An Introduction to Polypharmacy
Every day, patients clutch plastic bags filled with prescription bottles while they patiently sit in their practitioner’s waiting room until their name is called. (8) This scenario is becoming increasingly common among seniors. In fact, the Centers for Disease Control and Prevention report that one in five people between the ages of 40 and 79 take five or more prescription drugs every day. (7)
Polypharmacy is nearly universal in those over age 80, especially among people living in assisted living, memory care, or nursing homes. (12) One study by the Society for Post-Acute and Long-Term Care Medicine reported that up to 91% of patients in long-term care facilities take at least five medications daily. (9) While some of these medications may be needed to treat specific health problems, nearly half of older people take one or more medications that aren’t medically necessary. (27)(14)
What is polypharmacy?
It’s generally defined as taking five or more medications for multiple health conditions. (15) And, as noted above, it’s extremely common in older patients. Oftentimes, these patients suffer from complicated health problems like cardiovascular disease that need to be addressed on several fronts. Other times, a patient may be suffering from several different conditions requiring targeted treatment. But that’s not always the case. Some health care practitioners strictly go “by the book,” prescribing multiple medications to meet disease-specific quality metrics instead of considering the individual patient as a whole, including the medications they may already be taking. (8)(18)
This becomes problematic and potentially dangerous when the reason for the medication is unclear. Other problems with multiple medications include those taken to treat the side effects of other drugs, complicated medication dosing and timing, and when medications interact with each other or with over-the-counter drugs or dietary supplements. (6)
The most frequently prescribed medications in patients include:
- Pain relievers, including opioids
- Proton pump inhibitors or H2 blockers
- Statin drugs (14)(21)(19)
Did you know? Hyperpolypharmacy is the term used to describe patients who take 10 or more drugs daily for more than 90 days. (15)
Although many medications are thoughtfully prescribed after taking into account the patient’s overall health and current medication use, overprescribing prescription and over-the-counter drugs can result in adverse outcomes, especially among elderly patients. (20) Factors that can lead to negative consequences include:
- 1. Automated refills
Automatically refilling prescriptions, especially those used for chronic conditions, may delay deprescribing because of unclear communication between the practitioner and the patient on why removing a medication may be in the patient’s best interest. (8)
- 2. Drug-drug interactions
Increasing the use of multiple medications has been linked to a greater risk of adverse reactions or drug-drug interactions. (25) The most common medications implicated in drug-drug interactions include aspirin, antacids, beta-blockers, HMG-CoA reductase inhibitors (statins), calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, ondansetron, and H2 blockers. (10)
- 3. Financial burden on patient
Not only does polypharmacy increase the risk of adverse reactions and drug-drug interactions, it also increases the health care cost to patients. Deprescribing unnecessary medications can result in a significant decrease in medication-related costs. (11)
- 4. Patient compliance
Complex dosing instructions for multiple medications, side effects, drug-drug interactions, and high drug costs can lead to decreased patient compliance, especially among elderly patients. (22) What’s more, according to the World Health Organization, the need to take more than one dose of a drug daily results in a 10% decline in medication adherence with each dose that’s required. (2)
- 5. Poor medical record keeping
Poor record keeping can lead to unnecessary drug use if discontinued medications are not removed from the patient’s medical record, especially if these medications are automatically refilled. (8)
- 6. Sub-specialist prescribing
Primary care providers and specialists like pulmonologists, cardiologists or endocrinologists don’t always share information with each other about a patient’s health history or medication use. (17) What’s more, a study that appeared in BMJ Open noted that specialists may only look for and treat problems related to their specialty rather than viewing the patient as a whole. This approach can lead to prescribing redundant medications or drugs that are contraindicated. (16)
