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| Dangers of Polypharmacy |
Risk factors for polypharmacy related medical complications include: concurrent use of medications, multiple physicians prescribing, significant medical comorbidities, impairments in vision or dexterity and recent hospitalization (Landis, J., 2007). With regard to the aging population, altered drug absorption, metabolism, distribution and excretion must also be considered. In this group where chronic disease is common and current standards of care indicate what is considered "rational polypharmacy", incidence of adverse drug reactions is high. Adverse event risk with the use of two to seven concurrent medications was found to be 13-82% respectively (Fulton, M. & Allen, E., 2005).
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| Getting the Right Mix of Medications |
According to researchers, primary care providers may be adding to the problem. Reports indicate that 75% of all office visits result in a written prescription. Reasons noted in the review of literature included lack of coordination of medication regimens prescribed by multiple providers and that it is often easier to write a requested prescription than to spend time educating the patient (Fulton, M. & Allen, E., 2005).
Among the various methods of intervention used to reduce the incidence of polypharmacy, the most widely noted is the Beers criteria (Beers, 1997). The Beers criteria helps to identify inappropriate medications for seniors and also lists appropriate alternatives in a provider friendly format.
Excellent post, Lori. This topic is quite a debatable one. Pharmacy or physician "MAPS" (MI Automated Prescription Systems) can track what medications are prescribed to who, by whom. An elderly individual I recently worked with was prescribed Bisoprolol and Lopressor by two different physicians. It took his daughter to realize that these were extraordinarily similar medications; she immediately called both physicians, who were unaware what the other had prescribed. Had she not noticed, he would have begun taking both pills daily. Will pharmacies run MAPS for each patient to catch these errors? We would hope so, especially for elderly who take a plethora of medications.
ReplyDeleteThat was a great topic Lori! I worry all the time about my grandparents taking medications. My grandmother has Alzheimer's and a bunch of heart issues, so worrying about her taking the right ones and not duplicates is high on my list. She has so many doctors and people that handle her medications that I wonder if she even knows which are which and what does what. I hadn't heard of MAPS, as Luke had mentioned. I saw a bit of a flaw in the system; you have to sign up and register before you can use it. Is this mandated? Does everyone who dispenses medications have to sign up? It also states only 2-5 controlled substances are recorded, so what about if someone has more?
ReplyDeleteThere are improvement efforts being done that address polypharmacy in nursing homes. The ARMOR (Assess, Review, Minimize, Optimize, Reassess) tool, created by Dr. Raza Haque, an Assistant Professor and Clinical Director of Geriatric Services at Michigan State University, takes into account the patient’s clinical profile and functional status and emphasizes quality of life as a key factor for making decisions on changing or discontinuing medications. The use of the ARMOR tool was observed during two visits at Dimondale Nursing Care Center in Dimondale, Michigan. The meeting was run by Dr. Haque and an interdisciplinary team that consisted of an MPRO representative, the nursing director, social worker, activities director, PT/OT, and a geriatric PA. Each week, the medications of selected patients are reviewed and monthly recommendations are provided regarding appropriate dosing, duplicates, and potential adverse drug reactions, to name afew. Dr. Haque recommends using the ARMOR tool in comprehensive geriatric assessments and outpatient settings; for evaluation of multiple falls, behavior, delirium, and unexplained functional decline. The purpose of this tool has led to significant reduction in polypharmacy, reduced cost of care, and marked decrease in hospitalization. Additionally, falls and behaviors with potential of harm to self and other residents also showed a decline in frequency. By assessing the patient for polypharmacy and for certain groups of medications with potential for adverse outcomes (such as using the BEERS criteria you described), the plan of care for medication management of each patient can be adjusted. The ARMOR tool strives to minimize nonessential medications such as drugs that lack evidence or whose risks outweigh the benefits, and optimize by addressing duplication, redundancy, kidney function, blood sugar targets, gradual dose reduction, and adjustments in beta blockers, anticoagulants, and anti-seizure medications. The ease of the tool offers a systematic approach to polypharmacy for all levels of caregivers. I hope that this effective albeit time-consuming model will be utilized in all types of settings in the future.
