Care of the older person
Polypharmacy from a pharmacist’s perspective
Polypharmacy is the prescribing of too many unnecessary or inappropriate medicines. Polypharmacy is not exclusive to older people, however because of aging and “wear and tear” on organs, the risk of polypharmacy increases as with age. There is no specific definition of polypharmacy but in general terms, polypharmacy is defined as the use of multiple drugs that is more than is medically necessary. There is no “standard cut of point” with regard numbers of medication prescribed to indicate polypharmacy. Medication has greatly improved our life expectancy and quality of life; however, the increase in use of numerous medications has many possible negative health consequences including side effects, drug-interactions, non-adherence to medications, decreased functional and mental status and high costs, all off which put increased strain on a health service that tends to operate on the verge of breaking point. In Ireland, polypharmacy accounts for over half of the annual costs of prescribing to the entire population aged over 50 years. The pharmacist has an important role in advising and reviewing prescribing and determining potentially inappropriate prescribing (i.e.) use of a medicine in which harms outweigh the benefits. The role out of a structured Medicine Use Review (MUR) system for pharmacists in Ireland the next few years should be welcomed and will be an important step in reducing inappropriate prescribing.
An Irish perspective.
A 2012 Trinity College Dublin based study called “Polypharmacy in adults over 50 in Ireland: Opportunities for cost saving and improved healthcare” showed that among Irish people aged over 50, 69% report taking medications regularly. The average number of medications taken regularly in the over 50s is 2, in the over 65s is 3 and in the over 75s is 4. Polypharmacy is more likely in patients who are older, have attained a lower educational level, have greater number of conditions, and have medical card eligibility. Although one in three people aged over 65 report polypharmacy, they are responsible for more than half of hospital outpatient and inpatient visits in this age group.
Residential care settings
My experience as a pharmacist who deals with patients in residential care settings is that regular pharmacist mediation reviews (at least every six months) with nurses and GPs results in significant reduction in unnecessary medication and more targeted prescribing. The advent of more specific guidelines from the Health, Information and Quality Authority (HIQA) and the Pharmaceutical Society of Ireland (PSI) on the role of the pharmacist in the review of medications for patients in residential care settings has helped in this area as it gives specific and clear guidance on what the role of the pharmacist should be.
Increased risk of adverse drug reactions
A 11-year study published in 2011 indicated that patients taking 5 or more medications had an 88% increased risk of experiencing a side effect compared to those who were prescribed less medications. In nursing home residents, the number of side effects are twice as high in patients taking 9 or more medications compared to those taking less.
Risk of Drug interactions
A 2013 study of older hospitalised adults taking 5 or more medications indicated drug-drug interaction was as much as 80%. The probability of a drug-drug interaction increased with the number of medications prescribed. To be more specific, a patient prescribed 5-9 medications had a 50% probability of drug-drug interactions whereas this probability increased to 100% for patients taking 20 or more medications.
Non-compliance is means not taking medications as directed and is associated with complicated medication regimens and polypharmacy. This is an area where the pharmacist has an important role; non-compliance can be significantly reduced where there is pharmacist counselling (including full explanation of what each medication is for), regular medication reviews and the use of compliance aids such as blister packing of medications. Non-compliance with medication regimes risks potential disease progression, treatment failure, hospitalisation and more potential for side effects.
Polypharmacy can cause functional decline in older patients. One study indicated increased prescription medication diminished patients’ ability to perform instrumental activities of daily living (IADLs) and decreased physical functioning. IADLs refers to everyday activities like getting in and out of bed, in and out of chairs, feeding, personal hygiene etc.
A study of 294 older people showed 22% of those taking 5 or less medications had impaired cognition as opposed to 33% of patients taking 6-9 medications and 54% in patients taking 10 or more medications. This is a double edge sword as while polypharmacy increases the risk of cognitive impairment, medication is often prescribed to counteract or slow down cognitive impairment (e.g. dementia, stroke) which increases number of medications prescribed.
As the number of medications increased, the falls risk increases. The use of 4 or more medications seems to be especially associated with increased risk of falling and the risk of recurrent fall. A study of older adults in residential care settings indicated the risk of experiencing a fall within the previous 30 days was by 7% for each additional medication.
Polypharmacy can affect patients’ nutritional status. A three-year study found that 50% of those taking 10 or more medications showed signs of malnourishment. Polypharmacy in older patients is associated with reduced intake of fibre, fat-soluble and B vitamins, and minerals as well as increased intake of cholesterol, glucose, and sodium. Almost half of women and a third of men reporting polypharmacy in Ireland take food supplements regularly such as calcium (with or without vitamin D), Omega-3’s and Glucosamine.
Frequent review of the person’s medication is essential to prevent unnecessary prescriptions and the harm this can cause. The pharmacist has an important role in reducing risks in reducing over-prescribing, especially in older patients who can be more susceptible to adverse effects.
References available upon request
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