Contents

Search

polypharmacy (unecessary drug prescription)

The administration of many drugs concurrently, usually meaning that a patient is receiving an excessive number of medications. Unnecessary medications are common in the elderly. Etiology: 1) reasons a) lack of indication b) lack of efficacy c) therapeutic duplication 2) agents inappropriately prescribed a) H2 receptor antagonists b) laxatives c) genitourinary anticholinergic agents d) ferrous sulfate e) tricyclic antidepressants f) potassium chloride g) benzodiazepines h) antibiotics i) antipsychotics j) proton pump inhibitors k) NSAIDs 3) predictors a) multiple prescribing physicians b) prescription of 9 or more medications c) multiple specialists consulted with no coordination of care d) multiple pharmacies prescribing medications e) lack of medication reconciliation f) lonely older adults [25] Epidemiology: 1) common with the elderly (36-44%) [10] 2) 15% of U.S. adults take >= 5 prescription medications [8] 3) 18% of elderly receive 2 or more inappropriate prescriptions 4) use of statins & antiplatelet drugs increased (2005-2011) [10] 5) rural elderly often prescribed >=3 psychoactive medicationsbin a single visit (2.8 visits per 100 visits in those with a pain diagnosis) [14] 6) > 90% of Medicare patients would stop taking certain medications but believe that all their medications are necessary [20] 7) 72% of elderly with dementia are prescribed >= 5 medications, 43% >= 10 medications [12] - these medications often include highly sedating & anticholinergic agents [12] Complications: - drug adverse effects - drug interactions - older patients with HIV1 infection taking > 15 medications have lower chance of viral suppression [24] - inappropriate drug use - medication noncompliance - duplication of therapy - medication errors [7] - 1 in 7 elderly with dementia who live outside nursing homes have overlapping prescriptions for >= 3 drugs that act on the central nervous system according to Medicare part D claims [23] increasing risks for falls, respiratory depression, & cognitive impairment - associated with risks for falls, disability, & death [21] - acute renal failure demonstrated by rising serum creatinine may be associated with diminished clearance of renally cleared drugs - with polypharmacy risk of elevated levels of renally cleared drugs increases - elevated gabapentin levels due to diminished clearance may manifest as dizziness [27] Management: 1) pharmacy intervention through patient education between patient visits can reduce mortality in the elderly [1] 2) successful drug discontinuation may lead to improved outcomes [4,21] 3) frequent, routine medication reconciliation to verify the need for a medication & the appropriate dosing [7] 4) even with guideline-recommended drugs, benefits might be affected by other conditions & drugs & effects on mortality may be unpredictable [9] 5) comprehensive geriatric assessment may reduce polypharmacy in the elderly [19] 6) lonely older adults may benefit from increased socialization [25] 7) drugs to consider deprescribing [18] - docusate - proton pump inhibitors - statins for primary prevention of cardiovascular disease - benzodiazepines - beta-blockers - bronchodilators in the absence of confimatory spirometry - antimuscarinic agents for urinary incontinence - cholinesterase inhibitors for Alzheimer's disease - muscle relaxants for low back pain - supplements

