Polypharmacy refers to problems arising when patients regularly take unnecessary or excessive prescription or non-prescription medications. In the United States, this is a common problem for seniors, who comprise over 13 percent of the population and consume about 30 percent of all prescription medications.¹

Research shows that more than 75 percent of adverse drug reactions resulting in hospitalization are caused by medications patients knowingly take and are frequently due to inadequate monitoring, inappropriate prescribing, lack of patient education or compliance, and lack of communication between various providers.¹ Studies suggest that the potential for an adverse reaction approaches 100 percent when more than eight medications are prescribed.²

FALL RISK

A serious consequence of polypharmacy in the elderly is an increased risk for falls. Every year, nearly one-third of people over 65 living in the community suffer a fall, and the rate in nursing homes is even higher.³ Many of these falls result in fractures, the most common of which involve the hip. Even with surgical intervention, these patients seldom fully recover. After suffering a hip fracture in a nursing home, one-third of patients never walk again and nearly half die in the subsequent year.

Drugs increase the risk of falling through sedative effects, balance impairment, delayed reaction times, unintentional lowering of blood pressure, drug-induced Parkinsonian symptoms and a variety of other mechanisms.

Several drug classes have a particularly strong association with impaired mobility and falls, including antidepressants, antipsychotics, antihypertensives, anxiolytics, sedative/hypnotics and benzodiazepines. Large surveys have consistently reported a two-fold increase in risk of falls and hip fractures in elderly persons given hypnotics, especially benzodiazepines.⁴

Managing polypharmacy and preventing drug-related falls have become vital concerns for long term care facilities, especially as patients tend to accumulate long lists of medications. This is most pronounced when they return to the nursing home following hospitalizations or visits to specialists. They usually arrive with more medications--not fewer--with the concomitant increase in related adverse risks, such as confusion, falls, incontinence, gastritis, diarrhea, constipation, urinary retention, metabolic abnormalities, malaise and a wide array of other problems. Many of these untoward effects are often addressed by adding even more medications to the patient's drug regimen.

For geriatricians working with residents in skilled nursing facilities, sorting through long lists of new medications accompanying returning patients is vexing, especially as provider-to-provider communication and documentation sent back with patients are often limited.

Care providers must determine if the new medications will actually provide a meaningful clinical benefit and, if so, for how long and at what cost financially and in terms of increased risk for drug-drug interactions or adverse effects.

SENIOR CHALLENGES

Polypharmacy results from a variety of factors:

• Many drugs are never studied in seniors, but they're routinely used based on studies done on younger, mostly male patients.
  
  
• Some diagnoses trigger treatment with the same medication(s) every time without specific evidence that the drug is necessary, and often without follow-up to ascertain its effectiveness (e.g., iron, B12 and folate for every patient with anemia). The lack of targeted follow-up or discontinuation date means these medications that may never have been indicated are continued for months or years.
  
  
• The average LTC patient is admitted on a long list of drugs and has others started over time, but an appraisal of their continued clinical value is commonly overlooked for months or years or is never done.
  
  
• Antibiotics are used even for obvious viral respiratory infections or cloudy, smelly urine. Though this seems innocuous, one should not overlook the adverse interactions with other drugs, growing antibiotic resistance, hypersensitivity, diarrhea and other potential problems that accompany their misuse.
  
  
• Alternative or homeopathic medications are casually added by family, recommended by friends or medical staff and are commonly overlooked by providers despite the potential to cause serious problems, especially in patients taking other medications with which they may react.
  
  
• Marginally useful medications can lead to a cascade of prescriptions. For example, an NSAID is started for mild arthritis. Later, edema is noted, so the doctor adds a diuretic with potassium. The resulting "drug stew" is caustic to the gastric lining, so a PPI is added, but not before the gastritis-induced blood loss leads to a drop in the hematocrit, so iron is added. A stool softener and laxative are prescribed for constipation, and the cocktail is topped off with an antidepressant. This previously healthy senior is now taking seven to 12 pills daily.
  

