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Protect older adults from polypharmacy hazards

Smith, Debbie Montgomery, R., BSN, RN; Kautz, Donald, D., PhD, RN

doi: 10.1097/01.NURSE.0000527602.17216.6d
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Many patients, especially older adults, take multiple medications to treat various health disorders. While these medications can improve health when taken individually, together they can trigger adverse reactions and may be associated with increased mortality and morbidity. Follow the practical steps outlined here to identify and eliminate unnecessary or potentially risky drugs in your patients' treatment regimen.

Debbie Montgomery R. Smith is an emergency nurse at W. G. (Bill) Hefner VA Medical Center in Salisbury, N.C., and float pool nurse at Wake Forest Baptist Health—Lexington Medical Center in Lexington, N.C. Donald Kautz is retired, Associate Professor Emeritus, in the School of Nursing at the University of North Carolina Greensboro.

The authors have disclosed no financial relationships related to this article.

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POLYPHARMACY can be simply defined as the use of multiple medications, including over-the-counter (OTC) products and dietary/herbal supplements, by one patient. The minimum number varies, but taking five or more medications is generally considered polypharmacy.1 Polypharmacy is common in older adults who may take medications to treat various health disorders, including hypertension, depression, constipation, gastroesophageal reflux disease, insomnia, and various other chronic diseases such as diabetes. Many older adults also take anticoagulation to prevent thromboembolism. While these medications can improve health when taken individually, together they can trigger adverse reactions and may be associated with increased mortality and morbidity.1

Drug interactions are common in older adults taking a polypharmacy regimen. In one study of older hospitalized adults taking five or more medications, the probability of a potential hepatic cytochrome enzyme-mediated, drug-drug interaction was 80%. The probability increased to 100% in patients taking 20 or more medications.2

Factors contributing to polypharmacy include underreporting of signs and symptoms related to polypharmacy by the patient, use of multiple prescribers, use of multiple pharmacies, taking another person's medications, limited time for discussions between patients and providers regarding medications, and limited knowledge of geriatric pharmacology by providers.1-3

In older adults, adverse drug reactions may be overlooked or misinterpreted because they're nonspecific and/or mimic common complaints of aging. Examples include dizziness, confusion, fatigue, nervousness, depression, and incontinence. The following scenario illustrates the problem of polypharmacy and potential consequences.

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Case in point

HM, 91, was taken by her daughter to her primary care provider (PCP) because of an escalation in disruptive behaviors. HM had previously been diagnosed with Alzheimer disease, so the PCP increased her dosage of donepezil, an acetylcholinesterase inhibitor indicated for the treatment of dementia of the Alzheimer type.4 A few months later, the daughter took the patient back to the PCP with a complaint of urinary incontinence. The PCP prescribed oxybutynin, an anticholinergic drug, to treat this additional problem. The home healthcare nurse realized HM's urinary incontinence could have been an adverse reaction to the increased donepezil dosage and notified the PCP. Together, the daughter, nurse, and PCP decided to reduce the patient's donepezil dosage. The oxybutynin was subsequently discontinued and the patient had no recurrence of the incontinence.3 The daughter hired a caregiver to help her mother in the morning, which helped resolve the disruptive behaviors. This “nonpharmacologic approach” was effective in reducing the patient's agitation.

This is an example of a “prescribing cascade,” which occurs when new drugs are prescribed to treat signs and symptoms of an unrecognized adverse reaction to an existing therapy. Prescribing cascades are especially problematic for older adults who take many drugs to treat multiple chronic conditions.1

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Multiple comorbidities complicate care

In a survey of Medicare beneficiaries, approximately 30% had all three of these chronic disorders: diabetes, hypertension, and hypercholesterolemia.5 Another study estimated that an older adult with five common chronic coexisting disorders (such as hypertension, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis) would be prescribed an average of 12 medications.6

When caring for patients being treated with multiple drugs, nurses must be alert to the potential for unanticipated drug-drug, drug-food, and drug-disease interactions. Medications to watch for when performing medication reconciliation for an older adult include those with anticholinergic properties. Anticholinergics are a class of drugs that block the action of the neurotransmitter acetylcholine in the brain and balance the production of dopamine and acetylcholine in the body. Indicated uses include treatment for asthma, urinary incontinence, gastrointestinal cramps, muscle spasms, depression, and sleep disorders.7 They can also be used to treat certain types of poisoning and are used as an anesthetic adjunct. The use of two or more medications with anticholinergic properties may amplify the risk of peripheral anticholinergic adverse reactions such as dry mouth, blurred vision, and tachycardia, as well as central nervous system complications, including sedation, delirium, and cognitive impairment.7

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Helpful tools

One way that nurses can help prevent problems associated with polypharmacy in older adults is to have a copy of The Beers Criteria handy as a reference during medication reconciliation. Developed by the American Geriatrics Society (AGS) and updated in 2015, this tool lists potentially inappropriate medications that should be avoided in older adults.7 Nurses can use it to quickly identify medications that may increase the patient's risk for medication-related problems and to educate patients and caregivers.

