May/June 2016

Polypharmacy: Strategies for Reducing the Consequences of Multiple Medications
By Robert C. Accetta, RPh, C-MTM, CGP
Today's Geriatric Medicine
Vol. 9 No. 3 P. 24

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?

Disease States
The elderly are diagnosed with chronic medical conditions, for which prescribers order maintenance medications. One review of what constitutes polypharmacy has identified different numbers of drugs for different settings. Ambulatory or community-dwelling older adults may be identified with polypharmacy when more than five medications are ordered; in hospitalized patients and long-term nursing home residents, polypharmacy occurs when the total reaches nine or more.4 In one study, polypharmacy was associated with duplicate therapy and contraindicated drug combinations.5 In addition, clinical practice guidelines provide a steplike approach to the management of many of the frequently diagnosed chronic illnesses. The standards recommended in guidelines include multiple medications; for example, a patient diagnosed with more advanced congestive heart failure may receive medications from four different pharmacological classes. Add a COPD diagnosis, which may include three different inhaled drugs as well as oral steroids, and we have already achieved polypharmacy.

Multiple Providers
The ability to function at the highest practicable level is a goal not easily achieved for individuals with chronic illness. As patients' providers, physicians, nurse practitioners, specialists, and hospitalists are all responsible for completing a thorough assessment of the whole patient. However, in practice, prescribers may overlook the complete picture and may be prescribing with only one specific disease state in mind.

Inappropriate Use of Prescribing Software
The advent of the electronic health record has made the task of prescribing safer from the risks associated with poor handwriting. Prescriptions are clearly provided with drug names and strengths, directions for use, and many times include the exact indication. The multitude of proprietary prescribing software products includes a suite of drug-related warnings and precautions. Therapeutic duplication alerts will frequently be triggered regardless of the severity or clinical indication for use. "Alert overload" is a phenomenon to which many providers fall susceptible, with so many warnings and "soft stops" to review that many times a prescriber will simply disregard a legitimate precaution on the potential additive adverse effects of two or more drugs.

Pharmacist Interventions at Pharmacies
Patients become susceptible to increased incidence of nonadherence due to complicated regimens and missed doses. The use of multiple pharmacies including community and mail order services complicate matters because a complete singular record of dispensing is not readily available.6 Pharmacy dispensing software contains informatics standards designed to help prevent duplications, providing multiple tiers of warnings for the dispensing pharmacist to process. Alert fatigue also plays a role when a pharmacist may approve a combination of medications that can increase the risk of adverse drug events secondary to cumulative side effects of multiple medications.

Pharmacology
Therapeutic duplications from the same pharmacological class can lead to cumulative effects. Drugs from different pharmacological classes may have similar side effect profiles, increasing the risks of adverse side effects. The use of herbal supplements used to self-treat common conditions should be avoided together with certain categories of drugs. For example, St. John's Wort for depression should be avoided if a patient is using warfarin because of the risk of reducing the effects of warfarin.

Standard Precautions Prevent Polypharmacy
Take advantage of opportunities for medication reconciliations. These exist at the hospital upon admission or between hospital and transfer to subacute care or long term care, or from subacute care back to the community. It's common to find duplications when medications used to treat acute conditions are continued postdischarge along with medications the patient has been taking at home. There is opportunity to review all drugs and supplements at each care transition and to perform a critical stop-and-think assessment to eliminate unnecessary drugs. Complete medication reconciliation is a crucial task identified in multiple standards of practice guidelines. The Joint Commission provides one such standard for medications in its 2016 National Patient Safety Goals: "Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell patients it is important to bring their up-to-date list of medicines every time they visit a doctor."7

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

Hospitalizations
In one study reviewing polypharmacy, inappropriate medication use in the elderly increased the risks of adverse drug events, hospitalization, and death; the number of prescribed drugs was identified as a creditable indication of the increased risks for most elderly patients.1 Budnitz et al studied the incidence of adverse event data from the National Electronic Injury Surveillance System — Cooperative Adverse Drug Event Surveillance project (2007–2009 data). An estimated 99,628 emergency hospitalizations occurred due to adverse drug events in the United States each year, with nearly 50% occurring in adults aged 80 or older. Unintentional overdoses were the cause of approximately 66% of the hospitalizations.1

Unnecessary Expenditures
Medications that are duplicated and cause side effects but not hospitalizations may result in prescribers ordering drugs to treat symptoms or adverse effects of cumulative drug therapy. Dollars are spent on avoidable medical appointments or for OTC or prescription drugs.

Polypharmacy's Influence on Patients' Functional/Cognitive Status and Risk of Falls
Consider the additive effects of multiple medications. Psychoactive drugs prescribed for the symptoms of Alzheimer's disease, behavior disorders, or dementia are notorious for their increased risk for adverse effects. Antipsychotics may induce episodes of orthostatic hypotension, thereby increasing the potential for falls. Use of multiple medications in a "cocktail" designed to treat behavioral symptoms frequently results in a reduction in cognition and the ability to function independently. One approach to reduce these risks requires first evaluating a single drug and then attempting to safely titrate its dose before adding another drug.

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
Nonpharmacological interventions include behavioral modification strategies, which should be included in any plan for care and documented. Our facility has a robust therapeutic activities program, and the medical staff and therapists incorporate activities centered around the preferences of each patient. Art, music, exercise, pet, and aromatherapy are all creatively offered as vital components of a resident's plan of care; each of these may help reduce the need for or frequency of using psychoactive medications to modify behavioral episodes.

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.

References
1. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-2012.

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.