DECEMBER 2, 2016
More and more older adults are taking more and more medications, and experts warn this is translating into trouble, from drug interactions to lower adherence to higher health care costs.
“Polypharmacy is a growing problem across age groups,” said Sean Jeffery, PharmD, CGP, a geriatric pharmacist at the University of Connecticut School of Pharmacy, in Storrs. Studies suggest it is particularly problematic in the elderly population. Research published this year found that 36% of patients aged 62 to 85 years took five or more medications during 2010 to 2011—a 5% increase over 2005 to 2006 (P=0.02)—with 15% of patients at risk for a major drug interaction (JAMA Intern Med 2016;176[4]:473-482).
Dr. Jeffery described a recent case of an 85-year-old woman who lived at home alone. She was followed by a care management team and had asked her nurse to do something about her water pills. The nurse identified in the electronic medical record seven medications, including two diuretics, prescribed by the patient’s primary care physician. “The nurse, in turn, asked me to meet with the patient and review her medications,” he recalled. “During our visit, she came in with a garbage bag full of medications. We ultimately identified 27 different drugs.”
Among those were four different diuretics—two from the same class—and at least three drugs on the Beers list, a selection of medications that are potentially harmful for older patients. “People had no idea she was taking all these medications,” Dr. Jeffery added. “The physician didn’t have the medications that the cardiologist and other specialists had prescribed, let alone the over-the-counter [OTC] medications the patient was taking.”
“The right hand didn’t know what the left hand was prescribing,” he said, “and she was stuck in the middle.”
Although this case might be an extreme example, Dr. Jeffery and other experts underscore how frequently they see polypharmacy result from disjointed care. Even multiple medications prescribed following evidence-based practice guidelines can result in harm. Of 27 medication classes, a study found that 15 (55.5%) recommended for one condition may adversely affect other conditions (PLoS One 2014;9[2]:e89447).
“We’re all trying to follow the evidence and best practices,” Dr. Jeffery said, “but if you layer COPD [chronic obstructive pulmonary disease] guidelines on top of heart failure guidelines on top of diabetes guidelines on top of hypertension guidelines for the same person—and this is common because those diseases travel in packs—then you can suddenly have someone on 24 medications.”
Risks from Multiple Prescribers
Polypharmacy can trigger trouble in older adults for several reasons. For one, as noted, these patients typically have multiple chronic conditions that are treated with multiple medications—and often by multiple prescribers. “An older adult might have one doctor for diabetes, another for a heart condition, another for arthritis,” said Thomas Clark, RPh, MHS, CGP, the executive director of the Commission for Certification in Geriatric Pharmacy (CCGP). “They can often see four or five prescribers, and no one person is coordinating their drug therapy.”
Multiple dispensers are another problem. Patients might pick up $4 generics at Walmart, visit a nutrition store for herbal products and supplements, and then use mail order for other drugs. “Older adults now are taking so many different drugs from so many different places that it’s very easy for them to get into trouble, including with drug duplications and interactions,” Mr. Clark said.
OTC pain medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are among the biggest culprits, he noted. These medications can cause sodium and water retention, which in turn can raise blood pressure. “A doctor might not realize their patient’s blood pressure is elevated because they are taking [OTC] products and might put them on blood pressure medications,” said Mr. Clark, adding that pain medicines can also interact with blood thinners such as warfarin. “NSAIDs can irritate the gastrointestinal tract and cause potentially severe bleeding.”
OTC drugs with “PM” in the name, such Advil PM, Tylenol PM and Motrin PM, are another common hazard, potentially causing mental confusion and memory loss due to their anticholinergic activity that can be mistaken for dementia, he added (JAMA Intern Med 2015;175[3]:401-407). In such a scenario, prescribers may opt for ordering yet more medications, Mr. Clark noted. Of course, some elderly patients do have memory impairments, which also exacerbate the polypharmacy problem by rendering them less likely to adhere to a laundry list of medications.
Constipation, diarrhea, low blood pressure and dizziness can be magnified when taking medications that share the same side effects. Additionally, it’s not just long lists of drugs that can pose problems, especially for frail patients—even one drug can put a patient at risk. Indeed, “you only need one medicine for it to be polypharmacy,” said Bradley Williams, PharmD, CGP, a geriatric pharmacist at the University of Southern California School of Pharmacy, in Los Angeles.
An otherwise healthy older patient, for example, may complain to their provider about sleeping trouble and be put on a sleep aid as their only medication. Then, when getting up in the middle of the night to use the bathroom, they might be unsteady, fall and break a hip.
In contrast, someone could be on multiple medications appropriately, Dr. Williams pointed out. In the case of diabetes, hypertension or Parkinson’s disease, for example, multiple medicines can be helpful due to their different mechanisms of action.
Go Team!
Experts agreed that pharmacists have an important role to play in reducing an older patient’s excessive use of prescription medications, OTC drugs and supplements. According to a 2013 review, putting a pharmacist on the geriatric team can improve drug safety and adherence as well as decrease hospitalizations (J Am Geriatr Soc 2013;61[7]:1119-1127).
Mr. Clark said his commission is working to increase the number of pharmacists with special expertise in geriatrics via the CGP credential. Licensed pharmacists with at least two years of experience are eligible for the certification examination. In a 2015 unpublished CCGP survey, CGP-credentialed pharmacists reported benefits including help in qualifying for an expanded scope of their practice (19%) and increases in pay (15%).
“Medicare changed their payment structures so that hospitals are penalized if a patient is readmitted too soon after hospitalization,” Mr. Clark said. “Stabilizing a person to keep them out of the hospital often involves looking at medications. We’re seeing a lot of growth in hospital pharmacists getting the CGP credential.”
The University of Southern California is among institutions working to get pharmacists more involved in patient care, specifically as part of a geriatric assessment team. That team, Dr. Williams noted, is now generally reducing the number of medications by 15% to 20%, sometimes even by half, although on rare occasions, they do increase the number of medications.
“As the pharmacy profession moves forward, we need to have some input regarding the drug therapy decisions that are being made,” said Dr. Williams, also one of original members of the CCGP board of commissioners, where he helped develop the CGP credential. “That’s one of the reasons provider status or some acknowledgment of reimbursement is necessary.”
California passed legislation in 2013 that allows pharmacists to have an Advanced Practice Pharmacy license. The CGP exam is among the credentials a pharmacist could use to qualify for the status.
Dr. Jeffery noted that his institution is ramping up its data analytic capabilities to prevent and resolve polypharmacy. They are building EMR alerts into prescribing systems, as well as engaging the care management team for patients already identified as being at risk from polypharmacy. A central component of the latter is deprescribing. He recommended beginning that process by identifying the least and most important medications to the patient. Then, for medications that are really tough to stop such as benzodiazepines, he suggested referencing the Canadian-based website, deprescribing.org, which illustrates how to slowly taper medications.
Polypharmacy is much like online banking, he added. “What is the likelihood that an individual is able to do online banking or manage their finances competently? If a patient is struggling with that ability, chances are they will struggle with managing their medications.”
—Lynne Peeples
Mr. Clark reported receiving a salary from CCGP. Drs. Jeffery and Williams reported no relevant financial relationships.