Sample Healthcare Paper on Implications of Polypharmacy on the Elderly

Definition

Polypharmacy is the use of multiple medications, mostly considered to be five or more. It is more common among the elderly, being a consequence of chronic diseases or a number of underlying medical issues. (Monégat, Sermet, Perronnin, & Rococo, 2014) It can either be legitimate or illegitimate but in both cases it has the risk of drug interactions or adverse effects. The major reason for polypharmacy is multiple pathology. In cases of ailments such as high blood pressure and heart failure, combinations of different medications are recommended. (Duerden et al., 2013).Sometimes a drug is prescribed to manage effects of another drug instead of discontinuing the offending drug.

Implications of polypharmacy on the elderly

Adverse Drug effects which often require a visit to the physician and sometime hospitalization. In some drug effects emergencies, It might be difficult to figure out which one of the many drugs is the culprit. A study done on unplanned hospitalizations among the elderly revealed that those taking five or more medications were 4 times at risk of being hospitalized from Adverse Drug than those taking fewer drugs. (Maher, Hanlon, & Hajjar, 2013) Drugs with the highest risks of adverse drug effects include hypoglycemic, anticoagulants, antibiotics, cardiovascular drugs, non-steroidal anti-inflammatory drugs and diuretics.

Drug interactions which refers to change of the effect of a particular drug, when administered together with another drug.  Knowledge regarding drug interactions that is acquired during drug development is usually limited by incomplete testing. Polypharmacy in the elderly poses a higher risk of drug interactions. (Shah & Hajjar, 2012). Chances of drug-drug interactions rise with increase in the number of medications. In particular, a patient consuming 5-9 medications has a drug interaction probability of 50 percent whereas the risk increases to 100 percent in a patient taking more than 20 medications. Drug interactions result to dose changes or additional medication which increases the risks of further drug-drug interactions.

Increased Risk of Geriatric Syndromes like falls, cognitive impairments, nutrition and urinary incontinence. Cognitive impairments like dementia and delirium are common in the elderly. Although they can be caused by other factors, polypharmacy is a risk factor and may be the cause of 12% -39% of the cases. Drugs commonly associated with delirium are anticholinergics, benzodiazepines and opioids. The categories of drugs associated with dementia include, benzodiazepines, anticholinergic drugs and anticonvulsants. Falls are common among the elderly. Different types of drugs can cause falls but the risk is higher in patients taking more than four drugs. Urinary incontinence is common in older adults and the use of many drugs only increases the risk. (Shah  & Hajjar, 2012). A study showed that an average of 60% of patients challenged by urinary incontinence we on four or more medications. Multiple drug use has also been linked to poor nutrition status among the elderly.

Polypharmacy heightens the risks of non-adherence and wrong medication use due to the complex medication schedules. The patient is tasked with remembering how and when they should take all prescriptions. (Monégat, Sermet, Perronnin, & Rococo, 2014). Non-adherence to medication is associated with life threatening situations like hospitalization, disease progression, treatment failure, and adverse drug interactions.

 

 

 

How to avoid Polypharmacy

Physicians should give patients simplified drug regimens for example drugs that can be taken once or twice in a day. (Atreja, Bellam & Levy, 2005). Instead of prescribing different medication for different aments, the physician can prescribe drugs that are used to treat several conditions.

Physicians should familiarize themselves with the extreme effects of medication. When possible, they should administer drugs that possess extensive therapeutic indices. Each medication should have a defined and indicated realistic therapeutic objective. (Atreja, Bellam & Levy, 2005). Medication that causes adverse effects to the patient should be discontinued when possible.

The patient and their family should be educated on non-pharmacologic and pharmacologic treatments. They should be informed on medication side effects, potential extreme effects and parameters for monitoring. If possible, physicians should consider non-pharmacologic alternatives such as diet changes. They should however not under-prescribe medication. . (Woodruff, 2010). Adverse impacts should be evaluated and balanced against potential benefits in order to settle for the appropriate strategy

When looking into a patient’s medication list, the physician should make an effort of identifying a diagnosis for all medications on the list. Besides identifying the diagnosis, the physician should ask the patient if the indication for which the drugs were originally prescribed is still present. Unnecessary medication usage often occurs during indication, duplication and efficacy. (Planton & Edlund, 2010). The Beers criterion lists drugs that should be avoided in treatments of the elderly. Some of these drugs may be administered if the patient is in a critical condition.

Applying pharmacodynamics and pharmacokinetic principles to personalize medication routines. Hepatic and/or renal impairment patients should have their doses adjusted. (Atreja, Bellam & Levy, 2005). Administering medication should also be started at smaller doses then titrate steadily.

