Polypharmacy: What You Need to Know

Discover what is polypharmacy, its impact on older adults, and strategies to manage and reduce risks.

April 27, 2024

Understanding Polypharmacy

Polypharmacy is a topic that may not be familiar to many, but it is a common occurrence, especially among the elderly population. Understanding what polypharmacy is and its impact on older adults is critical in managing health outcomes effectively.

Definition of Polypharmacy

Polypharmacy is a term that has been variously defined and lacks a consensus definition. According to a systematic review, there are over 138 definitions of polypharmacy and associated terms, including minor and major polypharmacy.

The most commonly reported definition of polypharmacy is the numerical definition of taking five or more medications daily, with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy using descriptive definitions.

The World Health Organization suggests that while the definition of polypharmacy is numerical, emphasis should be given to evidence-based practice and the goal of reducing inappropriate polypharmacy [2].

Polypharmacy is also defined as the regular use of at least five medications and is common in older adults and younger at-risk populations. It increases the risk of adverse medical outcomes [3].

Impact of Polypharmacy in Older Adults

The impact of polypharmacy on older adults is significant. The elderly population often has multiple comorbid conditions requiring multiple medications. The prevalence of polypharmacy in the elderly age group is high in all health care settings across all countries. Additionally, over 50% of the elderly population is taking one or more medications that are not clinically indicated.

Polypharmacy is associated with lower health-related quality of life (HRQOL) in terms of EQ-5D-5L index values, EuroQol visual analogue scale (EQ-VAS) scores, and SF-12 physical component scores (PCS), but not with psychological distress or SF-12 mental component scores (MCS). Patients with polypharmacy have a higher frequency of problems across all dimensions of the EQ-5D-5L, with significant differences found for the dimensions of mobility and usual activities.

Understanding the concept of polypharmacy and its impact on the elderly is crucial in promoting better health outcomes and managing the health care needs of this vulnerable population.

Risks and Consequences

Understanding the potential hazards and negative consequences associated with polypharmacy is crucial for managing health, particularly in older adults. Polypharmacy, the use of five or more medications, can lead to adverse outcomes such as falls, frailty, disability, and mortality in older adults.

Adverse Outcomes Associated with Polypharmacy

Several adverse outcomes have been associated with polypharmacy. Polypharmacy has been identified as an independent risk factor for hip fractures in older adults. Also, patients taking more than four medications have an increased risk of injurious falls, with the risk of falls increasing significantly with each additional medication, regardless of medication type.

Further, polypharmacy is significantly associated with lower health-related quality of life (HRQOL) in terms of EQ-5D-5L index values, EuroQol visual analogue scale (EQ-VAS) scores, and SF-12 physical component scores (PCS), but not with psychological distress or SF-12 mental component scores (MCS) [5].

Polypharmacy Outcomes	Impact
Hip Fractures	Increased risk
Injurious falls	Increased risk with each additional medication
HRQOL (EQ-5D-5L, EQ-VAS, SF-12 PCS)	Significantly lower scores

Common Problems Due to Polypharmacy

Common issues due to polypharmacy include problems with medication adherence in older adults, especially if associated with visual or cognitive decline, leading to bad outcomes like treatment failure or hospitalizations.

Inappropriate polypharmacy, involving the use of excessive or unnecessary medications, increases the risk of adverse drug effects, harmful drug interactions, and drug-disease interactions. This can lead to a worsening of conditions or the emergence of new ones. It also creates a burden for patients and their families who need to understand multiple prescriptions, get refills, take medications at the correct time, and recognize side effects [6].

Polypharmacy is particularly risky for people with dementia, as they often receive psychotropic or opioid medications that can cause serious side effects when used in combination. Prescribing three or more of these medications, known as central nervous system (CNS)-active polypharmacy, may increase the risk of falls, overdoses, memory problems, and death.

Polypharmacy Problems	Impact
Medication Adherence	Problems due to cognitive/visual decline
Adverse Drug Effects	Increased risk
CNS-Active Polypharmacy	Increased risk of falls, overdose, memory problems, death

Understanding these risks and consequences is important in addressing polypharmacy, particularly in older adults. Appropriate strategies, including deprescribing and careful medication management, can help mitigate these risks while ensuring effective treatment for the underlying health conditions.

