Download Biren Patel King`s College London 1 Community Care for Older

Biren Patel
King’s College London
Community Care for Older People
Polypharmacy: Implications for the Older Population
Introduction
Definitions of Polypharmacy
Prevalence of Polypharmacy
Causes of Polypharmacy
Consequences of Polypharmacy: Adverse Drug Reactions
Drug-Drug Interactions
Medication Errors
Non adherence
Interventions to Reduce Polypharmacy in Older Patients
Morden College: A Unique Nursing and Residential Home
Conclusion
Total pages: 18
Figures: 4
Words: 6119
1
Biren Patel
King’s College London
Polypharmacy: Implications for the Older Population
Introduction
Life expectancy in the UK has been increasing over many years. The population of the over 65’s is set to
increase by two thirds to reach 15.8 million in 2031. The population of the over 85’s has doubled since 1983
to 1.3 million in 2008 and is estimated to further increase by 131% in the next twenty years (1). From a
medical and pharmacological perspective as people age they often develop multiple illnesses that are often
treated with multiple medications. This concept of polypharmacy, literally meaning the use of many drugs, is
a serious issue that needs addressing because of its many negative health consequences in the older
population (2-4).
As part of researching the issue of polypharmacy in the older population, I had the good fortune of spending
several days at Morden College, a long standing charitable organisation situated in Blackheath, Greenwich.
It provides residential care for the elderly consisting of accommodation in close proximity to a health centre.
The health centre is staffed by nurses and 2 GP’s who work there a few days a week. An on site
physiotherapist is also available and together the team provides support to the older residents of the college
compound. Furthermore an on site nursing home is also available for those residents of the college who
require basic medical treatment and nursing care (5). During my time at Morden College, I had the
opportunity to speak to both independent older residents living in the college compound as well as staff and
patients in the nursing home. I will include some of the valuable information that I gained from them in this
report.
Definitions of Polypharmacy
The literal meaning of polypharmacy is the use of many medications (2) and this is probably the common
definition amongst healthcare professionals. Bushardt et al investigated this issue further and found that no
consensus definition of the term exists in the medical literature (6). Some authors have placed a numerical
value on the number of concurrent medications used by patients. Some authors have stated that
polypharmacy is the concurrent use of more than one drug and that minor and major polypharmacy is the
use of 2-4 and ≥5 drugs simultaneously (7). On reviewing 11 studies Bushardt et al concluded that the most
common numerical definition cited was the concurrent use of ≥ 6 medications (6).
Simply accepting a numerical definition of polypharmacy has the disadvantage in that it fails to recognise
that in some cases the combination use of certain medications is beneficial to the older patient. Older
people commonly suffer from chronic diseases such as coronary heart disease, diabetes, hypertension,
2
Biren Patel
King’s College London
congestive heart failure and COPD or a combination thereof. These often necessitate the use of multiple
drugs including aspirin, beta blockers, ACE inhibitors, statins and diuretics which have all proven to be
beneficial (8). Since a numerical definition does not take into account the adequacy of the drug regime it is
often useful to sub define polypharmacy as appropriate or inappropriate polypharmacy.
Appropriate polypharmacy is the use of several medications all of which have indications and hence are
appropriate for use. In some cases older patients may simply require several medications and hence it may
be difficult to reduce the overall number. Rather it would be more beneficial to ensure that the prescription is
appropriate. Inappropriate polypharmacy is when the patient takes more drugs than are clinically indicated
(4). Besides numerical definitions Bushardt et al found that the term polypharmacy was also used to indicate
those situations where the “medication did not meet diagnosis” and where there was “inappropriate drug
use” (6). Both definitions are more or less similar since using a drug where a diagnosis and hence indication
has not been established is potentially inappropriate. Other connotations of polypharmacy include drug
regimes where patients are exposed to potential drug-drug interactions (DDIs), prescribing cascades
whereby drugs are used to treat the side effects of other drugs and inappropriate dosing and duration of
medications (3,6).
The use of many definitions makes it difficult to compare those studies aiming to reduce polypharmacy
amongst older patients. This is because the outcomes are different and may include reducing the overall
number of drugs, reducing inappropriate drugs or reducing DDIs. This then makes it more difficult to
compare the interventions due to the variable outcomes. It is no wonder that Bushardt et al have suggested
that the term polypharmacy should no longer be used. They suggest that the term “hyperpharmacotherapy”
be used since it indicates the use of excessive drugs to treat disease (6). During the course of this report the
word polypharmacy will be used in its numerical sense and will not be synonymous to inappropriate drug
use.
Prevalence of Polypharmacy
Older people in the UK make up some 18% of the population and yet consume 45% of all prescription
medication (9). This along with the fact that many older people are on long term medication emphasises the
need to optimise their drug therapy.
