triple whammy" → AKI); opioid + benzodiazepine/gabapentinoid (respiratory depression); multiple QT-prolongers; anticoagulant + antiplatelet/NSAID (bleeding); drugs needing monitoring (lithium, methotrexate, DOACs, warfarin). Rationalise
Frailty changes the goalsIn frailty/limited life expectancy, the time-to-benefit of preventive medicines (statins, tight glycaemic/BP control, bisphosphonates) may exceed remaining life, while risks (hypos, falls, AKI) are immediate. Relax targets, deprescribe preventives, and prioritise comfort and function
Shared decisions, not edictsEvery change is a shared decision: explain benefits/risks/uncertainty, respect the person's wishes, document, and follow up. Coordinate across conditions and clinicians; nominate a continuity GP; consider the carer. The goal is care that fits the person's life
📋 Clinical Stem — Multimorbidity & Polypharmacy
An 82-year-old woman on 14 medicines, increasingly frail with falls and dizziness, brought by her daughter for a "medication review" — who quietly says she'd rather take fewer tablets
Edith Hargreaves, 82, attends with her daughter for a medication review. She takes 14 medicines for hypertension, type 2 diabetes, atrial fibrillation, osteoporosis, depression, an overactive bladder, reflux, osteoarthritis and high cholesterol. Over the past months she has become more frail, with two falls, light-headedness on standing, daytime drowsiness and some new forgetfulness. Her HbA1c is "very well controlled" and her blood pressure runs low (she feels dizzy). She finds the tablets a burden, doesn't always take them all, and tells you quietly she'd "rather not be on so many". Her daughter worries about the falls and the forgetfulness. Edith's priority, she says, is to "stay on my feet and keep my marbles".
This stem tests the ability to conduct a person-centred structured medication review in multimorbidity (NICE NG56): starting with "what matters to you" (Edith wants to avoid falls and preserve cognition, and take fewer tablets); weighing benefit vs treatment burden and harm for each medicine in THIS frail, older person; identifying the medicines contributing to her presentation — postural hypotension from over-treated BP, hypoglycaemia risk from over-tight diabetes control, anticholinergic burden (the bladder antimuscarinic ± antidepressant) driving falls/confusion, and the time-to-benefit problem with preventives (statin, bisphosphonate) in frailty; recognising high-risk combinations and monitoring needs (anticoagulant for AF — stroke prevention to keep); and deprescribing deliberately, one change at a time, by shared decision, with monitoring and safety-net. The SCA challenge is balancing safe deprescribing with not stopping the medicines that genuinely matter (e.g. anticoagulation), and doing it as a collaboration with Edith and her daughter.
Scenario A — Frail elder, falls & ACB (this stem) Postural hypotension (over-treated BP), hypo risk (tight HbA1c), anticholinergic burden, preventives with long time-to-benefit. Person-centred SMR; deprescribe deliberately; keep anticoagulation; relax targets; monitor.
Scenario B — Conflicting guidelines Single-disease guidelines pulling in opposite directions (e.g. NSAID for OA vs CKD/AF/anticoagulation). Individualise; prioritise what matters; avoid harm.
Scenario C — High-risk prescribing "Triple whammy" (NSAID+ACE+diuretic), opioid+benzodiazepine, missed monitoring (lithium/methotrexate/DOAC), QT-prolongers. Identify & rationalise.
Scenario D — Adherence & burden Intentional/unintentional non-adherence, confusion over regimens, cost/dexterity issues. Simplify, address barriers, blister packs/aids where appropriate.
Scenario E — End of life / very limited prognosis Deprescribe preventives; focus on comfort/symptom control; anticipatory care; involve patient/family.
Key variables to adapt for "What matters to you"; benefit vs burden/harm per drug; frailty & time-to-benefit; falls & ACB; postural BP & over-treatment; hypo risk & relaxed targets; keep vs stop (anticoagulation in AF); high-risk combinations & monitoring; adherence & simplification; shared decisions; carer & continuity.
Steps:
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Step 1
History — What Matters · Symptoms from Medicines · Adherence & Burden · ICE
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The review begins not with the drug list but with the person: what matters to Edith, what she's experiencing, and how the medicines fit (or don't) into her life. Then connect her symptoms — falls, dizziness, drowsiness, forgetfulness — to likely drug causes, and understand her adherence and the burden the regimen imposes. This reframes a "tick-box review" into individualised care.
