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What is Polypharmacy

Thursday, June 4, 2020

According to the World Health Organization, approximately one out of every nine people in the world is over the age of 60 years. By the year 2050, the proportion of elderly individuals is expected to rise to one out of every five individuals. Throughout the world, chronic diseases have created significant challenges in healthcare as elderly populations globally struggle with chronic diseases including:

 

●       Heart disease

●       High blood pressure

●       Diabetes

●       Renal disease

●       Arthritis

●       And more

 

Doctors often prescribe multiple medications to elderly patients to treat one or more chronic diseases which means that many older patients today take two or more prescription and/or over-the-counter medications daily. Though there’s no agreed-upon definition of polypharmacy or over-medication, studies have shown that  the use of more than one medication can lead to poorer health outcomes, adverse drug reactions, and a generally lower quality of life in elderly individuals.

 

Among elderly populations worldwide, the average number of medications taken daily averages between 2 and 9 and the prescribed use of inappropriate or unnecessary medication by the elderly has been calculated to be somewhere between 11.5% and 62.5%. As such, polypharmacy represents not only a major health risk, but also a major expenditure for families and for society. Caregivers who work directly with patients can provide a safeguard against the risks of polypharmacy if they know what to look for and how to prevent this problem.

 

Home care aides, nurses, friends, and family members can all play an important role in the prevention of polypharmacy by watching a patient closely whenever a new medication is prescribed and noting changes in the patient’s overall health and mental or emotional well-being if changes occur. Every drug on the market causes a different list of possible side effects and adverse reactions and often, when two or more drugs are prescribed, they can interact negatively to cause symptoms that mimic diseases and disorders like dementia, insomnia, Parkinson’s disease, arthritis, and more. It can be virtually impossible to tell the difference between the side effects caused by a drug and the emergence of a new disease. Anytime a new drug has been prescribed, a patient’s family, friends, and caregivers all play a role in speaking up at doctor’s offices, pharmacies, and other healthcare visits to alert healthcare professionals about the possibility that polypharmacy is the cause of the patient’s distress.

 

Once referred to as the “drug treadmill”, the problem of polypharmacy has many names today. Some doctors refer to it as a “prescribing cascade” and the lack of a strong definition of this problem and a widely recognized term to define it makes it hard for healthcare professionals to discuss it and identify it correctly. Indeed the term “polypharmacy” is not well-known in the general population and so the problem of over-medication and the prescription of unnecessary or inappropriate medications is often overlooked as a potential problem by caregivers and loved ones. When a patient develops cognitive problems mimicking dementia, the idea that a simple and elegant solution to the problem exists to cure the patient never occurs to family members or caregivers. And overworked doctors who don’t have a full list of the patient’s medications that have been prescribed by specialists and other physicians in other fields, are likely to overlook the possibility of polypharmacy as the cause of serious symptoms and instead order tests for dementia that don’t screen for the possibility of negative drug interactions or drug side effects and adverse reactions.

 

While elderly patients may not be able to do research or ask questions on their own to find out whether they’ve been prescribed a medication that’s having a negative effect on their health, home care aides and other caregivers can fill this role and do a tremendous service to patients. Some hospice workers have noted that up to 25% of all patients who have been pronounced terminally ill will recover when all of their supportive medications are discontinued. Though these reports are anecdotal, they function as a warning and a wake-up call to patients, family members, and caregivers to perform monthly reviews of medications that are being given to elderly individuals. Doctors may not have time to adequately research prescription medications before prescribing them for potential drug interactions so patients and caregivers should double check for drug-interactions themselves and ask for second opinions from other doctors as well as pharmacists. The use of inappropriate and unnecessary medications not only diminishes a patient’s quality of life, but also have a negative impact on the patient’s finances so asking questions, doing research, and following up with primary physicians about the possibility of polypharmacy is often worth the time and effort.

What is polypharmacy?

Polypharmacy is the use of multiple prescription and non-prescription medications due to the presence of multiple illnesses. It is especially common among older individuals. Scientists disagree about the exact definition of polypharmacy. How many medications are too many medications? When elderly patients have been diagnosed with multiple illnesses (multi-morbidity), it is common for them to take a number of different meds and in some cases, the medications benefit the patient and do not cause any problems.

