The aim of medicine (both the practice of medicine and the medication itself), is to help alleviate symptoms and perhaps cure an ailment. But all too often, for a variety of reasons, medicine does the exact opposite. It exacerbates symptoms, creates new ones, and even leads to death.
Polypharmacy is one way that medicine can be detrimental rather than helpful. The definition can be surprisingly broad, but it boils down to multiple (poly) drugs (pharmacy).
The term is most often associated with seniors who take too many medications that are unnecessary and/or harmful when combined. Polypharmacy is a risk factor for the elderly on a global scale.
What Is Polypharmacy?
Though it seems pretty straightforward, polypharmacy can be described as:
- the co-prescribing of multiple medications
- the inappropriate use of medication(s)
- using medications without a clinical indication
- visiting multiple providers/pharmacies
- the use of five or more medications
Regardless of how you define it, the use of potentially inappropriate medications can result in medication-related issues like:
- duplication of drug therapies
- unwanted side effects
- adverse drug interactions
- unnecessary medications
- ineffective medications
- poor patient adherence to the protocol
- a strain on healthcare resources
A report furnished by the Centers for Disease Control and Prevention indicates that 83 percent of U.S. adults in their 60s and 70s have used at least one prescription drug in the previous 30 days. About one-third used five or more prescription drugs. As you might expect, the most common prescriptions were for cholesterol issues, high blood pressure, and diabetes.
Often it feels like “something has been done about it” when we walk out of the doctor’s office with a prescription in hand. This can be true for doctors and patients alike. And it might seem like we’re giving up if we remove certain medications from the regimen: they aren’t working, so we give up. But perhaps we should think of it instead as “they’re not working, so we’re moving on.” The potential consequences of inappropriate polypharmacy are too great to ignore.
Why And How Does Polypharmacy Happen?
There are many potential reasons why a patient may take upwards of 10 medications daily. Here are a few that come to mind:
- In the US particularly, healthcare is such big business that doctors may not have the time or inclination to truly understand their patients’ needs and address them properly, thereby missing a core intention of medicine altogether.
- There are doctors who flat out don’t care, who leverage their medical licenses for personal gain and nothing more. For example Dr. Simone Gold, leader of a group known as America’s Frontline Doctors. This telemedicine company prescribes drugs like Ivermectin, a de-worming medication, over the phone. How will this interact with any other drugs you’re taking? Not their concern!
- There is also potential for herbs, vitamins, and supplements to interact with medications a patient is taking. Does Centrum Silver have something in it that will interact with your other medication(s)? It’s important to know, though it may not be obvious to ask.
Knowledge is power, and this is the only way to truly protect yourself. Understanding what each of your prescriptions are, and what they do, is an important first step.
Polypharmacy is not inherently bad. Appropriate polypharmacy does exist, and may involve a regimen with numerous medications. The difference is that each medication and its potential interactions must be thoroughly vetted. In the case of inappropriate polypharmacy, the problem we’re discussing here, that doesn’t happen.
Make your doctor make it make sense to you… don’t just trust them because they wear a white coat. Too many medical professionals simply can’t or won’t bother to make it clear to you unless you push. Start with these two questions:
- Can you share studies and evidence with me of this medication helping my [insert condition here]?
- Will this interact negatively with any of my other vitamins, supplements, and medications? Have a complete list of everything you take handy.
Can Polypharmacy Be Problematic?
Inappropriate polypharmacy has the potential to wreak havoc on a person’s life. Drug interactions can cause new symptoms to surface, exacerbate old symptoms, and more. Severe falls, overdoses, memory problems, personality issues, depression, and death are among the common issues related to inappropriate polypharmacy.
Our bodies, their composition, and their reactions to medications change over time. So periodically auditing one’s drug regimen can help avoid problems as we age. The dosage that was appropriate 10 years ago may not be anymore. This is one reason the elderly are disproportionately affected.
Reducing inappropriate medications can potentially relieve some of the strain on patients and their families who grapple with keeping track of drug regimens that are difficult to administer and convoluted to understand.
How Does Polypharmacy Affect The Elderly?
Numerous global studies confirm that on average, elderly people take 2-9 medications daily. How many of those medications are viewed as inappropriate? Anywhere from 11.5 to an astonishing 62.5 percent. To treat chronic conditions, it is estimated that 25 percent of people aged 65 to 69 take five or more prescription drugs. That figure nearly doubles to 46 percent for those between 70 and 79.
