• Dr. Mrigakshi Aggarwal, PULMONOLOGIST

Polypharmacy in the Elderly:  How many medicines are too many? 

There is an increase in the total population worldwide, and a sizable number of this population is of the elderly above the age of  65. India with people aged 60 years and above is going to be the highest in Asia. The population study has shown that population of this + 65 aged people in Sweden was 17.4%, Australia was 12.1%, China was 6.8%, and  India was 7% in the year 2000, and the predictive value for  2030 will be 25%, 20%, 15.7%, and 9.6%, respectively.

As age advances, more diseases develop resulting in the use of more medications.  As people age, they develop multiple symptoms and illnesses.  In addition to chronic diseases of adulthood, they have  an increased incidence of  many conditions including 

Alzheimer’s disease, Parkinson’s disease, vascular dementia,  stroke, arthritis, osteoporosis, and fractures.

Hence,  polytherapy is often mandatory in the management of the common ailments. The term polytherapy refers to the use of multiple medications, ranging from 5 to 10.

The prevalence of inappropriate medication use in the elderly ranges from 11.5% to 62.5%.

Consequences of polypharmacy include adverse drug reactions and interactions, nonadherence, increased risk of cognitive impairment, impaired balance and falls, increased risk of morbidity, hospitalization, and mortality. Physiological changes, alterations in homeostatic regulation and diseases modify pharmacokinetics and drug response in older patients. The risk for drug interactions and drug-related problems increases in the elderly along with multiple medications. 

The risk of an adverse drug event has been estimated at 13% for two drugs, 58% for five drugs, and  82% for seven or more drugs. The overall incidence of drug reactions in geriatric patients is estimated to be at least twice that in the younger population because of errors both in the prescription pattern of practitioners and drug usage by the patients.  

Practitioner errors occur because of a lack of knowledge of geriatric clinical pharmacology and not conducting medication review with the patient. Patient errors may result from non-compliance and the use of multiple pharmacies. Poor compliance in geriatric patients is due to poor communication with health professionals and a decline in cognitive abilities. Other predictors for drug interactions include the severity of the diseases being treated, age of the patient, and renal and hepatic dysfunction. The increase in the drug counters with fixed-dose combinations, self‑medication,  etc., further contributes to the increased incidence of drug interactions.  The elderly frequently use medicinal herbs and other dietary supplements and ignore to tell their health‑care providers. Medicinal herbs can interact with drugs and lead to adverse effects. 

Drug prescription in elderly is a serious challenge as there is an increased possibility of drug interaction resulting in toxicity, treatment failure, or loss of drug effect. Duplicative prescribing within the same drug class often occurs, and unrecognized drug side effects are treated with more drugs. To minimize polytherapy, periodic evaluation of a patient’s drug regimen is necessary. Prescribers need to know what other prescriptions patient is taking including herbs and teas. Drugs such as digoxin and theophylline with a narrow therapeutic index should be carefully evaluated for potential interactions. The small number of drugs in low doses with a simple regimen is good for drug therapy in the elderly.

Hence the multidimensional approach is required to tackle the issue of polypharmacy. Following approaches may be used : 

1. Medication reconciliation

A first step in managing polypharmacy is to create a complete and accurate list of all medications a patient is taking. When patients are admitted with an incomplete or inaccurate medication list, they may be prescribed duplicate medications or medications that can interact with an existing regimen. The result can be an interaction or adverse drug event during their stay and some that may continue after discharge. 

2. Ask patients if they are being treated by other physicians and providers

Patients taking multiple medicines to manage multiple conditions are most likely being treated by multiple specialists and other providers. Without realizing it, each provider may take a condition or disease centric approach to prescribing. And patients may not understand, for instance, that the cardiologist needs to know about the pills that the pulmonologist and orthopedist prescribed. 

3. Verify that there is an actual indication for every medication being taken

Simply put, every medication must map to a diagnosis or other indication, and be clearly communicated to the patient so he or she understands the reason for taking it. If not, physicians should question the purpose of the patient taking the medication at all. If there is no indication, “deprescribing” may be in order. Deprescribing is the process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects.

4. Assess deprescribing opportunities at every visit or care transition

Patients age, conditions change. Physicians should conduct a systematic, one-on-one review of polypharmacy patient regimens with the goal of simplifying, deprescribing or modifying medication regimens while still maintaining efficacy. Ask questions about the purpose of each medication.

5. Involve a pharmacist

Pharmacists can provide insights into a patient’s regimen from a pharmacologic perspective, and recommend medications that can be removed and/or dosages that should be modified. Engage them in the review of polypharmacy patient medications and care.

6. Try behaviour modification strategies before adding a new drug

These could include exercise and dietary changes for patients with diabetes or certain cardiovascular conditions, art and music for patients with dementia or depression.

A vigilant and updated clinician can avoid the problems caused by polypharmacy and hence reduce the problems of an ageing adult patient.