With an estimated 6 in 10 Americans living with a chronic disease the risks of polypharmacy are an increasing threat, especially in older patients.
There is not a single definition of polypharmacy, but the American Academy of Family Physicians (AAFP) says polypharmacy is “defined as regular use of at least five medications.”
Taking multiple medications daily, common in older adults and younger at-risk populations, has its benefits, but also increases the risk of adverse medical outcomes.
“Medications are proven useful to manage the comorbidities of diseases and extend life,” says a paper published in the Mayo Clinic Proceedings. “Improper overuse of medications often results in toxicity, morbidity, and a plethora of problems. Most care providers recognize the patients who are taking more medications than can be practically and safely consumed. We label this problem “polypharmacy,” which is a vague and imprecise word.”
Polypharmacy is a common issue in long-term care (LTC) environments where a Cleveland Clinic Journal of Medicine paper in 2018 estimated that up to 74 percent of patients in skilled nursing facilities and LTC take 9 medications or more.
“There is supporting data from pharmaceutical-care principals that, on average, patients taking five medications will average one significant drug problem,” said the Mayo Clinic article. “What remains clear is that higher numbers of medications increase the frequency of adverse drug events (ADEs), nonadherence, and costs.”
Putting a Prescription Number on Polypharmacy
Researchers for a paper published in BMC Geriatrics combed through 1,156 published articles to find out the standard definition of polypharmacy.
“There was a wide range of variability in the definitions of polypharmacy as well as associated terms such as minor, moderate, and major polypharmacy,” said the authors. “The most commonly used term was polypharmacy, but there was variation with regard to the actual definition of polypharmacy, which ranged from two or more medications to 11 or more medications.”
The authors found that:
- The most used definition for polypharmacy was five or more medications daily, with 46.4 percent of studies using this definition
- The second most common definition for polypharmacy was 6 or more medications
“Polypharmacy definitions incorporating a healthcare setting included the use of five or more medications at hospital discharge, and the use of 10 or more medications during hospital stay,” concluded the paper. “While the use of multiple medicines may be clinically appropriate for some patients, it is important to identify those patients who may be at risk of adverse health outcomes as a result of inappropriate polypharmacy.”
It should be noted, that while 5 or more medications is a commonly accepted level for polypharmacy, the Centers for Medicare and Medicaid Services (CMS) have defined polypharmacy in a position paper as the taking of 3 to 5 or more medications.
Risk Factors That Can Lead to Polypharmacy
The AAFP says that the following patient-related risk factors can lead to polypharmacy:
- Age older than 62 years
- Cognitive impairment
- Development disability
- Frailty
- Lack of a primary care physician
- Mental health conditions
- Multiple chronic conditions (e.g., pain conditions, diabetes mellitus, coronary artery disease, cerebrovascular disease, cancer)
- Residing in a long-term care facility
- Seeing multiple subspecialists
“Polypharmacy is most recognized in older adults, because patients with one or more chronic conditions have longer medication lists. Older adults with multiple subspecialist physicians and no primary care physician are particularly vulnerable to polypharmacy,” says the AAFP paper. “Adults residing in long-term care facilities are also at risk, because they are more frail than community-dwelling populations and have multiple medical issues and cognitive impairment that often warrant pharmacologic treatment. Up to 91 percent of patients in long-term care take at least five medications daily.”
The following health care system-related risk factors can lead to polypharmacy:
- Poor medical record keeping
- Poor transitions of care
- Prescribing to meet disease-specific qualify of metrics
- Use of automated refill systems
“Poor medical record keeping can lead to polypharmacy if discontinued medications are not removed from the record and are refilled automatically or if a physician receives an automated refill request for a discontinued medication,” said the AAFP article.
Negative Consequences of Polypharmacy
The AAFP paper says that polypharmacy has “negative consequences for patients and the health care system. For example, patients taking more than four medications have an increased risk of injurious falls, and the risk of falls increases significantly with each additional medication, regardless of medication type.”
The Mayo Clinic Proceedings article agrees and says that “Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems.”
Negative consequences of polypharmacy for patients includes:
- Decreased quality of life
- Increased mobility issues
- Increased mortality
- Increased risk of adverse drug events, disability, falls, frailty, inappropriate medication use, long-term care placement and medication nonadherence
- Increased use of the health care system (clinic visits, emergency department visits, hospitalizations)
Negative consequences of polypharmacy for the health care system include:
- Decreased physician functionality (workflow impairment, decreased quality of care)
- Decreased physician productivity
- Increased burden on the health care system
- Increased medication errors
Best Practices in Pharmacology: Deprescribing
The AAFP says The American Society of Health-System Pharmacists recommends not prescribing medications for patients currently on five or more medications or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements.
Best practices in pharmacology could include:
- Consider new medication prescribed as a trial vs. a permanent addition
- Follow up with patients in a timely manner after adding medications
- Use follow-up visits to assess effectiveness and safety of medications
- Consider the benefits vs. risks of continuation of medication before renewing refills
“Physicians should view deprescribing as initiating a “therapeutic intervention” similar to initiating clinically appropriate therapy,” says the AAFP.
The Mayo Clinic says that reducing polypharmacy starts with assessment and interview of patients and that best practices include:
- Care team members reconciling medications, assess adherence, and help systematically identify drug therapy problems
- Choose pharmacotherapy that avoids drug therapy problems and risk of rehospitalizations
- Simplify the regimen for ambulatory patients in long-term care, whenever possible, to reduce hospitalizations or negative incidents
“At some point, a regimen of multiple drugs to treat multiple diseases in an older person becomes overtly problematic,” noted the Mayo Clinic article. “The evidence concerning polypharmacy and high-risk medications suggests that our older patients benefit from a purposeful, dynamic move to fewer drugs.”
