Understanding Polypharmacy In The Elderly

As the geriatric population in the United States continues to rise, so do the incidences of polypharmacy in the elderly. The term, polypharmacy, is typically defined as the concurrent use of multiple drugs by the same patient. Polypharmacy, however, is more complex than just the number of drugs that a patient takes. Clinically, the criteria utilized for identifying polypharmacy involves taking medications that have no apparent indication, using therapeutic equivalents to treat the same illness, concurrent usage of interacting medications, and using an inappropriate dosage.

According to an article published in the January 2008 edition of Critical Care Nursing (CCNQ), a peer-reviewed journal that provides current practice-oriented information for the continuing education and improved clinical practice of critical care professionals, including nurses, physicians, and allied health care professionals, polypharmacy in the elderly is a major problem and a challenge that contributes to costs, adverse drug events, confusion, compliance issues, and errors in management. The article goes on to say that a systematic approach to drug monitoring is an important aspect of appropriate prescribing. In addition, attention to the prescribing of medications, a consistent review of medication lists, and re-evaluation of indications and outcomes of prescribing are essential to ensure that polypharmacy is minimized and safety for patients is maximized.

Each year, many people face complications due to dangerous drug interactions involving prescription, medications, and over-the-counter remedies. Elderly persons are the most likely age group to become ill from medication mistakes for a number of reasons. Older individuals typically have more than one physician. Elders may also use more than one pharmacy to have prescriptions filled and to satisfy other medicinal needs. Using multiple doctors and pharmacies are just two situations where an older person may accidentally acquire incompatible drugs. Home Care Companies, like Always Best Care, provide Caregivers for elderly persons to help them with their daily activities of living, including assistance with medication reminders. Along with family members, Caregivers can also accompany seniors with visits to the pharmacy or to their physician. This can assist in providing medical professionals with an insight to the seniors medical history or behavior and possibly reduce the risk of combining medications that work against each other. Senior Health Care Companies can also play a role in helping to reduce polypharmacy in the elderly by providing clinical enrichment to nursing professionals through Continuing Education Units (CEU) and Educational Webinars. According to Angela Graczyk, a Registered Nurse and Field Trainer with Always Best Care, seniors account for 12% of the population and over 32% of prescriptions, spending $3 billion annually prescriptions. Angela facilitates an Educational Webinar that Care Coordinators at Always Best Care use to educate the nursing professionals they work with. In the webinar, Graczyk states that the most consistent risk factor for adverse drug reaction is the number of drugs being taken and that the risk of experiencing an adverse drug reaction rises exponentially as the number of drugs taken increases.

There are several ways seniors can help to reduce the risks of complications that may arise from polypharmacy. Recommendations include using one pharmacist/pharmacy when possible as well as reducing the need to see multiple Primary Care Physicians. Seniors should implement a program called the The Annual Brown Bag. This is a program where on an annual basis, seniors place all of the medicines they are taking, including over-the counter medicines, creams, vitamins, supplements, and natural herbs, in a brown bag. They are then encouraged to take the brown bag with them on a visit to their physician to inform them of every thing they are taking to treat medical issues. This program, along with the reporting all symptoms to the physician, play a huge role in reducing the risks of complications that may arise from polypharmacy. Finally, never use medications from others.

Polypharmacy and older people29 April, 2003

VOL: 99, ISSUE: 17, PAGE NO: 54

Anne Bretherton, MSc, MRPharmS, BSc, is pharmacy and prescribing adviser, Dartford Gravesham and Swanley Primary Care Trust;

Liz Day, MA(Gerontology), PGCEA, BA, RGN, HV, DN(Cert), is elderly care nurse adviser, Dartford Gravesham and Swanley Primary Care Trust andGillian Lewis, BSc, RGN, RM, DN(Cert) is nurse practitioner/practice nurse adviser, Gravesend Medical Centre, Dartford Gravesham and Swanley Primary Care Trust

Polypharmacy is defined as the practice of prescribing four or more medications to the same person (Department of Health, 2001). This often occurs with older people who have concurrent disease processes, each needing a specific treatment regime (Box 1). Older people receive more prescriptions per head than any other group. The National Service Framework for Older People (DoH, 2001) shows that 5-17 per cent of hospital admissions are caused by adverse reactions to medicines. It also indicates that 6-17 per cent of older patients in hospital experience adverse drug reactions.

Polypharmacy is defined as the practice of prescribing four or more medications to the same person (Department of Health, 2001). This often occurs with older people who have concurrent disease processes, each needing a specific treatment regime (Box 1). Older people receive more prescriptions per head than any other group. The National Service Framework for Older People (DoH, 2001) shows that 5-17 per cent of hospital admissions are caused by adverse reactions to medicines. It also indicates that 6-17 per cent of older patients in hospital experience adverse drug reactions.

Managing multiple health problem

Some older people have multiple health problems. The prevalence of hypertension in those over 60 years is 50 per cent (Ramsey et al, 1999) and it is suggested that the number of people with diabetes will double by 2010 (DoH, 2002). Hypertension, diabetes, obesity and smoking are all risk factors for cardiovascular disease, ischaemic heart disease and stroke.