In a Europe wide study investigating the use of inappropriate drug use amongst patients ≥65 receiving home
care, Fialova et al found that 51% of the overall study population (n=2707) were taking ≥6 drugs and that
22% were taking ≥9 drugs. Figures for the UK subpopulation of patients (n=289) was 48% and 20%
respectively. Using the Beer’s Criteria 2003 -which lists various drugs that are deemed inappropriate for use
3
Biren Patel
King’s College London
in older people- it was found that 17% of the entire study population and 13.5% of the UK group used at
least one inappropriate medication. The authors also noted that those patients taking ≥6 drugs were almost
2 times more likely to be taking an inappropriate drug (10). A worrying statistic was that 56% of the UK
group had not had a medication review by a doctor in the preceding six months (10) putting them at risk of
inappropriate drug use. Other studies have shown that age seems to be a predictor of polypharmacy since
those between 75-95 years of age are more likely to be taking ≥5 prescription drugs compared to those
between 65-75 (9).These studies confirm the high prevalence of polypharmacy in the community and
especially amongst the eldest of the old. The high prevalence on its own does not indicate whether the drug
regimes are appropriate or inappropriate. However data from Fialova et al does show a link between
polypharmacy and inappropriate drug use and hence highlights the need for doctors to optimise their
patients’ medication.
Data for the prevalence of polypharmacy in nursing homes and hospitals is somewhat sparse. One US
study found that on average patients in a particular nursing home took 6 to 8 medications concomitantly (4).
Mamun et al found that almost 60% of the patients in 3 nursing homes (n=454) in Singapore were taking ≥5
medications and that a substantial 70% of patients were taking at least one inappropriate medication
according to Beer’s list 1997. A cause for concern is that of all patients taking inappropriate medication,
almost a third were classed as being completely dependent for all aspects of care (11). This figure highlights
that the practice of inappropriate drug prescription often targets the most vulnerable of elderly patients who
are potentially most susceptible to the adverse side affects of such drugs.
Causes of Polypharmacy
Doctors have long been blamed for prescribing inappropriate and multiple drugs to older patients. In fact up
to 75% of all GP visits may end with a prescription being issued (12). Tamblyn et al investigated the
prevalence of inappropriate medication prescriptions amongst a group of older Canadian residents (n=62
917) and found that those with four prescribing doctors were almost 3 times more likely to be taking two
cardiovascular drugs that could interact and 2 times more likely to be taking psychotropic drugs that could
interact (13). The data implies that too many doctors involved in a patient’s management can lead to
increased exposure to potential DDIs. Whether this is due to the doctors themselves or because of a failure
in the communication system between physicians is a separate issue. However the fact that interventions
such as frequent medication reviews by doctors or increased communication between doctors and
pharmacists can reduce the rate of polypharmacy and inappropriate drug use (4,14) suggests that part of
the fault may lie with doctors in the first place.
4
Biren Patel
King’s College London
There is also a clear association between polypharmacy and the risk of adverse drug reactions (ADRs) (15)
and it is thought that up to 80% of such reactions are treated by other medications (4). It is also possible that
doctors may interpret ADRs as new illnesses and hence issue yet more prescriptions and further increase
the pill burden for the patient (3). Repeat prescriptions can represent up to 75% of the total number of
prescriptions issued in primary care. It is common for such prescriptions to be issued without a consultation
(4). In fact 20% of prescriptions in one study were issued without a consultation with a doctor (16). Such
practice could lead to doctors not reviewing patient’s medication regularly and thus could contribute to some
patients receiving large numbers of unnecessary medication for months or years.
Patients can also contribute to their own polypharmacy. Older patients with multiple illnesses and those
suffering form medication side effects may have to be prescribed several drugs to manage their situation.
Certain drugs may have to be co prescribed to reduce the side effects of other drugs such as is the case
with proton pump inhibitors and non steroidal anti-inflammatory drugs (NSAIDs). There also seems to be a
general consensus that one should be prescribed a medication when one visits the doctor. In fact up to 50%
of patients expect something to be prescribed possibly as an acknowledgement of their illness (4). The use
of over the counter (OTC) medications can also contribute to polypharmacy. Up to 40% of OTC medications
in the US are thought to be consumed by the elderly. Other studies have shown prevalence of OTC
medication use amongst the elderly is frequently between 60% and 90% (17). Older people generally tend
to self medicate for minor aches and pains, constipation and gastrointestinal symptoms (18). Such high
prevalence of self medication by older patients has the potential to contribute to their own polypharmacy.