Related

Beers criteria medication deprescribing

General

inappropriate prescription

References

  1. Wu JY, Leung WY, Chang S, Lee B, Zee B, Tong PC, Chan JC. Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial. BMJ. 2006 Sep 9;333(7567):522. Epub 2006 Aug 17. PMID: 16916809
  2. Terrell KM et al Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: A randomized, controlled trial. J Am Geriatr Soc 2009 Aug; 57:1388 PMID: 19549022 - Fortuna RJ et al Reducing the prescribing of heavily marketed medications: A randomized controlled trial. J Gen Intern Med 2009 Aug; 24:897. PMID: 19475459
  3. Steinman MA et al Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing. Arch Intern Med 2009 Jul 27; 169:1326. PMID: 19636035
  4. 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(18):1648-1654 PMID: 20937924
  5. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  6. Hayes BD, Klein-Schwartz W, Barrueto F Jr. Polypharmacy and the geriatric patient. Clin Geriatr Med. 2007 May;23(2):371-90 PMID: 17462523
  7. Medical Knowledge Self Assessment Program (MKSAP) 16, 17. American College of Physicians, Philadelphia 2012, 2015
  8. Kantor ED, Rehm CD, Haas, JS et al Trends in Prescription Drug Use Among Adults in the United States From 1999-2012. JAMA. 2015;314(17):1818-1830 PMID: 26529160 http://jama.jamanetwork.com/article.aspx?articleid=2467552
  9. Tinetti ME et al. Association between guideline recommended drugs and death in older adults with multiple chronic conditions: Population based cohort study. BMJ 2015 Oct 2; 351:h4984 PMID: 26432468
  10. Qato DM et al Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med. Published online March 21, 2016 PMID: 26998708 http://archinte.jamanetwork.com/article.aspx?articleid=2500064 - Jou J, Johnson PJ Nondisclosure of Complementary and Alternative Medicine Use to Primary Care PhysiciansFindings From the 2012 National Health Interview Survey. JAMA Intern Med. Published online March 21, 2016 PMID: 26999670 http://archinte.jamanetwork.com/article.aspx?articleid=2500061 - Steinman MA Polypharmacy - Time to Get Beyond Numbers JAMA Intern Med. Published online March 21, 2016 PMID: 26999383 http://archinte.jamanetwork.com/article.aspx?articleid=2500058
  11. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014 Jan;13(1):57-65. Review. PMID: 24073682 Free PMC Article
  12. Onder G, Liperoti R, Foebel A et al Polypharmacy and mortality among nursing home residents with advanced cognitive impairment: results from the SHELTER study. J Am Med Dir Assoc. 2013 Jun;14(6):450.e7-12 PMID: 23647778
  13. Tamura BK, Bell CL, Lubimir K et al Physician intervention for medication reduction in a nursing home: the polypharmacy outcomes project. J Am Med Dir Assoc. 2011 Jun;12(5):326-30. PMID: 21450207 Free PMC Article
  14. Maust DT, Gerlach LB, Gibson A et al Trends in Central Nervous System-Active Polypharmacy Among Older Adults Seen in Outpatient Care in the United States. JAMA Intern Med. Published online February 13, 2017. PMID: 28192559 http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2601416
  15. Lipska KJ, Krumholz H, Soones T, et al. Polypharmacy in the aging patient: a review of glycemic control in older adults with type 2 diabetes. JAMA. 2016;315:1034-1045 PMID: 26954412 Free PMC Article
  16. LeBlanc TW, McNeil MJ, Kamal AH, et al. Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol. 2015 Jul;16(7):e333-e341 PMID: 26149885
  17. Frellick M Physicians Express Unease Around Deprescribing, Suggest Changes Medscape - Jul 13, 2017. http://www.medscape.com/viewarticle/882912 - Brookes L Easy to Start, Hard to Stop: Polypharmacy and Deprescribing. Medscape - Jun 01, 2017. http://www.medscape.com/viewarticle/880716 - Mishori R Targeting Unnecessary Meds: A Guide to Deprescribing. Medscape - Jun 09, 2017. http://www.medscape.com/viewarticle/880516
  18. Paauw DS 11 Drugs You Should Seriously Consider Deprescribing. Medscape. September 5, 2017 http://www.medscape.com/slideshow/deprescribing-6009041
  19. Unutmaz GD, Soysal P, Tuven B, Isik AT Costs of medication in older patients: before and after comprehensive geriatric assessment. Clinical Interventions in Aging Volume 13 https://www.dovepress.com/costs-of-medication-in-older-patients-before-and-after-comprehensive-g-peer-reviewed-article-CIA
  20. Reeve E, Wolff JL, Skehan M et al. Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. JAMA Intern Med 2018 Oct 15 PMID: 30326004 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2706177
  21. Montero-Odasso M, Sarquis-Adamson Y, Song HY et al. Polypharmacy, gait performance, and falls in community-dwelling older adults. Results from the Gait and Brain Study. J Am Geriatr Soc 2019 Jun; 67:1182. PMID: 30698285 https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15774 - Reeve E, Low LF, Hilmer SN. Attitudes of older adults and caregivers in Australia toward deprescribing. J Am Geriatr Soc 2019 Jun; 67:1204. PMID: 30756387 https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15804
  22. Zoorob MJ. Polydrug epidemiology: benzodiazepine prescribing and the drug overdose epidemic in the United States. Pharmacoepidemiol Drug Saf 2018 May; 27:541 PMID: 29537112
  23. George J Dementia Patients Often Have Dangerous Mix of Drugs at Home. Combinations increase risk of falls, respiratory suppression, cognitive impairment. MedPage Today March 9, 2021 https://www.medpagetoday.com/neurology/dementia/91541 - Maust DT, Strominger J, Kim HM et al Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US. JAMA. 2021;325(10):952-961. March 9 PMID: 33687462 https://jamanetwork.com/journals/jama/article-abstract/2777235
  24. Murray MM, Lin J, Buros Stein A et al. Relationship of polypharmacy to HIV RNA suppression in people aged >= 50 years living with HIV. HIV Med 2021 Jun 2 PMID: 34077632 https://onlinelibrary.wiley.com/doi/10.1111/hiv.13122
  25. Gever J Loneliness, Aging, and Polypharmacy Doctors advised to try "social prescribing" in place of more meds. MedPage Today July 26, 2021 https://www.medpagetoday.com/geriatrics/generalgeriatrics/93748
  26. Growdon ME, Gan S, Yaffe K, Steinman MA. Polypharmacy among older adults with dementia compared with those without dementia in the United States. J Am Geriatr Soc 2021 Sep; 69:2464 PMID: 34101822 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17291
  27. Levy HB. Polypharmacy reduction strategies: tips on incorporating American Geriatrics Society Beers and screening tool of older people's prescriptions criteria. Clin Geriatr Med. 2017;33:177-187. PMID: 28364990