Polypharmacy and the Elderly Patient

By Natalia Tarasiuk, PharmD with Marigel Constantiner, RPh, MS, BCPS, CGP

As the U.S. population ages, a greater number of older individuals are experiencing chronic illness. With these conditions comes the need for medications. Beyond prescription drugs, many people also take over-the-counter medications, vitamins and supplements, all of which increase the physical burden associated with taking different substances.

What is Polypharmacy?

Polypharmacy can be defined simply as taking more than five medications, or it can be described as the use of inappropriate medications. Common examples of inappropriate medication usage include the use of medications without appropriate therapeutic indications, multiple medications used to treat the same condition, use of interacting medications, inappropriate medication dosage, and the use of medications to counteract the side effects of another medication (also known as the prescribing cascade).

Increased drug consumption is more harmful to the aging population due to altered pathophysiology. Older individuals are more susceptible to anticholinergic side effects, orthostasis, cognitive changes, increased risk of falls, and difficulty with medication adherence. These effects predispose the elderly to medication-related problems. A multidisciplinary healthcare team can work together to effectively manage polypharmacy in this population.

How Can We Manage polypharmacy?

Awareness is the first step, because preventing polypharmacy is the most effective way of managing patients. We need to be proactive rather than reactive in addressing it. This means having pharmacists play an active role by providing medication reconciliation, medication therapy management services, and face-to-face patient counseling. It is also advised that physicians perform pharmacy medication reconciliation at every patient visit to identify appropriate-use criteria. This gives doctors the opportunity to educate patients and improve medication adherence.

Pharmacists are uniquely positioned to provide guidance in appropriate prescribing practices, medication review and monitoring, and patient education. In Ohio, the passage of Ohio House Bill 188 in December 2015 expanded the role of the pharmacist to include initiation and discontinuation of medications through a consult agreement. This allows appropriate de-escalation and optimization of therapy in patients who are followed by a pharmacist. Although collaborative practice agreements are common and widespread across the U.S., Ohio law is now in line with 30 percent of the most progressive states in the country. Each state has specific guidelines and nuances; therefore, reviewing your specific state board of pharmacy laws is important to knowing if collaborative drug therapy management is an option.

Are There Tools to Help Reduce Polypharmacy?

Balancing the risks and benefits of medication use is more of an art than a science, but various tools are found in the literature for effective medication use. Two tools for pharmacists and all healthcare providers in a clinical setting include the American Geriatrics Society (AGS) Beers

Criteria and the Anticholinergic Cognitive Burden (ACB) scale. These tools should be utilized before prescribing a medication for the first time as well as at subsequent visits to ensure continued appropriateness of therapy.

The AGS published an updated “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” in November 2015. This list is readily available online and provides evidence-based recommendations on drugs to be used with caution, drug interactions to avoid, drugs to be avoided with kidney impairment, and drugs with highly anticholinergic properties. This recent update expanded into the community setting and also may be helpful for outpatient primary care providers and geriatricians.

The ACB scale is a tool that can be used to identify drugs in a patient’s medication regimen that may affect cognition due to their anticholinergic properties. Drugs in a patient’s regimen are given a score of 1, 2 or 3 based on possible or definite negative cognitive effects due to blood-brain barrier permeability. The cumulative score represents the overall anticholinergic burden of the patient’s medication regimen.

These two tools highlight commonly misused medications in older patients. Examples include diuretics, nonsteroidal anti-inflammatory agents, antiplatelet/anticoagulant medication, antidiabetic agents and antipsychotics. Nonprescription medications are often overlooked. Over-the-counter medications and herbal supplements should always be reviewed and evaluated with patients. These supplements may interact with other medications and are not quality tested to verify safety and efficacy.

To conclude, there needs to be a collaborative relationship between the healthcare team, patients and all caregivers in order to reduce the implications of polypharmacy. Providers are responsible for appropriate diagnosis, prescribing and education, while patients are responsible for being honest and adhering to the prescribed regimen.

A Pharmacist’s Tips on Polypharmacy Management

1) Visually inspect patient’s medications at every visit

2) Perform medication reconciliation

1. Ensure dose, frequency and route are appropriate
2. Evaluate if timing is appropriate (i.e., in regard to meals, separation of doses)
3. Ensure medical indication still exists, and eliminate medications no longer necessary
4. Evaluate Beers Criteria and ACB scale
5. Inquire about side effects

3) Identify drug interactions, fall risk medications, swallowing risk medications

4) Ask about over-the-counter medications and herbal supplements

5) Educate patient and caregiver regarding safe medication use

1. Ensure patient understands indication for all medications
2. Review common side effects to expect
3. Encourage patient to fill all medications in one pharmacy
4. Review disposal of inappropriate or expired medications
5. Discourage use of self-medicating with nonprescription/herbal supplements (including vitamins) without prescriber’s advice

Natalia Tarasiuk, PharmD, is an ambulatory care pharmacy resident at Cleveland Clinic’s main campus. She can be reached at tarasin@ccf.org or 216.442.5542.

Marigel Constantiner, RPh, MSc, BCPS, CGP, CPh, is specialized as a drug information pharmacist and preceptor at Cleveland Clinic with a special interest in geriatrics. She can be reached at constam@ccf.org or 216.444.1126.

References

U.S. Department of Health and Human Services, Administration on Aging. Aging statistics. Administration on Aging. http://www.aoa.acl.gov/aging_statistics/index.aspx

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015

House Bill 188. The Ohio State Legislature. https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA131-HB-188

Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.

American College of Clinical Pharmacy, McBane SE, Dopp AL, et al. Collaborative drug therapy management and comprehensive medication management-2015. Pharmacotherapy. 2015;35(4):e39-e50.

Pasina L, Djade CD, Lucca U, et al. Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: results from the REPOSI study. Drugs Aging. 2013;30(2):103-112.