HEIGHTENED ADVERSE EFFECTS

Several factors increase the adverse effects of unnecessary medications. These include:

Inappropriate dosing. A poor grasp of pharmacokinetics often leads to drugs being dosed at inappropriate intervals, both too frequently (e.g., drugs with long half-lives being given multiple times daily) or not often enough (e.g., short-acting drugs given once daily). Separately, dosages appropriate for younger individuals may be entirely too high for seniors.

Lack of appreciation of adverse effects. Drugs serving a useful purpose acutely can cause serious problems if continued chronically. Anxiolytics and sedative/hypnotics might ease work burdens for a hospital staff, but may cause serious problems when used chronically.

Bad timing. Some medications should be given on an empty stomach while others are better with food. Many medications interfere with each other, nullifying or enhancing effects. Without careful attention to the entire regimen, including PRNs and dosing times, it's easy to make mistakes than cause problems or inhibit desired outcomes.

Educational lapses. As reimbursement and access to good educational opportunities both decrease, many physicians sacrifice continuing medical education to increase their patient volume or free time. Knowledge gaps eventually emerge that interfere with good clinical decision-making.

AVOIDING PROBLEMS

With all of the problems described, how can good physicians avoid unnecessary drugs? They can rely on common sense, and educate their patients to get them involved in informed decision making. For each new drug, estimate the chances that it really will lead to a better outcome.

Here are some additional tips. 

Use the evidence pertinent to your patient population. Don't routinely use drugs without proven clinical efficacy in seniors or those that have been shown to be either ineffective or contraindicated. Consult the Beers' List. (The most recently published version was in the Archives of Internal Medicine, Vol 163, Dec 2003.)

Include patients' wishes in decision-making. When educated about potential risks and benefits, most patients and families make good decisions about how aggressively they want clinical issues treated. This requires investing sometimes lengthy, non-reimbursed time on the provider's part upfront, but the rewards are measured in fewer surprises, and outcomes more in line with patients' wishes. Most patients will opt for fewer drugs as long as pain, discomfort and dignity are addressed.

Understand the regulatory environment. Though physicians are seldom held accountable for facility survey deficiencies, the regulations are well intended and were put in place to protect patients while improving patient care.

Define target goals. Decide in advance how to measure the effectiveness of a drug.  When the target it reached, it may signify resolution of the problem and you may be able to discontinue the drug. If the target can't be reached, stop the medication.

Use a team approach. Carefully consider recommendations from an interdisciplinary team of midlevel practitioners, pharmacists, medical directors, facility nurses, therapists, social workers and others. Their input can help detect duplicate medications, potential drug-drug interactions and drugs that are just not necessary in a particular person's regimen.

Consider costs and adverse effects. If the patient were a family member, would you have them take all of the drugs prescribed? Would you pay extra attention to potential risks such as falls resulting from polypharmacy or drug interactions? Would you want to pay for all of them?

Discontinued medications can usually be restarted without harm if they were still needed.  Most epilepsy medications can be safely stopped in those who haven't seized for years, and many diuretics have little or no effect on edema. If patients and families are advised in advance that the drug can be safely restarted in the unusual case where it really was necessary, few will object.  

Communicate. Take the time to contact consulting physicians to discuss patients both before you send them and when they return. Both parties will make fewer mistakes and save time and expense in the long run.

Continue your education. Schedule time to read journals or regularly attend conferences to keep current on topics that will improve your ability to care for seniors.

References

1.  Terrie YC. Understanding and managing polypharmacy in the elderly. Pharmacy Times Dec 2004;volume(number):84-87.

2.  Montamat SC, Cusack B. Overcoming problems with polypharmacy and drug misuse in the elderly. Clin Geriatr Med 1992;8 (1):143-59.

3.  Cumming RG. Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging 1998;12(1):43-53.

4.  Allain H, Bentue-Ferrer, Polard E, Akwa Y, Patat A. Postural instability and hip fractures associated with use of hypnotics in the elderly: a comparative review. Drugs Aging 2005;22(9):749-65, 

Dr. Gregory Gahm is senior medical director for Evercare of Colorado.  Evercare is a United Health Group company that serves the frail elderly, chronically ill, and disabled.