The average lifespan for an American today is about eighty years, roughly thirty years longer than it was a century ago. Our quality of life as we age is vastly better as well, heavily influenced by new vaccines and better drugs. [ (D’ Oratzio, 2012) ] The likelihood of having at least one chronic disease increases substantially in older adults. It is estimated that eighty percent of people over the age of sixty-five have at least one chronic disease and fifty percent have more than one.
Along with the improved life expectancy polypharmacy has become an increasingly serious problem in the current healthcare system. Polypharmacy is recognized as an expensive practice: the US Center for Medicare and Medicaid Services estimates that polypharmacy costs the nation’s health plans more than fifty billion US dollars annually. Addressing the issue of polypharmcy is essential to healthcare providers to prevent negative clinical consequences and provide for a better quality of life for this vulnerable population. (Perry, 2011) ]
The word polypharmacy is not well defined in the healthcare literature and the term often varies from scholar to scholar. In a research article by Bushardt, Massey, Simpson, Ariail, and Simpson (2008) titled “Polypharmacy: Misleading, but Manageable” no consensus definition was readily identified. The most commonly cited definition stating “medication did not match diagnosis. ” was included in four articles. While the term “Inappropriate” was part of definitions in six articles.
Several other different definitions, involved one of the following concepts: many medications, duplication of medications, drug/drug interactions, and excessive duration. Some definitions place a value on the number of concurrent medications; the most commonly referenced number was six medications or more. Another study titled “Polypharmacy in the Elderly: A Literature Review” found definitions such as two or more drugs for 240 days or more, and use of four or more medications. Additional definitions include regular daily consumption of multiple medications as well as the use of high-risk medications and questionable dosing.
European studies defined polypharmcy according to the number of medications taken, whereas the studies conducted in the United States defined polypharmacy according to whether a medication was clinically indicated. [ (Fulton & Allen, 2005) ] Edification of this phenomenon can be a key component to a patient’s safety and well being. Causes of Polypharmacy Mentioned earlier was life expectancy, and chronic diseases as two causes for polypharmacy. Comorbitity has been found to be the determinant of drug consumption in the elderly rather than old age.
As reported in the 2004 US national nursing Home Survey, the prevalence of nursing home residents receiving more than nine drugs a day was three-fold higher for patients with more than ten co-morbidities than for those with less than three concomitant diseases. The most frequently prescribed categories of medications have effects on the cardiovascular, metabolic and central nervous system. The diseases commonly associated with polypharmacy are coronary artery disease or stroke, heart failure, diabetes mellitus and chronic obstructive pulmonary disease.
The severity of the concomitant disease is also an important factor associated with multiple drug use for prescription medications. [ (Giuseppe, De Rui, Sarti, & Manzato, 2011) ] Prevention for conditions such as osteoporosis is another reason medications are prescribed. Self-medication is another contributing factor to polypharmacy. The number of over-the-counter medications continues to increase as medications that once were prescription only are now becoming available over the counter. Complementary and alternative therapies are more popular as demonstrated by a significant increase in sales.
Patients often do not consider complementary and alternative therapies to be medications and do not disclose herbal and homeopathic use to primary care providers. [ (Fulton & Allen, 2005) ] It also has been reported that five or more visits to a primary care physician increased the risk of polypharmacy by fifteen times. Approximately 75% of all the visits to primary care physicians end with a written prescription. [ (Vyas, Pan, & Sambamoorth, 2012) ] The discovery of a broad range of pharmaceuticals to help patients has unfortunately led to both overuse and inappropriate use of medications.
The phenomenon called the prescribing cascade can develop when an elderly patient develops side effects from a medication. However the healthcare provider interprets the symptoms not as a side effect of the drug but as a symptom of a disease and prescribes yet another drug, creating potential for even more side effects. Altered pharmacokinetics (the way in which the body reacts to the drug) and pharmacodynamics (the effect a drug has on a body) in older patients are major factors when discussing polypharmacy. Responses to medications differ with advancing age; mediation effects may be variedand less predictable.
