Polypharmacy in MRCP PACES23: A Practical Approach

Polypharmacy is one of the most consistent high-yield themes in MRCP PACES, and in the PACES23 format it has become even more central. Where older diets of the exam rewarded a spot diagnosis of aortic stenosis or a crisp Parkinson’s examination, PACES23 rewards the candidate who can manage complexity — and there is no clinical complexity more common in the real-world NHS than the frail older patient on ten medications. Knowing how to recognise, assess and safely reduce polypharmacy in a five-minute consultation is now a near-mandatory PACES skill.

This guide is written to help you walk into any PACES23 station involving an older patient and demonstrate a senior, safe, patient-centred approach to medicines — the kind of approach that examiners are explicitly trained to reward.

Why Polypharmacy Matters So Much in PACES23

The PACES23 blueprint deliberately increases the weighting of Station 2 (history taking and management planning) and Station 5 (brief clinical consultation). Both stations now lean heavily on the management of chronic disease in older adults, and medication review is a routine part of that management. Several reasons make polypharmacy a high-yield revision target:

• It is common. Roughly one in three people over 75 in the UK takes five or more regular medicines, and one in ten takes eight or more.

• It is harmful. Adverse drug reactions are implicated in up to 10% of hospital admissions in older adults and are a leading cause of falls, delirium, AKI and GI bleeding.

• It is assessable in five minutes. A focused medication review is one of the few geriatric interventions that can be performed, structured and explained in a single short station.

• It differentiates candidates. Most candidates will list a medication; few will demonstrate a structured, evidence-based approach to stopping or simplifying it.

The Common PACES23 Polypharmacy Scenarios

Across the new PACES23 diet, polypharmacy appears in three main guises. Recognising the shape of the station before you enter the room gives you a significant head start.

1. The Falls Patient on Multiple Drugs

A 78-year-old attends after a fall. The notes (or the history itself) reveal they take a beta-blocker, a thiazide, an ACE inhibitor, a PPI, a statin, an opioid analgesic, a benzodiazepine and a sedating antihistamine. The examiner is not testing whether you can list each drug; they are testing whether you can identify the modifiable contributors and propose a sensible plan.

2. The Patient With Cognitive Symptoms and a Long Drug Chart

A relative brings an 82-year-old who has become increasingly confused. The drug history includes an anticholinergic bladder drug, amitriptyline, oxybutynin, a benzodiazepine and hyoscine. The candidate who spots anticholinergic burden will score; the candidate who simply attributes confusion to dementia will not.

3. The Patient With Multimorbidity Asking About "Too Many Tablets"

This is a classic Station 5 brief consultation. The patient — or their carer — raises the issue of polypharmacy directly. The candidate must combine empathy, shared decision-making and a credible deprescribing plan.

In all three, the underlying skill is the same: structured medication review.

The Structured Medication Review You Should Rehearse

The NHS and the Royal Pharmaceutical Society both endorse a four-step framework, and it maps perfectly onto a five-minute PACES station.

Step 1: Verify the Indication

For every medicine, ask: what is this for, and is the original indication still active? Many older patients continue on drugs initiated years ago for transient problems — proton pump inhibitors started in hospital and never stopped, bisphosphonates continued ten years after a fragility fracture, aspirin continued indefinitely after a non-specific finding.

Step 2: Assess the Continuing Benefit

Is the drug still achieving its goal? An HbA1c target of 48 mmol/mol may have been appropriate at 65 but causes dangerous hypos at 82 with a frail trajectory. Tight BP control in an 80-year-old with orthostatic symptoms is more often harmful than helpful.

Step 3: Identify Harm and Risk

Look for:

• STOPP/START triggers (see below)

• Anticholinergic burden (use the ACB scale or equivalent)

• Falls-risk drugs — sedatives, antihypertensives, hypoglycaemics, alpha-blockers

• Renally cleared drugs in someone with a low eGFR

• Bleeding risk combinations (anticoagulant + antiplatelet + NSAID)

• Delirium precipitants — anticholinergics, benzodiazepines, opioids, antihistamines

Step 4: Agree a Plan With the Patient

This is the step most candidates neglect. Deprescribing without shared decision-making is unsafe and is exactly what PACES23 examiners are trained to detect. The plan should be explicit, prioritised and reviewed.

STOPP/START in PACES23: The High-Yield Triggers

You do not need to memorise the full 190 criteria, but the following are reliably tested and easy to learn. Use them as mental prompts during the station.