Consequences of Polypharmacy
“Is polypharmacy in older people always harmful?” – This is undoubtedly not true since the use of
appropriate polypharmacy has been shown to have proven benefit in the treatment of many conditions. In
fact several drugs may need to be prescribed after a myocardial infarction to reduce long term mortality and
morbidity. Inappropriate polypharmacy however can adversely affect health as well as having financial
implications. The financial consequences of polypharmacy are not just due to the increased costs of
medication but also due to the treatment of ADRs or DDIs. One author predicted the annual cost of
polypharmacy to be $76.6 billion (12). Discussed below are some of the adverse health affects that are
known to be linked to polypharmacy and inappropriate drug use in older people.
5
Biren Patel
King’s College London
Adverse drug reactions (ADRs)
Adverse drug reactions in older patients account for some 10-20% of acute geriatric admissions to hospital.
Older people are at increased risk of ADR due to numerous coexisting illnesses and decreased
physiological reserve which reduces the ability for them to deal with physiological changes (15). ADRs are
defined by the WHO as “any response that is noxious and unintended and that occurs at doses normally
used in man for diagnosis, prophylaxis or therapy, and excluding a failure to accomplish the intended
purpose” (15). Another term used in the literature is “adverse drug event” (ADE) which is defined as an
injury that occurs due to the patient’s drug regime resulting from either appropriate or suboptimal care (3).
Numerous studies have shown that polypharmacy increases the risk of ADRs in older patients (4,15). Field
et al investigated the incidence of ADEs in 18 nursing homes. Over the course of 12 months the team
identified 410 ADEs amongst the combined residents (n=2916). The most common ADEs included
neuropsychiatric changes, falls, allergic skin reactions, GI symptoms, haemorrhage and extrapyramidal
symptoms. 56.1% of the ADEs were classed as significant and included falls without fractures,
haemorrhages that did not require a transfusion, oversedation or rashes. Almost 1/3 of the total ADEs were
serious and included delirium, falls with fractures, haemorrhages requiring transfusion or hospitalisation.
These results alone illustrate the seriousness of ADEs since older patients probably tolerate ADRs less well
than the younger population. Polypharmacy (≥5 medications) was found to be an independent risk factor for
ADEs since these patients were significantly more likely (p<0.05) to experience an ADE compared to those
taking <5 medications (figure 1). A cause for concern is that more than 50% of the ADEs (226 of the 410
ADEs) were preventable and resulted from medication errors in prescribing, dispensing, administrating or
monitoring the medication (19). Such ADEs are important to distinguish from non preventable ADEs since
they allow interventions to be drawn up to reduce them.
This study highlights the need for doctors to reduce the overall number of medications if possible and that
both doctors and nurses should carefully review and administer medications to reduce the incidence of
unnecessary ADEs which needlessly cause harm to older patients.
6
Biren Patel
King’s College London
Figure 1: Independent Risk Factors for
having an ADE from Field et al. Those
taking 5-6 medications are 2 times more
likely to have an ADE compared to those
taking <5 medications. The risk
increases as the number of medications
taken increases (19).
Drug-Drug Interactions (DDIs)
As the number of medications a person takes increases it is feasible to assume that some of them will
probably interact with each other. It has been suggested that by the time a person is receiving eight
medications the chances of having a DDI is virtually 100% (4). DDIs are important in older patients since
they often consume multiple drugs and hence are potentially exposed to the most DDIs. Furthermore they
are more likely to be sensitive to ADRs (20). Many studies have shown that older people are often
prescribed medications that could interact with each other and that polypharmacy is a risk factor for such
interactions. However, only a few studies have investigated the clinical significance of such interactions (3).
It is thought that the prevalence of DDIs in older inpatients may be as high as 35-60% (4). Johnell et al
investigated the relationship between polypharmacy and potential DDIs in older people in Sweden. They
gathered data from the Swedish Prescribed Drugs Register which holds information about community drug
prescriptions for the entire population of Sweden. A substantial 60% of ≥75 year olds (n=630,000) were
taking ≥5 drugs and hence were potentially exposed to the consequences of polypharmacy. 26% of the
group had at least one clinically relevant DDI (the commonest being furesomide and enalapril) that may
have warranted dose adjustment and 5% had at least one serious DDI (the commonest being aspirin and
diclofenac) that should have been avoided (20). Since we do not have any other information it is difficult to
ascertain why such combinations were prescribed and whether this was due to clinical error or whether
these drug combinations were clinically indicated. The results also indicated a strong relationship between
the number of drugs dispensed and the risk of DDIs (20). Figure 2 shows a substantially increased risk of
clinically relevant DDIs in those taking ≥5 medications.
7
Biren Patel
King’s College London
The data from the study only provides information about potential DDIs since the group did not investigate
drug adherence amongst the residents or whether they were being closely monitored by their doctors for
ADRs. Hence it is difficult to comment on the consequences of these potential DDIs on the residents.
