PLAB 2 Geriatrics: Mastering Polypharmacy Guidelines for OSCE Success

As an experienced examiner for medical licensing exams like PLAB 2, I've observed that Geriatrics, particularly the challenge of polypharmacy, is a consistently high-yield topic. Elderly patients often present with multiple comorbidities, leading to the prescription of numerous medications. Navigating this complexity safely and effectively is crucial for patient well-being and a key skill assessed in the PLAB 2 OSCEs.

What is Polypharmacy and Why is it Critical in Geriatrics?

Polypharmacy is generally defined as the concurrent use of multiple medications by a patient. While there's no universally agreed-upon number, it often refers to taking five or more medications regularly. In the elderly, who constitute a significant proportion of patients in UK healthcare, this issue is amplified due to:

• Physiological changes: Altered pharmacokinetics (absorption, distribution, metabolism, excretion) and pharmacodynamics.

• Multiple comorbidities: Leading to specialist-driven prescriptions without holistic oversight.

• Prescribing cascades: Where side effects of one drug are treated with another, perpetuating the cycle.

The Risks: Why Polypharmacy is a Red Flag

Unmanaged polypharmacy carries significant risks, which examiners will expect you to be aware of and mitigate:

1. Adverse Drug Reactions (ADRs): Increased risk of interactions and side effects.

2. Falls: Especially from sedative, hypotensive, or anticholinergic drugs.

3. Cognitive Impairment: Delirium or worsening dementia due to psychoactive medications.

4. Non-adherence: Complexity of regimens leads to confusion and missed doses.

5. Increased Hospital Admissions: Due to ADRs or decompensation from inappropriate medication.

6. Reduced Quality of Life: Medications can interfere with daily activities and well-being.

Essential Guidelines for Managing Polypharmacy in PLAB 2 OSCEs

Your approach to a polypharmacy station must be systematic, patient-centred, and adhere to best practice guidelines. Here’s what examiners look for:

1. Comprehensive Medication Review (CMR)

This is the cornerstone. You must demonstrate a structured approach to reviewing all medications. Think beyond just prescribed drugs; ask about:

• All prescribed medications: Doses, frequencies, indications.

• Over-the-counter (OTC) medications: Painkillers, cold remedies.

• Herbal remedies and supplements: Patients often don't consider these 'medications'.

• Recreational drugs and alcohol: Can interact with prescribed drugs.

• Adherence: How reliably are they taking their medications? Are there practical barriers?

• Side effects: Are they experiencing any new symptoms that could be an ADR?

• Patient understanding: Do they know why they're taking each drug?

Examiner Tip: Familiarize yourself with principles like the STOPP/START criteria (Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment) or the Beers Criteria. While you don't need to quote them verbatim, your thought process should align with identifying potentially inappropriate medications to STOP and potentially beneficial ones to START.

2. Deprescribing Principles

Deprescribing is the systematic process of withdrawing inappropriate medications under medical supervision. It's not just about stopping drugs, but doing it safely. Consider:

• Is the medication still indicated? Has the original condition resolved?

• Is the benefit still outweighing the harm? Consider life expectancy and patient goals.

• Are there non-pharmacological alternatives?

• Can the dose be reduced or stopped slowly? To avoid withdrawal symptoms.

• Prioritize: Medications with high risk (e.g., benzodiazepines, anticholinergics) or those no longer indicated.

3. Patient-Centred Communication & Shared Decision Making

This is paramount in PLAB 2. Never unilaterally decide to stop a patient's medication. Instead:

• Explain the rationale clearly: Use simple language, avoid jargon.

• Discuss risks vs. benefits: Of continuing and stopping medications.

• Elicit patient preferences and concerns: What are their priorities? Do they feel attached to certain medications?

• Involve carers/family: If appropriate and with patient consent.

• Agree on a plan together: This fosters adherence and trust.

4. Holistic Assessment

Polypharmacy is rarely an isolated issue. Your management plan should reflect a holistic understanding of the patient:

• Functional status: How does their medication affect their mobility, cognition, and independence?

• Social circumstances: Do they have support at home? Can they manage complex regimens?

• Nutritional status: Are medications affecting appetite or absorption?

• Goals of care: What does the patient want to achieve? Symptom control, cure, quality of life?

5. Multidisciplinary Team (MDT) Approach

Recognize when to involve other healthcare professionals. In the UK, pharmacists play a vital role in medication reviews. Consider referrals to:

• Community Pharmacist: For adherence aids, medication review.

• GP: For ongoing management and liaison with specialists.

• Geriatrician: For complex cases, comprehensive geriatric assessment.

• Occupational Therapist/Physiotherapist: If falls are a concern related to medication.

OSCE Scenario Approach: A Step-by-Step Guide

When faced with a polypharmacy station in PLAB 2, structure your consultation:

1. Introduction & Rapport: Greet the patient, explain your role, gain consent.

2. Initial History: Ascertain the patient's main concern. If it's a general review, state that.

3. Detailed Medication History: Go through every medication. Ask: "Can you tell me all the medications you're currently taking? This includes anything prescribed by a doctor, anything you buy over the counter, any herbal remedies, or supplements. Also, can you tell me why you take each one, how often, and if you ever miss a dose? Have you noticed any side effects from any of them?"

4. Targeted Systems Review: Ask about symptoms that might indicate ADRs (e.g., dizziness, constipation, confusion, falls).

5. Impact on Daily Life: "How do all these medications affect your daily routine or quality of life?"

6. Collateral History: If appropriate, with consent, speak to a family member or carer.

7. Formulate a Plan (Think Aloud): "Based on what you've told me, it seems you're on quite a few medications, and some of them might be causing issues. We need to review them carefully. My plan would be to..."

   • Prioritize: Identify medications that are high-risk or potentially no longer needed.

   • Discuss potential changes: E.g., "We might consider slowly reducing or stopping X medication, as it could be contributing to your falls, and we can manage your pain with Y non-pharmacological approach."

   • Explain risks of stopping: "However, stopping it quickly can lead to... so we'll do it slowly."

   • Safety netting: Explain what symptoms to look out for if a medication is changed or stopped.

8. Safety Netting & Follow-up: "If you experience any new or worsening symptoms, please contact us immediately. We'll arrange a follow-up appointment to see how you're getting on with the changes."

Examiner's Insight: What Makes a Candidate Excel

• Systematic Approach: Don't just list drugs; show a structured thought process for review and deprescribing.

• Patient-Centred Care: Empathy, clear communication, shared decision-making are paramount. You're treating the patient, not just their medications.

• Safety First: Demonstrate awareness of potential harms and how to mitigate them (e.g., slow tapering, close monitoring).

• Holistic View: Connecting medications to the patient's overall health, functional status, and quality of life.

• Appropriate Referrals: Knowing when to involve other members of the MDT.

Mastering polypharmacy management is a cornerstone of safe and effective geriatric care. By integrating these guidelines and practicing a structured, empathetic approach, you'll not only excel in your PLAB 2 exam but also become a safer, more competent doctor for your elderly patients.