Polypharmacy: Evaluating Risks and Deprescribing


Am Fam Physician. 2019 Jul 1;100(1):32-38.

Author disclosure: No relevant financial affiliations.

Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes. There are several risk factors that can lead to polypharmacy. Patient-related factors include having multiple medical conditions managed by multiple subspecialist physicians, having chronic mental health conditions, and residing in a long-term care facility. Systems-level factors include poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics. Tools that help identify potentially inappropriate medication use include the Beers, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to right treatment) criteria, and the Medication Appropriateness Index. No one tool or strategy has been shown to be superior in improving patient-related outcomes and decreasing polypharmacy risks. Monitoring patients' active medication lists and deprescribing any unnecessary medications are recommended to reduce pill burden, the risks of adverse drug events, and financial hardship. Physicians should view deprescribing as a therapeutic intervention similar to initiating clinically appropriate therapy. When deprescribing, physicians should consider patient/caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to slow disease progression, prevent health decline, and address symptoms. Point-of-care tools can aid physicians in deprescribing and help patients understand the need to decrease medication burden to reduce the risks of polypharmacy.

As the size of the older adult population (those older than 62) and the number of younger people with complex health conditions have increased in the United States, polypharmacy has become a growing problem.1  Polypharmacy has negative consequences for patients and the health care system (Table 1).217 For example, patients taking more than four medications have an increased risk of injurious falls, and the risk of falls increases significantly with each additional medication, regardless of medication type.18

 Enlarge     Print


Clinical recommendationEvidence ratingComments

Physicians should identify and prioritize medications to discontinue and discuss potential deprescribing with the patient.3134


Expert consensus and narrative review articles

When deprescribing, always develop a specific follow-up plan with the patient.31,33,38,41


Expert opinion from review articles

Once a medication reconciliation and deprescribing plan has been put into place, it should be considered at each visit as time allows and comprehensively reviewed at health maintenance visits.19,20,29,32


Cochrane review with inconsistent and limited evidence and expert consensus

Before starting any new medications, consider underlying causes to treat first, necessity of treatment, alternative nonpharmacologic treatments, and benefits vs. risks of treatment.13,26,29,32,40


Survey study, narrative review, and expert consensus

When starting any new medication, consider it a trial rather than a permanent addition.13,26,32,40


Survey study and narrative review articles

When refilling medications, consider the benefits vs. risks of continuation in the short term and long term.13,26,32,40


Survey study and narrative review articles

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

ANNE D. HALLI-TIERNEY, MD, is an assistant professor and geriatrician at the University of Alabama Family Medicine Residency and a physician at the DCH Regional Medical Center, both in Tuscaloosa....

CATHERINE SCARBROUGH, MD, MSc, FAAFP, is a faculty member at St. Vincent's East Family Medicine Residency Program at Christ Health Center in Birmingham, Ala.

DANA CARROLL, PharmD, is a faculty member at Auburn (Ala.) University Harrison School of Pharmacy and is an adjunct faculty member in the Department of Family, Internal and Rule Medicine at the University of Alabama.

Address correspondence to Anne D. Halli-Tierney, MD, 850 Peter Bryce Blvd., Tuscaloosa, AL 35401 (e-mail: halli002@ua.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Steinman MA, Miao Y, Boscardin WJ, Komaiko KD, Schwartz JB. Prescribing quality in older veterans: a multi-focal approach. J Gen Intern Med. 2014;29(10):1379–1386....

2. Ahmed B, Nanji K, Mujeeb R, Patel MJ. Effects of polypharmacy on adverse drug reactions among geriatric outpatients at a tertiary care hospital in Karachi: a prospective cohort study. PLoS One. 2014;9(11):e112133.

3. Nguyen JK, Fouts MM, Kotabe SE, Lo E. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother. 2006;4(1):36–41.

4. Jano E, Aparasu RR. Healthcare outcomes associated with Beers' criteria: a systematic review. Ann Pharmacother. 2007;41(3):438–447.

5. Akazawa M, Imai H, Igarashi A, Tsutani K. Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother. 2010;8(2):146–160.

6. Frazier SC. Health outcomes and polypharmacy in elderly individuals: an integrated literature review. J Gerontol Nurs. 2005;31(9):4–11.

7. Gnjidic D, Hilmer SN, Blyth FM, et al. High-risk prescribing and incidence of frailty among older community-dwelling men. Clin Pharmcol Ther. 2012;91(3):521–528.

8. Gnjidic D, Le Couteur DG, Abernethy DR, Hilmer SN. Drug burden index and Beers criteria: impact on functional outcomes in older people living in self-care retirement villages. J Clin Pharmacol. 2012;52(2):258–265.

