RxCe - Multidisciplinary Polypharmacy Materials

LESS CAN BE MORE: A MULTIDISCIPLINARY APPROACH TO MITIGATING POLYPHARMACY

Faculty:

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 

Sandra Rogers, MD

Sandra Rogers, MD, is a primary care physician in Texas. She is board-certified in Family Medicine and Internal Medicine by the American Board of Family Medicine and the American Board of Internal Medicine.

Anna Shurtleff Smith, MPH, BSN-RN

Anna Shurtleff Smith is a graduate of the University of North Texas Health Science Center, School of Public Health, with a community health focus, and Texas Tech University School of Nursing. She has clinical experience in both inpatient and outpatient settings. Anna is passionate about patient education, health literacy, and health communications.

Pamela Sardo, PharmD, BS

Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.

Abstract

Polypharmacy—the concurrent use of multiple medications—is often necessary to manage complex, chronic conditions, particularly in aging and medically complex populations. However, when not appropriately managed, polypharmacy can lead to medication overload, adverse drug events, and diminished quality of life. In today’s healthcare environment, optimizing medication regimens requires more than simply counting prescriptions. It demands collaborative, interprofessional efforts that engage pharmacists, prescribers, nurses, patients, and caregivers in shared decision-making to align treatment plans with patient goals and reduce unnecessary medication use. This activity explores strategies to identify and address inappropriate polypharmacy, emphasizing team-based interventions that support safer prescribing, deprescribing where appropriate, and improved care transitions. A coordinated approach across disciplines is essential to reduce medication-related harm, optimize therapeutic outcomes, and improve operational efficiency across care settings.

Accreditation Statements

In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation Council^TM for Continuing Medical Education (ACCME^®), the Accreditation Council for Pharmacy Education (ACPE^®), and the American Nurses Credentialing Center (ANCC^®), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credits for learning and change.

Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:

Pharmacists: JA4008424-0000-26-029-H01-P

Pharmacy Technicians: JA4008424-0000-26-029-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.

Credit Types:

IPCE Credits - 2 Credits

AAPA Category 1 Credit™️ - 2 Credits

AMA PRA Category 1 Credit™️ - 2 Credits

Pharmacy - 2 Credits

Type of Activity: Application

Media: Computer-Based Training (i.e., online courses)

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Activity Pre-Test, Post-Test, and Activity Evaluation.

Release Date: March 16, 2026 Expiration Date: March 16, 2029

Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians

How to Earn Credit: From March 16, 2026, through March 16, 2029, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Take the “Educational Activity Pre-Test;”

Study the section entitled “Educational Activity;” and

Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

CME Credit: Credit for this course will be uploaded to CPE Monitor^® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.

Statement of Need

Older adults with comorbidities are a vulnerable population and are increasingly exposed to complex medication regimens. Rates of polypharmacy, associated adverse drug reactions, and associated rising costs are increasing across health care settings. Healthcare professionals often lack a uniform approach to decision-support tools and easy-to-access evidence to support patients taking five or more medications together. This gap potentially leads to inappropriate prescribing and fragmented monitoring. Suboptimal care can be a result. This result is compounded by limited interprofessional coordination and underutilization of structured medication reviews and deprescribing frameworks. This activity aims to describe risks, prevalence, and contributors to polypharmacy, and to apply interdisciplinary strategies for medication review and deprescribing to improve patient-centered outcomes.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe the risks and prevalence of inappropriate polypharmacy

List the risk factors associated with polypharmacy

Identify strategies to evaluate and manage polypharmacy

Apply interdisciplinary approaches to reduce medication-related harm and improve patient outcomes

Disclosures

The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Sandra Rogers, MD; Anna Shurtleff Smith, MPH, BSN-RN; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

Educational Activity Pre-Test

Which of the following statements best defines or characterizes polypharmacy?

All polypharmacy is harmful.

Polypharmacy is strictly a factor of the number of medications prescribed.

Polypharmacy is the use of more medications than are medically necessary.

Polypharmacy does not include appropriate medications.

An interprofessional care team is reviewing medications for an 86-year-old patient with cognitive impairment, hypertension, and Parkinson’s disease. Which of the following team-based strategies best aligns with a structured approach to evaluating and managing polypharmacy?

