Med2Date — Clinical Guidelines
Home Geriatric Medicine Polypharmacy and Deprescribing

Polypharmacy and Deprescribing

Last updated 1 Jun 2026 · Geriatric medicine

📋 Key Information Summary

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  • Definition: Polypharmacy is the concurrent use of ≥5 regular medicines; excessive polypharmacy is ≥10 medicines. In Australia, approximately 25 % of community-dwelling adults aged ≥65 years and >50 % of residential aged-care facility (RACF) residents meet polypharmacy criteria.
  • Why it matters: Polypharmacy is an independent risk factor for falls, delirium, hospitalisation, adverse drug events (ADEs), functional decline and mortality in older Australians.
  • Medication reconciliation must be performed at every transition of care (hospital admission, transfer and discharge) and at least annually in the community. A Home Medicines Review (HMR, MBS Item 900) or Residential Medication Management Review (RMMR, MBS Item 903) should be requested whenever polypharmacy is identified.
  • Potentially inappropriate medicines (PIMs) are drugs whose risks outweigh benefits in older adults — benzodiazepines, anticholinergics, proton-pump inhibitors beyond 8 weeks, NSAIDs, and sliding-scale insulin are common examples.
  • STOPP/START v2 is the preferred screening tool in Australia because it is organ-system–based, clinically actionable and validated for predicting ADEs. The Beers Criteria serve as a complementary reference.
  • Deprescribing is the planned, supervised process of dose reduction or cessation of medicines that are no longer beneficial or are causing harm. It is not the withdrawal of essential therapy.
  • A structured deprescribing plan includes shared goal-setting, prioritisation of target medicines, gradual tapering with monitoring for rebound/withdrawal, and follow-up within 2–4 weeks.
  • Common deprescribing targets include benzodiazepines (≥4-week taper), proton-pump inhibitors (step-down over 2–4 weeks), antipsychotics (≥4-week taper with behavioural monitoring), antihyperglycaemics (relaxed HbA1c target 53–64 mmol/mol in frail elderly) and opioids.
  • Validated tools for ADE risk include the Anticholinergic Cognitive Burden (ACB) scale and the Medication Appropriateness Index (MAI).
  • Aboriginal and Torres Strait Islander peoples experience higher rates of polypharmacy–related harm due to multimorbidity earlier in life, limited access to pharmacist-led reviews, and culturally unsafe prescribing practices. Targeted HMR engagement is essential.
  • Clinicians should apply the principle: "Start low, go slow, but don't stop what's working." Every medicine should have a documented indication, therapeutic goal and review date.

Introduction & Australian Epidemiology

Polypharmacy — conventionally defined as the concurrent use of five or more regular medicines — is one of the most pressing medication-safety challenges in Australian healthcare. It is a major driver of falls, delirium, hospitalisation and functional decline in older adults, and accounts for an estimated 250,000 preventable medication-related hospital admissions annually across Australia.

As the population ages and the burden of multimorbidity grows, the average number of medicines dispensed per person has risen steadily. The Australian Institute of Health and Welfare (AIHW) reports that Australians aged ≥65 years receive a mean of 8.4 prescription items per year, with the figure rising to >12 in RACF residents. Almost one in four community-dwelling older Australians takes ≥5 regular medicines, and one in ten takes ≥10 (excessive polypharmacy).

The relationship between number of medicines and harm is exponential, not linear. Each additional medicine increases the risk of drug–drug interactions, adverse drug events (ADEs) and non-adherence. In people taking ≥10 medicines, the probability of an ADE within 12 months approaches 80 %. Despite this, many patients continue receiving medicines whose original indication is forgotten, whose benefit is no longer relevant, or whose harm now exceeds their therapeutic value.

Deprescribing — the structured, patient-centred process of reducing or ceasing inappropriate medicines — is now recognised as a core competency for all prescribers involved in the care of older Australians. National bodies including the Australian Commission on Safety and Quality in Health Care (ACSQHC), the Royal Australian College of General Practitioners (RACGP) and NPS MedicineWise have published guidance supporting routine medication review and deprescribing.

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Key concept: Polypharmacy is not inherently inappropriate — many patients with multimorbidity legitimately require multiple medicines. The clinical focus is on appropriate polypharmacy (evidence-based, goal-concordant) versus inappropriate polypharmacy (no clear indication, therapeutic duplication, risk exceeds benefit).

