Role of Medication Assessment Tools and Deprescribing Organizations in Managing Polypharmacy
The ACB (Anticholinergic Cognitive Burden) tool should be routinely used to identify and reduce anticholinergic medications in older adults, while STOPP/START criteria and Beers Criteria serve as the primary screening tools for identifying potentially inappropriate medications, with pharmacist-led deprescribing interventions reducing inappropriate medications by 36.4%. 1
Core Assessment Tools and Their Specific Functions
Anticholinergic Cognitive Burden (ACB) Tool
The ACB scale quantifies cumulative anticholinergic exposure from multiple medications. An ACB score ≥3 indicates clinically significant anticholinergic burden requiring intervention 2. This threshold matters because:
- Nearly 48% of community-dwelling older adults have ACB scores ≥3, placing them at high risk for delirium, cognitive decline, falls, urinary retention, and constipation 2
- Medications scored include old antihistamines (diphenhydramine, hydroxyzine), muscle relaxants (cyclobenzaprine), and overactive bladder agents (oxybutynin) 1
- Each 1-unit increase in anticholinergic burden correlates with measurable cognitive decline on standardized testing 3
The ACB tool should be calculated at every medication review, with scores ≥3 triggering immediate deprescribing consideration, particularly for medications causing CNS impairment, vision problems, and increased fall risk 1.
STOPP/START Criteria
These paired screening tools identify both inappropriate medications (STOPP) and treatment gaps (START):
- STOPP identifies high-risk medications including sedative/hypnotics, opioids, anticholinergics, benzodiazepines, and hypoglycemics that should be avoided in older adults 1
- START identifies undertreated conditions such as coronary artery disease without statins or missing antiplatelet therapy after stenting 1
- Studies demonstrate STOPP criteria effectively reduce potentially inappropriate medications and associated adverse drug events 4
Beers Criteria
This widely validated tool categorizes medications by risk level in older adults, focusing on drugs with heightened sensitivity due to age-related pharmacodynamic changes 1. The criteria specifically target medications causing toxicity from opioids, benzodiazepines, and anticholinergic agents 1.
The Systematic Deprescribing Process
Step-by-Step Algorithm
1. Medication Reconciliation (Joint Commission priority)
- Document every medication the patient actually takes, including discontinued, unfilled, or incorrectly taken medications 1
2. Adherence Assessment Using Morisky Scale
- Identify barriers: complex dosing schedules (3-4 times daily), cost issues, missing medications, side effects 1
- Simplify regimens by eliminating agents with adverse effects and using cost-effective alternatives 1
3. Apply Screening Tools in This Order:
- Calculate ACB score first—if ≥3, prioritize anticholinergic reduction 2
- Apply STOPP criteria to identify inappropriate medications 1
- Apply Beers Criteria for additional high-risk medication identification 1
- Use START criteria to identify treatment gaps 1
4. Screen for Drug-Drug and Drug-Disease Interactions
- Check for QT prolongation, bleeding risk with anticoagulants, serotonin syndrome 1
- Identify NSAIDs in heart failure/CKD, sulfonylureas in kidney disease 1
5. Identify Overtreatment
- Find duplicates and medications with additive toxicity 1
6. Monitor for Efficacy and Safety
- Ensure appropriate lab monitoring (TSH, INR, glucose, renal/liver function) 1
Role of Deprescribing Organizations and Pharmacist-Led Interventions
Trained clinical pharmacists performing structured medication consultations reduce potentially inappropriate medications by 36.4% and optimize adherence 1. This represents the strongest evidence for systematic deprescribing effectiveness.
The systematic team approach should include:
- Pharmacist assessment of medications, indications, and drug-therapy problems 1
- Actionable therapeutic plans communicated with providers 1
- Implementation with patient and caregiver acceptance 1
Multiple deprescribing tools exist (95 tools identified across populations), though most tools (83.2%) target older adults, with only 14 specifically designed for those with limited life expectancy 5. A critical limitation: only 25% of medications in these tools have high-quality evidence supporting their classification as inappropriate 5.
Priority Medications for Deprescribing
Highest Risk Categories Requiring Immediate Action:
Anticholinergics - Cause broad muscarinic blockade leading to delirium, falls, urinary retention 1
Benzodiazepines - Associated with cognitive impairment, falls, fractures, addiction; use EMPOWER protocol showing 27% successful discontinuation through patient education about risks 1
Hypoglycemics - Sulfonylureas and short-acting insulins cause dangerous hypoglycemia, especially with declining renal function 1
Opioids - Contribute to sedation, cognitive impairment, falls; establish firm expectations before initiation and consider acetaminophen as first-line for chronic pain 1
NSAIDs - Worsen heart failure, hypertension, kidney disease; consider topical diclofenac as safer alternative 1
Critical Caveats
The prescribing cascade occurs when adverse drug events are misinterpreted as new medical conditions, leading to additional inappropriate medications 6. Always consider whether new symptoms represent medication side effects before adding therapy.
Evidence quality varies significantly - the same medication may be classified as appropriate in one tool and inappropriate in another due to limited evidence, particularly for patients with limited life expectancy 5. When evidence conflicts, prioritize patient-specific factors: functional status, care goals, and life expectancy 1.
Herbal supplements and multivitamins add complexity and cost without proven benefit for mortality, cardiovascular disease, cancer, or cognitive function (with few exceptions like vitamin D) 1. These should be systematically eliminated unless specifically indicated.
The Drug Burden Index (DBI) provides an alternative measure, with studies showing that reducing DBI scores improves cognitive function more effectively than simply reducing medication numbers 3. A 1-unit increase in DBI correlates with measurable MMSE score decline 3.