The physician evaluates all medications and makes independent deprescribing decisions, then alerts the pharmacist

The pharmacist discontinues all non-essential medications to reduce pill burden based on patient/caregiver concerns

The nurse provides home safety education and refers the patient to a geriatrician for all medication-related decisions

The nurse relays patient concerns, the pharmacist facilitates medication review, and the physician adjusts therapy

Which of the following describes how age-related physiologic changes affect older adults?

Decreased renal and hepatic blood flow slows drug excretion, causing toxicity

Frailty increases activity in drug-metabolizing pathways, making drugs less effective

Decreased body fat and dehydration affect drug distribution and cause toxicity

Physiological changes affect all older adults exactly the same, making risks easy to quantify

Educational Activity

Less Can Be More: A Multidisciplinary Approach to Mitigating Polypharmacy

Introduction

Managing chronic illness frequently involves the use of multiple medications to control symptoms and prevent complications. Polypharmacy is more prevalent in older populations with multiple morbidities. Treatment of this population poses substantial clinical and safety challenges. While the use of several medications may be appropriate, polypharmacy becomes problematic when the risks outweigh the benefits or when medications are continued without a clear indication. This activity provides a framework for healthcare professionals to identify and manage inappropriate polypharmacy, emphasizing the value of interprofessional collaboration in optimizing medication use. By understanding the perspectives and roles of other healthcare professionals and engaging patients and caregivers in shared decision-making, each member of a healthcare team can help reduce medication-related harm, improve outcomes, and enhance care efficiency in clinical settings.

Defining Polypharmacy

No universal definition exists for polypharmacy.¹ Literature generally refers to it as the use of 5 or more medications, but the use of 3 to 10 medications or more can also be considered polypharmacy.¹ Individuals often use the term interchangeably with overprescribing, medication overload, multiple-drug consumption, excessive use of drugs, unnecessary drug use, inappropriate medication use, the “other” drug problem, and medication use without indication.^1-3

A common misconception is that all polypharmacy is harmful; however, prescribing more than one medication is often necessary to help patients improve their health. Numerical definitions of polypharmacy fail to distinguish this circumstance from overprescribing multiple medications.¹ These numerical guidelines do not consider a patient’s specific disease state or comorbidities, and they may disregard the safety and appropriateness of pharmacotherapy in the clinical setting.¹

To help clarify the definition of polypharmacy, some experts propose a new definition of the term: “the use of more medications than are medically necessary.”⁴ Under this definition, medications that are not indicated, not effective, or duplicative and unnecessary would be considered polypharmacy.⁴

Consequences of Inappropriate Polypharmacy

Inappropriate polypharmacy is associated with preventable adverse drug events, poor adherence, increased hospitalizations, and rising healthcare costs.⁵ These challenges call for coordinated, interprofessional strategies that support comprehensive medication review, deprescribing, and individualized care planning.

Polypharmacy: Prevalence and Risks

Polypharmacy’s Prevalence

Polypharmacy is particularly common in older adults, who often manage multiple chronic illnesses requiring complex medication regimens.¹ As the population ages and multimorbidity rates increase, polypharmacy is becoming more common.⁶

In the United States, the prevalence of polypharmacy has increased steadily over the past few decades.⁶ Between 1999 and 2000 and 2007 and 2008, prevalence increased from 6.3% to 10.7%.⁶ One national survey found that 36.7% of adults aged 60 years and older were taking five or more prescription drugs, while 27.3% were taking three to five.⁷ By 2011–2012, prescription drug use had increased significantly, with 59% of U.S. adults reporting at least one prescription and 15% meeting criteria for polypharmacy.⁸ This trend continued into 2019, with the Centers for Disease Control and Prevention reporting that among U.S. adults aged 40 to 79, 22.4% had used five or more prescription drugs in the past 30 days, representing a more than threefold increase since 1999.⁹

Polypharmacy is prevalent across a wide range of healthcare settings, including outpatient clinics, community pharmacies, hospitals, and long-term care facilities.^3,10,11 The burden is particularly substantial in long-term care settings. One review found that 65% of long-term care residents were prescribed 10 or more medications.¹² When over-the-counter (OTC) products and supplements are included, the number of older individuals exposed to polypharmacy is likely substantially higher.¹³ The United States Nursing Home Survey found that nearly 40% of residents up to age 84 had been prescribed multiple medications, and among those aged 85 and older, the rate remained high at 34.8%.⁴

These trends highlight the growing demand for interprofessional approaches to medication management. As the complexity of care increases, so too does the risk of medication-related harm, underscoring the importance of coordinated medication reviews, deprescribing efforts, and patient-centered care planning across disciplines.