Medication Reconciliation and Review

Medication reconciliation is the process of comparing a patient's current medicine list against clinician orders to identify and resolve discrepancies. It is a National Safety and Quality Health Service (NSQHS) Standard (Standard 4 — Medication Safety) and must be performed at every transition of care.

When to Reconcile

  • Hospital admission and discharge (mandatory under NSQHS)
  • Transfer between wards, facilities or care settings
  • At least annually in community-dwelling older adults (RACGP Red Book recommendation)
  • After any new hospital presentation, specialist visit or emergency department attendance
  • When a new prescriber assumes care

Components of a Comprehensive Medication Review

  1. Medicine inventory: All prescription medicines, over-the-counter (OTC) products, complementary and alternative medicines (CAMs), and topical preparations. Record dose, frequency, route, indication and prescriber for each.
  2. Indication review: Every medicine should have a clear, documented indication. Medicines without an identifiable indication should be flagged for deprescribing consideration.
  3. Effectiveness assessment: Is the medicine achieving its therapeutic goal? If not, is dose optimisation, switch or cessation indicated?
  4. Safety assessment: Screen for drug–drug interactions, duplicate therapies, contraindications (especially renal/hepatic dose adjustment), anticholinergic burden and ADEs.
  5. Adherence evaluation: Identify practical barriers (cost, dexterity, cognition, swallow ability) and beliefs driving non-adherence.
  6. Patient goals: Elicit patient/carer preferences and treatment priorities, particularly regarding quality of life versus longevity.

Australian Funded Review Programmes

Programme MBS Item Setting Key Details
Home Medicines Review (HMR) 900 Community GP referral; accredited pharmacist visits home; written report to GP. Patient must be taking ≥5 medicines OR have had a recent medication-related hospitalisation. No cost to patient.
Residential Medication Management Review (RMMR) 903 RACF GP referral; accredited pharmacist reviews residents on ≥5 medicines or upon entry. Minimum every 2 years, more frequently if clinically indicated.
Medication Management Reviews (MMR) 905 Community / Hospital-in-the-Home Collaborative review involving GP and pharmacist; increasingly used in transitional-care models.
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Clinical tip: An HMR is one of the highest-value interventions in geriatric medicine. Studies in Australian settings show HMRs reduce emergency presentations by 15–20 % and are cost-neutral to the health system within 6 months. All older adults on ≥5 regular medicines should be considered for referral.

Potentially Inappropriate Medicines (PIMs)

Potentially inappropriate medicines (PIMs) are agents whose risks of adverse effects outweigh their clinical benefits in older adults, particularly when safer alternatives exist. PIMs are common in Australian practice: a 2023 AIHW analysis estimated that 20–30 % of community-dwelling Australians aged ≥65 years receive at least one PIM, rising to >40 % in RACFs.

Common PIMs in Australian Practice

Drug / Class Risk in Older Adults Preferred Alternative / Action
Benzodiazepines (diazepam, temazepam, oxazepam) Falls, fractures, cognitive impairment, delirium, dependence Gradual taper; CBT-I for insomnia; low-dose mirtazapine if needed
Anticholinergics (amitriptyline, promethazine, oxybutynin, chlorphenamine) Delirium, urinary retention, constipation, dry mouth, cognitive decline Switch to non-anticholinergic alternatives; calculate ACB burden
NSAIDs (ibuprofen, naproxen, diclofenac) GI bleeding, AKI, CV events, fluid retention Paracetamol first-line; topical NSAIDs; short courses only if essential
PPIs beyond 8 weeks (omeprazole, esomeprazole, pantoprazole) C. difficile infection, hypomagnesaemia, osteoporotic fractures, community-acquired pneumonia Step-down to lowest effective dose or deprescribe; re-indicate before continuing
Long-acting sulfonylureas (glibenclamide/glyburide) Severe prolonged hypoglycaemia Switch to gliclazide or metformin; relax HbA1c targets
First-generation antihistamines (diphenhydramine, doxylamine) Anticholinergic effects, sedation, falls Avoid in older adults; use cetirizine or loratadine if antihistamine required
Digoxin >0.125 mg/day Toxicity (reduced renal clearance); nausea, arrhythmia Reduce dose; monitor levels (target 0.5–0.9 ng/mL for AF)
Antipsychotics (risperidone, quetiapine) for behavioural symptoms of dementia Stroke, mortality, falls, extrapyramidal effects Non-pharmacological strategies first; deprescribe after ≥3 months
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Safety alert: Benzodiazepines are the single most common PIM in Australian older adults. Long-term use (>4 weeks) is associated with a 40–60 % increased risk of hip fracture. Gradual taper (reducing dose by 10–25 % every 1–2 weeks) is safer than abrupt cessation.

