Tuesday, 17 Sep 2019

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Polypharmacy Puts Elderly at Risk

Managing the elderly patient is a challenge, often ascribed to greater comorbidities, toxicities, suboptimal treatments or responses and worst of all – polypharmacy.

The elderly are at greater risk for comorbidities, drug interactions, drug reactions and adverse events, and poorly predictive serologic and laboratory abnormalities. Although the elderly do not often receive the best or optimal therapies, they are highly prone to polypharmacy.  This problem is growing as our population ages. It is estimated that by 2030 there will be 72 million Americans over the age of 65.

Polypharmacy is defined as the use of four or more medications by a patient, generally applied to adults aged over 65 years. Studies show patients over age 65 years may take 14-18 different medications each year. The average rheumatoid arthritis patients takes 5.4 drugs, with less than half of these related to RA.  In this same study, polypharmacy had no relationship to disease activity as measured by DAS28 scores (see http://t.co/CPwdNr2xpD).

Avoiding polypharmacy is paramount in all, but is frightening and preventable in the elderly. A drug should only be prescribed when it’s needed, indicated, available, affordable, effective, safe and understood by the patient.  I’m often amazed how frequently patients do not know why a particular drug is taken. This seems to accompany polypharmacy. Surveys show only 65% of patients admitted to receiving understandable education on what their prescribed medicine was for and what possible side effects they might expect. Education becomes increasingly difficult when polypharmacy is in play. Mistakes are inevitable and safety risks are compounded daily. 

The 10 Drug Rule.  A red flag should be launched when a patient's medications amount to ten or more. Admittedly, there is no evidence that 10 or more meds is the dividing line between safe and unsafe. Rather, it seems to be a universally agreed upon number, for both patients and physicians, that is either worrisome and just too much.  Patients receiving 10 or more meds should be counseled on these problems and solutions to polypharmacy: 

  1. Less is Safer than More. More is not better, it is rather WORSE – especially when it comes to medications.
  2. Safety. Patients need to know the prime hazard of polypharmacy is diminishing safety. The safest drug is the one not prescribed or taken. When possible, drugs, vitamins and nutraceutical should be slowly withdrawn unless they are crucial or necessary, proven to be effective and rigidly adhered to. If the patient is <50% compliant with their statin, then do they really need the statin?
  3. Non-Essential Pills. Drug inventory must be discussed by the doctor or pharmacist with the patient and care-giver or family member(s). The goal is to identify drugs that may potentially be removed for being nonessential.
  4. One Doctor-One Drug. The only person who can/should stop a drug is the physician/office that prescribed and refills that drug. Not all doctors are equal in their ability to judge the necessity of all drugs taken by the patient. Moreover, very few doctors conference about complex drug management for individual patients. Thus if Dr. AA wants to stop a drug prescribed by Dr. BB then Dr. AA and Dr. BB need to talk by phone.
  5. No More Additions; Only Drug Exchanges.  Patients must be taught to recite the “Add a drug- Discontinue a drug rule”.  When a doctor wishes to add one new drug, he/she must remove two drugs from the medication list. These additions and deletions should preferably be from the that doctor's domain – cardiologists should not be stopping arthritis drugs unless sure harm is in evidence.
  6. Over-the-Counter. OTC meds, vitamins and nutraceuticals must be declared, discussed and added to the Medication List.
  7. Medication List. All patients must have a medication list that conforms to the instructions on the drug label or doctor instructions. Polypharmacy patients must bring the med list and ALL medication bottles to EVERY doctor visit. Doctors and patients need to review all pills with the goal of confirming the need and utility of every drug.
  8. Purpose. Patients must know the purpose for each drug and what side effects can be expected.
  9. Be Organized. Must use a pill organizer designed to deal with the complexity of their current multidrug regimen.
  10. Avoid Duplicate Drugs. Duplicate drugs with same intended effect can be avoided in some patients either with a better drug choice or change in dose or administration.
Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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