Risks of Polypharmacy

A major concern with polypharmacy is a lack of clinical evidence. Researchers overwhelmingly employ randomized controlled trials to study drug efficacy and safety. However, these studies typically exclude patients with multiple chronic conditions or frailty, severely limiting data regarding the potential harms of these agents’ use in a polypharmacy setting.⁶ This means most of the data surrounding polypharmacy is gathered through post-marketing and retrospective studies.

Age-related physiologic changes affect how the body responds to drugs, further complicating polypharmacy. With advancing age, the incidence of frailty increases, leading to a syndrome characterized by a gradual decline in physiological reserves. This results in reduced activity in several drug-metabolizing pathways (e.g., glucuronidation) and baseline inflammation, which downregulates drug metabolism and reduces systemic drug clearance.¹⁴ Hepatic and renal blood flow also decrease by 40% and 50%, respectively, thereby slowing drug metabolism and excretion. Older adults also tend to have reduced lean body mass, increased body fat, reduced water volume due to dehydration, and decreased serum protein levels, which affect drug binding.^14,15

Polypharmacy is associated with adverse outcomes.^1,6 The number of drugs a person takes is directly correlated to the risk of adverse events and harm. For example, using 5 concomitant medications is associated with a risk of adverse outcomes such as falls, disability, drug interactions, nonadherence, reduced function, and mortality.^1,16 Polypharmacy also leads to extended hospital stays and readmissions soon after discharge.¹

Older patients are at an especially increased risk of polypharmacy and its associated harm and adverse effects. Individuals aged 65 years and older take an average of six to eight medications, and 66% take three or more medications each month.^15,17 Older adults prescribed two medications have a 6% chance of experiencing an adverse event, compared with 50% for patients prescribed five drugs, with risk increasing significantly as more medications are added.¹⁸ Each new medication added to a patient’s regimen adds one adverse drug reaction (ADR) annually, taking 6 or more medications increases ADR risk by fourfold, and each additional prescriber increases ADR risk by 30%.^15,17

Common Causes of Polypharmacy

Polypharmacy is the main risk of potentially inappropriate prescribing. Evidence shows that patients with polypharmacy of six to ten medications or excessive polypharmacy of 11 or more medications are more likely to be prescribed anticholinergic drugs, which are associated with adverse health outcomes.⁶ Community-dwelling older adults also commonly use prescription and nonprescription medications together, placing 1 in 25 of these individuals at risk for a major drug-drug interaction.¹³

Physicians caring for patients with complex comorbidities report that current decision-support processes are inadequate for optimizing benefits and minimizing harm.¹⁹ Various factors, listed in Table 1, contribute to polypharmacy, including patient-related, systems-related, condition-related, medication-related, or social issues.

Table 1

Common Factors Contributing to Polypharmacy^20,21

Category	Examples
Patient	Chronic mental health conditions Comorbidities managed by multiple subspecialists Residing in a long-term care facility
Systems	Automated refill services Poorly updated medical records Prescribing to meet disease-specific quality metrics
Condition	Combinations of chronic mental and physical diseases (e.g., diabetes and schizophrenia) Depression Dementia or cognitive decline Frailty Fall history
Medication	Drugs with high interaction potential Narrow therapeutic index drugs Need for constant monitoring
Social	Not living independently Limited ability to understand treatment recommendations

The use of OTC therapies is another critical contributor to polypharmacy. Many patients self-medicate by purchasing OTC medicines, which may interact with prescribed medications and cause potential harm. This includes the use of herbal products and complementary and alternative medications. Healthcare professionals must ask patients about all medications and remedies to obtain a clear picture of polypharmacy risk.²²

Prescribing cascades are an under-recognized contributor to polypharmacy.²³ This refers to instances where an ADR is misinterpreted as a new medical condition, leading to the subsequent prescribing of another drug to address it. This results in inappropriate prescribing of new therapies, increasing risk of ADRs, pill burdens, and costs to individuals and healthcare systems.²³

Familiarity with common prescribing cascades listed in Table 2 can help clinicians identify causative and cascade medications. If a medication causing an ADR remains clinically indicated, pharmacists should communicate with prescribers to ensure the use of the lowest effective dose or to recommend switching to a safer alternative with fewer adverse effects, rather than initiating a cascade of medications to address the adverse effect.