Polypharmacy impacts the elderly most severely in two main ways: multiple chronic conditions (MCC) and adverse drug reactions (ADRs).
MCC is defined as two or more chronic conditions like arthritis, chronic obstructive pulmonary disease (COPD), cardiovascular disease, depression, diabetes, and high blood pressure. Often where two or more of these conditions exist, more medication is used to manage them. With the addition of each new medication, the potential for problematic interactions is heightened. And remember, vitamins, over-the-counter medications, and dietary supplements can contribute to this complex health matter.
Elderly people are also at greater risk for adverse drug reactions (ADRs), because of the metabolic changes that naturally occur with aging. As you might expect, the risks grow as the patient’s age and the number of medications they use increases.
Polypharmacy can sometimes lead to what’s known as “prescribing cascades”. This is when signs and symptoms of an ADR are misinterpreted as a disease. A new drug or treatment is added to the patient’s regimen, inviting more side effects and more potentially inappropriate medications, creating a cascade effect.
Is there any way to stop this, like a system of checks for doctors? There are several, all with their own strengths and weaknesses. One of the most commonly used tools is the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
The Beers Criteria & STOPP/START
The Beers Criteria shows us five categories of medications that should be avoided or used with extreme caution in older adults:
- medications that are potentially inappropriate
- those that are potentially inappropriate with certain conditions
- medications that should be used with caution
- potentially clinically important drug-drug interactions that should be avoided
- medications that should be avoided or have their dosage reduced with varying levels of kidney function.
One clear limitation of the Beers Criteria is that it does not address any alternatives the patient might consider.
The STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatments) criteria are two more tools to offer patients and healthcare providers guidance on inappropriate and under prescribed medications. STOPP/START offers 80 criteria for stopping medications, and 34 criteria for starting them.
Is deprescribing the best option? Will this drug cause a new concern because of that other one? Utilizing these tools together, in hand with a personalized plan, can help navigate this safely.
The Uncharted Waters Of Deprescribing
As we’re learning, optimizing our medication use is crucial to our health and wellbeing, particularly as we age. This is what the U.S. Deprescribing Research Network is all about. From their website: “The goal of the US Deprescribing Research Network (USDeN) is to develop and disseminate evidence about deprescribing for older adults, and in doing so to help improve medication use among older adults and the outcomes that are important to them.”
Though it is not wise to stop a medication or change its dosage without doctor supervision, doing so in the right way may be the right thing to do for many people around the world, and the medical community is waking up to that.
A Medication Review: Well Worth The Time
Incredibly, in 2017, 94 percent of adults aged 65 and older were prescribed a fall-risk-increasing drug. In 1999, that number was only 57 percent.
Which drugs are most apt to increase the likelihood of falls?
- antipsychotics (Risperdal, Abilify)
- antidepressants (Zoloft, Paxil, Lexapro)
- benzodiazepines (Valium, Xanax, Klonopin)
You might recognize these names because they are some of the most widely used pharmaceuticals out there. That’s a lot of fall risk. And falling is just one of the potential risks.
How Do I Know If Inappropriate Polypharmacy Is Affecting Me?
As we know appropriate polypharmacy does exist. It’s so worth a sit-down with a comprehensive list of everything you’re putting in your body each day, to weigh the risks against the benefits. Together with your healthcare provider, ask:
- could this medication be replaced with something else?
- can we reduce the dosage without reducing its effectiveness?
- could it be deprescribed altogether and replaced with diet, exercise, and lifestyle changes?
How Do I Prevent Falls At Home?
In 2016, nearly 25,000 people aged 75 and older died as a result of a fall — almost three times as many as in 2000. Is this increase a result of the sharp uptick in medication usage? Hard to say, but experts say it will continue to rise. There are many things you can do to help mitigate the risk of falling and injury.
- empower yourself and get stronger physically too with an exercise program that’s designed to improve leg strength and balance.
- get regular eye exams and update your prescription as needed.
- make your home safer by removing tripping hazards and obstacles, installing handrails in the shower, and hiring in-home assistance if needed.
Aging is a privilege denied to many, and that’s just one reason to regularly audit your medications, vitamins, supplements, possible interactions, and their appropriate dosages too. It’s important to have sufficient knowledge yourself, and not rely solely on your healthcare provider to keep you safe. Knowing what your medications have the potential to do, and taking steps to prevent or reduce those risks (such as making your home safer), will help make the golden years some of your most treasured.
This blog is dedicated with love to all my senior friends in Puerto Vallarta and beyond.
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