🎓 SCA framing — "what matters to you?" first
"Before we look at the tablets, I'd love to understand what matters most to you, Edith — what you want your health to let you do, and what's bothering you. You mentioned staying on your feet and keeping your mind sharp — let's build the plan around that."
Anchoring the review in Edith's goals (avoid falls, preserve cognition, fewer tablets) turns it from a guideline audit into person-centred care — and gives a clear yardstick for every keep/stop decision.
1A — Goals, drug-related symptoms, adherence
1B — Red flags / things not to miss
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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; dementia risk. | 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 |
1C — ICE
💭 Ideas
"What do you feel the tablets are doing for you — which ones do you value, and which feel pointless?"
Edith has views on her own medicines and has informally stopped some. Surfacing this respects her expertise in her own life, reveals adherence reality, and identifies the medicines she'd most welcome stopping — a collaborative starting point.
😟 Concerns
"What worries you most — the falls, your memory, or the number of tablets?"
Her concerns (and her daughter's about falls/memory) align with the clinical priorities. Naming them lets you target the review at what's frightening them and frame deprescribing as the solution, not a loss.
🎯 Expectations
"What would a good outcome from today look like for you?"
She wants fewer tablets and to stay well on her feet and mentally sharp. Naming this lets you agree a realistic, staged plan (a few changes now, review, more later) rather than overhauling everything at once.
1D — Psychosocial context
⚖️ 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."🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills
Key phrases that score
"What matters most to you about your health?" — the NG56 opening.
"The dizziness and falls may be from over-treating your blood pressure and the bladder tablet — those we can safely reduce." — links symptoms to drugs.
"We'll keep the blood-thinner that prevents strokes." — deprescribes the right things, keeps the high-value ones.
Deductions
- 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
🔴 Red
Guideline-by-guideline; no "what matters"; misses drug-caused falls/confusion; stops anticoagulation or changes everything at once
🟠 Amber
Person-centred; identifies some culprit drugs; some deprescribing; targets/monitoring partial; ICE partial
🟢 Green
"What matters" first; links symptoms to drugs (BP/ACB/hypo); benefit-vs-burden per drug; keeps high-value, deprescribes low-value one change at a time; involves carer; ICE all three
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Step 2
Triage — Acute Harm Now · Priority Deprescribing · Routine Optimisation
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Triage by harm: acute drug-related harm (significant hypos, AKI, falls causing injury, bleeding) needs action now; the medicines actively causing Edith's falls and confusion are priority deprescribing targets; and the lower-priority optimisation can be staged over reviews.
🔴 Act now
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
🟠 Priority
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
🟢 Stage
Over reviews
Optimise- Simplify regimenReduce burden; adherence aids
- Keep high-value treatmentsAnticoagulation for AF
- Monitoring & follow-upRe-check after each change
🎓 SCA Checkpoint — Step 2Tasks
Triage rationale
"Let's start with the changes most likely to stop your falls and clear your head — easing the blood-pressure tablets and the bladder tablet — and do one or two at a time so we can see the effect, keeping the important ones."
Deductions
- Changing everything at once / no prioritisation
- Missing acute harm (hypo/AKI/injurious falls)
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Step 3
Assessment — Lying/Standing BP · Falls · Cognition · Frailty · Function
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"Examination" gathers the objective data that drives deprescribing decisions: lying and standing blood pressure (postural drop), a falls and gait assessment, a cognitive screen, frailty status, and functional assessment.
🎓 SCA Checkpoint — Step 3TasksGlobal Skills
Narration that scores
"I'll check your blood pressure lying down and standing up to see if it's dropping — that's a common cause of dizziness and falls — and do a quick memory check and assess your balance, which helps me decide which tablets to ease back."
Deductions
- Not measuring lying/standing BP in falls/dizziness
- Not assessing frailty/cognition to inform deprescribing
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Step 4
Investigations — Renal/Electrolytes · Monitoring Bloods · ACB Score · Review Tools
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Investigations support safe deprescribing: renal function and electrolytes (especially with ACE/diuretic/NSAID and dosing), the monitoring bloods her drugs require, and structured tools — STOPP/START and an anticholinergic burden score — to systematise the review.
🎓 SCA Checkpoint — Step 4Tasks
Key reasoning
"I'll check your kidney function and blood count, look at the anticholinergic load of your tablets, and use a checklist to spot anything that's doing more harm than good — then we'll decide together."
