Strategies to reduce and prevent polypharmacy in older patients

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Applied Evidence

Strategies to reduce and prevent polypharmacy in older patients

J Fam Pract. 2019 October;68(8):429,435-440

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References

1. All Wales Medicines Strategy Group. Polypharmacy: Guidance for Prescribing. July 2014. http://awmsg.org/docs/awmsg/medman/Polypharmacy%20-%20Guidance%20for%20Prescribing.pdf. Accessed October 3, 2019.

2. Bushardt RL, Massey EB, Simpson TW, et al. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3:383-389.

3. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13:57-65.

4. Masnoon N, Shakib S, Kalisch-Ellett L, et al. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230.

5. Milton JC, Hill-Smith I, Jackson SH. Prescribing for older people. BMJ. 2008;336:606-609.

6. Laursen J, Kornholt J, Betzer C, et al. General practitioners’ barriers toward medication reviews in polymedicated multimorbid patients: How can a focus on the pharmacotherapy in an outpatient clinic support GPs? Health Serv Res Manag Epidemiol. 2018;5:2333392818792169.

7. Christensen M, Lundh A. Medication review in hospitalized patients to reduce morbidity and mortality. Cochrane Database Syst Rev. 2016;2:CD008986.

8. Zurakowski T. The practicalities and pitfalls of polypharmacy. Nurse Pract. 2009;34:36-41.

9. Ponte ML, Wachs L, Wachs A, et al. Prescribing cascade. A proposed new way to evaluate it. Medicina (B Aires). 2017;77:13-16.

10. 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;63:2227-2246.

11. Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004;329:434.

12. Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse events in older people. BMC Geriatr. 2009;9:5.

13. Skinner M. A literature review: polypharmacy protocol for primary care. Geriatr Nurs. 2015;36:367-371.

14. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31.

15. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers criteria. Age Ageing. 2008;37:673-679.

16. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045-1051.

17. Samsa G, Hanlon JT, Schmader KE, et al. A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47:891-896.

18. Carnahan RM, Lund BC, Perry PJ, et al. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. J Clin Pharmacol. 2006;46:1481-1486.

19. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25:1636-1645.

20. Thio SL, Nam J, van Driel ML, et al. Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials. Br J Gen Pract. 2018;68:e663-e672.

21. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175:827-834.

22. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170:1648-1654.

Appropriateness

Polypharmacy is classified as appropriate or inappropriate:

Appropriate polypharmacy is the optimization of medications for patients with complex or multiple conditions, when the use of medicine is in agreement with best evidence.
Inappropriate polypharmacy can increase the risk of adverse drug effects and drug–drug interactions and can be characterized by medication underuse and duplication.⁴

There are subdefinitions of “appropriateness,” but these are beyond the scope of this article.

What variables contribute to polypharmacy?

Polypharmacy is not only medically unnecessary; it also causes significant morbidity and mortality and is expensive.

Multimorbidity is common in the older population. The presence of multiple chronic conditions increases the complexity of therapeutic management for health professionals and patients; such complexity can have a harmful impact on health outcomes. Combinations of medications to treat chronic diseases automatically push many patients into polypharmacy. Few treatment guidelines provide recommendations on when to stop medications.

Consequences of polypharmacy, some of which are masked as syndromes in the older patient, include delirium and dementia, urinary incontinence, dizziness, falls, adverse drug reactions, increased length of hospital stay, readmission soon after discharge, and death.^3-5 Relatively high rates of drug consumption and other variables (eg, decreased renal and hepatic function, decreased total body water and lean body mass, cognitive impairment, age-related decline in vision and hearing, frequency of chronic diseases and medical comorbidities, communication barriers, prescribing cascades, and health care delivery involving multiple prescribers) can contribute to an increased prevalence of medication-associated morbidity and mortality as the result of polypharmacy.

In a descriptive study⁶ that examined these variables, researchers explored whether general practitioners experience barriers to medication review in multimorbid patients with polypharmacy. They concluded that the primary barriers were (1) lack of communication and teamwork with specialists and (2) the challenge of handling polypharmacy in a culture that encourages adding medications and inhibits conversations about medication withdrawal.⁶

Continue to: Reducing consequences of polypharmacy