 

But therapeutic management of different disease-states is complex and it requires coordination among doctors, nurses, and other caregivers. Indeed, when an individual has been diagnosed with more than one disease, health outcomes are often negatively affected in part because prescription medications that are used to diminish the symptoms of one disease can create negative side effects that in turn may adversely affect the patient’s general health.

 

As a rule, multimorbidity decreases a patient’s quality of life, and it increases the frequency of hospitalization and it can even lead to premature death. The use of multiple medications, which is commonly called polypharmacy (whether it causes adverse reactions or not), may play a significant role in the problems associated with multimorbidity in elderly populations. Drug-drug interactions can cause harm to young patients, but in older populations with decreased kidney and liver functioning the potential for harm is even greater. Elderly individuals already suffer from lower lean body mass, reduced vision, reduced hearing, and mobility and cognitive decline. As a result, issues related to polypharmacy may be hard for caregivers to tease apart from the normal process of aging.

Why is polypharmacy dangerous?

Polypharmacy is dangerous because negative drug-drug interactions can kill patients! It is also dangerous because the use of multiple medications to treat symptoms of disease can actually cause the patient to become sicker. Indeed, when a patient is prescribed more than one medication, the intended outcome is always to help relieve symptoms of disease, but, in fact, the interactions of medications can actually cause the appearance of new symptoms that mimic common diseases.

 

The term “polypharmacy” was coined to reflect the fact more medications are being used to treat the patient than what is clinically indicated. Some doctors and patients refer to “polypharmacy” as “the drug treadmill” or “prescription cascades” and the progressive need for additional medications over time to treat the side effects caused by the medications the patient is already taking.

 

The elderly population is in a particularly dangerous situation in regard to polypharmacy because their bodies are not able to process the negative effects of drugs in the same ways as younger individuals. And often, elderly individuals have multiple health issues that require the use of multiple medications.

Who is at risk for polypharmacy?

Though anyone who has been diagnosed with multiple illnesses requiring medication can be at risk of polypharmacy, elderly individuals are at the highest risk. Most of the elderly population takes more than one drug to treat multiple health issues. They may see several different doctors who specialize in treating different diseases and disorders and these doctors may prescribe medications to the patient without realizing that the patient is taking a drug that interacts negatively with the new prescription. Often, doctors don’t communicate with each other about the drugs they prescribe to an individual patient. Patients, caregivers, and family members should assume that if multiple doctors have prescribed medications to a patient, that there is a high probability that negative drug interactions could be causing distress to the patient.

 

Caregivers who work directly with patients and are aware of the dangers of polypharmacy are in a position to identify negative side effects and drug-drug interactions that can lead to distress and illness in elderly populations. While doctors, pharmacists, and other members of the patient’s healthcare team may fail to identify the dangers of polypharmacy for a particular patient, caregivers may notice strange behaviors, the emergence of new symptoms, and other signs of polypharmacy when a new drug is introduced.

 

An example of polypharmacy is an elderly patient with insomnia. An 87-year old patient was prescribed amitriptyline at 50 mg to be taken at bedtime. The patient adhered to the treatment schedule and began to experience gastrointestinal problems including constipation and urinary incontinence. The patient was taken to a general practitioner who referred her to a urologist for further tests. No one in the patient’s family or on the patient’s caregiving team mentioned the new prescription of amitriptyline to the urologist who then prescribed oxybutynin. Both oxybutynin and amitriptyline can cause constipation, dizziness, dry mouth, and vision changes. Additionally, oxybutynin can cause drowsiness and difficulty sleeping. The patient returned home with the new oxybutynin prescription and proceeded to take it according to the doctor’s guidelines along with the amitriptyline. The patient then began to have difficulty sleeping and as a result, she experienced extreme drowsiness during the day as well. As a result of the sleep problems the patient started experiencing along with dizziness and difficulty seeing, the patient appeared to be having cognitive issues. Her behavior changed and she became very depressed. Family members considered the possibility that she was experiencing age-related cognitive decline when in fact, she was merely experiencing the effects of polypharmacy.

 

Polypharmacy is the use of either unnecessary or inappropriate meds to treat symptoms that are actually nothing more than the side effects of drugs or the side effects of negative drug interactions. The over-prescription of medications or the inappropriate prescription of medications can lead not only to the development of major health issues, but it also results in a lack of adherence to the medication regime, and over-expenditure on medications over time. A patient like the one described above may end up taking 6 to 9 medications as a result of the side effects caused by the amitriptyline for insomnia. An astute caregiver will take note of issues related to polypharmacy and bring them to the attention of doctors, pharmacists, and caregivers.