Common STOPP triggers in PACES cases:

• Any anticholinergic in a patient with dementia, narrow-angle glaucoma or chronic constipation

• Long-acting benzodiazepines, Z-drugs, or any sedative in someone with a history of falls

• First-generation antihistamines (chlorpheniramine, promethazine) in older adults

• NSAIDs in those with CKD, heart failure, peptic ulcer disease, or on anticoagulation

• Loop diuretics as first-line for hypertension

• Aspirin as primary prevention in someone over 70

• Oral hypoglycaemics with a high hypoglycaemia risk (glibenclamide)

• PPI at full dose for more than 8 weeks without clear indication

• Antipsychotics for behavioural and psychological symptoms of dementia

• Anticholinergic bladder drugs (oxybutynin, tolterodine) in frail patients

Common START triggers you may be expected to recognise as omissions:

• Vitamin D and calcium in housebound or institutionalised older adults

• ACE inhibitor or ARB in diabetic nephropathy or heart failure with reduced ejection fraction

• Bisphosphonate in documented osteoporosis

• Anticoagulation in non-valvular atrial fibrillation where CHA₂DS₂-VASc supports it

• Laxatives in chronic opioid use

Knowing four to five of each — and being able to justify them in a single sentence — is more than enough to demonstrate competence in a five-minute station.

Anticholinergic Burden: A Single High-Yield Concept

Anticholinergic burden is one of the most commonly tested polypharmacy concepts in PACES23, because it is simple to assess and clearly linked to cognitive decline, falls and mortality.

Common culprits you should be ready to name:

• Amitriptyline (very high burden)

• Oxybutynin, tolterodine (high)

• Chlorpheniramine, hydroxyzine, promethazine (high)

• Hyoscine butylbromide (high)

• Loperamide (moderate)

• Cetirizine, loratadine (low–moderate)

If a station presents an older patient with confusion, dry mouth, constipation, urinary retention or falls, and you spot a high-anticholinergic drug, you have almost certainly found the exam question.

How to Frame the Deprescribing Plan in the Station

PACES23 examiners are looking for a plan, not a list. Use this phrasing pattern in the station and you will sound like a registrar rather than a final-year medical student.

"Given the history of falls, the most important medicines to review are the bendroflumethiazide, which we could consider stopping as her blood pressure is now borderline low, and the temazepam, which is a recognised falls-risk drug. I would also reconsider the oxybutynin because of its anticholinergic burden and her cognitive symptoms. I would discuss each of these with her, one at a time, starting with the one she is most willing to change, and review in two to four weeks."

This single sentence covers identification, prioritisation, shared decision-making and follow-up — the four things the examiner is marking.

Communicating About Medicines: The PACES23 Soft Skills

Polypharmacy stations are as much about how you talk about medicines as what you say. The PACES23 communication descriptors are explicit about patient-centred language and shared decision-making. Practical phrasing to rehearse:

• "Some of these medicines may be doing more harm than good now that you are frailer."

• "I'd like to go through each tablet and check it is still helping you."

• "Would it be alright if we stopped one at a time and see how you feel?"

• "I will write to your GP with a clear plan and review in a few weeks."

• "If you feel dizzy, lightheaded or unwell after we change anything, please contact us."

Avoid saying "we should stop your tablets" — it sounds paternalistic. Always frame change as a collaborative decision.

A Five-Minute PACES23 Station Blueprint

Use this as a rehearsal template before your next practice session.

Rehearsing this template against two or three polypharmacy cases per week for the final month of preparation will produce a measurable improvement in your Station 5 score.

Common Pitfalls in PACES23 Polypharmacy Stations

• Listing without prioritising. Mentioning ten drugs is not the same as managing polypharmacy. Examiners reward the candidate who can rank.

• Stopping everything at once. This is unsafe and demonstrates a junior approach. Always stop one drug at a time.

• Ignoring the patient's own views. The patient may value symptom relief over theoretical long-term benefit. Reflect this in your plan.

• Forgetting non-pharmacological alternatives. Continence, sleep hygiene, exercise, social prescribing and pain-management strategies are all part of good deprescribing.

• Failing to safety-net. Tell the patient what to watch for and when to seek help. This is a Station 5 marker.

How to Practise This Before Exam Day

Polypharmacy is one of the few PACES topics that is best rehearsed with real patients or realistic AI patient simulations, not flashcards. Look for practice tools that allow you to:

• Open a structured drug history without prompting

• Receive an interruption if you take the history too quickly

• Have the patient challenge your plan ("I've taken that tablet for 20 years, why change now?")

• Get examiner-style feedback on prioritisation, justification and safety-netting

The PACES23 format is designed to test whether you can do this in real time, and only timed, interactive practice builds that fluency.

Key Takeaways

• Polypharmacy is a high-yield, predictable PACES23 theme, especially in Stations 2 and 5.

• Use a four-step structured medication review: indication, benefit, harm, agreement.

• Learn four to five STOPP and four to five START triggers rather than the full list.

• Anticholinergic burden is a single concept that explains a large proportion of stations.

• Always prioritise, always share decisions, always stop one drug at a time, always safety-net.

• Rehearse the five-minute station blueprint against timed, realistic patient practice.

Master this approach and you will not only pass PACES23 — you will walk into your first registrar on-call shift genuinely equipped to look after an older patient on a long drug chart.