ReplyDeleteLori, I enjoyed your topic on polypharmacy in the elderly and I agree, there are many risks involved. I have heard many elderly patients say they don't know what their pills are for, they just take them. About a year and a half ago, a product for organizing medications was advertised on Good Morning America. It was specifically targeted for elderly individuals who take numerous medications. It had 16 pouches (one for each pill) and 16 "information cards". The purpose was to place one of each pill in a pouch for a visual reminder, and then add information about the pill on the card below. I thought it was a great concept, and I am curious to know if the product is successful. Unfortunately, the product does not address the underlying concern that elderly individuals are being prescribed numerous medications leading to unintentional abuse.
ReplyDeletePolypharmacy is definitely an issue we should worry about with the elderly. When I did my rotation with the VA visiting nurses, it baffled me to hear about how many medications these patients were taking (or forgetting to take). Thankfully, the pharmacist that worked with this group strongly pushed for medication reconciliation. As Lori mentioned, the elderly are also at an increased risk of adverse reactions to their numerous medications. Couple their increased risk of adverse reactions with the altered mental status that some elderly possess and you get a recipe for disaster. Many of these patients think they are taking their medications as directed, but when I visited them with the nurse, they were far from following the appropriate medication regimen. This link provides further information about the increased of adverse medication reactions in the eldery:
ReplyDeletehttp://www.modernmedicine.com/modern-medicine/news/polypharmacy-keeping-elderly-safe
The problem does not lie with the patient, but with the physician and medical team. Some of the issues that these patients are having may be treated without medication, but as Lori mentioned, 75% of doctor's visits result in a prescription.
Lori raises a pertinent issue, and I absolutely agree that hyperpharmacotherapy, or polypharmacy, or whatever title you want to give it is a serious concern for an elderly patient population. Prior to reading Lori's post I wanted to brief myself on the topic to make sure I knew any particular terminology, or ancillary issues/questions that were raised by this issue. I read through an article from American Nursing Today entitled "Preventing polypharmacy in older adults" by Kathleen Woodruff, an instructor from St. John's University, and she many educational points on the topic. One in particular was that when considering adverse drug interactions, one of the most common adverse effects of polypharmacy within the elderly population, healthcare providers need to consider any dietary or herbal preparations the patient may be using when reconciling a patients' list of medications. Just a couple minutes of research turned up a handful of studies highlighting that a substantial percentage of the individuals were at risk for adverse drug interactions with their current combination of prescribed medications and herbal/dietary supplements. The geriatric population is particularly vulnerable to a lack of education on the possible consequenses of these often conquerently used therapies, and nurses have a well defined opportunity to address this issue during their direct patient interactions. Here is a list of common herbal medications that could be assessed for during patient interactions.
ReplyDeletehttp://www.medicalcorps.org/pharmacy/Herbals.htm
I think the MAPS idea would be a good one, unfortunately you would have to drastically expand its fairly limited current coverage. As it stands the MAPS only applies to controlled substances (opiates, narcotics, stimulants, etc., and the like), and a system that would incorporate all of a patients possible medications would be quite an undertaking. Sure would be helpful though.
Thanks Lori for this thorough report of polypharmacy and its link to unintentional substance abuse by the elderly. I am always fascinated by reports of how severely healthcare issues impact the economy, but I think the most interesting information you present here relates to the length of time that these issues have identified and characterized by researchers as a problem. I specifically remember polypharmacy as a theme of great focus in pharmacology, but I did not know the phenomenon had been identified over 20 years ago! I wonder how much of the issue is related to our nation's unique cultural characteristics, but an article from the NIH website explains that polypharmacy is a ubiquitous issue plaguing almost every healthcare system.
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661606/
This is such an interesting and unexpected topic within this category. It was not at all what I expected to find when I clicked on the "substance abuse" tag, but very relevant. I tend to think of substance abuse as something that is instigated by the party using the substance. However, it does make sense that substance abuse could actually result from the using party unwittingly abusing substances as a result of a faulty system. Perhaps if medication reconciliation is done every time a physician prescribes a new medication, then the time it takes to write a prescription would be closer to equaling the time it takes to provide education.
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