Deductions
- Deprescribing without checking renal function/monitoring
- Not using a structured tool / not quantifying ACB
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Step 5
Formulation — Keep · Reduce · Stop · Relax Targets (per Medicine)
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The "diagnosis" is a per-medicine plan — keep, reduce, stop, or relax the target — built on benefit vs burden/harm in THIS person, aligned to her goals.
🚩 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), consider stopping preventives whose benefit lies years away, 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.
🎓 SCA Checkpoint — Step 5Tasks
Explaining the plan
"My suggestion: ease your blood-pressure and diabetes tablets so you're less dizzy and less likely to have a low, stop the bladder tablet that may be fogging your memory, and pause a couple of long-term prevention tablets — but keep the blood-thinner that protects you from stroke. We'll do it gradually and check as we go."
Deductions
- No per-medicine benefit/burden reasoning
- Stopping high-value drugs or keeping clearly harmful ones
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Step 6
Referral & Coordination — Pharmacist · Specialists · Falls · Frailty/MDT
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Multimorbidity care is coordinated: the clinical pharmacist for structured medication review, specialists for condition-specific advice where deprescribing is uncertain, falls and frailty services, and a nominated continuity GP — avoiding fragmented, contradictory care.
🎓 SCA Checkpoint — Step 6Tasks
Coordinated care
"I'll work with our pharmacist on the medicine changes and get the falls team to assess your balance and home. I'll be your named GP so it's joined-up, not lots of different people changing different things."
Deductions
- Fragmented, uncoordinated changes
- Not using pharmacist/falls/frailty support
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Step 7
Management — Deprescribe One Change at a Time · Monitor · Simplify · Review
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Management is deliberate, collaborative deprescribing: agree changes with Edith, make one or two at a time, taper where needed, monitor the effect, simplify the regimen, keep the high-value medicines, and review — turning the plan into safe, staged, person-centred action.
🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills
A plan that scores
"Let's start by easing two tablets — the blood-pressure one and the bladder one — and I'll check your blood pressure and how you feel in a few weeks. If the dizziness and fog improve, we'll go on to the next ones. We'll keep your stroke-prevention tablet. Here's what to look out for, and I'm your point of contact throughout."
Deductions
- Stopping many drugs at once / abrupt withdrawal of taper drugs
- No monitoring/safety-net/review; not simplifying
- Imposing changes rather than shared decisions
Multimorbidity & Polypharmacy — SCA Consultation Scorecard
What matters · benefit vs burden · falls/ACB · deprescribe deliberately · keep high-value
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, review, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
Guideline-by-guideline; no "what matters"; misses drug-caused falls/confusion; stops anticoagulation or changes everything at once; no monitoring
🟠 Amber
Person-centred; identifies some culprits; some deprescribing; targets/monitoring partial; ICE partial
🟢 Green
"What matters" first; links symptoms→drugs; benefit-vs-burden per drug; reduces ACB, relaxes targets, keeps anticoagulation; one change at a time + monitor; coordinated; ICE all three
Complete the checklist to see your score and feedback
"The nurse said I should come for a medication review. To be honest, doctor, I'm on so many tablets — fourteen, I think — and I'd really rather not be. I keep going dizzy and I've had a couple of falls, and my memory's not what it was."
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?"
"Honestly, can't we just get rid of most of these tablets? But I don't want you stopping something important and giving me a stroke — how do you decide which ones?"
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, considering stopping low-value preventives, 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.
Clinic Quick Reference
Multimorbidity & Polypharmacy — Clinical Decision Framework
NG56 · what matters · benefit vs burden · deprescribe
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🧭 1 — Approach (NG56)
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.
📉 2 — Deprescribe & keep
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).
SCA Quick Reference
Multimorbidity — Consultation Playbook
What matters · benefit vs burden · deprescribe deliberately
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🎯 The three pivots that pass this case
1 · What matters to you
Lead with the person's goals (fewer tablets, avoid falls, keep cognition), not the disease list.
2 · Benefit vs burden
Per medicine, in THIS frail person: link falls/confusion to drugs (BP/ACB/hypo); relax over-tight targets; mind time-to-benefit.
3 · Deprescribe, keep, monitor
Stop harmful/low-value one change at a time (taper where needed); KEEP high-value (AF anticoagulation); monitor & review.
⛔ Don't manage disease-by-disease without asking what matters · Don't miss drug-caused falls/confusion (BP/ACB/hypo) · Don't stop high-value medicines (e.g. AF anticoagulation) or change everything at once · Don't deprescribe abruptly where withdrawal occurs (steroids/benzos/beta-blockers) · Share decisions, monitor, simplify, coordinate