Polypharmacy: Pandora's Medicine Chest?
by Maura Conry, Pharm.D., M.S.W.| Geriatric Times |  |
September/October 2000 | |
Vol. I | |
Issue 3 |
Medication misadventures are endangering the health of the geriatric population, filling emergency rooms and hospitals, and contributing to escalating health care costs. Polypharmacy, wherein elderly patients must manage compliance with regimens of several prescription drugs and concurrently may be self-medicating with over-the-counter (OTC) products, should be of concern to all members of the health care team who work with geriatric patients.
The elderly are particularly impacted because they use 30% of the prescriptions written and 40% of OTC drugs sold in the United States. At the same time, their physiological ability to effectively metabolize and excrete multiple drug products diminishes as they age. It is estimated that medication-related problems cause up to 106,000 deaths annually (ASCP Update, 2000). As the safety nets that once prevented polypharmacy are restructured out of health care, the problem worsens.
Recent studies indicate that as much as 28% of hospitalizations of elderly patients are related to medication misadventures (ASCP Update, 2000). Approximately 95% of these events are predictable, and approximately 66% are preventable (Dennehy et al., 1996). Adverse drug events rank fifth among the greatest and most preventable health threats to the elderly, after congestive heart failure, breast cancer, hypertension and pneumonia (Zagaria, 2000). Such events are estimated to account for $76.6 billion in hospital costs and $17 million in emergency room visits (Johnson and Bootman, 1995) and result in 8.7 million hospital admissions yearly.
Overuse of medications and lack of adherence to medical treatment are common causes. Patients have arrived at emergency rooms and hospitals after taking 15 or more drugs and OTC remedies. Physicians struggle to evaluate which presenting symptoms are side effects of medications and which belong to disease states. Emergency room personnel are on alert to suspect a medication adverse event in an older patient until proven otherwise.
Polypharmacy is not to be confused with substance abuse, which is the intentional misuse of medications and other drug products. In polypharmacy, patients simply become confused and begin following unsafe medication practices. Attempts by the patient to follow sound medical advice and achieve good health can sometimes backfire into life-threatening episodes, leading to doctor visits and hospitalizations that would otherwise be unneeded. Inappropriate drug use can cause side effects that mimic conditions such as Alzheimer's disease and scores of other disorders, which can lead to the prescribing of even more medications and, in turn, lead to more medication-related problems.
Patient Communication
Polypharmacy results from changes occurring at multiple points in our system of health care. Patients frequently consult multiple physicians, all of whom may prescribe medications within their specialty. Comprehensive medication assessment of all drugs and other products used by the patient are rarely done at this point. Patients, for any number of reasons, fail to inform physicians of the total number of pharmaceutical and health-related products they use, including prescriptions from other doctors. The patient may present with symptoms that appear to be associated with a disease process, but are actually side effects of drugs the physician does not know the patient is taking. A cascade of events ensues in which new medications are prescribed for symptoms that are actually side effects of other medications.
In the past, the patient-physician-pharmacist relationship protected the patient when prescriptions were filled at a pharmacy. A patient used a single physician and a single pharmacy, consulted specialists only occasionally, and used few OTC and health-related products. The community pharmacist knew the patient and family well and consulted with the physician on their behalf when necessary. Community pharmacists prevented many medication mishaps and steered the patient toward safer products. The consumer was usually unaware that an interdisciplinary intervention had occurred.
Today many patients purchase prescriptions concurrently from several different community pharmacies. In addition, they use mail order pharmacies, Internet suppliers, overseas sources and ample supplies of physicians' samples. Each supplier conducts a safety check for drug duplications, interactions, inappropriate doses and similar classes of drugs, but only on the medications purchased directly from them. Suppliers often have no way to know a patient's total drug profile.
OTC Drugs
Another contributor to medication misadventures is the increase in the use of nonprescription or OTC drugs, especially by the elderly. Additionally, herbal and nutritional supplements and other alternative remedies are becoming part of the culture of health and wellness. Many of these products have not been proven effective, much less safe. Over-the-counter drugs, health food products and alternative products are widely available. When the legal drugs of alcohol, caffeine, tobacco and home remedies are factored in, the number of products that people consume is astounding.