Prescribing Cascade

A prescribing cascade occurs when a new medicine is started to treat an ADE caused by an existing medicine (e.g., a dihydropyridine calcium-channel blocker causing ankle oedema, leading to furosemide, which causes gout, leading to allopurinol). Recognising and interrupting the prescribing cascade is a core skill in medication review.

STOPP/START and Beers Criteria

Two internationally validated screening tools help clinicians identify PIMs and prescribing omissions in older adults. Australian geriatricians and GPs increasingly prefer STOPP/START v2 (Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment, version 2) because it is organ-system–based, generates actionable recommendations, and has superior sensitivity for predicting ADEs compared with the Beers Criteria.

STOPP/START v2 (2015 — O'Mahony et al.)

STOPP identifies potentially inappropriate prescribing; START identifies prescribing omissions (i.e., evidence-based medicines that should be considered but have not been prescribed).

STOPP Criteria (Examples)
  • Benzodiazepines for ≥4 weeks (risk of falls, dependence)
  • NSAIDs with heart failure (fluid retention, exacerbation)
  • Anticholinergic drugs with dementia or delirium
  • PPIs at full therapeutic dose for >8 weeks without justification
  • Sulfonylureas with eGFR <30 mL/min (hypoglycaemia risk)
  • Duplicate drug class prescriptions
  • Loop diuretics for dependent ankle oedema without heart failure
START Criteria (Examples)
  • Statin therapy with documented CV disease and reasonable life expectancy
  • ACE inhibitor or ARB in diabetes with nephropathy
  • Antiplatelet therapy in AF where anticoagulation is contraindicated
  • Bisphosphonate in patients on long-term corticosteroids
  • Vitamin D supplementation in older adults with falls risk
  • Laxative when opioid is regularly prescribed
  • Inhaled bronchodilator/COPD therapy when indicated

Beers Criteria (2023 — American Geriatrics Society)

The Beers Criteria list medications to avoid in older adults in most circumstances, medications to avoid in specific diseases, and medications requiring dose adjustment for renal function. While developed for the US market, they are widely referenced in Australia and complement STOPP/START.

Feature STOPP/START v2 AGS Beers 2023
Origin Europe (Ireland/UK) United States
Structure Organ-system–based (22 STOPP, 14 START criteria in v2) Tables of drugs to avoid, disease–drug interactions, renal dosing
Prescribing omissions Yes (START) Limited
Actionability High — each criterion suggests a specific alternative or action Moderate — identifies risk but alternatives less explicit
Validation for ADE prediction Superior (sensitivity 68–98 % for ADEs) Good (sensitivity 50–80 %)
Australian endorsement Preferred by RACGP, ACSQHC, Australian Deprescribing Network Referenced as supplementary tool
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Practical recommendation: Use STOPP/START v2 as the primary screening tool at each medication review. Cross-reference with the Beers Criteria for drugs not covered by STOPP. Document findings and an action plan in the patient's health record.

Deprescribing Plans and Monitoring

Deprescribing is the process of reducing the dose, frequency, or number of medicines with the goal of improving outcomes and quality of life. It requires the same rigour as prescribing: a clear rationale, patient consent, a structured tapering plan and scheduled follow-up.

Stepwise Deprescribing Approach

1
Identify & Prioritise
Compile a complete medicine list. Identify PIMs using STOPP/START and Beers. Prioritise medicines with the highest risk-to-benefit ratio and those most likely to cause current symptoms.
2
Shared Decision-Making
Discuss goals of care with the patient and/or carer. Explain the rationale for stopping, expected benefits, possible withdrawal effects and monitoring plan. Obtain informed consent.
3
Develop the Taper Plan
Reduce dose gradually (generally 10–25 % per 1–2 weeks). Never stop abruptly unless the medicine is causing immediate harm. One medicine at a time (or up to two if low risk).
4
Monitor & Support
Follow up at 2–4 weeks after each dose change. Assess for rebound symptoms, withdrawal effects and improvement in target outcomes. Involve pharmacist for HMR at start and completion.