Table 2

Common Clinically Significant Prescribing Cascades²³

Causative Drug Class	Adverse Effect	Cascade Drug Class
Alpha-1 blockers	Orthostatic hypotension/dizziness	Antihistamine or benzodiazepine
Antipsychotics	Extrapyramidal symptoms	Antiparkinsonian agent
Benzodiazepines	Cognitive impairment	Cholinesterase inhibitor or memantine
Benzodiazepines	Agitation	Antipsychotic
Calcium channel blockers	Peripheral edema	Diuretic
Diuretics	Urinary incontinence	Anticholinergic
NSAIDs	Hypertension	Antihypertensive
SSRI/SNRIs	Insomnia	Sedative hypnotic, benzodiazepine
Urinary anticholinergics	Cognitive impairment	Cholinesterase inhibitor or memantine

NSAID, nonsteroidal anti-inflammatory drug; SNRI, serotonin–norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor.

Polypharmacy Identification and Mitigation

Strategies for Identifying Polypharmacy

Identifying and managing polypharmacy is particularly challenging when traditional, disease-specific guidelines fail to account for comorbidities and polypharmacy risk. Clinical decision-making in the context of multimorbidity necessitates personalized, goal-directed care that extends beyond typical algorithmic prescribing.²¹

One of the most effective strategies to mitigate inappropriate polypharmacy is interprofessional medication review, a structured, collaborative process in which pharmacists, prescribers, nurses, and other care team members systematically evaluate a patient’s medication regimen. Medication reviews focus on aligning therapy with clinical and personal goals, minimizing risks of medication-related problems, and ensuring each medication has an ongoing indication.

The National Institute of Health and National Institute on Aging emphasize that deprescribing—thoughtful reduction or discontinuation of unnecessary or harmful medications—should be an integral part of patient-centered care.²⁴ Effective deprescribing requires contributions from the entire care team:

Pharmacists evaluate drug-drug and drug-disease interactions, identify therapeutic duplications, and recommend alternatives.

Nurses may recognize adverse effects, functional decline, changes, or burdens to adherence during routine assessments.²⁵

Physicians and other prescribers ultimately adjust medication regimens, guided by input from the care team and patient preferences.

Patients and caregivers offer valuable insights into treatment goals, daily challenges, and the values that inform care decisions.

Shared decision-making is a central component of this process. Medication reviews are not simply clinical audits; they are opportunities to engage patients and caregivers in understanding medication risks, weighing trade-offs, and co-creating a care plan that prioritizes quality of life.²²

Typically, nurses are the first to administer medications to patients and the last to explain discharge paperwork to them. However, pharmacists have been reluctant to understand nurses' roles because physicians and pharmacists often send discharge medications to the next healthcare professional rather than to the nurse. In addition, nurses provide patient education and, in many cases, case management for the patients.²⁶

Critical thinking about medications, particularly when comparing the diagnosis with the prescribed medication, is essential for all healthcare professionals, especially nurses. Nurses can utilize their company's electronic medical records (EMR) AI tools to reconcile medications with patients' diagnosis codes. Utilizing these internal AI systems ensures HIPAA compliance while enhancing patient outcomes. One of the current issues with healthcare staff is the reluctance to use these internal systems. However, research is emerging that when these internal AI systems are used for allergies, including drug allergies, they can contribute to identifying polypharmacy’s harmful outcomes and enhance patient safety.²⁷

Table 3 outlines a stepwise approach to team-based medication review that incorporates clinical judgment, patient values, safety considerations, and cost-effectiveness. For instance, in patients receiving gabapentin, diclofenac, and acetaminophen with codeine, the team must assess for indication overlaps, risk of sedation or falls, and whether all agents are necessary for pain control.