Management Strategies

In addressing the complex issue of polypharmacy, particularly in older adults, several strategies need to be employed to minimize the associated risks and improve patient outcomes.

Approaches to Address Polypharmacy

One of the primary approaches to addressing polypharmacy is through pharmaceutical care, where healthcare professionals, particularly pharmacists, play a key role in monitoring and managing the medication regimen of patients. This includes ensuring medication safety, appropriateness, and efficacy. Pharmaceutical care may slightly reduce the number of potential prescribing omissions and the proportion of patients with one or more potential prescribing omissions.

Another approach involves the use of computerized decision support systems. These systems can help healthcare providers identify potential drug interactions, adjust dosages, and select the most appropriate medications for patients.

Furthermore, various tools have been developed to help identify potentially inappropriate medication use in polypharmacy. These include the Beers, STOPP, and START criteria, and the Medication Appropriateness Index. It's important to note, however, that there is no one tool or strategy that has been proven to be superior in improving patient-related outcomes and decreasing polypharmacy risks.

Interventions for Reducing Polypharmacy Risks

Interventions for reducing the risks associated with polypharmacy typically involve a multi-faceted approach. This includes regular medication reviews, patient education, and the implementation of deprescribing strategies.

A study published by Zarowitz BJ showed pharmacist intervention twice a year identifying and managing high-risk drugs in patients decreased polypharmacy. The pharmacist also provided education about drug safety to the physicians and patients and ways to deprescribe medications. The first intervention led to a 67% reduction in polypharmacy, followed by 39% after the second intervention.

Intervention	Reduction in Polypharmacy
First Pharmacist Intervention	67%
Second Pharmacist Intervention	39%

Furthermore, interventions aimed at improving the appropriate use of polypharmacy in older people focus on reducing medication-related problems. This includes the optimization of medication regimens, the management of drug interactions, and the minimization of adverse drug reactions.

In summary, managing polypharmacy requires a comprehensive and individualized approach, taking into consideration the unique needs and circumstances of each patient. This involves regular monitoring, patient education, and a collaborative approach among healthcare providers to ensure the safe and effective use of medications.

Factors Influencing Polypharmacy

Understanding the factors that influence polypharmacy, defined as the regular use of at least five medications, can help in managing its risks and consequences. The impact of polypharmacy extends from the individual patient to the healthcare system as a whole, affecting the health-related quality of life and overall well-being of patients.

Risk Factors for Polypharmacy

Several factors increase the likelihood of polypharmacy. These include having multiple medical conditions managed by multiple subspecialist physicians, chronic mental health conditions, residing in a long-term care facility, poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics.

Patients taking more than four medications have an increased risk of injurious falls, and the risk increases significantly with each additional medication, regardless of the medication type.

Population	Polypharmacy Prevalence
Long-term care facility residents	Up to 91%
Patients with chronic pain	High
Patients with developmental disabilities	High
Patients with mental health conditions	High

Impact on Health-Related Quality of Life

Polypharmacy can significantly affect the health-related quality of life (HRQOL) of patients, particularly those with chronic illnesses such as multimorbidity.

Patients with polypharmacy have been found to have lower EQ-5D-5L index values, EuroQol visual analogue scale (EQ-VAS) scores, and SF-12 physical component scores (PCS), but not with psychological distress or SF-12 mental component scores (MCS).

HRQOL Measure	Impact of Polypharmacy
EQ-5D-5L index	Lower index values
EQ-VAS	Lower scores
SF-12 PCS	Lower scores
SF-12 MCS	No significant impact

Polypharmacy is associated with a higher frequency of problems across all dimensions of the EQ-5D-5L, with significant differences found for the dimensions of mobility and usual activities.

These findings underscore the importance of careful medication management and the need for strategies to reduce the risk of polypharmacy, particularly in populations at high risk, such as the elderly and those with chronic conditions. This is especially crucial given the high prevalence of polypharmacy in the elderly population across all health care settings and countries, and the finding that over 50% of the elderly population are taking at least one medication that is not clinically indicated.

The impact of polypharmacy on HRQOL, combined with the high prevalence and associated risks, highlights the need for strategies to manage polypharmacy effectively. This includes efforts to reduce unnecessary medication use and promote safe and appropriate medication management.

