Polypharmacy: Strategies for Reducing the Consequences of Multiple Medications
Conducting medication reconciliations at care transition, eliminating duplicate medications, assessing for drug-drug interactions, and reviewing dosages can reduce the incidence of polypharmacy, ensure patient safety, reduce hospitalizations, and decrease associated costs.
We've all heard or read about polypharmacy, the practice of one patient using multiple medications, over-the-counter (OTC) drugs, and supplements to treat several diagnoses and comorbidities. Prescribed drugs may be duplicative, counteracting, and implicated in a cascade leading to additional drugs ordered to treat side effects. Even when used with caution and according to directions, prescribed drugs all have the potential for interactions, adverse drug events, and more severe consequences.
An older adult's medical profile may include diagnoses from one or more of the more prevalent medical conditions from more than one than physician, including congestive heart failure, adult onset diabetes mellitus, hypertension, chronic obstructive pulmonary disease, glaucoma, osteoarthritis, depression, and anticoagulation for deep vein thrombosis prophylaxis. These patients could potentially be taking a combination of prescription drugs, OTC drugs, and supplements in excess of 20 different products. Research on the leading causes of hospital admissions in the United States identifies adverse drug events and medication errors as two of the most frequently preventable reasons for admissions.1
The Institute of Medicine, chartered under the National Academy of Sciences, provided the clarion call in 2000 with the ground-breaking report, "To Err Is Human: Building a Safer Health System."2 According to the Institute's Agency for Healthcare Research and Quality and the National Institutes of Health, adverse drug events result in approximately 1 million emergency department visits per year, with a dollar value approaching $3.5 billion in the US health care system.3 Avoidance and prevention of adverse drug events and medication errors would greatly reduce spending on remediation and help redirect resources to the provision of care.
What Contributes to Polypharmacy?
Inappropriate Use of Prescribing Software
Pharmacist Interventions at Pharmacies
Standard Precautions Prevent Polypharmacy
Complete medication reviews and take action. The Centers for Medicare & Medicaid Services has identified polypharmacy in the elderly as critically important to the safety of the nation's long term care population. Nursing home residents must have a monthly Medication Regimen Review by a pharmacist who specializes in the care of geriatric patients. It's the role of the consultant pharmacist to ensure that a resident's medication regimen is free from unnecessary drugs, including prescription medications, OTC drugs, or supplements, that have no indication, are prescribed at unsafe doses, or are causing or at risk for producing drug-drug interactions. Whenever a potential for these conditions exists or has in fact occurred, the prescriber must acknowledge the recommendation of the pharmacist and decide what action should be taken to ameliorate the condition.
Consequences of Polypharmacy
Polypharmacy's Influence on Patients' Functional/Cognitive Status and Risk of Falls
Our facility incorporates routine psychotropic rounds team review, consisting of physicians, nurses, dietitians, pharmacists, activity therapists, and social workers. Each resident receiving a psychoactive drug has his or her pharmacy regimen evaluated by team discussion, and ultimately an attempt is made to reduce or discontinue a drug, if not contraindicated. Long term care residents receiving psychotropics from any of the categories including anxiolytics, hypnotics, antipsychotics, and antidepressants all are required to have their medications evaluated for attempts at gradual dose reductions to ensure that medications are at the lowest possible doses to treat symptoms.
Potential interventions include the use of documentation systems that can help identify behaviors targeted for medication treatment and effectiveness. Common side effects that are appropriate to each category of psychotropic medications ordered are listed within the side effect monitoring system. Long term care facility nursing staff routinely receives continuing education/inservices, reviewing common side effects pertaining to each class of drug (eg, antipsychotics, antianxiety, hypnotics, and antidepressants) prescribed. Class-specific listings can provide better recognition of adverse reactions, especially if drugs from multiple psychotropic drug classes are being administered to an individual. Less common side effects can be added to the monitoring list if they are observed in an individual.
The use of multiple medications can increase the risk of untoward effects, as side effects of one or more drugs are potentiated. Most common are those drugs that affect the central nervous system, increasing sedation and reducing mental acuity, which leads to an increased risk for cognitive decline as well as an increased risk for falls. Drugs including anticholinergics, anxiolytics, and antihistamines all have risks for common adverse reactions including nervousness, dizziness, drowsiness, ataxia, confusion, and hypotension. Combining two or more medications with the same side effect profile will increase the likelihood of adverse drug events.
Steps to Address Polypharmacy
Identify the indications. All prescribed medications should include the indication or diagnosis for which the drug has been prescribed. This information should be clearly communicated on the prescriptions and in the directions for use, especially if the medication is ePrescribed. Indications for every medication will encourage safe prescribing, as the clinical use for the drugs should be correlated during instances where polypharmacy exists.
The term "deprescribing" describes the systematic review of medications for reduction and discontinuation. Scott et al have defined a protocol that may be helpful for prescribers to use in their most challenging patients who are at risk for polypharmacy-related adverse drug events. Medications are evaluated in a systematic personalized review process using a risk vs benefit analysis; the objective is to attempt to simplify drug regimens while maintaining clinical efficacy.8
There are several helpful tools that are both evidenced based and peer reviewed. These guidelines are meant to provide an opportunity to evaluate and discontinue the prescribing of medications that are potentially inappropriate for use in the elderly. Reducing the use of these medications will help reduce polypharmacy and the potential for adverse drug events. Note the italics on potentially inappropriate, as there are no contraindications for use of the medications in the criteria, but newer medications have fewer side effects. Tools include the following:
• START (Screening Tool to Alert Doctors to Right Treatment); and
• STOPP (Screening Tool of Older People's Potential Inappropriate Prescriptions).9
The American Geriatrics Society maintains a widely cited reference: The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The document has been recently revised in 2015, and is intended to "improve medication selection, educate clinicians and patients, reduce adverse drug events, and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults."10
— Robert C. Accetta, RPh, C-MTM, CGP, is senior director of pharmacy services at RiverSpring Health, featuring the Hebrew Home at Riverdale in Bronx, New York. He has extensive experience with geriatrics, long term care, community pharmacy, medication therapy management, and transitional care management. He is a director of pharmacy in New York for Partners Pharmacy, the third largest provider of long term care pharmacy services in the United States.
2. Front matter. In: Institute of Medicine Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
3. Medication safety. Delmarva Foundation website. http://delmarvafoundation.org/providers/quality-patient-safety/dc/pharmacy-medication-safety/documents/Med-Safety-DC-Infographic-508.pdf. Accessed February 15, 2016.
4. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.
5. Golchin N, Frank SH, Vince A, Isham L, Meropol SB. Polypharmacy in the elderly. J Res Pharm Pract. 2015;4(2):85-88.
6. Lang A, Macdonald M, Marck P, et al. Seniors managing multiple medications: using mixed methods to view the home care safety lens. BMC Health Serv Res. 2015;15:548.
7. 2016 national patient safety goals. The Joint Commission website. http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed March 17, 2016.
8. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834.
9. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.
10. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227-2246.