What are the dangers of polypharmacy and the case for deprescribing in older adults?

According to the Centers for Disease Control and Prevention, nearly one-third of older adults take five or more prescription medications regularly. This widespread practice raises significant questions about what are the dangers of polypharmacy and the case for deprescribing in older adults? This article will explore the risks and highlight a proactive approach to medication management.

Quick Summary

Polypharmacy, the use of multiple medications, increases risks for older adults, including adverse drug reactions, dangerous falls, cognitive impairment, and drug interactions. Deprescribing is the systematic process of reducing or stopping medications to minimize these harms and improve quality of life, aligning treatment with a patient's care goals.

Key Points

• Understanding Polypharmacy: Polypharmacy is the use of multiple medications, which is particularly risky for older adults due to altered drug metabolism and a higher chance of adverse effects.

• Risks are Widespread: Dangers include serious adverse drug reactions, dangerous drug interactions, increased risk of falls, and cognitive impairment, which can worsen or mimic other health issues.

• Deprescribing as a Solution: Deprescribing is the intentional, careful process of reducing or discontinuing inappropriate medications to minimize harm and enhance a patient's overall well-being.

• Patient-Centered Approach: A successful deprescribing strategy requires a collaborative effort between the patient, their caregiver, and the healthcare team, with decisions based on individual health goals and risk-benefit analysis.

• Proactive vs. Reactive Care: Deprescribing moves from a reactive model—adding medications to address side effects—to a proactive one, optimizing the drug regimen to improve quality of life and safety.

• Open Communication is Key: Patients and caregivers can facilitate deprescribing by bringing an updated medication list to appointments and openly discussing symptoms, side effects, and health goals with their doctor.

What is Polypharmacy?

Polypharmacy is most often defined as the regular use of five or more medications, including prescription, over-the-counter, and herbal supplements. While it is sometimes necessary to manage multiple chronic conditions (multimorbidity), it becomes problematic when the medications are excessive, unnecessary, or potentially harmful. The aging process itself contributes to the risk, as physiological changes can alter how drugs are absorbed, distributed, metabolized, and eliminated. This can lead to the accumulation of drugs in the body, increasing the likelihood of adverse effects.

The Dangers and Risks of Polypharmacy

The potential for harm from multiple medications in older adults is significant and multifaceted. The risks extend beyond simple side effects to affect overall health, cognitive function, and quality of life.

Adverse Drug Reactions (ADRs) and Interactions

• Higher Incidence: The more medications a person takes, the higher the chance of a negative drug-drug interaction. Studies show that a person taking five to nine medications has a 50% chance of an adverse drug interaction.
• Symptoms Often Misinterpreted: ADRs can manifest as symptoms like dizziness, confusion, or fatigue, which are often mistakenly attributed to aging or a new medical condition. This can lead to a 'prescribing cascade,' where an additional medication is prescribed to treat the side effect of another, perpetuating a dangerous cycle.

Increased Risk of Falls and Fractures

Many medications commonly used by older adults, such as sedatives, antidepressants, and blood pressure medications, can cause dizziness, drowsiness, or balance problems. This dramatically increases the risk of falls, which are a major cause of injury, disability, and mortality in this population.

Cognitive Impairment

Certain drug classes, especially those with anticholinergic properties (e.g., some antihistamines, muscle relaxants), are known to affect memory and cognition. Excessive polypharmacy is a risk factor for mild cognitive impairment and dementia. When combined, these medications can exacerbate existing cognitive issues or cause new ones.

Functional Decline and Decreased Quality of Life

A complex medication regimen can be overwhelming and burdensome, leading to reduced medication adherence. The side effects themselves can also limit a person's ability to participate in social activities or hobbies, directly impacting their quality of life. The financial cost of multiple medications can also be a significant burden.

The Case for Deprescribing

Deprescribing is the intentional and planned process of reducing or stopping medications when the potential for harm outweighs the benefits. It is not about simply removing medications but about optimizing a person's drug regimen to improve outcomes and quality of life. This is especially relevant in cases of inappropriate polypharmacy where medications are unnecessary, potentially harmful, or no longer aligned with a patient's care goals.

Deprescribing is a critical component of geriatric care, helping to mitigate the risks associated with multiple medications. The goal is to reduce pill burden, minimize side effects, decrease costs, and enhance overall well-being.