Did you know? Half of all patients with chronic conditions don’t take their medication as prescribed. (22)
Although people with complex medical conditions or two or more chronic conditions may require multiple medications, this can increase the risk of a host of adverse consequences, including:
- Adverse drug reactions (14)
- Anxiety or excitability (5)
- Cognitive impairment (14)(26)
- Constipation (5)
- Decreased quality of life (23)
- Depression (5)
- Diarrhea (5)
- Dizziness (5)
- Dry mouth (5)
- Fatigue (22)
- Higher fall risk (14)
- Increased functional and mobility issues (14)
- Insomnia (5)
- Loss of appetite (5)
- Malnourishment (14)
- More frequent hospital stays (13)(19)(4)
- Readmission to hospital shortly after being discharged (19)
- Tremors (5)
- Urinary incontinence (14)
- Weakness (5)
Deprescribing unnecessary prescriptions
How can healthcare providers and their patients ensure that medications are necessary, up-to-date, and don’t result in adverse effects? There are several tools that can help identify potentially unnecessary or inappropriate medication use. These include the Beers List, which is a criteria list of potentially inappropriate medications by drug class and disease state. (8)(1) The Screening Tool of Older People’s Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) are two additional tools that are used together to identify medication that may be inappropriate and provides alternative medications that may be started to safely treat a specific health condition. (8) Another tool that provides guidance specific to nursing home patients is the Multidisciplinary Multistep Medication Review (3MR), which assesses the patient’s perspective, medical history, and current medications. The review also involves both the health care provider and the pharmacist. (28)
If inappropriate medications are being used, deprescribing—the tapering off or stopping drugs in an effort to minimize polypharmacy—may reduce the burden of adverse effects on the patient. (24) Steps include:
- Finding out all of the medications a patient is taking—including over-the-counter drugs and dietary supplements—and why.
- Evaluating the overall risk of harm from the medications being taken.
- Assessing each medication and determining if they are truly needed.
- Prioritizing medications for discontinuation.
- Implementing and monitoring a plan for discontinuing medications which includes all health care providers, the pharmacist, and the patient or caregiver. (24)(28)
Did you know? Medication use has more than doubled since 1990. (3)
The bottom line
Polypharmacy—the use of five or more medications—is prevalent among older adults and increases the risk of adverse medical outcomes. In the spirit of “first do no harm,” health care providers should routinely review medication use and reduce or eliminate unnecessary prescriptions to mitigate side effects and interactions while improving the patient’s overall health and quality of life.
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- Brown M.T. & Bussell, J.K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings, 86(4), 304-314.
- Bushardt, R.L., Massey, E.B., Simpson, T.W., Ariail, J.C., & Simpson, K.N. (2008). Polypharmacy: misleading, but manageable. Clinical Interventions in Aging, 3(2), 383-389.
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- Hales, C.M., Servais, J., Martin, C.B., & Kohen, D. (2019). Prescription drug use among adults aged 60-79 in the United States and Canada. NCHS Data Brief No. 347. https://www.cdc.gov/nchs/products/databriefs/db347.htm
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- Jokanovic, N., Tan, E.C.K,. Dooley, M.J., Kirkpatrick, C.M., & Bell, J.S. (2015). Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. Journal of the American Medical Directors Association, 16(6), 525 e1-12.
- Khandeparkar, A. & Rataboli, P.V. (2017). A study of harmful drug-drug interactions due to polypharmacy in hospitalized patients in Goa Medical College. Perspectives in Clinical Research, 8(4), 180-186.
- Kojima, G., Bell, C., Tamura, B., & Inaba, M. (2012). Reducing cost by reducing polypharmacy: the Polypharmacy Outcome Project. Journal of the American Medical Directors Association, 13(9), 818.e11-15.
- Lai, X., Zhu, H., Huo, X., & Li, Z. (2018). Polypharmacy in the oldest old (>80 years of age) patients in China: a cross-sectional study. BMC Geriatrics, 18, 64.
- Lalic, S., Sluggett, J.K., Ilomäki, J., Robson, L., Emery, T., & Bell, J.S. (2016). Polypharmacy and medication regimen complexity as risk factors for hospitalization among residents of long-term care facilities: a prospective cohort study. Journal of the American Medical Directors Association, 17(11), 1067.
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