Polypharmacy

Original Editor - Shwe Shwe U Marma Top Contributors - Shwe Shwe U Marma and Lucinda hampton

Introduction

Tablets and pills
Polypharmacy refers to the use of multiple medications in a patient, commonly an older adult.[1] While the most commonly used definition of polypharmacy is being on five or more medicines, definitions are variable.[2]

Catagories

There is no universally agreed definition of polypharmacy, however it can be described in 3 groups-

  1. Excessive polypharmacy (EPP): concurrent use of ten or more different drugs.
  2. Polypharmacy (PP): the use of five to nine drugs.
  3. No polypharmacy: taking four or less drugs (included those taking no medicines)[4]

Prevalence

Older women exercising in group
  • Individuals greater than 65 years old are the biggest consumers of medications; however, evidence shows that greater than 50% of elderly patients are taking at least one medication that is not medically necessary. Nearly 40% of elderly adults take more than five prescription medications and almost 20% take more than 10.
  • Polypharmacy declines in patients older than 85 years of age secondary to poor drug tolerance with age and increasing deprescribing practices as medical providers fear serious adverse drug reactions that may be more common in the very elderly.[5]

Issues of Concern

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Polypharmacy is a particular concern in older people due to the following reasons.

  1. Adverse effects (ADE): refers to an injury resulting from the use of a drug and refers to harm caused by a drug at usual dosages. ADEs are causative in 5% to 28% of acute geriatric medical admissions. Preventable ADEs are among one of the serious consequences of inappropriate medication use in older adults. The drug classes commonly associated with preventable ADEs are cardiovascular drugs, anticoagulants, hypoglycemics, diuretics, and NSAIDs. Adverse drug effects are higher in older adults due to metabolic changes and decreased drug clearance that come with age. This risk compounds by increasing numbers of drugs used[3].
  2. Drug interactions: The use of multiple medications increases the potential for drug-drug interactions ie the pharmacologic or clinical response to the administration of a drug combination that differs from the response expected from the known effects of each of these two agents when given alone. Cardiovascular drugs are most commonly involved in drug-drug interactions. The most common adverse events related to drug-drug interactions are neuropsychological (delirium), acute renal failure, and hypotension[3]. eg Anti-inflammatory medications may increase blood pressure and worsen kidney function.[6]
  3. Prescribing Cascades: when additional drugs are prescribed to treat the adverse effects (ADE) of other drugs by misinterpreting the ADE as a new medical condition.
  4. Inappropriate therapy, or nonadherence[1]: especially if associated with visual or cognitive decline.
  5. The risk for Hip Fracture: Polypharmacy has been shown as an independent risk factor for hip fractures in older adults in some case-control studies; although the number of drugs may have been an indicator of a higher likelihood of exposure to specific types of drugs like central nervous system (CNS)-active drugs associated with falls.[3]
  6. Use of Over-the-Counter and Complementary Medications: use has increased over the past decade with studies showing that these agents are highly prevalent in the elderly population. Less than half of the patients discuss the use of herbal supplements or other products or complementary medicine with their medical providers. There are safety issues regarding their use including risks for herb-drug interactions.
  7. Transitions of Care: eg between hospital and home or institutional setting like a nursing home. Common source of medication errors putting patients at risk for polypharmacy. This is because many times, patients start new medications or stop previous medications, which can cause a lot of medication errors and negative outcomes.
  8. Changes in Pharmacokinetics Associated with Aging: ie drug absorption, distribution, metabolism, and elimination. Physiologic changes that occur with aging result in multiple alterations to the pharmacokinetics and pharmacodynamics of drugs, which, in turn, increase the risk of adverse drug reactions. Consideration of initial dose adjustment, along with frequent medication reconciliation and analysis of the medication list, are keys to providing optimal pharmaceutical care for elderly patients[7].

Associated Factors

Individual/Patient Factors Physician Factors Systems-Level Factors
  • Increasing age
  • Female gender
  • White ethnicity/race
  • Lower socioeconomic status
  • Poor self-reported health
  • Multiple chronic conditions
  • Declining nutrition/ability to function
  • Decreased cognitive capacity
  • Self-medication
    • Use of over-the-counter medications
    • Borrowing from friends/family
  • Use of multiple pharmacies
  • Lack of education/competence
  • High patient workload
  • Prescribing habits
    • Adherence to multiple medical guidelines
    • Use of potentially inappropriate medications
  • Improper medication reconciliation
  • Poor physician-patient communication
  • Multiple prescribers
  • Different electronic medical record systems
  • Poor physician-physician communication
    • Lack of continuity between multiple medical providers
    • Ineffective transitions of care[5]

Managing Polypharmacy

  • Doctor patient.png
    List of prescribed medication should be updated and accurate
  • Each clinician should review ongoing prescription
  • Physician should be informed of any supplements, herbal products or over-the-counter medication a patient taking
  • Understanding the purpose of each medication
  • Being aware of side effects of each medication
  • Simplification of medication regimen
  • Discontinuation of any medication if needed
  • Taking medications as prescribed
  • Taking any prescribed medication should not be stopped suddenly[6]

Conclusion

Along with all other health practitioners, physiotherapists should be aware of the tools and methods to manage polypharmacy-related issues to optimize patient outcomes.[1]

[8]

References

  1. 1.0 1.1 1.2 Nguyen T, Wong E, Ciummo F. Polypharmacy in Older Adults: Practical Applications Alongside a Patient Case. The Journal for Nurse Practitioners. 2020 Mar 1;16(3):205-9.
  2. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC geriatrics. 2017 Dec 1;17(1):230.
  3. 3.0 3.1 3.2 3.3 3.4 Varghese D, Koya HH. Polypharmacy. StatPearls [Internet]. 2020 Feb 18.Available from:https://www.ncbi.nlm.nih.gov/books/NBK532953/ (last accessed 24.11.2020)
  4. O'Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ open. 2016 Apr 1;6(4).
  5. 5.0 5.1 Valenza PL, McGinley TC, Feldman J, Patel P, Cornejo K, Liang N, Anmolsingh R, McNaughton N. Dangers of polypharmacy. InVignettes in Patient Safety-Volume 1 2017 Sep 13. IntechOpen.
  6. 6.0 6.1 Onder G, Marengoni A. Polypharmacy. Jama. 2017 Nov 7;318(17):1728-.
  7. Sera LC, McPherson ML. Pharmacokinetics and pharmacodynamic changes associated with aging and implications for drug therapy. Clinics in geriatric medicine. 2012 May 1;28(2):273-86.Available from:https://pubmed.ncbi.nlm.nih.gov/22500543/ (accessed 24.11.2020)
  8. Medskl.com. Geriatrics – Polypharmacy in the Elderly: By Balakrishnan Nair M.D.. Available from: https://www.youtube.com/watch?v=vGcAr9tK_30 [Last accessed 22 November, 2020]