However the figures highlight the caution that is required when prescribing in older people and the
importance of medication review to try and discontinue unnecessary drugs in a bid to reduce potential DDIs.
Figure 2: Table from Johnell et al.
Those taking between 5-7 drugs are
almost 4 times more likely to be exposed
to a potential DDI compared to those
taking between 2-4 drugs. The risk
increases as the number of medications
taken increases (20).
Besides prescription medications, OTC drugs and herbal remedies also have the potential to contribute to
both polypharmacy and DDIs (3). It is estimated that between 60-90% of ≥65’s may be consuming OTC
(17). It has been suggested that on any one day in developed countries between 20-30% of ≥65’s use
analgesics (18). Herbal supplements are also commonly used by older patients. Dergal et al interviewed
195 older outpatients and found that 27% were either current or past users of herbal supplements. 56% of
patients were taking OTC and virtually everyone was taking at least one prescription medication with about
half taking more than one. Gingko was reported to be the most commonly used herbal medicine. This is an
important finding since gingko has the potential to increase the antiplatelet activity of aspirin and hence
increase the risk of bleeding (21). 4% of patients were found to be using gingko and aspirin together and
therefore exposing themselves to the risk of a DDI. Doctors should routinely ask their older patients about
OTC and herbal drugs alongside prescription drug use since their prevalence is common amongst this age
group and such supplements can expose older people to adverse events.
8
Biren Patel
King’s College London
Medication Errors
Older people are often faced with the task of taking several tablets at different times of the day. This can
potentially cause medication errors and probably more so for those with cognitive decline and absence of
help from family, friends or carers. Whilst having to take multiple medications such people may commit
errors such as taking the wrong tablet or dose. The term “flip flopping” has been used to describe the
situation when a patient confuses the frequencies of two medications and hence takes tablet A twice daily
and tablet B once daily when in reality it should be the opposite (3).
Pronunciation of complex medical names can also lead to medication errors. Older people often find it
difficult to pronounce the names of their tablets and refer to them by their colours or size. This is particularly
important for those who are taking several medications of which a few have similar sounding names. For
example an older patient may wrongly take Xanax® (anxiolytic) for heartburn rather than Zantac® (H2
receptor antagonist) or take nitrofurantoin (antibiotic) for their angina rather than nitroglycerin (3). Such
phonetic confusion is a serious issue as is illustrated by the fact that the Food and Drugs Administration
(FDA) reviews and rejects many new names proposed by drug companies each year due to similarity. The
best way to reduce such problems is to carry out a regular “brown bag assessment” of medications for the
most vulnerable patients whereby the physician can ensure that each aspect of the medication regime is
understood by the patient or their carer (3).
Non adherence
Adherence with medical advice is defined as “the extent to which a person’s behaviour (in terms of taking
medication, following diets, or executing lifestyle changes) coincides with medical or health advice” (22). It is
often assumed that adherence to medication decreases with age due to decreased cognitive function,
memory impairment and physical problems such as visual loss (3). Several studies have shown that age is
predictive of non adherence but others have shown this not be the case. Monane et al measured the rate of
adherence to antihypertensive medication amongst 4068 community residents ≥65 years old. Adherence
was calculated from quantity of medication that was dispensed over the course of one year. Adherence
rates were surprisingly higher amongst those >85 compared to those between 65-74 and 75-84 (23). Having
talked to some very old independent residents at Morden College I have found that such people are willing
to adhere to their prescribed medication. They feel the need to take their medication due to their multiple
illnesses and they genuinely feel that doctors are prescribing in their best interests. In the literature this type
of behaviour has been termed the “Health belief model” whereby older patients with greater severity of
illness are motivated to comply with their medication (3).
9
Biren Patel
King’s College London
The evidence for decreasing adherence rates amongst those on polypharmacy is also inconsistent.
However several large studies have shown that polypharmacy decreases adherence rates. Jackevicius et al
investigated the rate of adherence to statins in three separate cohorts prospectively over a period of two
years. The groups included those recently diagnosed with a myocardial infarction (n=22,379), coronary
artery disease (36,106) or those without coronary artery disease (85,020). Adherence was based on the
amount of prescriptions dispensed over the study period. It was found that there was a slight decrease in
the rate of adherence for each additional medication the patient was taking (24). Avorn et al has also shown
a decreased adherence to statins amongst older people taking >16 drugs (25).