9. Gómez C, Vega-Quiroga S, Bermejo-Pareja F, Medrano MJ, Louis ED, Benito-León J. Polypharmacy in the elderly: a marker of increased risk of mortality in a population-based prospective study (NEDICES). Gerontology. 2015;61(4):301–309.

10. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300(24):2867–2878.

11. Dequito AB, Mol PG, van Doormaal JE, et al. Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands. Drug Saf. 2011;34(11):1089–1100.

12. Jyrkkä J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs Aging. 2009;26(12):1039–1048.

13. Ie K, Felton M, Springer S, Wilson SA, Albert SM. Physician factors associated with polypharmacy and potentially inappropriate medication use. J Am Board Fam Med. 2017;30(4):528–536.

14. Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med. 2004;164(3):305–312.

15. Gyllensten H, Rehnberg C, Jönsson AK, Petzold M, Carlsten A, Andersson Sundell K. Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey. BMJ Open. 2013;3(6):1–12.

16. Veehof L, Stewart R, Haaijer-Ruskamp F, Jong BM. The development of polypharmacy. A longitudinal study. Fam Pract. 2000;17(3):261–267.

17. Gnjidic D, Le Couteur DG, Pearson SA, et al. High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level. BMC Public Health. 2013;13:115.

18. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999;47(1):40–50.

19. Rankin A, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;(9):CD008165.

20. American Geriatrics Society 2019 updated AGS Beers criteria® for potentially inappropriate medication use in older adults [published ahead of print January 29, 2019]. J Am Geriatr Soc. https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767 (login required). Accessed February 22, 2019.

21. Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr Med. 2012;28(2):159–172.

22. Lunsky Y, Modi M. Predictors of psychotropic polypharmacy among outpatients with psychiatric disorders and intellectual disability. Psychiatr Serv. 2018;69(2):242–246.

23. Jokanovic N, Tan EC, Dooley MJ, Kirkpatrick CM, Bell JS. Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2015;16(6):535.e1–535.e12.

24. Haider SI, Ansari Z, Vaughan L, Matters H, Emerson E. Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability. Res Dev Disabil. 2014;35(11):3071–3080.

25. Yazici E, Cilli AS, Yazici AB, et al. Antipsychotic use pattern in schizophrenia outpatients: correlates of polypharmacy. Clin Pract Epidemiol Ment Health. 2017;13:92–103.

26. Pesante-Pinto JL. Clinical pharmacology and the risks of polypharmacy in the geriatric patient. Phys Med Rehabil Clin N Am. 2017;28(4):739–746.

27. Kaufmann CP, Tremp R, Hersberger KE, Lampert ML. Inappropriate prescribing: a systematic overview of published assessment tools. Eur J Clin Pharmacol. 2014;70(1):1–11.

28. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–218.

29. Hanlon JT, Schmader KE. The Medication Appropriateness Index at 20: where it started, where it has been, and where it may be going. Drugs Aging. 2013;30(11):893–900.

30. Samsa GP, Hanlon JT, Schmader KE, et al. A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47(8):891–896.

31. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–834.

32. Choosing Wisely. An initiative of the ABIM Foundation. http://www.choosingwisely.org. Accessed July 20, 2018.

33. Endsley S. Deprescribing unnecessary medications: a four-part process. Fam Pract Manag. 2018;25(3):28–32.

34. Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ. 2016;353:i2893.

35. Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017;38:3–11.

36. Woodward MC. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33(4):323–328.

37. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of ‘deprescribing’ with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254–1268.

38. Brandt NJ. Optimizing medication use through deprescribing: tactics for this approach. J Gerontol Nurs. 2016;42(1):10–14.

39. Case SM, O'Leary J, Kim N, Tinetti ME, Fried TR. Older adults' recognition of trade-offs in healthcare decision making. J Am Geriatr Soc. 2015;63(8):1658–1662.

40. Burt J, Elmore N, Campbell SM, Rodgers S, Avery AJ, Payne RA. Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study. BMC Med. 2018;16(1):91.

41. Bemben NM. Deprescribing: an application to medication management in older adults. Pharmacotherapy. 2016;36(7):774–780.

42. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793–807.

43. Reeve E, Low LF, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study. Br J Gen Pract. 2016;66(649):e552–e560.

44. Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns. 2015;98(2):220–225.

45. Bohnert AS, Guy GP Jr, Losby JL. Opioid prescribing in the United States before and after Centers for Disease Control and Prevention's 2016 opioid guideline. Ann Intern Med. 2018;169(6):367–375.



Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed


Jul 15, 2019

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article