Nine key questions to address polypharmacy in the elderly

Elderly patients take more medications, both prescription and OTC, than any other segment of the population, and they’re at great risk for suffering the consequences of polypharmacy.

Reamer L. Bushardt, PharmD, PA-C; Kelly W. Jones, PharmD, BCPS

Reamer Bushardt is Assistant Professor, Physician Assistant Program, Medical University of South Carolina College of Health Professions, Charleston. Kelly Jones is Associate Professor of Family Medicine, McLeod Family Medicine Residency Program, McLeod Family Medicine Center, Florence, SC. The authors have indicated no relationships to disclose relating to the content of this article.

Persons aged 65 and older comprise approximately 12% of the population of the United States, yet they consume one third of all prescription medications and more than half of OTC medications.^1,2 Data from the Third National Health and Nutrition Examination Survey (NHANES III) reveal that 74% of people in this age-group confirmed recent use of prescription medication.³ For persons aged 65 to 74 years, more than half used two or more prescription drugs—and 12% used five or more prescription drugs. For those aged 75 and older, 60% used at least two prescription drugs—and 16% used at least five.

Given these facts, the PA providing care to elderly patients must understand the risks and benefits associated with medication use in older patients. A report from the US General Accounting Office (GAO) cites an annual cost of $20 billion for hospitalizations due to the inappropriate use of prescription medication.⁴ A study of adverse drug events (ADEs) in older outpatients found that more than one third had experienced ADEs. Among those with ADEs, 63% required a clinic visit, 10% were seen in an emergency department, and 11% were hospitalized.⁵ The need to improve prescribing practices for elderly patients is evident in the GAO report, which noted that nearly 18% of outpatient Medicare recipients, representing 30 million patients, consumed at least one medication considered unsuitable for elderly patients.⁴

Treating patients, not diseases

Inappropriate medication use is particularly detrimental to elderly patients—not only because they consume more medications than any other age-group, but for a variety of other reasons as well. As the incidence of multiple chronic illnesses rises in the elderly, so does the number of medications used to manage those illnesses. Moreover, as the number of medications taken grows, the incidence of ADEs increases exponentially.⁶

Another important issue to consider is the implementation of disease management programs. According to Kleinke, a leader in health information technology research and frequent commentator on the business of health care, “One of the hallmarks of managed care in the United States has been the deliberately liberalized use of pharmaceuticals, based on the uncodified but widely embraced theory of disease management . . . [I]n the short run, the typical disease management program conspires to induce prescriptions and increase pharmacy costs.”⁷ An approach to medical decision making that is both evidence-based and sensitive to an individual patient’s needs may offer a viable alternative to the disease management approach. Angell, of the New England Journal of Medicine, states that a good decision is “one that achieves the optimum improvement in health and peace of mind for the patient.”⁸ Rimer, Dean of the University of North Carolina at Chapel Hill School of Public Health, also describes the process of good decision making: “In attempting to improve our clinical decision-making ability, we focus on standard guidelines for disease management, outcomes of alternative strategies of care, and occasionally the processes by which we interpret evidence and apply it to patient care . . . [A]lthough such evidence can be drawn from experience with groups of patients, it often needs to reflect the individual circumstances of the patient sitting before us.”⁸

The elderly patient

The physiologic process of aging makes elderly patients more susceptible to adverse outcomes with medications. Elderly patients have decreased total body water, decreased lean body mass, increased body fat, decreased serum albumin levels and altered protein binding, decreased hepatic perfusion and phase I metabolism, reduced renal plasma flow, reduced glomerular filtration rate, decreased tubular secretion function, and various alterations in determinants of tissue sensitivity.² These normal consequences of aging may be confounded by others, as well as by disease processes, environment, diet, and medications.

The physiology of aging varies among individual patients, leaving some more vulnerable than others to a drug’s effects. This variability lies behind the oft-heard advice to “start low and go slow” when dosing medications in elderly patients. In addition, the number of older patients included in clinical trials for many drugs tends to be low, even though this population includes those most likely to take the drug.² Table 1 lists certain patient characteristics that have been shown to increase the risk of medication-related problems. Other factors that increase risk include atypical presentation of illness, dementia, diminished hearing or vision, use of multiple health care professionals, poor adherence to a medication regimen, and polypharmacy.^6,9,10

Polypharmacy

Most simply defined, polypharmacy is the use of multiple medications. The term polypharmacy, however, is often used to describe the inappropriate use of multiple medications rather than the rational use of concomitant drugs. Some authors have described this phenomenon as simply bottle proliferation, while others have attached descriptions like excessive number, high frequency, multiple doses, and unnecessary use of medications.^11-13 Another definition is the prescription, administration, or use of more medications than are clinically indicated in a given patient.⁶ Technically, then, use of even one unnecessary medication could be defined as polypharmacy. Recently, we have preferred the term hyperpharmacotherapy, since polypharmacy may be confused with the use of multiple pharmacies.

