Polypharmacy - A Review Of Strategies To Reduce Polypharmacy
Polypharmacy is widely acknowledged as a factor in geriatric patients' poor outcomes. The burden of associated comorbidities managed with medications will increase as the population's proportion of elderly people (≥65 years of age) continues to rise.
Polypharmacy is defined as the use of five or more medications, which may imply that patients who use fewer medications are not at risk for adverse drug events (ADE).
Instead, Viktil et al. discovered a straight line between the number of ADEs and the number of drugs used. As a result, recent studies have shifted to a relative definition of "taking more medications than is clinically indicated."
Polypharmacy reduction in vulnerable populations necessitates a multi-pronged approach involving risk assessment, medication minimization strategies, and interdisciplinary collaboration.
Identifying, stratifying, and targeting individual patients at higher risk of polypharmacy and ADE is an important strategy. Several studies have found risk factors for polypharmacy and ADE patients.
There are three groups of patient characteristics to consider: 1) demographic (advanced age, white race, female gender, higher levels of education), 2) health status (general ill health, cardiovascular disease, hypertension, asthma, diabetes), and 3) health-care access (increased number of visits, multiple providers, type of insurance).
Furthermore, patients who had previously experienced ADE were more likely to experience it again. Because of comorbidity and age-related functional decline of the kidney and liver, which affects drug metabolism and clearance, geriatric patients are particularly vulnerable to the effects of polypharmacy.
Drug kinetics can also be influenced by a reduction in lean body mass and total body water combined with an increase in total body fat. As a result, medications for the elderly may have a faster onset, greater bioavailability, and a longer duration of action. Providers should pay special attention to these variable factors in the elderly when prescribing medications, as they can lead to ADE and other problems.
Recognizing inappropriate prescription medications is recognized as an important indicator of care quality linked to clinical outcomes, and it is used as a benchmark in Medicare and other managed care plans for older patients. Researchers and clinicians use a variety of methods to identify potentially inappropriate medications (PIMs) in practice. The Beers criteria is the most ancient and well-known of these. In patients over the age of ≥65, the criteria include a list of medications to avoid or replace.
It is simple and can be applied to large populations, but it has several flaws, including 1) the inclusion of obsolete drugs, 2) the need for periodic updating, 3) some contentious contraindications, 4) the omission of drug-drug interactions or drug duplications, and 5) the failure to recognize medication omission errors.
When exposed to a drug on the list, a study using the Beers criteria from 2003 found a non-significant increase in the risk of developing an ADE. Another study found a significantly increased association with ADE (adjusted odds ratio [OR]: 2.14; 95% confidence interval [CI]: 1.01-2.61) when the Beers criteria were combined with other explicit criteria (that accounted for drug-drug interactions and therapeutic duplication).
Most clinical trials that are used to develop clinical targets exclude the elderly and cancer patients, two groups that have been identified as having a higher risk of ADE. However, a growing body of evidence suggests that in the elderly, strict goals (such as hemoglobin A1c <7 in diabetes or tighter blood pressure control based on comorbidities) may be harmful.
The widely-cited Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial found that tight glycemic control was associated with an increased risk of hypoglycemia, adverse events, and death, not a reduction in MI, stroke, or cardiovascular death.
Researchers found a link between hypoglycemic events and hospital admissions for cardiovascular events (e.g. MI, CABG, revascularization, PCI, unstable angina) in a retrospective study examining healthcare claims data from over 860,000 diabetic patients over the age of 18.
Even the Hypertension in the Very Elderly Trial (HYVET), a randomized controlled trial that found that blood pressure management reduced stroke and overall mortality in very elderly patients (>80 years old), showed benefit at a goal blood pressure of 150/80, which is higher than commonly-cited goal blood pressures.
By loosening our clinical targets, we may be able to reduce morbidity and reduce the use of medications like sulfonylureas and antihypertensives that have the potential to cause more harm than good.
Multiple non-essential therapies are frequently discontinued by palliative care teams at the end of life (for example, in patients with advanced dementia), and these strategies may be applicable to elderly patients who do not have an end-stage diagnosis.