The Deprescribing Process

A successful deprescribing strategy requires a systematic, thoughtful approach involving the patient, their family or caregiver, and the entire healthcare team. Here is a general framework:

1. Comprehensive Medication Review: The first step is to gather a complete and accurate list of all medications, including prescriptions, over-the-counter drugs, and supplements. A "brown bag review," where the patient brings all bottles to an appointment, is often used.
2. Assess Risks vs. Benefits: Each medication is evaluated individually to determine if the potential for harm outweighs the potential benefit, considering the patient's current health status, life expectancy, and care goals. Tools like the Beers Criteria can help identify potentially inappropriate medications.
3. Prioritize Medications: The healthcare team identifies the drugs that are the most likely candidates for reduction or discontinuation, prioritizing those with the highest risk of adverse effects or the least evidence of benefit.
4. Create a Tapering Plan: Many medications, especially those affecting the central nervous system like benzodiazepines or antidepressants, cannot be stopped abruptly. A gradual tapering plan is developed to minimize withdrawal symptoms.
5. Implement and Monitor: The plan is put into action with careful monitoring for any adverse withdrawal events or changes in the patient's condition. The patient and caregiver must be educated on what to expect and when to report any issues.

Talking to Your Doctor About Deprescribing

Initiating a conversation about deprescribing can be intimidating, but it is a crucial step toward better health. Here are some steps you can take:

• Schedule a dedicated appointment. Instead of bringing it up at the end of a quick visit, request a specific time to review medications.
• Bring an up-to-date medication list. Include all prescriptions, over-the-counter drugs, and supplements with dosage and frequency.
• Be prepared to discuss symptoms. Document any side effects or concerning symptoms you've experienced, no matter how minor they seem.
• Ask for clarification. Make sure you understand the purpose of each medication and what evidence supports its use for your specific condition.
• Communicate your goals. Discuss what matters most to you regarding your quality of life and health priorities. For more resources on this topic, the National Institute on Aging offers valuable guidance on having this conversation with your healthcare provider.

Polypharmacy vs. Deprescribing: A Comparison

Feature	Polypharmacy (Inappropriate)	Deprescribing
Primary Goal	Treating multiple conditions, often leading to excessive medication use and prescribing cascades	Optimizing medication use, reducing harm, and improving quality of life
Risks	Increased adverse drug reactions (ADRs), drug-drug interactions, falls, cognitive decline, financial burden	Potential for withdrawal symptoms if not managed carefully, recurrence of symptoms if a needed medication is stopped
Patient Involvement	Often passive; patient takes what is prescribed without full understanding or input	Active patient and caregiver involvement in decision-making and goal-setting
Approach	Reactive prescribing; adding medications to manage side effects	Proactive, systematic review and reduction of potentially inappropriate medications
Typical Outcome	Worsening side effects, potential hospitalization, reduced functional independence	Improved well-being, better adherence, reduced risk of falls and cognitive issues

Conclusion

While many medications are vital for managing chronic conditions, the dangers of polypharmacy in older adults are real and require a proactive approach. Deprescribing is a critical, patient-centered strategy that can significantly reduce the risk of harm, improve quality of life, and align treatment with a person's individual health goals. By collaborating with healthcare providers and taking an active role in medication management, older adults and their caregivers can navigate the complexities of their drug regimens and promote safer, healthier aging.

Frequently Asked Questions

What is considered polypharmacy in older adults?

Polypharmacy is most commonly defined as the regular use of five or more medications, including prescriptions, over-the-counter drugs, and dietary supplements. The risk of adverse events increases as the number of medications rises.

What are the most common dangers of polypharmacy in older adults?

The most common dangers include an increased risk of adverse drug reactions, falls and fractures, cognitive impairment (such as confusion and memory loss), drug-drug interactions, and a general decline in quality of life due to side effects.

What is deprescribing and why is it important?

Deprescribing is the systematic process of reducing or stopping medications to improve a person's health or reduce the risk of harm. It is important because it can prevent the negative effects of unnecessary medication and align treatment with the patient's individual care goals.

How can I tell if an older adult is experiencing negative effects from polypharmacy?

Symptoms can be subtle and easily mistaken for normal aging. Look for signs like increased confusion, dizziness, fatigue, balance problems, falls, loss of appetite, or unexplained changes in behavior. Any new symptom should be evaluated as a potential side effect of medication.

Who can help with deprescribing?

Deprescribing is a team effort involving healthcare providers, including a primary care physician, a pharmacist, and often a geriatric specialist. Pharmacists are medication experts and can be especially helpful in identifying drug interactions and creating a safe tapering plan.

How do I talk to a doctor about deprescribing medications?

Schedule a dedicated appointment to review medications. Bring a complete list of all medications and supplements. Discuss any potential side effects or concerns and express your care goals. Ask about the purpose and continued necessity of each drug.

Are all cases of polypharmacy bad?

No, not all polypharmacy is inappropriate. In many cases, taking multiple medications is necessary to manage complex chronic conditions. The issue arises with inappropriate polypharmacy, where drugs are unnecessary, harmful, or no longer serving their intended purpose.