The elderly, who use 40% of all nonprescription products, consider them to be safe and relatively innocuous. Since the mid-'80s, a large number of prescription drugs have been moved from prescription-only to over-the-counter status, and more are on the way. Patients now have access to effective nonprescription drugs, many of which produce physiologic responses that interact with prescription medications. The prevailing attitude is that OTC products can be used nonchalantly because they are not as powerful as prescription medications.
An almost mythical attitude persists in the general public that anything labeled as a health food product will both produce health and be completely safe. This cannot be further from the truth. Natural health store products can and do create havoc with medication regimens. Such supplements are only just beginning to be available in computer drug programs that scan for medication-related problems.
Polypharmacy most often is generated by simple misunderstanding. The patient fails to discontinue one drug when another is prescribed or discontinues the wrong one. Patients are given prescriptions by different doctors for the same drug or class of drugs but under different names. When these prescriptions are then filled by different pharmacies, duplications cannot be caught using traditional pharmacy safety procedures.
Compliance
Another type of medication misadventure occurs when patients do not take their medications as prescribed. Positive therapeutic results can be observed only when people take their medications regularly. In the words of C. Everett Koop, M.D., former U.S. Surgeon General, "Drugs don't work if people don't take them." Significant numbers of patients need help to modify their lifestyles to adhere to life-saving medical treatments. If patients do not take their medications regularly, a potential exists for dangerous events to multiply. The physician, unaware of the noncompliance, can increase doses or change drugs, believing that the patient is not responding to treatment. In the event that a patient is hospitalized and suddenly receives medications as ordered, an overdose can occur. Variations on these themes are endless, but the results are the same: Accidental misuse of medications can be deadly.
Prevention
Solutions to the dilemma of polypharmacy are complex and are out of the reach of any single health care discipline in our present system. Most providers are unaware of the breadth and scope of the problem. Remedies must be sought in interdisciplinary support teams that target polypharmacy and medication problems where they occur, in the community and in the home.
Two professions offer promise for more hands-on medication management strategies for elderly patients. They are pharmacy and social work, both of which enjoy easy access and availability in most communities. Pharmacists possess the expertise to solve complex polypharmacy problems. Social workers already help the elderly, the disabled and the chronically ill to manage all aspects of their lives, including adherence to medical treatments. An interdisciplinary realignment of these professions offers promise. The major barrier to using pharmacists to solve medication-related problems more effectively is that pharmacists are not reimbursed for these services. The same system that pays billions for emergency room visits and hospitalizations does not cover the services that could prevent them.
In the meantime, elderly patients, and their families, can promote safety by following a few guidelines:
Count the total number of drug-related products in use in the home. If the number is more than six or seven, or if the patient consults with more than one physician, get a comprehensive medication review.
Ask one of your physicians to function as the gatekeeper for all medications, even those prescribed by other physicians. Ask this physician to simplify medication regimens so that medications can be taken once or twice daily, if possible.
Use a single pharmacy, and choose one offering extensive pharmaceutical services including computer scans of all prescription, nonprescription and drug-related items. The pharmacy should offer medication adherence and compliance support. Any addition of a new prescription should be assessed in the context of total medication use. If side effects occur, or if a change is observed in the patient's level of functioning, a new medication assessment should be performed.
The key lies in the empowerment of patients, families and communities to understand the dangers of polypharmacy and how to prevent them. The public must become aware of what health care professionals have known all along: The indiscriminate use of medicinal products, no matter how unintentional, can endanger health and can even be fatal.
Dr. Conry is a clinical pharmacist and clinical social worker practicing in the greater Kansas City area.
References
ASCP Update (2000), IOM: medical errors responsible for 44,000 deaths. ASCP Update: The Monthly Newsletter of the American Society of Consultant Pharmacists (Jan.) pp1-5.
Dennehy CE, Kishi DT, Louie C (1996), Drug-related illness in emergency department patients. Am J Health-Syst Pharm 53(June 15):1422-1426.
Johnson JA, Bootman JL (1995), Drug-related morbidity and mortality. A cost-of-illness model. Arch Intern Med 155(18):1949-1956.
Zagaria MA (2000). Pharmaceutical care of the older patient. US Pharmacist (Feb.) pp94-95.