Polypharmacy

Original Editor - Shwe Shwe U Marma Top Contributors - Shwe Shwe U Marma, Lucinda hampton and Kim Jackson

Introduction

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

The World Health Organization suggest that while the definition is numerical, emphasis should be on evidence-based practice and that the goal must be to reduce inappropriate polypharmacy.

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)

Prevalence

• 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.

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

Risks of Polypharmacy

• Multiple medications together at the same time can result in storing or taking them in wrong way, which eventually may lead to prescribing errors by clinicians. For example, the same type of medication might be prescribed twice.
• One medication may affect action of other medication which may result undesired effects.
• A medication used to treat a disease might affect another disease negatively. For example, anti-inflammatory medications may increase blood pressure and worsen kidney function.

Complications

This may result in various medication-related problems such as-

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.

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.

Inappropriate therapy, or nonadherence.

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.

Managing Polypharmacy

• 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

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.