 

What are the signs of over medication?

Over-medication or polypharmacy is a big concern for elderly populations. Often, elderly individuals react differently to over-medication than younger individuals because their bodies experience metabolic changes that can make it more difficult for them to clear drugs from their systems. And often, elderly individuals are prescribed multiple medications to take for multiple diseases. The use of multiple medications further increases their risk of over-medication.

 

Signs and symptoms of over-medication and polypharmacy are diverse. One scientific study noted that among elderly populations, polypharmacy was highly correlated with increased risk of hip fracture. Depending on the drugs that have been prescribed to the patient, signs and symptoms may affect multiple organ systems in the body such that the patient displays gastrointestinal, cognitive, circulatory, urogenital, or even sexual behaviors or symptoms. Because of the vast array of different drugs that could be prescribed to an elderly individual, it’s impossible to say exactly what symptoms an over-medicated individual might display. Caregivers and family members should be on the lookout for any newly emerging signs or symptoms that take shape after the patient is prescribed one or more new medications.

 

Prescribing Cascades

 

Polypharmacy may lead to what scientists refer to as “prescribing cascades”. A prescribing cascade occurs when an adverse drug reaction is misdiagnosed as a disease and a new drug treatment is prescribed that further compounds the problem by creating new adverse drug reactions that are masquerading as symptoms of disease. For elderly individuals, the most common adverse drug reactions may look a lot like the normal aging process.

 

Mathematically, it makes sense that as the number of drugs taken increases, the risk of polypharmacy and over-medication increases. But despite the mathematical logic underlying this thought, it remains true that over-medication can occur even when the patient is only taking two medications. If a patient with heart disease is given one medication that causes joint problems, physical weakness, and a sleep apnea and a doctor prescribes medication to treat these adverse events, thinking that the patient has developed arthritis and dementia (due to a lack of healthy sleep caused by an apnea), the patient may experience further adverse events caused by the new medication. Over time, it’s likely that the patient will be less likely to comply with his medication administration schedule and experience a poorer quality of life as a result. The unnecessary drug expenses put a burden not only on the patient and family members, but also on society.

 

Dry Mouth

One of the most commonly reported adverse effects caused by over-medication is dry mouth (xerostomia). Below is a list of commonly prescribed drugs that can cause dry mouth (note that this is not an exhaustive list):

 

●       Cardiovascular medications such as calcium channel blockers and diuretics

●       Anti-psychotics

●       Anti-depressants

●       Central analgesics

●       Anti-allergy medications

●       Sedatives

●       Anti-Parkinson’s medications

●       Antacids

 

Though a dry mouth may seem like an inconsequential symptom of polypharmacy, it can lead to dental issues that can be costly and that can ultimately cause a diminished quality of life for patients. Caregivers and family members should note the presence of dry mouth and bring it to the attention of the patient’s primary care physician along with a list of the pharmaceuticals (both over-the-counter and prescription) vitamins, minerals, and herbal supplements that the patient is taking.

Dementia

Though many doctors, nurses, family members, and home care aides have provided anecdotal evidence that signs and symptoms of dementia may often actually be the result of polypharmacy, only a few scientific studies have been conducted to verify these reports. Dementia is a growing concern among elderly individuals and polypharmacy and prescribing cascades have been implicated as a possible cause of the disease for some patients.

 

One scientific study in South Korea showed that the odds that a patient would be diagnosed with dementia increased significantly as the number of prescribed drugs increased. This study also assessed the relationship between comorbidities or the presence of more than one disease and the risk of being diagnosed with dementia. Significant drug interactions were particularly prevalent in patients who were diagnosed with two or more of the following diseases:

 

●       Depression

●       All mental disorders

●       Hypertension (high blood pressure)

●       Congestive heart failure

●       Chronic Obstructive Pulmonary Disease (COPD)

●       Cerebrovascular disease (e.g. stroke)

●       Diabetes

●       Hemiplegia

●       Peptic ulcers

●       Chronic liver disease

 

Anytime potentially inappropriate medications are prescribed to patients, the risk that a patient will experience cognitive issues is increased. Prolonged exposure to polypharmacy may result in dementia so it is vital that home care aides, nurses, doctors, family members, and everyone on a patient’s caregiving team pay close attention to the role of polypharmacy in the development of cognitive impairments.