Common Deprescribing Targets — Practical Guidance

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Benzodiazepines
Diazepam, temazepam, oxazepam · Sedative-hypnotic
Taper strategy Reduce by 10–25 % every 1–2 weeks. For long-term use, consider switching to diazepam equivalent (longer half-life) and then tapering over 8–12 weeks.
Monitor for Rebound insomnia, anxiety, seizures (rare with gradual taper), agitation
Support CBT-I (cognitive behavioural therapy for insomnia); sleep hygiene education
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Proton-Pump Inhibitors
Omeprazole (Losec®), pantoprazole (Somac®), esomeprazole (Nexium®)
Taper strategy Step down from BD to OD, then to alternate-day dosing over 2–4 weeks. If symptoms recur, consider on-demand PPI or H2RA (famotidine) cover.
Monitor for Rebound acid hypersecretion (common in first 2 weeks, self-limiting), dyspepsia recurrence
PBS status ✔ PBS General Benefit
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Antipsychotics (for behavioural symptoms of dementia)
Risperidone (Risperdal®), quetiapine (Seroquel®)
Taper strategy Reduce by 25 % every 2–4 weeks. Risperidone: reduce 0.5 mg increments. Monitor behaviour and BPSD scores throughout.
Monitor for Behavioural and psychological symptoms of dementia (BPSD) recurrence, extrapyramidal symptoms rebound
PBS status ℞ Authority Required
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Antihyperglycaemics
Metformin, gliclazide (Diamicron®), insulin
Taper strategy Relax HbA1c target to 53–64 mmol/mol (7.0–8.0 %) in frail/elderly. Stop sulfonylureas first (hypoglycaemia risk). Reduce basal insulin by 10–20 % at a time. Monitor BGLs.
Monitor for Hypoglycaemia, glycosuria, hyperglycaemic symptoms
PBS status ✔ PBS General Benefit (metformin, gliclazide)

Monitoring Framework

Time Point Action Parameters to Assess
Baseline (pre-deprescribing) Document target symptoms, functional measures, cognitive scores MMSE/MoCA, BP, BGL, pain scores, sleep quality, bowel habit, symptom diary
2 weeks Phone or in-person review Withdrawal symptoms, symptom recurrence, adverse effects
4–6 weeks Comprehensive review Repeat baseline measures; adjust taper plan; refer to HMR if not already done
3 months Stabilisation assessment Confirm cessation or stable dose; update medication list; close HMR loop
6–12 months Ongoing surveillance Annual medication review; re-screen with STOPP/START
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Withdrawal syndromes to anticipate: Rebound anxiety/insomnia (benzodiazepines, SSRIs), rebound acid hypersecretion (PPIs), cholinergic rebound (anticholinergics, antipsychotics), adrenal insufficiency (corticosteroids used >3 weeks), rebound hypertension (clonidine, beta-blockers). Always taper — do not stop abruptly unless life-threatening.

Adverse Drug Events and Harm Pathways

Adverse drug events in older adults are common, predictable and frequently preventable. The pathophysiology of medication-related harm in ageing relates to both pharmacokinetic and pharmacodynamic changes.

Age-Related Pharmacokinetic Changes

Parameter Change with Age Clinical Implication
Absorption Reduced gastric acid, delayed gastric emptying Generally clinically insignificant; most drugs adequately absorbed
Distribution ↑ Body fat, ↓ lean mass, ↓ total body water, ↓ serum albumin ↑ Volume of distribution for lipophilic drugs (diazepam, amiodarone) → prolonged half-life. ↑ Free fraction of highly protein-bound drugs (warfarin, phenytoin)
Metabolism ↓ Hepatic mass (20–30 %), ↓ Phase I (CYP450) metabolism, preserved Phase II (conjugation) Reduced clearance of CYP-metabolised drugs; paracetamol Phase II relatively preserved
Excretion ↓ GFR (by ~1 mL/min/year after age 40), ↓ renal blood flow Must use measured or estimated CrCl (Cockcroft-Gault) for renally cleared drugs. eGFR may overestimate function in frail elderly.