The Beers list of medications can be used in any healthcare setting. The AGS website (www.americangeriatrics.org) offers resources for patients, nurses, and other providers to assist with identifying medications that are known for causing adverse reactions in older adults.

The key to avoiding polypharmacy in older adults isn't determining a set number of medications and trying to stay below it, but rather using the right medications at the right doses and for the shortest possible duration on a case-by-case basis. ARMOR (Assess, Review, Minimize, Optimize, Reassess) is a tool nurses can use to meet these goals.8 With this approach, nurses and prescribers

  • assess medications
  • review them for possible interactions
  • minimize nonessential medications
  • optimize medications by noting duplication and adjusting doses
  • reassess the patient for functional, cognitive, and clinical status along with medication adherence.

Before starting the patient on any medication that's eliminated through the renal system, the healthcare provider must calculate the patient's kidney function. Most medication package inserts use the Cockcroft-Gault equation when suggesting renal dosing.1

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Questions to ask

When first reviewing a patient's complete medication list, the nurse should attempt to identify a health problem for every medication on the list and ask the patient if the problem still exists. The nurse should also determine the following:

  • Are there any duplications in drug therapy from the same category or drug classification?
  • Does the list include medications prescribed to treat an adverse drug reaction?
  • Are the medication dosages therapeutic?
  • Is the patient experiencing any substantial drug-drug, drug-food, or drug-disease interactions?
  • Have nondrug therapies been used when possible?

If the nurse identifies a potential problem, he or she can approach the patient's PCP to see if the patient still needs the problem medications, as illustrated in the following example.

A nurse's father called her complaining of edema in his legs. Together, the nurse and patient reviewed the list of medications he was taking: warfarin, diltiazem, losartan, hydrochlorothiazide, clorazepate, pravastatin, esomeprazole, gabapentin, and an antihistamine. On his last visit, the PCP had increased his gabapentin dosage because of increased lower extremity neuralgia. The nurse knew that diltiazem and gabapentin can cause edema.1 The patient and his daughter returned to the PCP to review the medications he was taking and to discuss his edema. The PCP reduced the gabapentin dosage, which resolved the edema, and discussed the risks and benefits of other possible treatment strategies for the patient's neuralgia.

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Start low, go slow

Medical advances have increased the lifespan of patients with chronic diseases. Almost half of people older than age 65 have three chronic diseases, with 21% having five or more.6 A single approach for each disease is likely to lead to polypharmacy. At some point, additional treatment is likely to cause more harm than benefit, so every drug in an older adult's regimen, including drugs used for symptom relief, needs to be reassessed regularly. In addition, the symptom severity must be balanced against the potential for adverse drug reactions.

Polypharmacy itself should be recognized as a disease with potentially more serious complications than those of the diseases that different drugs have been prescribed for initially.1Start low and go slow is a safe recommendation for medication prescription in older adults. The best approach is to minimize the initial dosage, titrate doses slowly, and monitor the patient's response closely for both beneficial and adverse effects.3

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Assessing for adherence to the regimen

Medication adherence is a major problem for many older adults, who may not follow directions for taking medications and often take a lower dose than prescribed due to cost. Besides polypharmacy, other risk factors for nonadherence include multiple medical disorders, complex treatment regimens, and cognitive impairment.1

Until the issue of polypharmacy is aggressively addressed in the geriatric population, older adults will continue to be at risk for potentially dangerous health hazards created when multiple drugs are prescribed to improve the original health problems. As healthcare professionals, we can empower patients to become the team captain on their healthcare team with this advice:

  • Keep a current medication list with you at all times. Along with prescription medications, include any OTC drugs, herbal preparations, and dietary supplements you use.
  • Know your diagnoses and the diagnosis for which each drug is prescribed.
  • Question the PCP about the plan of care and work with the PCP to eliminate any medications you no longer need.
  • Ask the PCP to prescribe once-a-day dosing for the most medications, if possible, to simplify the regimen.
  • Ask your pharmacist questions and use the same pharmacy for all medications.

Working together with patients, PCPs, pharmacists, and family caregivers, we can reduce polypharmacy and its poor health outcomes.

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REFERENCES

1. Rochon PA. Drug prescribing for older adults. UpToDate. 2017. http://www.uptodate.com.
2. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57–65.
3. Riker GI, Setter SM. Polypharmacy in older adults at home: what it is and what to do about it—implications for home healthcare and hospice, part 2. Home Healthc Nurs. 2013;31(2):65–77.
4. Adricept (donepezil hydrochloride) tablets. Prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020690s035,021720s008,022568s005lbl.pdf.
5. Iyengar RN, LeFrancois AL, Henderson RR, Rabbitt RM. Medication nonadherence among Medicare beneficiaries with comorbid chronic conditions: influence of pharmacy dispensing channel. J Manag Care Spec Pharm. 2016;22(5):550–560.
6. Fried TR, O'Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatr Soc. 2014;62(12):2261–2272.
7. American Geriatrics Society. American Geriatrics Society 2015 updated BEERS criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–2246.
8. Planton J, Edlund BJ. Strategies for reducing polypharmacy in older adults. J Gerontol Nurs. 2010;36(1):8–12.
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