Polypharmacy is defined as the taking of multiple drugs by any one patient. While this is often unavoidable, it is a cause of concern as the potential for drug-to-drug adverse interaction rises with the number of drugs taken. International research shows that polypharmacy is common in older adults with the highest number of drugs taken by those residing in nursing homes. Nearly 50 percent of older adults take one or more medications that are not medically necessary. (Expert Opin Drug Saf 2014 Jan; 13(1): 10.1517/14740338.2013.827660)

Polypharmacy increases the possibility of drug-drug and drug-disease interactions. The elderly population is at greater risk because of normal physiologic changes that occur with the ageing process. These physiologic changes, particularly decreased renal and hepatic function, in turn may contribute to changes in pharmacodynamics and the pharmacokinetics process.

Inappropriate polypharmacy can be due to many causes and some drugs are the most commonly identified.

Causes of inappropriate polypharmacy are:
  1. Seeing multiple doctors without one coordinating physician, pharmacist to liaise with doctors
  2. Doctor-hopping without informing doctors the patient is on multiple drugs
  3. Multiple drugs together with supplements which are not often declared to physicians
  4. Taking of the correct drug but inappropriate dosage, timing with multiple drugs interacting with each other. This is especially of concern in elderly with dementia or when the taking of the medication must be timed correctly before meals, after meals, empty stomach
  5. Taking of multiple drugs, that while appropriate, results in high pill load

Table 1: Summary of Observational Studies of Polypharmacy in Older Adults

Abbreviations: ACEi (ACE inhibitors), CCB (calcium channel blockers), OTC (over-the-counter products), PPI (proton pump inhibitors), Rx (prescriptions), SSRI (selective serotonin reuptake inhibitors)

Source: Expert Opin Drug Saf. 2014 Jan; 13(1): 10.1517/14740338.2013.827660
Abbreviations: ACEi (ACE inhibitors), CCB (calcium channel blockers), OTC (over-the-counter products), PPI (proton pump inhibitors), Rx (prescriptions), SSRI (selective serotonin reuptake inhibitors) Source: Expert Opin Drug Saf. 2014 Jan; 13(1): 10.1517/14740338.2013.827660

Whereas appropriate drug therapy is necessary in the maintenance and prevention of disease states, excessive use of medications can result in adverse reactions leading to complex drug regimens and the risk of further complications. There is also the added burden of increased health costs.

The problems that may be associated with polypharmacy can be so extensive that it was designated as the principal medication safety issue in the Department of Health and Human Services report Healthy People 2000.

What can we all do to minimize polypharmacy?
In most cases, polypharmacy can be managed through a multidisciplinary approach. The objectives of appropriate pharmacologic therapy are to treat or manage disease states, to prevent complications associated with comorbidities, and to ease or eradicate pain.

It requires a “tripartite” 3Ps approach.

The patient
Patients need to take ownership of the medical conditions and inform the doctors treating him of all his conditions. Keep track of all medication and if forgetful or worried, get a dosette or ask someone else to help monitor. This is especially important for seniors.

The professionals
Doctors and nurses can work with pharmacists as a team to regularly review all medications and reconcile. While this is easier in a hospital setting, in the community, the family physician can play that role of coordination and liaison. For more complicated elderly patients, geriatricians often play that role.

The pharmaceutical industry
There is also a role for the pharmaceutical industry to develop medications that are easier to ingest preparations, once-a-day preparation, combination medication to reduce overall pill load. Developing and providing simple patient information leaflets has also been found to be helpful to patients to better understand what medication they are on and the side effects so that they can self-monitor and inform their physicians in the event of adverse effects.

Conclusion


Medications are essential to better treatment of diseases, prevention of certain diseases, and better health outcomes. The ultimate challenge for all healthcare professionals is to ascertain the most suitable drug therapy for each patient that will enhance quality of life without compromising the patient’s ability to function and put him or her at risk for adverse reactions. Managing medication costs is also key to managing escalating healthcare costs.