How can polypharmacy be prevented?

 

Polypharmacy can only be prevented by staying informed and asking questions. When patients aren’t able to stay informed and ask questions, family members and caregivers must do this job for them. The patient should always have a list of their medications, dosage, and the administration schedule with them whenever they visit a healthcare provider. Often, patients see several different doctors to treat different illnesses and these doctors may not communicate with each other or even know about each other. When this happens, medications may be prescribed that interact negatively to cause health issues that appear to require a new diagnosis and new medications.

 

Asking Questions and Getting a Second Opinion

 

Some doctors may be more in-the-know about certain medications than others depending on their specialty. So, when patients and caregivers ask a doctor about the possibility that polypharmacy is the cause of certain signs and symptoms, they may reject the idea. Ask more than one doctor about negative drug interactions to get secondary opinions and follow-up these inquiries at the pharmacist if you want to be certain that the patient is not suffering from polypharmacy. Being assertive with healthcare providers ensures that you’ll receive the attention and information you need to prevent polypharmacy.

 

Online Resources for Checking Drug Interactions

 

In addition to asking questions at the doctor’s office and at the pharmacy, you can also do preliminary research using a Drugs Interaction Checker to look for negative interactions online. If you suspect polypharmacy, you can also do online research to learn more about each individual’s drugs’s specific side effects and adverse effects. Make a list of the side effects and adverse effects that line up with the patient’s new symptoms and ask the doctor and/or a pharmacist if the patient’s symptoms could be caused by the medications they’re taking.

 

The Comprehensive Medication Review

 

A risk assessment along with a comprehensive medication review should be done monthly by an interdisciplinary team to identify over-medication issues and possible adverse effects in patients. The use of the Comprehensive Geriatric Assessment has proven effective at reducing the use of inappropriate prescription medications and lowering drug doses in older patients. A Comprehensive Medication Review often leads to the discontinuation of medications that are either unnecessary or inappropriate. Many elderly patients experience significantly better health when they receive monthly medication reviews.

 

By identifying and avoiding over-medication, elderly populations experience better health outcomes and a higher quality of life. The comprehensive medication review is essential to prevent polypharmacy and the negative effects that it can cause patients.

 

One Drug vs. Multiple Drugs

Whenever possible, patients should be prescribed one drug rather than multiple drugs to treat a disease or disorder. If given a choice between one prescription or several to treat a given disease, patients should almost always choose to take one drug to reduce the likelihood of negative drug interactions and adverse drug reactions.

Lower Doses

 

Ideally, when a new medication is prescribed, it would be best to start with the lowest possible dose of the medication. Dosage can be increased incrementally over time, as needed. Drugs that are administered more than one time per day are preferable over those that are administered just once a day.

 

Drug Discontinuation

 

Any drugs that seem to be causing problems should be discontinued. Often, drugs are prescribed to treat the side effects or adverse events caused by other prescribed medications. When this is the cause, any drug that has no therapeutic benefit except to treat the side effects of another drug should be eliminated. The drug causing the negative side effects and adverse events should be changed or eliminated as well. Whenever possible, the use of safer drugs or non-pharmaceutical treatments would be ideal.

How is polypharmacy treated?

Polypharmacy is treated simply by reducing or eliminating prescription drug use in patients who have been given medications that cause unwanted side effects. In some cases, this can be challenging if patients have been diagnosed with a disease that is difficult to treat or for which there are few medications to choose from. But whenever possible, caregivers, healthcare providers, and patients should look for symptoms of adverse reactions from drugs and note changes in the physical, mental, or emotional well-being of patients when new drugs are added to the medication schedule.

 

Symptoms of polypharmacy will vary depending on the type of illness and the specific drugs that have been prescribed to the patient, but any change in the patient’s psychological or cognitive well-being should be noted when a new drug is added to a regimen. And patients who suddenly experience declining health in any area of their lives after the addition of a new drug to their medication schedule should be evaluated by a doctor to determine whether or not the problem is the result of polypharmacy. Families and caregivers who are not satisfied with the evaluation of their doctor may consider double-checking with a pharmacist or get a second opinion about the possibility of negative drug interactions and polypharmacy as the cause of the patient’s distress.