Regardless of the terminology and whether the medications are prescribed or purchased OTC, inappropriate polypharmacy is a major challenge for the primary care PA. This clinician is often the source of continuity of care for patients and has a tremendous opportunity to ensure that adequate medication histories are maintained, prescription and nonprescription medication regimens are assessed regularly, complementary and alternative treatments are evaluated, communications regarding prescribed treatments from specialists or other providers are reviewed, monitoring parameters regarding drug therapy are current, and communications from pharmacists are addressed.

Assessing and managing polypharmacy in the elderly patient can be an overwhelming task that, without a systematic approach, can take an unfair share of time away from other patients. We have developed an assessment system based on the various definitions of polypharmacy. It consists of nine key questions designed to evaluate medication management in the elderly patient (see Table 2). Incorporating our system into the primary care visit, together with educating the patient regarding medication use, may provide the PA with opportunities to address polypharmacy and help patients avoid medication-related problems.

The nine key questions

1. Is each medication necessary? Many pharmacologic agents were used in the past in ways no longer considered valid today. The rapid rise in evidence-based medicine supports the need for health care practitioners to seek validation of better outcomes for their patients before prescribing a given drug. For example, in the past dipyridamole was prescribed commonly as an antithrombotic and antianginal agent.^14,15 Today, oral dipyridamole generally has only two uses in clinical practice, both requiring combination with warfarin or aspirin to prevent thrombosis following valve replacement surgery or stroke. Another example is pentoxifylline, a drug approved to treat intermittent claudication but that has also been used for problems ranging from multiple sclerosis to the common cold, often with minimal or no supporting evidence. The practitioner can minimize polypharmacy by using only medications that have demonstrated their usefulness for a particular condition. Otherwise, a drug introduced for one use becomes a fix for all problems. This sometimes occurs with the SSRIs,¹¹ as well as other medications such as gabapentin and modafinil.

When the primary care PA attempts to determine if any of an elderly patient’s medications are unnecessary, criteria developed by Beers, which were recently updated, can be useful.^16,17 The criteria should be used in conjunction with clinical judgment and knowledge of an elderly patient’s specific risks and benefits from therapy.

2. Is the drug contraindicated in the elderly? Inappropriate prescription drug use in the elderly is a major cause of morbidity and mortality in the United States, and the challenge for primary care PAs may be in determining which medications are not safe for their elderly patients. Beers described certain drugs that are potentially inappropriate for the elderly.^16,17 Rather than avoiding all the medications identified by Beers, clinicians may prefer to use that list to identify drugs to use cautiously or those that require a regular risk-benefit analysis. Among NSAIDs, for instance, indomethacin is associated with the greatest risk of CNS adverse effects; these combined with its relatively high risk of GI adverse effects make indomethacin a high-risk drug in elderly patients.¹⁷ Additionally, diazepam and the other benzodiazepines with long half-lives are associated with prolonged sedation and increased risk of falls and fractures.¹⁷

3. Are there duplicate medications? Duplicate medications may contain the same active ingredient, or the patient may be taking more than one drug from the same general pharmacologic class. Another form of duplication is in therapeutic or adverse effects. A commonly encountered example is acetaminophen, which is present in a variety of prescription analgesics as well as in OTC analgesics and cold products; a patient who uses any of these products simultaneously may easily exceed the generally accepted maximum daily dosage of 4,000 mg for chronic therapy. Antihistamines are another example and may come from a variety of sources including OTC and prescription cold and cough products, a prescription appetite stimulant, or OTC sleep aids. Of particular concern for elderly patients are the CNS depressant effects associated with a large number of OTC and prescription products, including many antihistamines.

4. Is the patient taking the lowest effective dosage? Bearing in mind the principle of starting low and going slow, the PA must choose drug dosages that are sensitive to a patient’s age, health status, renal and hepatic function, comorbid conditions, and concurrent drug regimen. Since the pharmacokinetics and pharmacodynamics of many drugs are altered by normal physiologic changes of aging, instead of asking what a drug may do to an elderly patient, the clinician needs to consider what effects aging may have on a particular drug in a specific patient. Elderly patients may benefit from an initial dosage that is lower than normal and slow titration of drugs—such as anticholinergic agents, sedatives or hypnotics, hypoglycemics, and NSAIDs—that have an increased incidence of adverse effects at higher dosages. A lower but equally effective dosage of a medication may also save money.

5. Is the medication intended to treat the side effect of another medication? The more medications that are added to a treatment regimen, the greater the chance for adverse effects. If medications do not relieve the symptoms or if they aggravate them, or if the patient experiences new symptoms, the PA will have to determine which of these problems are the result of disease and which are related to medication. This form of polypharmacy is often difficult to quantify (see Table 3). When a drug is added to treat the side effects of another drug, the PA must evaluate the risk-benefit ratio of the initial drug, the discomfort for the patient, the added cost of adjunctive therapy, and any existing medications that may serve as safer, equal, or more effective alternatives to the initial drug.