Physiologic changes related to aging effect how the body absorbs, distributes, metabolizes, and eliminates a medication. Aging increases the risk of drug to drug interactions with multiple medication use. The half-life of some medications is substantially increased in older patients. [ (Fulton & Allen, 2005) ] Other contributing factors to polypharmacy are communication barriers. Lack of knowledge regarding the prescribed medication regime, storing medications out of original prescription containers, and similar medication names and appearance add confusion to the issue of polypharmacy.
Direct marketing to consumers by pharmaceutical companies can also contribute to polypharmcy. For example, after exposure to clever advertising, individuals may request a specific brand name medication of their own providers without an actual need. Often prescribers find it easier to write a prescription that to spend time educating the client. Older patients often have multiple providers prescribing medications without coordination between medication regimes. [ (Fulton & Allen, 2005) ] Clinical Implications Polypharmacy has implications to healthcare costs. Obvious costs are for the medication itself.
Visits to specialists, emergency care, and hospital admissions contribute to polypharmacy because of multiple prescribers and account for an annual cost of $76. 6 billion. It is also reported that up to 28% of hospital admissions are secondary to an adverse drug event and the incidence of events in the over 65 age group is more than double that in 45 and younger age group. [ (Fulton & Allen, 2005) ] Polypharmacy has also contributed to length of stay in hospital in the elderly. [ (Berryman, et al. , 2012) ] Adverse drug events are commonly the end result of polypharmacy.
The degree of an adverse drug event can range from mild to fatal. It has been reported that 106,000 people in the United States die annually that have been properly prescribed and taken correctly. Nurses must be aware that some medications have a narrow therapeutic range because the life-threatening drug toxicity is high (e. g. , Digoxin, Coumadin). [ (Fulton & Allen, 2005) ] Falls and hip fractures are associated with high morbidity and mortality rates. Polypharmacy has been associated with these two [ (Giuseppe, De Rui, Sarti, & Manzato, 2011) ].
There is some suggestion that elderly patients taking multiple medications irrespective of pharmacological classifications is also associated with greater risk for falls, especially among those taking five or more medications. [ (Perry, 2011) ] Adherence to prescriptions is a major determinant of the effectiveness of medications, and by negatively affecting adherence; polypharmcy can impair the efficacy of a drug. In the elderly, the need to take more than three medicines a day raises the likelihood of noncompliance in direct proportion to the number of different drugs that need to be taken and with the number of daily doses.
Poor compliance has a negative effect on healthcare outcomes and costs. [ (Giuseppe, De Rui, Sarti, & Manzato, 2011) ] Polypharmacy is a large contributing factor for non-adherence to medication regimes. [ (George, Elliot, & Stewart, 2008) ] Avoiding Polypharmacy Healthcare workers such as nurses, pharmacists and doctors are all positioned to decrease the occurrence and adverse effects polypharmcy has on the elderly population and the healthcare system. A medication review assessing the appropriateness of the patients’ medications and focusing on regime simplifications should be undertaken first.
Medication administration times should be tailored to fit in with the patient’s daily routine or linked to activities in the patient’s routine. [ (George, Elliot, & Stewart, 2008) ] Knowledge of the Beers Criteria List used to decrease utilization of inappropriate or potentially harmful medications is another tool that healthcare workers can use to decrease the instances of polypharmcy. [ (Berryman, et al. , 2012) ] Nurses can protect their patients from the potentially harmful consequences of polypharmcy by taking a thorough drug history. This is imperative when caring for an elderly patient.
Investigate and document all medications the patient is taking including OTC and herbal products. Confirm that each drug’s class and clinical indication are correct as ordered for your patient. Find out what other healthcare providers the patient is seeing and if possible which ones prescribed which medications. The “brown bag” is one way to take an effective drug history. Have the patient bring all medications with him to the hospital or office visit. A recent study found that this method produces a more accurate list of the drugs the elderly patient takes, rather than relying on the patients’ medical record or memory.
In conclusion, polypharmcy has both positively and negatively impacted the elderly population. Medications can be used to effectively treat patients regardless of their age, and there continues to be a lack of consensus on the definition of polypharmcy. There is no one way for providers to ensure safe medication management. However taking the time to review medications with your elderly patient can reduce the risk of this phenomenon. Polypharmcy continues to represent a significant problem involving both costs to the health care system and to the elderly population.