Managing multiple health problems creates a tension for prescribers between the need to treat common conditions while avoiding the risks associated with polypharmacy. These tensions are evident in the National Institute for Clinical Excellence guidance on the medical management of conditions such as hypertension, hyperlipidaemia, diabetes and cardiovascular disease. Although NICE emphasises the need for health promotion and lifestyle change for patients with these health problems, recommendations for prescribed medicines for any one patient could include: up to three different anti-hypertensives; drugs for glycaemic control; aspirin; and statins for lipid control. It is important to consider that the number of medicines could be further increased if patients have other diseases.

Problems associated with polypharmacy

The hazards of prescribing include causing secondary morbidity from unnecessary or inappropriate medicines and drug incompatibility. Problems can also occur when patients have a poor understanding of the purpose of their medicine regime and how to take their medicines.

The effects of polypharmacy

There are age-related physiological changes that alter the ways in which drugs are handled by the body. Pharmacokinetics describes what happens to a drug in the body from the point of administration, absorption, distribution, metabolism and excretion. Pharmacodynamics describes what the drug does to the body (Heath and Schofield, 1999). Pharmacokinetics and pharmacodynamics may both be altered by the ageing process.

Age-related changes that are relevant to pharmacokinetics include: - Reduced renal function; - Reduced liver function; - Reduced ratio of body fat to water; - Delayed stomach emptying. Age-related factors that are relevant to pharmacodynamics include: - Toxicity of the drugs and interactions between different drugs; - Site of action; - Side-effects; - Response of the body to the drugs. The effect of altered biophysiology may result in the older person being unable to tolerate the medications prescribed to them in the recommended doses. They may experience side-effects and the combinations of medicines taken together may cause iatrogenesis. For example, some drugs can cause confusion, increase the risk of falls or reduce salivary secretions. In addition, polypharmacy may severely affect quality of life and well-being (Box 2). It is, therefore, important that the nurse is aware of the possible side-effects of prescribed medicines and can act on this knowledge.

Why polypharmacy happensReasons for polypharmacy are complex and may include one or all of the factors listed below: - Multiple pathology; - The use of repeat prescriptions, which may result in a lack of direct patient contact between prescriber or pharmacist; - Computerised records not being updated after home visits where prescriptions are issued; - Poor communication between health care providers; - Lack of knowledge about ageing; - Use of NICE and NSF guidelines without considering the individual's needs. When a prescribing guideline is used it is important to weigh up the potential risks to the individual patient. It is essential that every effort be made to keep the number of medicines prescribed to manage chronic health problems to a minimum and that clear and simple regimes are created and are reviewed regularly. (Medicines Partnership, 2002; DoH, 2001).

Undertaking a medicines review

The NSF for older people recommends that medicines reviews are undertaken every six months when patients aged 75 years and over are prescribed more than four medicines, and annually for patients prescribed fewer than four medicines, to evaluate effectiveness and changing needs (DoH, 2001).

Reviews should include a face-to-face interview between the health professional and patient to review every medication they are taking. Room for Review (Medicines Partnership, 2002) provides helpful information on how to undertake reviews and should be essential reading for all those involved in the prescribing and administration of medicines.

The Department of Health has also recommended that by 2004 every primary care trust will have schemes in place that will enable people to obtain more help from pharmacists in using their medicines (DoH, 2000).

The role of nurses and pharmacists

There are many ways in which nurses and pharmacists can contribute to the reduction in the number of prescribed drugs including taking a lead role in the management of chronic health problems.

Practical measures include: - Supported self-administration of medications for people in hospital; - Evaluating how the patient manages to take prescribed medicines; - Being alert to unexpected interactions, and effects of medicines (Mallett and Dougherty, 2000);

- Providing written materials for patients, that complement pharmaceutical leaflets with larger print and good colour contrast between paper and print for people with poor vision;

- Verifying that the patient understands and agrees to the regime; - Advising on lifestyle changes that may reduce the need for medication and combat the side-effects of necessary medicines; - At times of illness, older people may experience temporary cognitive problems, and nurses must be acutely aware of the need to provide prompts and aids so the patient can revise, rehearse and remind themselves about their medicines. Alternatively, carers may take responsibility and will need information and advice. There is potential for polypharmacy to occur when a patient is discharged from hospital due to poor communication between primary and secondary care. When a patient is discharged from hospital, information sent to the GP, care home and community staff must clarify whether the new medicine regime replaces or is taken with any previously prescribed medications. Nurses and pharmacists can play an important part in prevention, health promotion and the management of common physical problems such as constipation, insomnia and pain relief, which can avoid the use of prescribed medicines. Conclusion

Older people can benefit from many of today's medicines, but adverse reactions and side-effects can jeopardise their health. Prescribers, pharmacists, therapists and nurses can contribute to the reduction of the need to prescribe medicines, and polypharmacy can be managed by regular medication reviews.