 

Though treating polypharmacy is often as simple as decreasing the number of medications prescribed or changing the prescribed medications, the difficulty is in identifying the problem in the first place. Home care aides and other caregivers who work directly with the patient on a daily basis are the ones most likely to notice the ill-effects of polypharmacy. Treatment begins with identification of the problem by front-line caregivers. Proper care entails a discussion with a prescribing doctor who acknowledges the possibility of negative drug-drug interactions and side effects that are causing the appearance of illness in a patient.

 

Many of the symptoms of polypharmacy unfortunately mimic the symptoms of common diseases associated with aging. Below is a list of common symptoms of polypharmacy:

 

●       Diarrhea

●       Constipation

●       Incontinence

●       Loss of appetite

●       Skin rash

●       Fatigue/lethargy/tiredness

●       Physical weakness

●       Tremors

●       Reduced alertness

●       Anxiety

●       Excitability/jumpiness

●       Depression

●       Lack of interest in usual activities

●       Insomnia

●       Visual or auditory hallucinations

●       Confusion

●       Dizziness/vertigo

●       Joint pain

 

The most important thing that caregivers can do to prevent polypharmacy is make sure that the patient’s doctor has an up-to-date list of all medications the patient is currently taking. This list should include not only the name of each medication, but also the dosage, and administration schedule. Include not only prescription, but also over-the-counter medications, vitamins, and herbal supplements on this list. This list should always accompany patients whenever they visit a doctor or healthcare provider. Update the list each time the patient is prescribed a new drug.

How many medications is considered polypharmacy?

Scientists and doctors have not yet agreed on the number of medications that are considered polypharmacy. Some sources say that the use of 3 or more medications defines polypharmacy because the first drug is prescribed to treat one diagnosed illness and a second drug is prescribed to treat a second diagnosed illness. The third drug, in contrast, is prescribed to treat side effects caused by either the first drug, the second drug, or the negative interaction of the two drugs together. In practice, however, the first drug by itself can cause side effects that lead to the appearance of a new disease state.

 

Some patients take many different medications and experience no adverse effects while other patients are at risk if they take only two medications. The real problem with polypharmacy is the mixture of different types of drugs and how one type interacts with another type. Because negative drug-drug interactions are a common occurrence among patients who take more than one medication, caregivers must be on the lookout for drug interactions even if the patient is only taking two different medications.

 

How can aides help in the prevention of polypharmacy?

 

Any patient who has recently been hospitalized, who has been prescribed medication by multiple doctors, or who purchases their prescription medications from multiple pharmacies is at risk of suffering the negative effects of polypharmacy. The use of multiple medications is not itself the problem. Not all patients have a negative reaction to taking multiple medications. But home care aides who notice a change in the patient’s health or behavior following the prescription of a new medication should speak with the patient’s doctor to make sure that there aren’t negative drug-drug interactions causing the patient distress.

 

As a caregiver, if you suspect that a patient is experiencing polypharmacy and adverse drug-drug interactions, speak to a pharmacist or the patient’s doctor and provide them with a list of all medications the patient is taking no matter who the prescribing physician is. Home care aides work with patients every day and have first-hand experience with the patient’s normal habits, general level of well-being, and their typical behaviors. When there is a change in the patient’s physical, mental, or emotional health, home care aides should consider polypharmacy as a potential cause if the patient’s medications have recently changed or if the patient has recently returned home from the hospital. If you’re a new caregiver and you notice that a patient is taking more than one medication and experiencing distressing health issues, consider mentioning polypharmacy and the possibility of over-medication at the patient’s next doctor visit.

 

Home care aides are in the unique position of being able to observe the patient’s daily habits including both daytime and night-time rituals and behaviors. Daytime tiredness and lethargy may be caused by sleep apneas, insomnia, or restless legs syndrome or or distressing issues that are caused by drugs that were designed to treat other problems like heart disease, depression, or anxiety. The inability to sleep at night may be caused by a drug that’s used to treat gastrointestinal problems or cardiovascular problems. A patient who is taking a drug that affects their appetite may begin to experience nutritional deficiencies that could lead to issues such as vision problems, dental problems, mental health issues, heart problems, skin problems, and more. By merely observing changes in the patient’s behavior, health, and well-being and reporting these changes to family members and doctors, home care aides can prevent years of unnecessary anguish or even the development of much more serious disease states in the patients they care for. Identifying polypharmacy is one of the most important aspects of caregiving currently affecting the aging population. Learning to identify it can literally save lives.

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