How polypharmacy reviews for older people living with frailty reduced medications and the need for social care visits: May 2025

Four services were part of the Focus on Frailty programme which ran from May 2023 to December 2024. They were:

  • NHS Dumfries and Galloway and Dumfries and Galloway Health and Social Care Partnership (HSCP).
  • Moray HSCP and NHS Grampian.

Spotlight

Polypharmacy reviews for older people living with frailty led to:

  • NHS Dumfries and Galloway and Dumfries and Galloway HSCP reducing medications.
  • Moray HSCP and NHS Grampian reducing medications and the need for social care visits.

In Dumfries and Galloway:

  • 11% of 230 medications were deprescribed.
  • 25% of deprescribed medications had a high anticholinergic burden score.

As part of this test of change the Dumfries and Galloway team identified older people living with frailty in several different ways. These included:

  • responding to medication related issues
  • picking up frailty flags on hospital discharge letters
  • searches on clinical systems including the Scottish Therapeutics Utility tool, and
  • through multidisciplinary team meetings.

People identified were then offered a polypharmacy review using a realistic medicine approach. Reviews were patient centred with an emphasis on shared decision making, supported by the use of the DECIDE and BRAN tools.

In Moray:

  • 200 people had their medications reviewed
  • 68 medications were stopped, and
  • the need for 74 potential daily carer visits was reduced.

The Moray team identified older people living with frailty using Scottish Therapeutics Utility data and searches for frailty on primary care clinical systems. They also worked with Moray council to develop a list of people receiving medicine management visits from the care at home team. These were combined to target polypharmacy reviews to the most appropriate people.

Changes for impact

Frailty identification

  • Use of Scottish Therapeutic Utility data and searches for frailty on primary care clinical systems.
  • Referrals from multidisciplinary team and council teams.
  • Frailty flags on discharge letters in Dumfries and Galloway.
  • Joint working with Moray council to produce a list of people receiving medicine management visits from the care at home team.

Polypharmacy reviews

Integrated care coordination

  • Multidisciplinary team working including general practice and social work colleagues.
  • Person centred approach, including face to face conversations with patients and carers.

Transferrable learning

  • The involvement of the patient and carers led to improved prescribing.
  • Availability of the multidisciplinary team gave more scope for discussion and person-centred care.
  • Staff capacity has been a constraint in both areas.
  • There is the potential to complement impact data with return on investment analysis which describes the total value of the medicines which have been deprescribed.

Further information

More information and updates on the Focus on Frailty programme are available on our webpages.   

To find out more about NHS Dumfries and Galloway and Dumfries and Galloway HSCP, and Moray HSCP and NHS Grampian’s approach, or to join the frailty learning system, please email: his.frailty@nhs.scot.

Further reading