Bain et al. proposed a conceptual framework based on medication discontinuation being done on a regular, rational basis. The framework includes four key steps: 1) identify and prioritize medications to be discontinued (e.g., diminished benefit, change in symptoms), 3) discontinue with proper planning, communication, and coordination with other providers, and 4) monitor for side effects.
The Comprehensive Geriatric Assessment (CGA) is a multilevel, global approach to identifying elderly patients' medical, psychosocial, and functional limitations and providing integrated care through an interdisciplinary team.
At a minimum, these teams include a geriatrician, social worker, and nurse who use standard protocols to: 1) assess functional, cognitive, affective, and nutritional status; 2) screen for geriatric syndromes like incontinence and falls; 3) assess caregivers and social support; and 4) develop a specific, individual plan for each patient.
The CGA focuses on medication management in order to improve prescribing quality and identify and prevent potential adverse events.
Multiple models of care, including acute care units, home geriatric assessments, and outpatient consults and clinics, have all been extensively studied using CGA principles. Inpatient units for Acute Care of the Elderly (ACE) were developed in the 1990s and have been shown to improve care quality without lengthening hospital stays.
In a prospective matched cohort study, a "mobile" version of this approach (that does not require a physical unit) was linked to fewer adverse events, shorter hospital stays, and higher satisfaction.
Similarly, when 834 elderly VA patients were randomly assigned to outpatient CGA services, the intervention was found to reduce the risk of serious ADE by 35% when compared to usual care in the outpatient clinical setting. The CGA's integrated, team-based, and patient-centered model improves geriatric care in a variety of settings.
Polypharmacy can be reduced by incorporating pharmacist expertise, which can be done in a variety of ways. First, a clinic pharmacist is in a unique position to educate both patients and providers, and has been shown in randomized trials to reduce both the total number of prescribed medications and the number of PIMs.
A recent prospective study found that having a clinic pharmacist review each medication regimen, counsel the patient, and provide a report to the health care provider improved clinical outcomes; after six months, not only did the number of ADE decrease from two to zero, but patient adherence also improved significantly.
Second, pharmacists in the community and at the managed-care level are able to consolidate data from a variety of sources. PIMs and high-risk drug combinations can thus be identified by these pharmacists, who can then notify patients and providers. Between 15% and 45% of physicians report changing their medication regimen as a result of managed care interventions that send out mailed recommendations to both patients and physicians. Reduced polypharmacy events and lower prescription costs per member per month are evidence of these changes.
Medication reconciliations at the point of care transition, removing duplicate medications, assessing for drug-drug interactions, and reviewing dosages can all help to reduce polypharmacy, ensure patient safety, reduce hospitalizations, and lower costs.
The nursing staff can assist the patient in determining whether tapering or stopping medications has beneficial or harmful effects. Patients and their families can be educated about the dangers of polypharmacy so that they are aware that if a medication is causing harm or no longer benefits the patient, it may be discontinued.
Here are some tips for helping patients avoid polypharmacy. Information is important. Discuss with patients the importance of maintaining an accurate list of all medications, including generic and brand names, dosages, dosing frequency, and the reason for taking the medication.
The polypharmacy conundrum can be solved by improving communication with patients and providers, assisting providers in deprescription when possible, and providing emerging opportunities to pharmacists, such as MTM, transitions of care, and refined computer systems that make prescribing and filling more seamless.
Patients with polypharmacy are more likely to experience adverse events, functional decline, and geriatric syndromes. The strategies outlined above, such as using a risk stratification tool and applying palliative care principles, are first steps toward reducing polypharmacy; however, there is still a lot of work to be done. The development and validation of risk assessment tools in various elderly populations and settings should be pursued in the future. Some of these tools may be integrated into an EMR in the future, allowing clinicians to quickly identify patients who are at risk.
Future clinical trials focusing on the elderly could also provide information on the most effective clinical targets and treatment strategies for the elderly. Finally, in elderly patients, care models that incorporate a comprehensive geriatric assessment approach should become standard of care. Pharmacists play a critical role in these models, minimizing medications and reducing errors, and thus improving patient safety and outcomes. There are evidence-based strategies available, but more research in the geriatric population is needed to assess their utility in clinical practice.