Pharmacodynamic Sensitivity

  • CNS sensitivity: Increased response to opioids, benzodiazepines and anticholinergics due to changes in receptor density and blood–brain barrier permeability.
  • Cardiovascular sensitivity: Impaired baroreceptor reflex → exaggerated hypotensive response to antihypertensives and diuretics → orthostatic hypotension → falls.
  • Anticoagulant sensitivity: INR instability is more common; lower doses of warfarin are typically needed.
  • Hypoglycaemic sensitivity: Reduced counter-regulatory hormone responses → prolonged, severe hypoglycaemia with sulfonylureas and insulin.

Anticholinergic Cognitive Burden (ACB) Scale

The ACB scale assigns a score (1 = possible anticholinergic activity, 2–3 = definite anticholinergic activity) to commonly prescribed medicines. A cumulative ACB score ≥3 is associated with increased risk of cognitive impairment, falls and delirium. Clinicians should calculate the total ACB burden during every medication review.

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High-risk combination: The concurrent use of ≥3 medicines with ACB score ≥2 (e.g., amitriptyline + oxybutynin + promethazine) dramatically increases delirium risk and should be actively deprescribed.

Clinical Presentation

Polypharmacy-related harm often presents non-specifically in older adults. Clinicians should maintain a high index of suspicion for ADEs in any older patient with unexplained functional decline, cognitive change, falls or recurrent hospitalisations.

Common Presentations of Medication-Related Harm

  • Falls: Polypharmacy (≥4 medicines) independently increases fall risk. Key culprits: benzodiazepines, antihypertensives (especially alpha-blockers, loop diuretics), antipsychotics, opioids.
  • Delirium: Anticholinergics, benzodiazepines, opioids, corticosteroids, fluoroquinolones, antipsychotics are common precipitants.
  • Urinary incontinence: Diuretics, cholinesterase inhibitors, alpha-blockers, anticholinergics (paradoxical overflow).
  • Constipation: Opioids, anticholinergics, calcium-channel blockers, iron supplements, 5-HT3 antagonists.
  • Cognitive impairment: Cumulative anticholinergic burden, benzodiazepines, antiepileptics, polypharmacy per se.
  • Acute kidney injury: NSAIDs, ACE inhibitors/ARBs (especially in combination with diuretics — "triple whammy"), aminoglycosides, vancomycin.
  • Orthostatic hypotension: Antihypertensives, diuretics, alpha-blockers, tricyclic antidepressants, antipsychotics.
  • Hyponatraemia: SSRIs/SNRIs, carbamazepine, thiazide diuretics, PPIs.
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Clinical pearl: When an older patient presents with a new symptom, always ask: "Is this a disease or is it a drug?" Review the medicine list before ordering extensive investigations.

Investigations and Assessment Tools

The investigation strategy in polypharmacy is twofold: identify harm caused by medicines and assess the conditions for which medicines are prescribed.

Essential
Full Medication Reconciliation
Complete inventory including OTCs, CAMs, eye drops, patches and PRN medicines. Best performed by pharmacist (HMR MBS 900 or RMMR MBS 903).
Essential
Renal Function (eGFR + CrCl)
Use Cockcroft-Gault for drug dosing. Many drugs require dose adjustment at eGFR <30 (e.g., metformin at <30, DOACs, gabapentin).
Available
STOPP/START v2 Screening
Systematic organ-based review of prescribing appropriateness. Can be completed by GP, pharmacist or geriatrician in <15 minutes.
Available
Anticholinergic Cognitive Burden (ACB) Score
Sum the ACB scores of all medicines. Total ≥3 warrants active deprescribing. Freely available at agingbraincare.com.
Available
Medication Appropriateness Index (MAI)
10-item tool evaluating indication, effectiveness, dose, directions, drug–drug and drug–disease interactions, duration, cost and practicality.
Available
Falls Risk Assessment (FROP-Com or timed Up-and-Go)
Quantify falls risk; medicines contributing to falls should be flagged for deprescribing.
Referral
Home Medicines Review
MBS Item 900. GP-initiated, pharmacist-delivered, patient-focussed review in the home. Report returned to GP with recommendations.
Specialist
Geriatric Medicine Consultation
For complex polypharmacy with multimorbidity, frailty, recurrent ADEs, or diagnostic uncertainty. Increasingly available via telehealth to rural/remote areas.