On reviewing the determinants of non adherence in older people Vik et al have concluded that the evidence
of a link between polypharmacy and non adherence is inconclusive. When investigating the reported
reasons provided by non adherent patients, Vik et al reported three studies where patients felt there was “no
need to take more drugs” (22). Sometimes doctors may not realise that non adherence may actually be a
good thing. This can only be determined if the doctor investigates the reasons provided by non adherent
patients. It is very possible that patients may be experiencing ADRs or they feel that there is no indication
for a certain medication and such opinions should be noted.
Interventions to Reduce Polypharmacy in Older Patients
The Department of Health recommends in its report titled “Medicine and Older People: Implementing
medicines-related aspects of the NSF [national service framework] for Older People” that older patients
taking four or more medications, those on specific medications e.g. warfarin and those who have been
recently discharged from hospital are at an increased risk of developing medicines related problems (26). It
is therefore imperative that physicians pay extra attention to these vulnerable older patients.
From reviewing the literature it is clear that inappropriate polypharmacy can predispose older patients to
numerous consequences. This may include patients developing ADRs or DDIs or being exposed to the
consequences of medication errors. These outcomes can directly impact the health of the older patient. It is
therefore important to search for ways in which the prevalence of this practice is reduced. Whilst searching
the literature one realizes the difficulty of this task since many authors have investigated numerous
populations and interventions which themselves vary from study to study. The variable definitions of
polypharmacy that are used by different authors influence the outcome measures and endpoints which
makes it difficult to systematically review these studies. Nonetheless such systematic reviews have been
published and have provided some important conclusions (4).
10
Biren Patel
King’s College London
Large nursing homes around the UK may employ GPs to look after the health needs of older residents who
are very frail and sick. At some point a pharmacist is probably also involved in the care of such patients.
One reason for this may be because patients in nursing homes are thought to take up to four times as much
medication than those living at home (27). Hence pharmacist intervention may be potentially beneficial.
Zermansky et al investigated the impact of pharmacist intervention in a population of older residents from
nursing homes, residential homes and mixed care homes (n=661). The patients were randomized to either
receive a pharmacist led medication review or continue to receive their usual care provided by the GP at the
respective home. The pharmacist reviewed and discussed any medication changes with patients before
passing the details to the GP whilst the other group continued to be reviewed by their GP as usual.
Interestingly the review rate amongst the pharmacist intervention group was 95% compared to only 20% of
the patients having their medication reviewed by the GP (28). On discussing this issue with a GP at Morden
College I came to realize that it is practically very difficult to review every patient’s medication in a nursing
home especially when the GP has several other tasks to perform. The consequences of this particularly
affects those patients who are well and hence not seen as often by the GP who therefore has less
opportunity to review their medication (29) . It could potentially be months before their medication is
reviewed. On analysis the authors found that the number of medication changes per patient was greater in
the intervention group. No data has been provided for the actual numbers of drugs that patients were on
and hence we can not conclude the impact of such an intervention on the level of polypharmacy. However
this study highlights the importance of pharmacist intervention to make necessary changes to ensure that
the medications prescribed to a patient are appropriate. In a similar study, Furniss et al found that though
pharmacist intervention in the form of medication reviews in a group of nursing home residents did not
significantly reduce the number of medications, the pharmacists did make a number of recommendations to
ensure that patients were receiving appropriate medicines (27).
Rollason et al systematically reviewed the impact of pharmacist interventions in reducing polypharmacy in
older outpatients, inpatients and nursing home residents. The interventions were variable and included
either sole intervention by a pharmacist, pharmacist intervention leading to recommendations to a doctor
and pharmacists working alongside doctors in an interdisciplinary team to conduct medication reviews.
Though it was difficult to combine the data of all the studies the authors concluded that an intervention of
any kind by a pharmacist resulted in a reduction in the overall number of prescribed drugs. This was more
marked when the pharmacist directly engaged face to face with the doctor or worked as part of an
interdisciplinary team. The authors also concluded that it is more difficult to reduce the prevalence of
polypharmacy in nursing homes which has also been confirmed by others such as Furniss et al (4, 27). This
may be because nursing home patients are often very frail and sick and may require numerous medications
11
Biren Patel
King’s College London
which are difficult to reduce. However pharmacist led interventions can still improve the quality of medicine
use amongst nursing homes residents.
A weakness in most studies that look at interventions to reduce polypharmacy amongst older patients is that
any reduction is not reported alongside a health outcome such as ADRs, risk of hospitalization and
medication errors which makes it difficult to just the health consequences of any such reduction. A few
studies provided an indication of the impact of reducing polypharmacy linking it with improved adherence
and a reduction in hospitalizations (4) but such health impacts need to be investigated in larger randomized
controlled trials where they are part of the primary outcome. Some have found that pharmacist led
interventions in nursing homes may significantly reduce the number of falls amongst older residents but this
has not been substantiated by others (27, 28).