Deprescribing and its Importance

In the context of addressing polypharmacy, deprescribing plays a pivotal role. This process involves reducing or eliminating medications that may be inappropriate or unnecessary. It's a targeted strategy aimed at reducing the risks associated with polypharmacy, particularly among older adults with multiple chronic conditions (MCC).

Deprescribing Strategies

Deprescribing strategies are currently being explored for various conditions, including Alzheimer's disease, heart failure, and MCC, aiming at optimizing medication use and improving the quality of care and health outcomes.

One effective strategy involves pharmacist intervention, as indicated by a study published by Zarowitz BJ. In this study, pharmacist involvement twice a year, identifying and managing high-risk drugs, led to a significant reduction in polypharmacy. The first intervention led to a 67% reduction in polypharmacy, followed by a 39% reduction after the second intervention.

Intervention	Reduction in Polypharmacy
First Pharmacist Intervention	67%
Second Pharmacist Intervention	39%

In dementia care, advanced care planning and goal-oriented discussions play a vital role in deprescribing decisions. Caregivers, who hold varied perspectives on deprescribing, play a crucial role. While some trust the physician's recommendation and are ready to discontinue medications, others have questions and seek assurances for close monitoring and options to restart medications if necessary [6].

Another effective approach involves pharmaceutical care and computerized decision support. These multi-faceted pharmaceutical care-based approaches have shown efficacy in improving the appropriate use of polypharmacy and reducing medication-related issues in older people.

Role of Deprescribing in Improving Outcomes

The overarching goal of deprescribing is to improve patient outcomes. By eliminating unnecessary or potentially harmful medications, deprescribing can reduce the risks commonly associated with polypharmacy. This includes lower incidences of adverse drug reactions, decreased healthcare costs, and improved patient adherence to necessary medication regimens.

However, it is important to note that while pharmaceutical care is a promising strategy, it remains uncertain whether it improves medication appropriateness or reduces potentially inappropriate medications. Further research is needed to substantiate these findings.

In conclusion, deprescribing is an essential aspect of managing polypharmacy, especially among older adults with multiple chronic conditions. By employing effective deprescribing strategies, healthcare providers can significantly improve patient outcomes and reduce the burden of medication management for patients and their families.

Polypharmacy in Specific Populations

The effects of polypharmacy can be more pronounced in certain populations, particularly those with specific health conditions. Two such populations that warrant special attention are individuals with dementia and those requiring advanced care planning for deprescribing.

Polypharmacy in Dementia Care

Polypharmacy is notably risky for people with dementia. These individuals often receive psychotropic or opioid medications, which can cause serious side effects when used in combination. The practice of prescribing three or more of these medications is referred to as central nervous system (CNS)-active polypharmacy. This practice may increase the risk of falls, overdoses, memory problems, and even death. Despite limited evidence of benefit for people with dementia, these medications can pose significant harms.

It's crucial for healthcare providers to regularly review and evaluate the medication regimen of patients with dementia. Emphasis should be placed on weighing the potential benefits of each medication against the risks, particularly when dealing with CNS-active polypharmacy. A careful and systematic approach can reduce the potential for adverse effects and improve overall patient safety.

Advanced Care Planning for Deprescribing

Deprescribing, or the process of discontinuing unnecessary or potentially harmful medications, is a crucial aspect of managing polypharmacy. This becomes even more important when dealing with advanced care planning. Caregivers play an important role in this process and have varied perspectives on deprescribing.

According to NIH, some caregivers trust the physician's recommendation and are prepared to discontinue medications. However, others may question the rationale behind deprescribing and seek assurances for close monitoring. They may also want options to restart medications if necessary. For this reason, deprescribing decisions should align with the patient's goals of care and consider the risks and benefits of continuing or discontinuing medications.

Advanced care planning involves having goal-oriented discussions with the patient and caregivers. It requires open communication and understanding of the patient's health status, prognosis, treatment options, and personal values. Through these discussions, healthcare providers can make informed deprescribing decisions that are in the best interest of the patient.

In summary, managing polypharmacy in specific populations necessitates a patient-centered approach. This involves a thorough understanding of the patient's health condition, a careful review of their medication regimen, and effective communication with both the patient and caregivers. By doing so, healthcare providers can mitigate the risks of polypharmacy and ensure optimal patient outcomes.