Polypharmacy in the Elderly: Risks, Benefits, Management Strategies

Overview

Polypharmacy is the consumption of multiple medicines, in order to manage one or more ailments. This situation can occur at any age, but it is more common in the elderly due to age-related decline in overall health. Polypharmacy comes with its own risks, so over time, the medical fraternity has come up with several guidelines on effective management and prevention of Polypharmacy.

What is Polypharmacy?

Age-related decline in the health of elders is a common matter today. Many elders need to take multiple medication, for one or more ailments such as heart disease, diabetes, hypertension, etc. This can cause secondary health-risks due to the side-effects of multiple drugs. Polypharmacy is an umbrella term used to describe this situation.

Aging changes the way a person reacts to one or more drugs. With aging,

• Water-levels in the body decrease: This leads to concentration of water-soluble drugs in the body
• Fat-levels in the body increase: The half-life of fat-soluble drugs increases. The half-life refers to the time taken by medications to reduce in concentration in the body. Although medication (drugs) is given to treat a condition, the liver still does its job of breaking down such molecules, which the kidneys then eliminate through the urine.
• Changes to the blood flow to liver, and the liver size changes the way some drugs are metabolized.
• Changes to kidney size, blood-flow to kidneys and reduction in glomerular filtration rate (GFR, or the kidney function) all reduce with time.

The sum total of all these developments is that there are various risks from Polypharmacy, as described below. Not to mention – increased healthcare costs.

Risks from Polypharmacy

Adverse Drug Reactions: Compared to younger patients, elders who are taking some medication for a long time, and in higher doses, are vulnerable to adverse reactions which often require hospitalization. Such classes of drugs include hypoglycaemic agents, anticoagulants, anticonvulsants, NSAIDs, antibiotics, cardiovascular medications, benzodiazepines and diuretics.

Drug-Drug Interactions: Drugs do interact with each other which in turn causes complications over time. For example, if an elder has to consume 5 to 9 different drugs, there is a 50% probability that these drugs may interact with each other. And if he/she is consuming 20 or more medications, the probability of such interactions increases to 100%. This phenomenon is not restricted to allopathic drugs only, but also to herbal extracts and vitamin supplements.

Medication Noncompliance: As the number of drugs an elder has to take increases, his/her ability to comply with the dosage, and frequency also suffers. This is because of incidental issues like forgetfulness (of the schedule, or misplacing the prescription), reduced vision which causes a mix-up in the dosage or drugs taken, and poor dexterity in the finger which makes it difficult to break pills into half, or causes dropping of and hence losing some pills. Further, the elder may dislike the symptoms of the medication and avoid taking them. In low-income families, the elder may even skip a few doses in order to reduce the overall cost of medication.

Multiple Geriatric Syndromes: So, what are the adverse reactions of such drugs or drug interactions? While this is unique to the patient or medications involved, most often, it includes:

• Cognitive impairment: Patients taking 5 or more drugs have reduced cognitive skills, and in rare cases suffer from dementia and delirium.
• Falls: Weakened bones, weakened muscles and poor balance are inevitable in old age and can cause falls. However, polypharmacy adds an additional layer of risk, thereby increasing the risk of falls and fractures in elders.
• Urinary incontinence: Not all elders suffer from urinary incontinence. However, for those suffering from it, polypharmacy worsens the condition, while those who do not have the condition may also develop it.
• Malnutrition: The reduced ability of the body to absorb vitamins and minerals from food is inevitable in old age. However, polypharmacy worsens the condition as some drugs may interfere with the body’s ability to absorb nutrients. Further, elders may even develop a distaste for healthy food due to various medicines, and seek out junk food that is high in added sugar, added salt and cholesterol. This increases malnutrition.

Why or how does Polypharmacy happen?

But if all these are well-known, then how can Polypharmacy be such a common problem? There are various incidental reasons for this, none of which may be deliberate.

