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Mari Edlin is a frequent contributor to Managed Healthcare Executive. She is based in Sonoma, California.
Polypharmacy presents real problems-especially for older adults.
Although the definition of polypharmacy is broad, encompassing the use of multiple medications, pharmacies and physicians, along with the potential for complex drug-drug and drug-condition interactions, one thing is for sure: It is a problem-especially for older adults.
The senior population (those aged 65 years and older) comprises 13.7% of the U.S. population but uses 40% of all prescription drugs. People aged 65 to 69 years fill an average of 14 prescriptions per year, and adults aged 80 to 84 years average 18 prescriptions per year, according to a 2009 report from the American Society of Consultant Pharmacists. Older adults also account for 30% of over-the-counter drug use, according to the National Council on Patient Information and Education.
A 2013 study the Journal of the American Geriatrics Society found that in a population of 1,000 adults aged 65 or older discharged from a hospital, at least one adverse drug event was identified in 18.7% of patients during the 45 days following discharge. Of those, 35% were seen as preventable.
Kyle Amelung, PharmD, senior clinical consultant for Express Scripts, says that prescribers need to balance the risk and benefit of multiple medications for one person. That means taking several factors into consideration, including assessing drug reactions and interactions when using two drugs, ensuring the right dose for the right person and incorporating nonmedical therapies to supplement drug treatment.
For example, taking warfarin and aspirin at the same time could cause gastrointestinal complications; or long-term use of an anti-clotting drug and aspirin could increase the risk of bleeding.
Polypharmacy could also cause a higher risk of falls, more hospital admissions, confusion, and an overall negative impact on morbidity and mortality, says David Brown, PharmD, founder and co-president, Middle Tennessee Pharmacy Services.
The problems of polypharmacy in older adults are exacerbated by:
2. Use of more than one prescribing physician and pharmacy;
3. Utilization of OTC medications, such as dietary supplements and herbal remedies that are often not reported to a physician;
4. Difficulty reading and understanding medication instructions;
5. Age-related, physiological changes;
6. Over- and under prescribing; and
7. Improper dosing.
The latter two are two of the most critical challenges for polypharmacy. A 2004 study in the Annals of Internal Medicine showed that the prevalence of omissions of appropriate medicines was 50%, while the prevalence of administering inappropriate medication was only 3%.
Regarding dosage problems, dosing might be appropriate at the onset of a condition and change as a patient’s status improves or worsens, or it might be based on inaccurate patient weight. Appropriate doses for warfarin, for example, could change more than once a week based on a patient’s target INR, a standard for evaluating blood coagulation.
Adam Woolley, PharmD, associate clinical professor, Northeastern University in Boston, suggests that electronic health records (EHRs) carrying information across transitions of care; using evidence-based guidelines at a patient level; evaluating a patient’s renal function and comorbidities; and medication assessments by pharmacists are some of the solutions for managing polypharmacy.
Woolley goes on hospital rounds with a medical team to evaluate risks and benefits of various medications.
Amelung and Brown agree with Woolley that pharmacists are an underutilized resource. “Doctors can’t know all therapies for every condition but could use pharmacists as a knowledge base,” Amelung says.
“The role of a pharmacist in the management of polypharmacy is absolutely critical,” Brown says. “Most senior residents-particularly those who struggle with multiple disease states)-see multiple prescribers. When this occurs, the patient is at a higher risk for drug interactions and duplicate therapy, making it critical that a pharmacist closely monitor a patient’s drug regimen to ensure efficacy and safety.”
Another cheerleader for the pharmacist’s role is Nicholas Ratto, manager, consumer drug information group, First Databank. He suggests that pharmacists sit down face-to-face with patients who have comorbidities and review conditions and drugs, verifying their safety and efficacy annually. But without knowing a patient’s history, it is difficult for a pharmacist to provide clinical assistance, he says.
He points out that a comprehensive medication review is available as part of medication therapy management reimbursed by CMS for Medicare beneficiaries.
Ideally, Charles Lee, president/founder Polyglot Systems, says there should be a universal medication list EHRs can tap into to prevent problems with polypharmacy.
To assist patients on the receiving end of polypharmacy, Polyglot has developed Meducation, an online tool that generates simpler, personalized medication instructions in a patient's preferred language.
“In addition,” Lee says, “patients need to understand when to take a drug and why, and potential interactions with OTC medications.”
Woolley places some responsibility on patients’ shoulders by emphasizing the importance of ensuring they buy into their medication regimens to promote adherence.
Amelung suggests patients share their medication lists with their doctors or pharmacists for a review of side effects, interactions and availability of lower-cost alternatives.
The new paradigm, says John Beckner, RPh, senior director of strategic initiatives, National Community Pharmacists Association, is putting a patient in the middle of a physician and pharmacist. “We often lose sight of the importance of the patient,” he says. “Pharmacists and physicians also need to trust each other; if a relationship doesn’t exist, it could impact prescriptions.”
As Brown suggests, it isn't always easy to decide which drugs are appropriate for which patient to optimize outcomes. “Every patient is unique; there really isn’t a one-size-fits-all solution when choosing a drug regimen. The disease state being treated, current drug regimens ensuring there aren’t any drug interactions, and the ability for a patient to tolerate a particular drug are all important factors (among others) when attempting to optimize outcomes.”
Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.