Polypharmacy Mitigation: A Lifetime of Education.
Submitted by Rick Rickman, RN, BSN, Carlow University, Pittsburgh PA,
Polypharmacy, defined by the University of Kansas’ Landon Center on Aging as “The use of several drugs or medicines together in the treatment of disease, suggesting indiscriminate, unscientific, or excessive prescription.” is rampant in our geriatric population. According to the Centers for Disease Control and Prevention, among Americans age 60 and older, 37% use 5 prescriptions or more. With the National Institutes of Health reporting that nearly 50% of older adults take one or more medications that are not medically necessary, it is obvious that healthcare providers are dealing with an immense problem. With patient safety paramount, it becomes incumbent on providers to constantly update patient medication lists and seek ways to mitigate polypharmacy and medication redundancy. This becomes especially important with patients who are seen by multiple specialties and with patients that suffer from multiple comorbidities who present with new diseases requiring the addition of other specialties to manage their care. With multiple providers prescribing medications, the chance for redundancy and polypharmacy is increased dramatically and can create a situation for the patient where the cure can be more debilitating than the disease.
Polypharmacy creates a host of problems for the patient. He or she is at risk for increased falls, medication adherence issues, adverse medication reactions, drug-to-drug interactions, medication errors, medication redundancy, and increased hospitalizations, not to mention increased cost to the patient, facility and taxpayer. The effects of medications on the elderly and the age-related changes the body undergoes in relation to pharmacodynamics and pharmacokinetics must also be taken into account. Also, we cannot forget geriatric use of over the counter (OTC) medications that patients often fail to mention because they do not see them as “medicine”. With such an obvious problem it stands to reason that there should be an obvious solution; unfortunately research does not provide an easy answer to the prescribers’ dilemma. Evidence does not bear out polypharmacy mitigation success in geriatric patients with multiple comorbidities. According to one randomized control trial conducted by the Helsinki University Hospital, there was no significant reduction of prescribed medications among the sample population (n=174, mean age 77 years). Any reduction in the number of medications prescribed was compensated for by increasing use of OTC medications during the hospital period (2-month daycare stay) with all patients reverting back to previous prescriptions levels by month 3 post trial. The studies’ conclusion was that, while some medication reductions could be achieved under study conditions with tight controls, once the interventions ceased the medication numbers returned to earlier levels.
So where does the answer lie?
With providers taking on more complicated patients in even greater numbers, the answer can only be found in prevention. Certainly, better computer programs can and will be developed to catch medication errors and possible reduce the number of medications a patient receives, but computer programs do not know the patient as a person. A computer cannot understand not only the patients’ physical but their psychosocial. They cannot make the determination between one medication and another while taking into account the patients’ needs, wants, or ability; only a provider can do this. With the increase in patient numbers and complications, prevention becomes the key to mitigating polypharmacy. Smoking, excessive alcohol intakes, obesity (to name a few) are all linked to various disease processes and to morbidity and mortality in the elderly. If we are ever to impact these factors patients must be educated early and often. This means at every level patient’s must receive education on healthy lifestyle choices. Not a cursory 20 second blurb on the dangers of smoking, alcohol, or obesity but an in-depth conversation about their effects, short and long-term and the positive effects of healthy diet and exercise on the body. These conversations, however painful, need to take place at every level of care and at every appointment. Certainly, this would only be a part of the solution and only by a concerted societal effort, to include parental, school, and government involvement in the education of today’s youth in regards to proper diet and exercise, would we see positive changes and healthier youth today would mean healthier geriatric patients in the future and therefore less comorbidities and less medications.
As providers, we are used to treating the symptoms of disease; if we are to truly impact the lifetime health of our patients and reduce polypharmacy in the elderly, we must start by educating patients about healthy life choices when they are young and continue the education throughout their lifespan.
1. Centers for Disease Control and Prevention. (2010). Prescription Drug Use Continues to Increase. Retrieved from: http://www.cdc.gov/nchs/data/databriefs/db42.htm
2. The University of Kansas Medical Center. (2016). Polypharmacy. Retrieved from: http://classes.kumc.edu/coa/Education/AMED900/Polypharmacy.htm
3. National Institutes of Health. (2013). Clinical consequences of polypharmacy in elderly. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/24073682
4. Rollason, V., Vogt, N. (2003). Reduction of polypharmacy in the elderly. Drugs & Aging (DRUGS AGING), 2003; 20(11): 817-832. (16p)
5. Pitkala KH; Strandberg TE; Tilvis RS. (2001). Is it possible to reduced polypharmacy in the elderly? A randomized control trial. Drugs & Aging (DRUGS AGING), 2001; 18(2): 143-149. (7p)