Risk Stratification

Not all polypharmacy carries equal risk. Stratification helps prioritise medication review resources to those at greatest risk of harm.

Lower Risk
Appropriate Polypharmacy
5–9 medicines, all with clear indications and evidence base. Stable chronic conditions (e.g., post-MI on secondary prevention). No PIMs identified on STOPP screen. ACB score <3. Good renal function.
Setting: Annual medication review by GP. HMR if complex.
Moderate Risk
Potentially Inappropriate Polypharmacy
≥10 medicines OR ≥1 PIM on STOPP screen OR ≥1 prescribing omission on START. History of one ADE in the past 12 months. ACB score 3–5. Mild–moderate CKD (eGFR 30–59). Recent hospitalisation.
Setting: HMR referral within 4 weeks. Consider geriatric outpatient review. GP-led deprescribing with pharmacist support.
High Risk
High-Risk Polypharmacy
≥15 medicines (excessive polypharmacy) OR ≥3 PIMs OR recurrent ADEs OR falls with injury OR anticoagulant + antiplatelet + NSAID combination OR severe CKD (eGFR <30) with multiple renally cleared drugs OR recent medication-related hospitalisation. ACB score ≥6. Frailty (Clinical Frailty Scale ≥5).
Setting: Urgent HMR/RMMR. Geriatric medicine referral. Multidisciplinary case conference (MBS Item 735/739). Consider inpatient medication review if acute harm.

Special Populations

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Frail Elderly (>75 years)

Pharmacokinetic changes are most pronounced — reduce starting doses of all new medicines by 50 % of the standard adult dose ("start low, go slow").
Relax therapeutic targets: HbA1c 53–64 mmol/mol, BP <150/90 mmHg, LDL individualised rather than protocol-driven statin intensification.
Life expectancy and time-to-benefit of preventive medicines must be considered — statins, bisphosphonates and tight glycaemic control may take 2–5 years to yield benefit.
Screen for frailty using the Clinical Frailty Scale (CFS) before intensifying treatment.
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Chronic Kidney Disease

Use Cockcroft-Gault CrCl (not CKD-EPI eGFR) for drug dosing decisions.
Metformin: contraindicated if eGFR <30; reduce dose to 500–1000 mg/day if eGFR 30–45. ✔ PBS General Benefit
DOACs: apixaban dose reduction (2.5 mg BD) if ≥2 of age ≥80, weight ≤60 kg, Cr ≥133 µmol/L. ✔ PBS General Benefit
Gabapentin, pregabalin, lithium, digoxin all require dose reduction and monitoring of levels.
NSAIDs accelerate CKD progression and should be deprescribed.
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Hepatic Impairment

Child-Pugh score guides dose adjustments. In moderate–severe impairment (Child-Pugh B/C), avoid drugs with high first-pass metabolism (e.g., propranolol, morphine, tramadol).
Paracetamol: maximum 2 g/day (not 4 g) in chronic liver disease.
Benzodiazepines: avoid in hepatic encephalopathy; lorazepam and oxazepam (Phase II metabolism only) are safest if a benzodiazepine is absolutely required.
Review all medicines for hepatotoxicity potential if LFTs are deranged.
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Cognitive Impairment / Dementia

Cumulative anticholinergic burden (ACB score) is a modifiable risk factor for cognitive decline. Aim for total ACB <3.
Antipsychotics for BPSD should be time-limited (review every 3 months; attempt dose reduction at 6 months).
Cholinesterase inhibitors (donepezil, rivastigmine) should be reviewed for ongoing benefit at 6–12 months. Deprescribe if no functional benefit or if intolerable GI/cardiac side effects. ℞ Authority Required
Consider deprescribing memantine in advanced dementia where communication is no longer possible.
Simplify medication regimens: once-daily dosing, compliance aids, carer administration.
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Residential Aged-Care Facility (RACF) Residents

RMMR (MBS 903) should be performed on entry and at least every 2 years; more frequently if clinical status changes.
Prn (as-needed) medicines should be reviewed monthly — frequent use suggests unaddressed symptoms and need for regular medicine adjustment.
Psychotropic medicine use in RACFs remains a national safety priority — the ACSQHC's Quality Indicators programme monitors antipsychotic prevalence.
Swallowing assessment before prescribing solid oral dosage forms; consider liquid, dispersible or patch formulations.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience a higher burden of chronic disease at younger ages, resulting in earlier onset of multimorbidity and polypharmacy. The AIHW reports that Indigenous Australians aged ≥50 years take a mean of 5.8 regular medicines — meeting polypharmacy thresholds a decade earlier than non-Indigenous Australians. Medication-related harm is compounded by health system barriers that limit access to pharmacist-led medication review services.