6. Can I simplify a drug regimen? When medication regimens are complicated, patients may not take their medications correctly or may not take them at all. In such cases, the PA will have difficulty evaluating the relationship between a drug dosage and its effect. Determining whether a patient is being exposed to greater toxicity or experiencing a lack of therapeutic effect will also be problematic.

One drug often associated with a complicated regimen is warfarin, which may be prescribed in multiple dosages that may differ depending on the day of week. Often it may be possible to simplify a warfarin regimen while maintaining a desired prothrombin time or international normalized ratio. Frequent changes in a drug regimen may also cause complications that adversely affect adherence. When PAs prescribe warfarin for patients with nonvalvular atrial fibrillation, they must also assess these patients for risk of bleeding until safer and more practical alternatives become available.¹⁸  

7. Are there potential drug interactions? When prescribing multiple medications, the PA must regularly evaluate the regimen for potentially significant drug interactions. Medications may interact with other prescription or OTC drugs, foods, diseases, and with natural or herbal products. Genetic predisposition and concomitant use of alcohol or tobacco products may also initiate a drug interaction. A review of the medication regimen allows the PA to assess the effect it is having on the patient and place a value on a drug interaction.

Much of the primary data on drug-drug interactions is based on in vitro testing and rarely takes into account the effects of more than two interacting agents, so the PA may have difficulty gaining a clear understanding of the clinical impact of drug-drug interactions until newer modalities for testing and evaluating them become available. Table 4 lists drugs and one substance that may put a patient at high risk for drug-drug interactions, based on a systematic review of drug interaction compendia and expert opinion-based reports. The list is by no means exhaustive and can be amended as the PA sees fit. A patient’s pharmacist may be a useful resource for the PA and patient with respect to identifying potentially significant drug interactions and, when necessary, suggesting alternative treatments to minimize the risk of interactions.

To fully evaluate a medication regimen for interactions, the PA must ask patients about more than just prescription drug use. Questions should cover usual diet, use of alcohol or tobacco products, and use of any OTC products including medications, vitamins and minerals, and natural or herbal products. For example, interactions may occur in a patient taking a natural remedy like St. John’s wort together with a prescription antidepressant such as paroxetine, or in a patient who regularly drinks grapefruit juice and uses felodipine for hypertension, or in a patient who uses both warfarin and amiodarone for atrial fibrillation.

8. Is the patient adherent? Continuing to prescribe medication for a patient who is not taking it appropriately is another form of polypharmacy. This is a practice that highlights the concept of nonadherence.¹⁹ A patient may not adhere to a medication regimen for several reasons, including an inability to afford a medication, a previously unreported adverse effect, a fear of a medication heightened by reports in the media, or dementia or a drug-associated alteration in mental status. The PA will find it use-ful to determine the underlying cause of nonadherence. Studies have shown that a careful explanation of the purpose of a medication increases patients’ rates of adherence.²⁰

9. Is the patient taking an OTC medication, an herbal product, or another person’s medication? A key step in identifying and managing inappropriate polypharmacy is the ability of the PA to gain an accurate and comprehensive drug history from the patient. Unfortunately, patients may not voluntarily offer the names of the OTC medications, vitamins or minerals, natural or herbal products, or other persons’ medications that they consume. Kroenke attests that “polypharmacy exaggerates amnesia.”¹¹ In a recent study evaluating polypharmacy, one out of five medications reported by a social worker from an in-home interview was not reported during a routine office visit with the health care practitioner.²¹ Obtaining a thorough medication history will enable the PA to better evaluate and manage inappropriate polypharmacy.

Conclusion

Polypharmacy is a widespread problem, and prescribers, pharmacists, and patients are all responsible. Patients may contribute to the problem by self-medicating, failing to follow prescribed directions, failing to report all medications or OTC products used, and borrowing or trading medication with other persons. Some patients may even be opposed to the discontinuation of certain medications and may require additional counseling, even when a drug is clearly unnecessary or the symptoms for which it was prescribed have long since disappeared. We have prepared an educational handout for patients that offers helpful tips to reduce inappropriate polypharmacy (see below).

PAs can use the nine polypharmacy assessment questions to evaluate patients and their medication regimens and then make changes as appropriate. When discontinuing chronic or long-standing medication, the PA should taper the dosage and should not discontinue too many medications at one time.¹¹ It is important to remember that the consequences of inappropriate polypharmacy can be particularly significant to an elderly patient’s well-being, financial security, and ability to adhere to prescribed therapy.  

Please also see "The safe use of medications: A handout for patients."

REFERENCES

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