The quality of prescribing can also be improved by reviewing repeat prescribing systems since many
medications taken by older people are obtained via a repeat prescription in the community (26).
This is also true to an extent in nursing homes like Morden College (5).This method of obtaining medication
needs to be monitored since it may invariably create a situation whereby patients may take numerous
and/or inappropriate medication due to a lack of medication reviews undertaken by their doctors. Repeat
prescribing can also result in patients not being regularly monitored for ADIs since they simply do not see
their doctor for medication review (26). Repeat prescribing was an issue that was identified during my
discussions with the GP at Morden College and I will elaborate on our discussions later on in this report.
The single most important step to ensure that the patient is prescribed appropriate medication is for a
healthcare professional (GP, geriatrician or pharmacist) to review a patient’s medication (8). The
Department of Health recommends that a thorough medication review should be carried out in older patients
at risk of medicines related problems. Amongst others this includes those taking ≥4 medicines and those in
care homes (26).
The “brown bag review”, which involves the patient bringing in all their tablets in their containers and boxes,
is often the best way to assess polypharmacy and inappropriate medication use since the doctor can directly
see what the patient is taking and review the medication as necessary (30). For an inpatient or nursing
home resident such reviews can be undertaken by a pharmacist and/or doctor. It seems though that
undertaking such a review is by no means easy. After a discussion with a GP at Morden College we
seemed to agree that such a task requires considerable skill and time especially when reviewing complex
patients with numerous medications such as those in a nursing home (29).
A number of guidelines have been published that give guidance on how to conduct medication reviews.
12
Biren Patel
King’s College London
An evidence based guideline to “Improve Medication Management for Older Adult Clients” has been drawn
up by Bergman- Evans et al and provides a framework for the structure of a medication review in older
patients. In brief the author outlines that a doctor or pharmacist should concentrate on reducing
inappropriate prescribing, decrease polypharmacy, avoiding adverse events and aim to maintain the
functional status of the patient. Regarding polypharmacy the guideline states that doctors should ensure that
any medications that do not meet the criteria in figure 3 should be avoided (30). These criteria are from a
previous 5 year prospective study by Hamdy et al. They instructed doctors caring for residents in long term
care institution to conduct six monthly medication reviews in those residents taking ≥10 drugs. This figure
was chosen for practical reasons to prevent overburdening doctors with medication reviews. Drug regimens
were reviewed using the criteria set out in figure 3 which were derived from guidelines used by pharmacists
during medication reviews. The criteria aimed to reduce the burden of polypharmacy and inappropriate drug
use by guiding doctors to stop medications that had no indication, stopping prescribing cascades and
removing those medications that may cause ADRs or DDIs (31).
Figure 3: Criteria for medication review
by doctors in a prospective study by
Hamdy et al (31).
Over a period of five years there was a significant and sustained decrease in the frequency of residents
taking ≥10 drugs (figure 4). It is thought that by following the guidelines, doctors may gradually change their
prescription habits which may result in long term decreases in the levels of polypharmacy and inappropriate
drug prescribing (31).
13
Biren Patel
King’s College London
Figure 4: The number of patients taking
10 or more medications was significantly
reduced over the course of five years
(31).
Other key interventions to reduce polypharmacy is to ensure that the regime be simplified where possible
and medications should not be duplicated. To simplify the regimen, physicians could make use of
combination drugs, reduce the frequency of dosing and use alternative routes of administration if possible.
Where more than one drug is being prescribed for the same purpose, only the best drug for the patient
should be continued to ensure that medications are not duplicated and prescribing cascades whereby drugs
are used to treat the side effects of other drugs should be identified and avoided (30). A comprehensive list
of points that should be covered during a medication review in the older patient is listed in the Department of
Health report titled “Medicine and Older People: Implementing medicines-related aspects of the NSF
[national service framework] for Older People” (26). By following these various guidelines the physician
should ideally aim to maintain the least number of drugs as possible ideally aiming to keep the number
below five (30).
Morden College: A Unique Nursing and Residential Home
Thorough out this report I have talked at length about the causes and consequences of polypharmacy and
inappropriate prescribing in older patients as well as outlining strategies that may reduce such practices.
These strategies are to an extent already in place at Morden College. The unique set up of the health centre
at the college confers it many advantages in providing good healthcare to its residents and nursing home
patients. Two GPs regularly visit the site each week seeing both residents in the compound as well as
patients in the nursing home. The set up is such that all residents and nursing home patients are registered
patients of the GPs at their corresponding surgeries (5). This maintains a continuity of care for the patients
14
Biren Patel
King’s College London
since they would continue to see the same doctor were they to leave Morden College in the future.
Furthermore it ensures there are good links between Morden College and the local GP surgery.