Disease States

The guidelines for treating chronic or serious ailments involves the use of multiple medications in order to maintain health parameters in the patient. For example, a patient diagnosed with myocardial infarction (heart attack) will require 4 different classes of drugs such as beta blocker, ACE inhibitor, statins and antiplatelets. Anaesthesia (IV or general) includes hypnotics, opioid analgesics, halogenated ether anaesthetic and a paralytic. Pain-killers and pain-management therapies involve multiple classes of drugs. Patients diagnosed with COPD will require oral steroids along with 3 different types of drugs. In all these cases, Polypharmacy is inevitable, else, the condition may become fatal.

Multiple Providers

Treatment and disease management is complex today and involves multiple types of healthcare providers such as doctors, specialists, nurse practitioners and hospitalists, who are responsible for the timely recovery of the patient. Sometimes, the larger picture is missed and multiple drugs come into the fray.

Inappropriate Use of Prescribing Software

The use of electronic medical records today comes with prescription softwares. These carry dosage information, drug-interaction warnings and overload alerts. This will require time to be spent on studying all this. In real-life and real-world emergencies, some of these warnings may be ignored or missed.

Pharmacist Interventions

Pharmacists may sometimes recommend alternatives due to lack of availability. This can lead to adverse drug reactions. Overworked pharmacists manning a busy pharmacy may not notice the drug combination and its consequences and approve the prescription. Or he/she may be under orders to follow the same.

Pharmacology

Duplication of drugs from the same pharmacological class can be dangerous. For example, taking an herbal and allopathic drug for the same ailment may lead to drug-herbal interactions. So also, taking 2 different allopathic drugs from different manufacturers for the same ailment may not be advisable as one of them may interact with other medicines being taken for other conditions.

Preventing and Managing Polypharmacy

Over time, various medical and healthcare regulation-bodies and the medical fraternity around the world has come up with various guidelines to prevent polypharmacy and/or manage it better, which apply to doctors and healthcare providers. This includes

• Identifying of indications for every drug
• Deprescribing (discontinuation, dosage reduction) of drugs based on drug-reaction data
• The use of tools such as START (Screening Tool to Alert Doctors to Right Treatment); STOPP (Screening Tool of Older People’s Potential Inappropriate Prescriptions) and The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, help provide guidelines while prescribing medicines, in order to reduce adverse drug and drug-drug reactions.

Further, doctors and healthcare providers today have clear guidelines about conducting drug reconciliations while moving the elder from the care-centre to home, striking out duplicate medicines, reviewing dosages or frequency, and assessing adverse-drug or drug-drug interactions for every medicine before prescribing it.

So also, for patients, there are guidelines which help them manage their medication better and reduce the need for Polypharmacy.

Information: The doctors must share the below information with the elder:

• A proper list of all medicines (both generic and brand names), their dosages in mg, dosing frequency per day or per week, and clear reason for taking that drug.
• A complete list of doctors and specialists whom they can reach out to in case of any emergency, along with their contact information.
• Name and telephone number of pharmacies in the patient’s vicinity.

Instruction: The doctors must educate the elder about:

• Each of the medicines prescribed, covering name and purpose for taking that
• Possible adverse effects of that drug, or how it may interact with another medicine
• The need to ask questions or discuss concerns with the doctor, and not generalize everything as an age-related problem
• Possible emergencies that can come up because of a particular drug, so that the elder and his/her caregivers are prepared
• How important it is to take medicines as per prescribed dosage and frequency
• The importance of not taking additional drugs than what is prescribed. This includes herbal extracts and vitamin supplements. The doctor will recommend them, if required.

Organization: The elder must be cautioned to:

• Not share medicines with others or recommend medicines to fellow elders without a doctor’s prescription
• Store medicines in a clean, dry and shaded (away from sunlight) box or cupboard
• Refrigerate medicines if told to do so. Keeping them in the open may dilute its affect or even alter its function
• Dispose or throw out old medicines in a responsible manner
• To set reminders for taking medicines. These could be electronic or memorized association of a particular task with a medication schedule.

Benefits of effective Management to the patient

• Reduced need for polypharmacy
• Better health safety
• Fewer hospitalizations
• Reduced overall cost of treatment

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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