Medication Review: Is There Polypharmacy?

What is Polypharmacy?
It is “The practice of administering many different medicines especially concurrently for the treatment of the same disease.” [WMDD]   It means taking more drugs than clinically indicated; and some state it occurs when any senior takes more than five medications total.  [Morley JE.]


Why is Polypharmacy a problem?

The following represent just a sampling of studies which demonstrate:

 

  1. taking more than three drugs increases the risk of falls.  [Leipzig et al. Drugs & falls in older people: II.  J Am Geriatr Soc 1999;47:40-50.]
  2. taking any nerve medicine greatly increases the risk of falling (about 1.5 times greater).  [Leipzig et al. Drugs in older people: I. J Am Geriatr Soc 1999;47:30-9.]
  3. when the drugs which increase ‘fall-risk’ are withdrawn, the risk of falls goes down by 35-56%.  [van der Velde, et al. Risk of falls after withdrawal of fall-risk-increasing drugs. Br J Clin Pharmacol. 2007;63:232-7.]
  4. the risk of falling and fractures goes up 32-97% when ‘nerve medicine’ is used.  [Hien et al. Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc. 2005;53:1290-5.    Thapa et al. Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents. Am J Epidemiol. 1995;142:202-11.]
  5. that many drugs are inappropriate for seniors and are responsible for many of the problems resulting.  [American Geriatrics Society. AGS 2015 Updated Beers Criteria for potentially inappropriate medication use in Older Adults. JAGS. 2015;63]
  6. 30% of seniors admitted to hospital may be linked to drug side-effects. [Hanlon et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc. 1997;45:945-8.]
  7. that many drugs for dementia are of minimal benefit.  [Tjia J, et al. Use of medications of questionable benefit in advanced dementia. JAMA 2014.4103]

In addition:

  • drugs are expensive and many are not covered by insurance.
  • The more drugs one takes, the greater the risk of side-effects, and feeling “unwell”.
  • Seniors have more trouble swallowing pills; they choke easily.

What is the purpose of taking a medication?
This depends on what the senior’s goal is:  is it “longevity” (keep me alive even if I don’t feel well), or is it “comfort” (keep me comfortable, avoid pain or suffering, and let me die naturally when my time comes).

Our experience and studies with seniors/families confirm that when a chronic/incurable disease is present, seniors prefer comfort and to not prolong dying if they can’t be comfortable.  [Singer et al. Quality end-of-life care: patient’s perspectives. J Am Med Assoc. 1999;281:163-8] [Steinhauser et al. In search of a good death: observations of patients, families, and providers. Ann Intern Med. 2000;132:825-32]

Therefore, for a drug to be appropriate and to help meet a senior’s goal, it should contribute to comfort and independence, and not add to their burden of suffering.

What should seniors do?
Clarify their goals (see handout Goal-Focused Care), then choose medications which will help reach it.  (based on the evidence, that means ask for pain and symptom control and stop drugs which are not comfort focused)