Stephen Jackson is Professor of Clinical Gerontology at King’s Health Partners
This is a recent King’s Fund Report which takes another look at polypharmacy. It is unclear why as there has been a rather better report published by NHS Scotland. One would assume the King’s fund would check who is doing what before commissioning such a report. Interestingly there is no mention of the G (geriatrician) word anywhere in the report although the terms “older care clinician”, “clinicians who specialise in care of older people” and orthogeriatrician do appear. I thought there was insufficient recognition of the fact that multiple pathology and hence polypharmacy is essentially a problem associated with ageing. The authors rightly differentiate between appropriate polypharmacy and what they call problematic polypharmacy known to many as inappropriate polypharmacy. Polypharmacy merely means “many medicines” as opposed to “too many medicines”. The report could be criticised for giving the impression that appropriate prescribing is only necessary when polypharmacy is present.
The report makes some statements that most members of the BGS would be surprised at. For example: “Rather than attending several disease-specific clinics, patients could have all their long-term conditions reviewed in one visit by a clinical team responsible for coordinating their care. Patients with multi-morbidity admitted to hospital under one specialty may require access to a generalist clinician to co-ordinate their overall care.” “This may require training and development of more ‘generalists’ skilled in the complexity of multiple disease alongside training to manage polypharmacy.” The authors have a lot to learn about geriatric medicine.
Another example is: “Guidelines should be developed to cover long-term conditions that commonly coexist, such as diabetes, coronary heart disease, heart failure, and chronic obstructive pulmonary disease.” This hasn’t been thought through – separate guidelines could be disastrous. Existing guidelines need to include guidance on management of patients on other drugs such as is seen with the BHS/NICE guidance on hypertension that includes compelling indications and contraindications which are conditions or concomitant medications.
The recommendation to keep the pill burden down is good, if not obvious, advice but inexplicably no advice to consider fixed dose combination tablets is offered. It has always been a mystery to me why the UK has the lowest use of fixed dose combinations in Europe. Perhaps we could infer an answer.
Sadly, as is so often the case in politics, yesterday’s good ideas are forgotten in favour of today’s. The NSF for Older People made specific recommendations for medication review which were never made mandatory and not referred to in this report. I think it’s time we built this into a CQUIN target.
The authors rightly point out that patient involvement in prescribing decisions is crucial although they don’t say much about the more difficult situation when a patient doesn’t have capacity for such involvement.
Overall I thought this report was disappointing but perhaps geriatricians are ahead of the game. I personally would prefer we all drop the term polypharmacy and consider appropriate and inappropriate prescribing. There is no cut off below which medications no longer need to be prescribed appropriately.