Morden College has also set up the EMIS (Egton Medical Information Systems) computer system ensuring
that it is linked to the main computer network at the GP surgery. This enables the doctors to have constant
access to information about their nursing home and residential patients from the surgery. From a prescribing
viewpoint it also helps to ensure safe prescribing since the system warns doctors about potential DDIs when
prescribing (29).
The GP surgery has its own part time pharmacist who also reviews the medications of the residential and
nursing home patients. The pharmacist has access to EMIS and therefore has constant access to patient
information which enables her to regularly conduct medication reviews though she formally conducts
reviews once a month when she visits the nursing home. Furthermore since the pharmacist is an
independent prescriber, she is able to commence and stop medications as required. This is beneficial since
it removes this burden from the GP who otherwise has many other duties in the nursing home. The close
cooperation between the GPs and the pharmacist helps to ensure that prescribed medications remain
appropriate and that any changes that need to be made are made by the relevant party (29).
The aim of the set up at the health centre and nursing home helps to ensure that a high standard of
healthcare is provided to residential and nursing home patients. However from a medication point of view I
found after glancing over several drug regimes in the nursing home that many patients were still taking
numerous medications. Since I have not analysed these regimes it is difficult for me to comment on their
appropriateness. After my discussions with the GP regarding this issue I have concluded that to an extent it
is inevitable that sick and frail patients will probably require numerous medications due to many underlying
co-morbidities. In such cases many drugs may be required but it is important to ensure that they are
prescribed appropriately. I feel that the set up at Morden College allows such appropriate prescribing to take
place.
After a discussion with the GP regarding medication reviews I found that certain modifications can be made
to improve the system yet further (29). Medication reviews take time and hence often the GPs only
opportunity to review medication arises whilst they are seeing a sick patient or dealing with a recent acute
problem. This inevitably means that the GPs have less time to review the drugs of those patients who are
well since they are seen less often. We agreed that a possible solution to this is by increasing the frequency
of reminders to review medication on the EMIS system. At present it is set such that after 6 months of
repeat prescriptions the system prompts the doctor to review the medication regime before resetting the
cycle. Whilst being suitable for patients at a general practice, the threshold ideally should be lower for those
15
Biren Patel
King’s College London
in a nursing home due to the increasing prevalence of polypharmacy in this group and the increased need to
conduct medication reviews. Ultimately the GPs should be given more time if possible to review medication
and it may be beneficial for the pharmacist to increase her frequency of visits to ensure that medication
reviews are carried out more frequently.
Conclusion
There is no doubt that modern medications are an asset to ensuring good health care is provided to the
older population. By treating disease and symptoms older patients can become more functional and
independent. However one must still exercise caution over the use of excessive but more importantly
inappropriate drugs. Unfortunately this practice is widely prevalent and can have negative outcomes for
older patients who already being frail may be more sensitive to ADRs or DDIs. Polypharmacy may also
indirectly cause an increase in the incidence of medication errors due to mistakes made by patients
regarding their medications. Some patients on polypharmacy may even refuse to take their medications and
hence may have to endure the consequences of omitting vital tablets from their drug regime. It is thus
important that doctors, nurses and pharmacists work closely to ensure that patients are prescribed the
appropriate medications and that they are not overburdened with numerous tablets without any clinical
indication. Doctors and pharmacists should closely work together and conduct regular medication reviews
as recommended by The National Service Framework (NSF) for Older People published by the Department
of Health. They should follow evidence based guidelines that aim to reduce inappropriate prescribing in the
older patient. Their goal should be to ensure that each patient receives the most appropriate medications in
light of their circumstances. This will help patients receive the benefits of modern medicines and reduce
exposure to the negative consequences of inappropriate polypharmacy.
References
(1) Wise J. Number of "oldest old" has doubled in the past 25 years. BMJ 2010 Jun 8;340:c3057.
(2) Werder SF, Preskorn SH. Managing Polypharmacy: Walking the fine line between help and harm. Vol. 2,
No. 2 / February 2003; Available at: http://www.jfponline.com/Pages.asp?AID=601. Accessed 06/01, 2010.
(3) Salazar JA, Poon I, Nair M. Clinical consequences of polypharmacy in elderly: expect the unexpected,
think the unthinkable. Expert Opin.Drug Saf. 2007 Nov;6(6):695-704.
(4) Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the
pharmacist. Drugs Aging 2003;20(11):817-832.
(5) Dr Tina Challacombe. 16/04/2010.
16
Biren Patel
King’s College London
(6) Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but
manageable. Clin.Interv.Aging 2008;3(2):383-389.
(7) Bjerrum L, Sogaard J, Hallas J, Kragstrup J. Polypharmacy: correlations with sex, age and drug regimen.
