Managing polypharmacy in older adults with HM17 deprescribing tools

Australasian hospitals are admitting increasingly complex older patients whose medication lists often exceed ten regular items. The 2017 Hospital Medicine conference in Las Vegas dedicated substantial time to the practical question of how hospitalists can safely reduce that burden. Deprescribing — the systematic process of identifying and withdrawing medications where harms outweigh benefits — has moved from a fringe idea to a core inpatient skill. For clinicians in Sydney, Melbourne, regional Queensland, and Perth, the lessons shared at Hospital Medicine 2017 translate directly into safer ward rounds and shorter lengths of stay.

Polypharmacy in older adults is rarely a single problem. It reflects decades of guideline-driven prescribing layered onto multiple chronic conditions, specialist input, and acute admission fixes that were never reconciled afterwards. Sessions at HM17 emphasised that the goal is not to count pills but to align each medicine with the patient's current goals, life expectancy, and functional status. That framing resonates with the Australian emphasis on patient-centred care and the Pharmaceutical Benefits Scheme's move toward quality use of medicines.

The scale of polypharmacy in Australian hospitals

Australian data consistently show that more than 40 per cent of patients aged over 75 take five or more regular medications at the time of admission. In tertiary centres such as the Royal Melbourne and Royal Prince Alfred, the figure climbs higher once over-the-counter products and complementary medicines are counted. Winter brings a predictable surge in admissions for falls, delirium, and heart failure decompensation — conditions frequently precipitated by preventable adverse drug events. Polypharmacy contributes to roughly one in ten unplanned geriatric admissions, according to local audit work, with sedatives, anticoagulants, and diuretics featuring prominently.

The cost burden falls partly on the Pharmaceutical Benefits Scheme, which subsidises medicines such as proton pump inhibitors and statins that are often continued beyond the original indication. Australia's Quality Use of Medicines framework, championed by NPS MedicineWise, recognises that prescribing more is not always prescribing better. Hospitalists therefore have both an opportunity and a responsibility to revisit each item on the admission drug chart before discharge.

Why older adults are uniquely vulnerable

Ageing changes pharmacokinetics and pharmacodynamics in ways that are clinically important but easy to miss. Reduced renal clearance, lower lean body mass, and altered hepatic metabolism mean that standard adult doses can accumulate to toxic levels over weeks. The cholinergic burden of an anticholinergic load score above three has been associated with cognitive decline, dry mouth, urinary retention, and falls in Australian community-dwelling seniors studied through the Hunter Community Study.

Adverse drug events are not always dramatic. A subtle drop in sodium from a thiazide, a minor bleed from concurrent NSAIDs and an anticoagulant, or a slow decline in renal function from combined ACE inhibitors and diuretics can be dismissed as ageing until a hospital admission becomes unavoidable. The HM17 faculty stressed that the first step is recognising that the patient's symptoms may actually be drug side effects. A useful bedside question — "Could any of these medicines be causing this?" — changes the diagnostic frame.

Tools and frameworks shared at HM17

The Las Vegas meeting showcased several structured deprescribing tools that work alongside clinical judgement. The STOPP/START criteria, now in their second iteration, list explicit medications to consider stopping and evidence-based indications to start. The American Geriatrics Society Beers Criteria remain the most widely cited, while the Australian-developed Meds75+ list offers an online resource tailored to patients aged 75 and over. Each tool has strengths and limitations that presenters at HM17 explored through case-based discussion.

Beyond explicit lists, faculty highlighted the importance of medication reconciliation as a precondition. A reconciled list allows clinicians to apply tools like the Drug Burden Index or anticholinergic risk scales. Conference attendees were pointed toward practical resources including follow-up phone call scripts, which demonstrate how to verify adherence and tolerability in the weeks after discharge. Aligning the in-hospital plan with what actually happens at home is essential.

A practical step-by-step approach

HM17 speakers walked through a five-step framework that fits comfortably into a 30-minute medication review on a post-take ward round. Step one is to gather a complete medication history, including the GP list, pharmacy dispensing record, and the patient's own brown bag. Step two involves listing each drug alongside its current indication, original prescriber, and the date it was started.

Step three asks whether each medicine is still appropriate given current goals, renal and hepatic function, and life expectancy. Step four prioritises medicines with the greatest harm-to-benefit ratio, such as benzodiazepines in patients with cognitive impairment or sulfonylureas in the frail elderly. Step five plans the taper, monitors for withdrawal or rebound, and documents the rationale clearly for the GP. The framework deliberately leaves room for shared decision-making rather than imposing a protocol-driven stop order.

The next question is which tool to layer onto this framework. Australian hospitalists can choose from several validated instruments, each suited to a slightly different context.

Choosing the right tool for the patient

No single tool fits every ward or clinic. STOPP/START works well in Irish and UK teaching hospitals and has been adopted in some Australian facilities, particularly where pharmacy-led reconciliation is well resourced. The Beers Criteria provide an authoritative reference that translates easily into teaching sessions for junior doctors. Meds75+, by contrast, was developed in New South Wales and reflects Australian prescribing culture, including the prominence of benzodiazepine prescribing and the long-term use of proton pump inhibitors.

The conference reinforced that tools are decision supports, not decision makers. A frail patient in a Perth hostel with limited prognosis may warrant very different choices from a vigorous 72-year-old in inner Sydney planning a trip overseas. Combining two tools — for example, using STOPP/START for a comprehensive sweep and Meds75+ for Australian-specific context — often yields the most clinically defensible answer.

Translating HM17 lessons into Australian practice

Putting deprescribing into routine practice requires more than good intentions. Australian hospitals already have the policy architecture: Home Medicines Review and Residential Medication Management Review programs funded through Medicare item numbers, supported by accredited pharmacists. Hospitalists can prime these reviews by flagging in the discharge summary which medicines they believe are no longer needed or which require reassessment.

Cultural change matters as much as system change. Senior clinicians modelling deprescribing on ward rounds, pharmacists attending medical handover, and junior doctors being encouraged to question legacy prescriptions all shift the default. Sessions like the HM17 COPD exacerbation pearls showed how condition-specific deprescribing — for example, reviewing inhaled corticosteroid doses after an exacerbation — can be woven into existing workflows rather than bolted on.

The most useful habit an Australian hospitalist can adopt this winter is to make a reconciled, indication-linked medication list a standard part of every post-take assessment. Pair that list with one structured tool, document the reasoning behind every stop, and arrange the post-discharge follow-up before the patient leaves the ward. Patients leave with fewer pills, clearer instructions, and a better chance of staying well at home.