© Geriatric Times. All rights reserved.
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.