A prescription database study. Eur.J.Clin.Pharmacol. 1998 May;54(3):197-202.
(8) Ballentine NH. Polypharmacy in the elderly: maximizing benefit, minimizing harm. Crit.Care Nurs.Q.
2008 Jan-Mar;31(1):40-45.
(9) Kennerfalk A, Ruigomez A, Wallander MA, Wilhelmsen L, Johansson S. Geriatric drug therapy and
healthcare utilization in the United kingdom. Ann.Pharmacother. 2002 May;36(5):797-803.
(10) Fialova D, Topinkova E, Gambassi G, Finne-Soveri H, Jonsson PV, Carpenter I, et al. Potentially
inappropriate medication use among elderly home care patients in Europe. JAMA 2005 Mar
16;293(11):1348-1358.
(11) Mamun K, Lien CT, Goh-Tan CY, Ang WS. Polypharmacy and inappropriate medication use in
Singapore nursing homes. Ann.Acad.Med.Singapore 2004 Jan;33(1):49-52.
(12) Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J.Am.Acad.Nurse Pract. 2005
Apr;17(4):123-132.
(13) Tamblyn RM, McLeod PJ, Abrahamowicz M, Laprise R. Do too many cooks spoil the broth? Multiple
physician involvement in medical management of elderly patients and potentially inappropriate drug
combinations. CMAJ 1996 Apr 15;154(8):1177-1184.
(14) Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am.J.Geriatr.Pharmacother. 2007
Dec;5(4):345-351.
(15) Atkin PA, Veitch PC, Veitch EM, Ogle SJ. The epidemiology of serious adverse drug reactions among
the elderly. Drugs Aging 1999 Feb;14(2):141-152.
(16) Saastamoinen L, Enlund H, Klaukka T. Repeat prescribing in primary care: a prescription study.
Pharm.World Sci. 2008 Oct;30(5):605-609.
(17) Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and
outpatients. J.Am.Geriatr.Soc. 2001 Feb;49(2):200-209.
(18) Francis SA, Barnett N, Denham M. Switching of prescription drugs to over-the-counter status: is it a
good thing for the elderly? Drugs Aging 2005;22(5):361-370.
(19) Field TS, Gurwitz JH, Avorn J, McCormick D, Jain S, Eckler M, et al. Risk factors for adverse drug
events among nursing home residents. Arch.Intern.Med. 2001 Jul 9;161(13):1629-1634.
(20) Johnell K, Klarin I. The relationship between number of drugs and potential drug-drug interactions in the
elderly: a study of over 600,000 elderly patients from the Swedish Prescribed Drug Register. Drug Saf.
2007;30(10):911-918.
(21) Dergal JM, Gold JL, Laxer DA, Lee MS, Binns MA, Lanctot KL, et al. Potential interactions between
herbal medicines and conventional drug therapies used by older adults attending a memory clinic. Drugs
Aging 2002;19(11):879-886.
17
Biren Patel
King’s College London
(22) Vik SA, Maxwell CJ, Hogan DB. Measurement, correlates, and health outcomes of medication
adherence among seniors. Ann.Pharmacother. 2004 Feb;38(2):303-312.
(23) Monane M, Bohn RL, Gurwitz JH, Glynn RJ, Levin R, Avorn J. Compliance with antihypertensive
therapy among elderly Medicaid enrollees: the roles of age, gender, and race. Am.J.Public Health 1996
Dec;86(12):1805-1808.
(24) Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without
acute coronary syndromes. JAMA 2002 Jul 24-31;288(4):462-467.
(25) Avorn J, Monette J, Lacour A, Bohn RL, Monane M, Mogun H, et al. Persistence of use of lipid-lowering
medications: a cross-national study. JAMA 1998 May 13;279(18):1458-1462.
(26) Department of Health (2001) Medicines and Older People: Implementing medicines-related aspects of
the NSF for Older People
(27) Furniss L, Burns A, Craig SK, Scobie S, Cooke J, Faragher B. Effects of a pharmacist's medication
review in nursing homes. Randomised controlled trial. Br.J.Psychiatry 2000 Jun;176:563-567.
(28) Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, et al. Clinical medication
review by a pharmacist of elderly people living in care homes--randomised controlled trial. Age Ageing 2006
Nov;35(6):586-591.
(29) Dr Tina Challacombe. 01/06/2010.
(30) Bergman-Evans B. Evidence-based guideline. Improving medication management for older adult
clients. J.Gerontol.Nurs. 2006 Jul;32(7):6-14.
(31) Hamdy RC, Moore SW, Whalen K, Donnelly JP, Compton R, Testerman F, et al. Reducing
polypharmacy in extended care. South.Med.J. 1995 May;88(5):534-538.
18