Emergency Geriatricians Triage Older Adults for Polypharmacy Issues

Polypharmacy has no consensus definition, says Geriatric Clinical Pharmacy Specialist Gina Ayers, PharmD, of Cleveland Clinic’s Center for Geriatric Medicine.

Medical literature typically defines polypharmacy as a certain quantity of medications — often more than five or 10 — prescribed for one patient. Higher quantities have been linked to higher healthcare costs, greater risk of drug interactions and adverse events, and worse functional status for the patient.

However, rather than defining polypharmacy solely by number of medications, it should be defined as either appropriate or inappropriate, notes Dr. Ayers.

“This approach allows us to better align medications with the patient’s values and preferences,” she says.

Since Dr. Ayers joined the Center for Geriatric Medicine in 2018, she has been working in Cleveland Clinic’s outpatient geriatric clinic to identify inappropriate polypharmacy and help optimize medication regimens for older patients. It’s a process that sometimes begins in the emergency department (ED), as polypharmacy is associated with increased ED use.

In 2020 geriatricians in the ED on Cleveland Clinic’s main campus — one of few EDs in the U.S. to receive Level 1 Geriatric Emergency Department Accreditation — began identifying high-risk older adults with potentially inappropriate polypharmacy. A referral process then was established for follow-up care with Dr. Ayers in an outpatient geriatric clinic.

“Addressing polypharmacy in the ED is important, but it’s just a start,” says Dr. Ayers. “Adjusting medications often requires a time-intensive tapering process and ongoing communication with the patient’s care team. Providers in the ED can point the patient in the right direction, but often a long-term care plan is needed to address inappropriate polypharmacy.”

Dr. Ayers reviewed the effectiveness of this unique geriatric-ED-to-pharmacist model in a study presented at the American Geriatrics Society 2021 Virtual Annual Scientific Meeting.

Alarming findings in high-risk geriatric emergency patients

In a chart review, Dr. Ayers and a research team identified 308 high-risk geriatric patients evaluated by an ED geriatrician in March through December 2020. High-risk geriatric patients were defined as those age 80 or older with one of the following criteria, or age 65-79 with two criteria:

• Use of more than 10 medications.
• History of falls.
• More than five ED visits in the past year.
• Diagnosed dementia.

Of the 308 patients, 82 had been referred to Dr. Ayers for polypharmacy concerns. Patients in this cohort had been prescribed an average of approximately 15 medications and had an average Charlson Comorbidity Index score of 7.7.

As of December 2020, 46 patients (56%) had completed at least one visit with Dr. Ayers. She reported that of these 46 patients:

• Approximately one in five had a problem accessing their medication. Some couldn’t afford their medication or didn’t know how to get it from the pharmacy. Some didn’t know there was medication waiting for them at a pharmacy.
• Approximately one in two had at least one medication deprescribed. One patient had nine medications deprescribed.
• Approximately 90% were taking at least one medication incorrectly. “This was alarming,” says Dr. Ayers. “Our findings reinforced that there is a lot of opportunity to optimize medications for high-risk older adults, specifically in educating them about appropriate usage.”

Effective model of care

While small, this study did indicate that ED referral to a geriatric pharmacist for medication management is an effective model of care. The next step is studying a larger cohort of patients, starting with increasing the percentage of patients who follow through with geriatric pharmacy visits when referred.

“We need to remove barriers to scheduling and attending follow-up appointments,” says Dr. Ayers. “Once we start addressing polypharmacy issues on a larger scale, it will be interesting to see how it affects healthcare utilization, like reducing ED visits and improving overall health outcomes.”