Key Considerations

Multimorbidity onset
Type 2 diabetes, cardiovascular disease, chronic kidney disease and rheumatic heart disease commonly coexist in Indigenous Australians from age 40, leading to complex regimens requiring regular reconciliation.
HMR uptake gap
HMR utilisation among Indigenous Australians is approximately one-third that of the non-Indigenous population. Barriers include lack of accredited pharmacists in remote areas, cultural unsafety of home-visit models and low awareness of the programme. Culturally responsive HMR models — including Aboriginal Health Practitioner (AHP)-supported reviews — are being piloted in several jurisdictions.
Continuity of medicines supply
Medicine access in remote communities relies on Remote Area Aboriginal Health Services (RAAHS) and the Continued Dispensing / Section 100 arrangements. Medication interruptions due to clinic stock-outs, transport barriers, or absence of prescriber contribute to erratic adherence and complicate deprescribing plans.
Communication and health literacy
Language barriers and low health literacy may mean patients do not understand the purpose of each medicine, increasing the risk of both non-adherence and inadvertent harm. Use visual medicine charts, involve family members and Aboriginal liaison officers, and provide information in first language where possible.
OTC and traditional medicine use
Bush medicines and OTC analgesics (particularly ibuprofen and paracetamol–codeine combinations) are commonly used alongside prescription medicines. These must be included in every medication reconciliation.
Renal dosing
CKD prevalence in Indigenous Australians is 2–3 times higher than the general population. Rigorous renal dose adjustment (using Cockcroft-Gault CrCl) is essential for metformin, DOACs, gabapentinoids, allopurinol and many antibiotics. Section 100 Highly Specialised Drugs Programme supports nephrology co-management.
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Cultural safety note: Deprescribing conversations require trust. Engage Aboriginal Health Workers/Practitioners (AHW/Ps) as partners in medication review. Use shared decision-making frameworks that respect Indigenous concepts of health and wellbeing (social and emotional wellbeing model). Avoid assumptions about non-adherence — explore barriers without judgement. The Australian Deprescribing Network's Indigenous deprescribing toolkit provides culturally adapted resources.

📚 References

  1. 1. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.
  2. 2. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
  3. 3. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.
  4. 4. Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults. Clin Pharmacol Ther. 2009;85(1):86-88.
  5. 5. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2021. Standard 4: Medication Safety.
  6. 6. Australian Institute of Health and Welfare (AIHW). Medicines use among people aged 65 and over. Cat. no. WEB 235. Canberra: AIHW; 2023.
  7. 7. Royal Australian College of General Practitioners (RACGP). Management of polypharmacy in older patients: A guide for general practice. Melbourne: RACGP; 2022.
  8. 8. Page AT, Clifford RM, Potter K, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(3):583-623.
  9. 9. Boustani M, Campbell N, Munger S, et al. Impact of anticholinergics on the aging brain: a review and practical application. Aging Health. 2008;4(3):311-320.
  10. 10. Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in frail older people: a randomised controlled trial. PLoS One. 2016;11(3):e0149984.
  11. 11. Department of Health and Aged Care (Cth). Home Medicines Review — MBS Item 900 factsheet. Canberra: DoHAC; 2023.
  12. 12. NPS MedicineWise. Deprescribing: a practical guide for health professionals. Sydney: NPS MedicineWise; 2023.
  13. 13. Australian Indigenous HealthInfoNet. Summary of Aboriginal and Torres Strait Islander health: chronic conditions and medicines use. Perth: Edith Cowan University; 2023.
  14. 14. Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012;65(9):989-995.
  15. 15. Thompson W, Farrell B. Deprescribing: an evidence-based approach to reducing polypharmacy. Can Fam Physician. 2013;59(3):e151-e152.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).