Managing your Medications: Raising Awareness about Polypharmacy
By Brian A. Hemstreet, PharmD
Assistant Dean for Student Affairs and Professor
CU Skaggs School of Pharmacy and Pharmaceutical Sciences ~
As patients age, often there are situations where multiple medications are prescribed for several different health conditions. The multiple medications by an individual is often referred to as polypharmacy.1 While there is no universal definition of polypharmacy, the most common description is either the concurrent use of at least 4 or 5 medications by a patient, or the use of more medications than is clinically indicated.1,2
While the use of multiple medications may be justified, polypharmacy may place patients at risk for adverse outcomes. This may include an increase in drug-related side effects, potential interactions between different drugs, and the use of potentially inappropriate medications based on their healthcare conditions.1-3 As the number of medications in patient’s regimen increases, the ability of patients to accurately take their medications may also decrease, resulting in potential loss of effectiveness.1,2 Age-related changes in drug metabolism may also impact the dose and frequency that medications should be administered. Serious consequences, such as increased risk of falls, hospitalizations, and death may occur as a result of polypharmacy.1, 3-5
There are several contributing factors to the development of polypharmacy. As medical and drug treatments have improved, increases in lifespan have resulted in patients living longer with multiple health conditions. Many conditions, such as high blood pressure, diabetes, and heart disease, may require the use of multiple medications to optimize their control.1-4 Patients may see multiple healthcare providers, who may be prescribing medications for these conditions. In addition, medications may be added to treat side effects of other medications, or may be inappropriately continued following an episode of hospitalization.1,2 Medications may also be added as preventative measures for various conditions, such as heart disease and constipation.
While the use of multiple medications is often required in older adults, some strategies may be beneficial in minimizing the risks from polypharmacy. Capitalizing on opportunities to assess a patient’s healthcare status and review their medication regimen is a good first step.5 This should occur during each annual healthcare visit, and during transitions of care from one setting to another, such as from the hospital to the patient’s home. Reassessment of patient risk factors for certain conditions may be performed at this time as well and may help to guide drug therapy recommendations.
Assessing for use of nonprescription medications and herbal or complimentary products should be performed, as these products are often not documented on patient’s medication lists but may carry similar risks to prescription medications. The patient’s pharmacist is often in a good position to facilitate this medication review process, as patients often get their medications from one pharmacy.4,5 Ensuring that each healthcare provider the patient sees has an accurate list of the patient’s current medications, and that changes in healthcare status are communicated amongst each provider, will ensure a good team approach to optimizing the medication regimen.4,5
It is also important to actively engage the patient and their caregivers in discussion regarding current health and functional status, goals of therapy, and quality of life. The patient’s preferences and motivations should be taken into account as part of this process. This will help establish realistic expectations for outcomes related to medication use, especially those used for disease prevention. 1,3
Prescribers should also strive to use evidence-based decision making when considering adding a medication for a given condition. This will ensure patients are receiving the maximal potential benefit based on the treatment evidence, and that patients are aware of the risk and benefits. Ultimately, systematic de-prescribing of select medications for which the benefit is unclear or risk is too great may be possible, especially if the medication regimen has become too complex for the patient to maintain adherence.3 Non-drug measures, such as diet and exercise, may also help to prevent and treat some conditions and lower the overall reliance on medications. Patients may benefit from seeking the help of other experts in these areas, such as dietetics, physical therapist, and personal trainers.
Realistically, many patients may ultimately require multiple medications for effective treatment of their healthcare conditions. Overall, the goal of addressing polypharmacy is to ensure the safe and appropriate use of these medications. Patients and caregivers should take an active role in addressing questions and concerns about their medications. Likewise, the patient’s healthcare team should seek to have good lines of communication with each other, and ensure they have the most up to date information about the patient’s medication regimen. While continually reassessing medication use and identifying potential medication related problems may be a complex process, this will hopefully result in overall improvements in quality of life and outcomes, and minimizing potential harm from polypharmacy.
1. Wastesson JW, Morin L, Tan ECK, Johnell W. An update on the clinical consequences of polypharmacy in older adults: a narrative review, Expert Opinion on Drug Safety, 17:12, 1185-1196, DOI: 10.1080/14740338.2018.1546841
2. Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD008165.DOI: 10.1002/14651858.CD008165.pub4.
3. Ammerman CA, Simpkins BA, Warman N, Downs TN. Potentially Inappropriate Medications in Older Adults: Deprescribing with a Clinical Pharmacist. J Am Geriatr Soc 67:115–118, 2019.
4. Evidence supporting the best clinical management of patients with multi-morbidity and polypharmacy: a systematic guideline review and expert consensus. J Int Med;2019;285:272–288.
5. Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. JAGS 2019; 67:1123–1127.