How to safely administer medication to the elderly and ensure compliance

Complex treatment regiments interfere with compliance. Physicians should therefore implement strategies that ease adherence to medication like prescribing drugs to be taken once in a day. This can be done in cases of longer acting drugs or pills that contain more than one drug. If the regimen frequency cannot be reduced, it can be modified to match the patient’s daily living activities. For instance scheduling pills to be taken at times that are easy to remember like before meals or before bedtime. (Atreja, Bellam & Levy, 2005).  Elderly patients face common deficits in memory, cognitive skills, and physical dexterity. The physicians should therefore simple language and encourage the patient to repeat the instructions to enhance understanding. A patient can also use adherence aids like alarms and medication boxes.

Patient communication ranges from telephone reminders, emails and physician-patient communication. During the physician patient communication, the physician should ask the patient about their concerns and feelings and their views on psychological factors regarding adherence to medication. The physician should then share all relevant information regarding the area that the patient finds challenging and assist them to develop a management plan. (Atreja, Bellam & Levy, 2005). Based on the patient’s perception of social support, communication with their family can significantly improve compliance. The family’s role is especially critical if the patient is suffering from a chronic illness, requiring continuous understanding and support.

Research has proven that satisfaction, compliance, understanding and recall are all related to the type and amount of information given to the patient regarding their conditions and treatments, and their level of understanding. (Atreja, Bellam & Levy, 2005). Patients with a better understanding of the prescription purpose are more likely to comply than those with less understanding. Patients sometimes fail to understand instructions and often forget potions of information given to them. Physicians can address this challenge by reducing instructions to a maximum of four during each session, using written material to supplement oral teaching, emphasizing the discussed concepts and involving patient’s family.

Physicians can sometimes underestimate non-adherence in patients. It is therefore important that they employ tools to help them reliably measure and evaluate non-adherence in a patient. This can be done through pill counting, measuring drug levels in urine and filling in self-reports. (Atreja, Bellam & Levy, 2005). Of these, self-reports is the most viable tool. Patients give accurate information regarding their adherence when asked directly and in simple terms.  Constant assessment in itself can be used to increase compliance.

Alterations in the absorption, distribution, metabolism and excretion in the elderly

Drug absorption, distribution, metabolism and excretion can generally be affected by ageing. Drug absorption is lower in the elderly due to low gastrointestinal flow of blood, less mucus on intestinal surfaces, and low gastric acidity. After absorption a drug is transported by the bloodstream throughout the body. Pattern and extent of distribution is dependent on tissue protein and plasma characteristics of the drug and lipid solubility. (Reeve, Wiese, & Mangoni, 2015). Body composition changes related to age affect drug distribution. Changes in concentration of plasma protein, body composition, and decreased blood flow affects drug distribution. Drugs are eliminated from the body through either liver metabolism or kidney excretion. Reduced liver size and reduced liver blood flow are the age related issues that affect liver metabolism in the older patients. In the elderly, acute illnesses could cause slowed renal clearance. This is more common when dehydration is present.

 

References

Atreja, A., Bellam, N., & Levy, S. R. (2005). Strategies to Enhance Patient Adherence: Making it Simple. Medscape General Medicine7(1), 4.

Duerden M., Avery T., Payne R. (2013). Polypharmacy and medicines optimisation. Making it safe and sound. London: The King’s Fund.

Maher, R. L., Hanlon, J. T., & Hajjar, E. R. (2013). Clinical Consequences of Polypharmacy in Elderly. Expert Opinion. doi:10.1517/14740338.2013.827660

Monégat, M., Sermet, C., Perronnin, M., & Rococo, E. (2014). Polypharmacy: Definitions, Measurement and Stakes Involved Review of the Literature and Measurement Tests. Questions D’économie De La Santé. Retrieved May 9, 2018.

Planton, J., PharmD, & Edlund, B. J., PhD, RN. (2010). Strategies for Reducing Polypharmacy in Older Adults. Journal of Geropharmacology Nursing, 36(1), 8-11. Retrieved May 10, 2018.

Reeve, E., BPharm, Wiese, M. D., BPharm, & Mangoni, A. A. (2015). Alterations in drug disposition in older adults. Alterations in Drug Disposition in Older Adults, 11(4), 491-508. Retrieved May 10, 2018

Shah, B. M., PharmD, & Hajjar, E. R., PharmD. (2012). Polypharmacy, Adverse Drug Reactions, and Geriatric Syndromes. Philadephia: Jefferson School of Pharmacy.

Woodruff, K., Ms. (2010). Preventing polypharmacy in older adults. American Nurse Today,1(10). Retrieved May 10, 2018, from https://www.americannursetoday.com/preventing-polypharmacy-in-older-adults/.