Table 3

Stepwise Approach to Interdisciplinary Medication Review^22,28

Step	Key Considerations	Team-Based Actions
Aims	Review diagnoses and objectives: Understand medication goals Manage existing problems Prevent future problems	• Pharmacist facilitates medication history review and clarifies therapeutic intent • Nurse helps assess functional status, goals, and adjuvant non-pharmaceutical options • Prescriber confirms priorities and adjusts treatment plan • Patient/caregiver shares values, preferences, and daily impact
Need	Identify essential medications: Essential functions (e.g., thyroxine, insulin) Preventing symptom decline (e.g., Parkinson’s treatment)	• Pharmacist flags life-sustaining therapies • Prescriber confirms ongoing indications • Nurse monitors symptom changes related to dose timing or omission
Need	Identify unnecessary medications: Temporary indications High-dose maintenance with limited benefit Duplications or non-beneficial therapies	• Pharmacist proposes candidates for discontinuation • Prescriber discusses and executes the plan • Patient/caregiver provides feedback on tolerability and response
Effectiveness	Identify if therapeutic objectives are met: Symptom control Biochemical/clinical targets Prevent progression or exacerbation	• Nurse provides monitoring data (e.g., BP, glucose, mood scores) • Pharmacist and physician evaluate therapeutic drug levels and clinical response • Prescriber adjusts regimen accordingly
Safety	Check for patient safety risks: Drug–disease or drug–drug interactions Monitoring adequacy Risk of falls or accidental overdose	• Pharmacist reviews interaction checkers and high-alert meds • Nurse documents functional changes, falls, and confusion
Cost	Evaluate the cost-effectiveness of alternatives	• Pharmacist recommends formulary-preferred or cost-saving options • The case manager or social worker may assist with financial support resources
Patient-centered	Ensure the patient can and will take medication as prescribed: Teach-back method Consider preferences and convenience	• Pharmacist uses teach-back to confirm understanding • Nurse identifies barriers (e.g., dexterity, schedule) • Patient/caregiver provides insight into adherence at home

By making medication reviews a routine and collaborative element of care—especially during transitions such as hospital discharge or admission to long-term care—healthcare teams can identify polypharmacy earlier, thereby reducing the risk of adverse events, improving adherence, streamlining care delivery, and enhancing outcomes.

Because polypharmacy is most common in older adults, various tools are available to identify inappropriate polypharmacy specific to this population. The American Geriatrics Society’s Beers Criteria^® is a comprehensive list of potentially inappropriate medications (PIMs) that older people should avoid or use with caution.²⁹ These criteria classify more than three dozen medications or classes as PIMs and more than 40 to avoid in the presence of certain diseases or conditions. The Beers Criteria are a cornerstone of geriatric care and an essential tool to ensure the safety and well-being of older adults, which can be used in the care of adults aged 65 years and older in all care settings except hospice and end-of-life care.²⁹ Intentions of the Beers Criteria^® are as follows:

Reduce older adults' exposure to PIMs by improving medication selection

Educate clinicians and patients

Serves as a tool for evaluating the quality of care, cost, and patterns of drug use in older adults

Shared decision-making is critical to interpreting the Beers Criteria. The criteria should serve as a guide, not a strict rulebook, as drug-related harms are more pronounced in the “old-old” and those with frailty or multimorbidity than in the “young-old.”²⁹ Individualized care remains paramount, especially for older adults with multiple chronic conditions. Clinicians must carefully weigh the risk-benefit ratio of each medication, considering the patient’s overall health status, life expectancy, and personal preferences.

Another tool used alongside the Beers Criteria for older adults is the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) Criteria. STOPP identifies 65 potentially inappropriate prescribing practices in older adults, aiming to prevent ADRs leading to hospitalization.¹⁵ Although the STOPP and Beers criteria overlap, each detects PIMs that the other does not. Additionally, the criteria are not comprehensive, even when used together, and several older adults are hospitalized with ADRs from medications not identified by either.¹⁵ This necessitates strong interprofessional collaboration and shared decision-making to mitigate as much risk as possible.

Polypharmacy Mitigation

Barriers to deprescribing in primary care

Deprescribing is a particularly important concept for mitigating polypharmacy. Literature describes many deprescribing tools and processes, but pharmacists can collaborate with other healthcare professionals to follow five critical steps:^30,31

Reconcile medications according to indication

Consider the overall risk of drug-induced harm

Assess eligibility for deprescribing

Prioritize which medication(s) to address first

Implement a deprescribing strategy and monitoring plan

When considering the overall risk of drug-induced harm, healthcare professionals must account for both drug factors and patient factors, including the following:^30,31

Drug factors: total number of drugs, use of high-risk drugs, past or present toxicity

Patient factors: age, cognitive impairment, comorbidities, multiple prescribers, adherence

Factors influencing eligibility for deprescribing include the following:^30,31

Potential or actual harm outweighs the benefit

Lack of valid indication

Therapy is ineffective

The drug is part of a prescribing cascade

Treatment adds a substantial burden

Safer alternatives exist

Additional assistance in the deprescribing process includes electronic systems such as MedStopper^®,³² FeelBetter Pharmaco-Clinical Intelligence,³³ IAM Medical Guidelines App,³⁴ and MediQuit.³⁵ When considering which of these systems works best, it is important to consider the system's ease of integration with your current pharmacy tracking system and whether its features will fit the population you currently serve. Additionally, many electronic medical record systems are integrating deprescribing features. Talking to your technology department could help you understand better any of these new features that might be available.

