Polypharmacy: a growing issue facing elderly patients

In the world of healthcare, less can be more. Following increasing investments and progress in pharmaceutical drug development, patients and medical professionals currently face an abundance of medications available to them. This phenomenon has led to a growing issue in healthcare called polypharmacy, which is when patients take five or more medications. This is a problem that disproportionately impacts the elderly who are likely to have multimorbidities (two or more chronic health conditions) [1]. Multimorbidities can lead physicians to prescribe one or more drugs to target each condition, potentially resulting in unforeseen drug-drug interactions or drug-disease interactions consequential to the patient. Clinical studies and guidelines for medications are often developed under the assumption that patients face a single medical condition, disregarding the study of alternate interactions [2].


In light of this health care challenge, many advocates have promoted the idea of deprescribing or simply lowering the number of drugs prescribed to patients. Preliminary research using randomized trials suggests that simply deprescribing has no significant impact on patient mortality [3], and can even improve the quality of life for patients with less than a year to live [4]. However, simply lowering the number of drugs a patient is prescribed may not be feasible or appropriate. For example, it is critical to consider drug withdrawal symptoms on the patient’s behalf and closely monitor how they are responding to new changes in their treatment [5]. Another crucial, but often overlooked, aspect of deprescribing is patient-centered decision-making and patient education.


Prescribed medications affect patients not only medically, but also financially and behaviorally. Because of this, the decision to deprescribe must be a collaboration between the clinician and the patient, ensuring that both parties are aware of existing options and the patient’s goals or preferences [5].


Another leading cause of polypharmacy is the lack of coordinated care in healthcare. Patients facing multimorbidities will often seek care through multiple medical specialists who may each prescribe medications independently. Without clear and consistent communication between medical providers, and even the different pharmacies where patients choose to fill prescriptions, there is a possibility of duplicating drug therapy [6]. As a result, implementing more cohesive coordinated care teams can improve the exchange of information about a patient’s care plan [7]. Additionally, it is important to target specific moments during the course of a patient’s care to address polypharmacy. These moments include care transitions (e.g. going from home to assisted living facility, hospitalizations discharge, etc.) as research suggests a high rate of medication errors during these periods [8]. A primary care physician also plays a key role in managing polypharmacy for patients. Because the patient-doctor relationship is the most developed with one’s primary care physician, these providers have an important responsibility to work alongside the patient in making sense of a patient’s care plan across different providers and medication regimens.


To address the challenges that come with the growing prevalence of polypharmacy, many institutions and organizations have begun to redirect their efforts to combat this issue. The Lown Institute is one such healthcare think tank that has put forth a national action plan to counter the consequences of polypharmacy [9]. Solutions put forth within this action plan include using prescription checkups, raising awareness for the general public and policymakers, and educating healthcare professionals on medication overload. The institute has also used its platform to regularly highlight promising research. One such clinical trial, labeled D-PRESCRIBE, found that when pharmacists simply gave older patients an educational brochure on deprescribing along with evidence-based pharmaceutical opinions to their primary care physicians, there was a 31% decrease in filled prescriptions for inappropriate medications after 6 months [10]. Clearly, the ability to address polypharmacy isn’t restricted to any single entity or individual. It should be a collaborative effort, characterized by accountability and increased access to information.


References


1. Masnoon, N., Shakib, S., Kalisch-Ellett, L., & Caughey, G. E. (2017). What is polypharmacy? A systematic review of definitions. BMC geriatrics, 17(1), 230. https://doi.org/10.1186/s12877-017-0621-2


2. Dumbreck, S., Flynn, A., Nairn, M., Wilson, M., Treweek, S., Mercer, S. W., Alderson, P., Thompson, A., Payne, K., & Guthrie, B. (2015). Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ (Clinical research ed.), 350, h949. https://doi.org/10.1136/bmj.h949


3. Page, A. T., Clifford, R. M., Potter, K., Schwartz, D., & Etherton-Beer, C. D. (2016). The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. British journal of clinical pharmacology, 82(3), 583–623. https://doi.org/10.1111/bcp.12975


4. Singh, S., Zieman, S., Go, A. S., Fortmann, S. P., Wenger, N. K., Fleg, J. L., Radziszewska, B., Stone, N. J., Zoungas, S., & Gurwitz, J. H. (2018). Statins for Primary Prevention in Older Adults-Moving Toward Evidence-Based Decision-Making. Journal of the American Geriatrics Society, 66(11), 2188– 2196. https://doi.org/10.1111/jgs.15449


5. Ouellet, G. M., Ouellet, J. A., & Tinetti, M. E. (2018). Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Therapeutic advances in drug safety, 9(11), 639–652. https://doi.org/10.1177/2042098618791371


6. Kim, J., & Parish, A. L. (2017). Polypharmacy and Medication Management in Older Adults. The Nursing clinics of North America, 52(3), 457–468. https://doi.org/10.1016/j.cnur.2017.04.007


7. Socha, T. (n.d.). Care Coordination Teams: A Managed Care Approach. Hmpgloballearningnetwork.com. Retrieved April 4, 2022, from https://www.hmpgloballearningnetwork.com/site/frmc/articles/carecoordination-teams-managed-care-approach


8. Carroll, C., & Hassanin, A. (2017). Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. JAMA internal medicine, 177(6), 871. https://doi.org/10.1001/jamainternmed.2017.0911


9. Medication overload and older Americans. Lown Institute. (2020, January 29). Retrieved April 4, 2022, from https://lowninstitute.org/projects/medicationoverload-how-the-drive-to-prescribe-is-harming-older-americans/


10. Martin, P., Tamblyn, R., Benedetti, A., Ahmed, S., & Tannenbaum, C. (2018). Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA, 320(18), 1889–1898. https://doi.org/10.1001/jama.2018.16131

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