Upon discovering therapies eligible for deprescribing, prescribers should consider whether withdrawal symptoms or disease recurrence are likely if therapy is discontinued. If not, therapy can be discontinued. Doses should be tapered, and the patient monitored closely when discontinuing a drug.^30,31

Barriers to Deprescribing in Primary Care

Various barriers can prevent prescribers, patients, and their families from pursuing deprescribing. Many patients and their families struggle with negative experiences when stopping a medication, concerns around the complexity of the deprescribing process, fear that symptoms will come back or new ones will arise, and the belief that the medication provides benefits that outweigh any harm. One of the main ways patients have been willing to deprescribe unnecessary medications is through a frank and honest conversation with a medical provider.³⁶

Clinicians can struggle with prescribing cascades, which contribute to harmful polypharmacy. Prescribing cascades occur when a medication is prescribed to manage the adverse effects of another medication. Many prescribers do not regularly use tools or guidance in their practice to identify and investigate further this harmful contributor to polypharmacy. Understanding the risks and benefits of continuing or deprescribing a medication is important to avoid this cascade. A-I-D (ask, investigate, deprescribe) is a helpful acronym that can help with reducing harmful polypharmacy.³⁷

Current Technology for Home Medication Management

Many family members no longer live close to their aging family members. One way they can keep up with medication dispensing is by using an FDA-cleared smart pill dispenser. Another option is a traditional automated dispenser. Many of these devices allow for up to a 90-day supply capability per medication. These options allow for family members to remain active in the medication dispensing to avoid harmful polypharmacy.

When assisting a patient in selecting a dispenser, it is important to find one that is FDA-approved and fits the patient's needs. The primary goal of the dispenser is to select an item that the patient will use daily. MyEMMA and EMMA e-Kit are options for “individual unit dose control of medication dispensing which is managed through a web-based scheduling system.³⁸ The system is remotely controlled and programmed by the pharmacist.” EMMA systems are the only FDA-approved dispensers.³⁸

However, there are FDA-listed devices that can also be recommended. One example is the Tenovi Pillbox, which “is designed to seamlessly integrate into patients’ existing routines. Identical to a standard 7-day morning and evening pillbox, it features built-in sensors that automatically detect when pill compartments are opened or refilled.”³⁹ Hero smart dispensers are another option for patients.⁴⁰

As of 2025, there are limited options for home-use devices. Most technology is focused on long-term care facilities. However, with the rise of artificial intelligence and agentic systems, clinicians will look to provide home medication management systems that integrate these technologies.

Case-Based Scenario: Team-Based Care for Polypharmacy Mitigation

Eleanor is an 82-year-old woman recently discharged from the hospital following a fall. Her medical history includes hypertension, type 2 diabetes, osteoarthritis, mild cognitive impairment, and insomnia. She lives alone but receives weekly visits from a home health nurse. Her current medication list includes:

Lisinopril

Amlodipine

Metformin

Glipizide

Acetaminophen

Tramadol

Lorazepam

Simvastatin

Omeprazole (OTC)

Multivitamin (OTC)

Diphenhydramine (OTC, nightly for sleep)

Melatonin (OTC)

During a routine visit, the home health nurse observes that Eleanor appears sedated and unsteady and witnesses another near fall. Concerned about potential polypharmacy, she initiates an interprofessional medication review.

Step 1: Reconcile Medications According to Indication

The pharmacist and primary care physician (PCP) confirm each medication’s current purpose, finding the following:

Simvastatin was initiated a year ago for primary prevention

Tramadol was prescribed 6 months ago for muscle pain

Omeprazole was initiated 3 months ago by an urgent care clinician following a severe heartburn episode

Lorazepam was prescribed 4 months ago for insomnia by her psychiatrist

Diphenhydramine and melatonin are self-administered nightly

Step 2: Consider Overall Risk of Drug-Induced Harm

Drug factors: 12 total medications; 4 CNS-active (lorazepam, diphenhydramine, tramadol, melatonin); high-risk Beers Criteria drugs present, including lorazepam (benzodiazepine), diphenhydramine (anticholinergic), tramadol (opioid with CNS effects and seizure risk), glipizide (sulfonylurea associated with prolonged hypoglycemia in older adults), and omeprazole (long-term PPI use linked to decreased bone density, fractures, and Clostridium difficile infections)

Patient factors: advanced age, cognitive impairment, recent fall, multiple prescribers (PCP, psychiatrist, endocrinologist), poor adherence reported by caregiver

Step 3: Assess Eligibility for Deprescribing

Several medications lack updated documentation of their indications or long-term benefits. The team identifies several therapies that meet deprescribing criteria:

Simvastatin: benefit no longer outweighs risk, and unclear indication

Lorazepam: high fall risk, cognitive impairment, and added therapy burden

Tramadol: possibly started to treat statin-induced myalgias, making it part of a prescribing cascade, and could contribute to insomnia

Diphenhydramine: inappropriate sedative for older adults; safer alternatives exist.

Omeprazole: long-term use not recommended, especially in older adults already at higher risk for osteoporosis and falls

Step 4: Prioritize Which Medications to Address First

Given Eleanor’s fall risk, cognitive symptoms, and functional decline, the team prioritizes lorazepam and diphenhydramine for tapering or discontinuation

Tramadol is also targeted due to sedation and a suspected cascade origin

Omeprazole is considered for deprescribing due to its lack of ongoing indication and elevated risk of adverse outcomes

Simvastatin is considered for deprescribing, given its unclear indication and minimal benefit at her age

Step 5: Implement Deprescribing Strategy and Monitoring Plan

The PCP advises her to stop diphenhydramine immediately and collaborates with her psychiatrist to initiate a tapering plan for lorazepam.

Tramadol is discontinued, and pain management is optimized with scheduled acetaminophen and nonpharmacologic measures.

Simvastatin is discontinued after discussion with the patient and family.

The pharmacist initiates outreach to the endocrinologist to recommend discontinuing glipizide, given the availability of safe, effective alternatives for blood sugar control

Omeprazole is discontinued, and the pharmacist advises Eleanor to use famotidine as needed for intermittent heartburn symptoms.

The pharmacist documents all changes and provides Eleanor and her family with a simplified medication schedule.

The nurse monitors cognition, sleep, and mobility during weekly visits.

Outcome

Within one month, Eleanor reported clearer thinking, steadier walking, and improved sleep, all without the need for sedatives. The care team noted improved adherence, and the nurse documented increased patient engagement and fewer safety concerns in the home. The prescribing cascade was successfully halted through interprofessional communication and patient-centered deprescribing.

Summary

Polypharmacy is a growing concern across healthcare settings, particularly in aging populations with multimorbidity and functional decline. While some degree of polypharmacy may be clinically appropriate, inappropriate or excessive medication use increases the risk of adverse outcomes, hospitalizations, and reduced quality of life. Pharmacists—working alongside prescribers, nurses, patients, and caregivers—play a central role in identifying high-risk regimens, recognizing prescribing cascades, and implementing deprescribing strategies. Through structured, team-based medication reviews and shared decision-making, healthcare professionals can optimize medication use, align treatment with patient goals, and reduce harm. Embedding these collaborative practices into routine care can meaningfully improve outcomes and support safer, more effective care delivery.

References

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Levenson S. “Unnecessary” medications: the never-ending pandemic. OBRA Regs Revisited. Caring for the Ages. 2020;21(5):16-17.

Beers M, Ouslander J, Fingold S, et al. Inappropriate medication prescribing in skilled-nursing facilities. Ann Intern Med. 1992;117(8):684-9. doi: 10.7326/0003-4819-117-8-684

Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65. doi:10.1517/14740338.2013.827660

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Automatic Pill Dispenser & Medication Manager | Hero. Hero Health. https://herohealth.com/

DISCLAIMER

The information provided in this course is general in nature, and it is designed solely to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals must consult their employer, healthcare facility, hospital, or other organization for guidelines, protocols, and procedures to follow. The information provided in this course does not replace those guidelines, protocols, and procedures, but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses is constantly changing. Any person taking this course understands that such a person must make an independent review of medication information before any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.

Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course or course material.

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