Understanding the Concept of Polypharmacy
Polypharmacy is most commonly defined as the concurrent use of five or more medications, but it encompasses more than just the number of pills. It can also involve the use of potentially inappropriate medications, prescribing cascades (where a new drug is prescribed to treat a side effect of another), and the increased risk of drug-drug or drug-disease interactions.
While polypharmacy can be appropriate and necessary for complex health conditions, it is the inappropriate or excessive use of medication that poses a significant threat. Unmanaged polypharmacy is a leading cause of adverse drug events (ADEs), hospitalizations, and even death, especially among the most vulnerable populations. Identifying and mitigating the risks associated with it is a critical component of modern healthcare and healthy aging.
The Elderly: The Primary At-Risk Population
Without a doubt, the population at greatest risk for polypharmacy is older adults, generally defined as individuals aged 65 and older. This demographic is particularly susceptible for several reasons, and the risk escalates significantly with age.
Why are older adults at higher risk?
- Multimorbidity: As people age, they are more likely to develop multiple chronic health conditions such as heart disease, diabetes, hypertension, and arthritis. Each condition may require its own medication, leading to an ever-growing list of prescriptions.
- Age-Related Physiological Changes: With age, the body's ability to absorb, distribute, metabolize, and excrete medications changes. Reduced kidney and liver function can cause drugs to stay in the system longer, increasing the risk of accumulation and side effects.
- Multiple Prescribers: A senior with several chronic conditions often sees a variety of specialists. Each specialist may add prescriptions without a complete understanding of the patient's full medication list, leading to redundant or interacting medications.
- Residing in Long-Term Care Facilities: Studies show an extremely high prevalence of polypharmacy in residents of nursing homes and other long-term care facilities, where medication regimens are often complex and not regularly reviewed for necessity.
Other High-Risk Subgroups
While older age is the single greatest predictor, other factors further stratify risk within the general population. Recognizing these high-risk subgroups is essential for targeted intervention.
Individuals with chronic pain
Patients experiencing chronic pain, such as from fibromyalgia, often require a mix of medications, including opioids, muscle relaxants, and antidepressants. This complex regimen significantly increases their risk of polypharmacy and its associated side effects, such as sedation and cognitive impairment.
Patients with mental health conditions
Individuals with complex mental health conditions often take multiple psychotropic medications. These drugs can have interacting side effects, and additional medications may be prescribed to manage those side effects, creating a prescribing cascade.
Those using over-the-counter (OTC) drugs and supplements
The risk is not limited to prescription drugs. Many individuals self-medicate with OTC medications, herbal supplements, and vitamins without informing their healthcare providers. These can cause dangerous interactions with prescribed medications, a fact often overlooked by patients and providers alike.
People in transitions of care
Medication errors and new cases of polypharmacy frequently occur during transitions of care, such as moving from a hospital to a home or nursing facility. Poor communication between providers during these handoffs can lead to old medications being continued unnecessarily or new ones being added without a full review.
Comparing Polypharmacy Risks Across Populations
| Risk Factor | Older Adults (65+) | Younger Adults (with chronic conditions) | Patients in LTC Facilities |
|---|---|---|---|
| Multimorbidity | Very High | High | Very High |
| Age-Related Changes | High | Low | High |
| Multiple Prescribers | High | Medium | Very High |
| Care Transitions | High | Low | Very High |
| Use of OTCs/Supplements | High | Medium | Medium |
Strategies for Mitigating Risk
Managing polypharmacy in high-risk populations requires a multi-pronged, coordinated approach involving patients, caregivers, and the entire healthcare team. Deprescribing, the process of tapering or stopping medications, is a key strategy for reducing unnecessary medication use.
Here are several steps to mitigate the risks:
- Conduct regular medication reviews. Healthcare providers, especially pharmacists, should routinely review a patient’s complete medication list, including prescriptions, OTCs, and supplements, to identify redundancies or unnecessary drugs.
- Encourage a team approach. Interprofessional communication is key. All members of a patient's care team—doctors, nurses, and pharmacists—should be aware of the patient's full medication regimen.
- Educate patients and caregivers. Provide clear, easy-to-understand information about medications, potential side effects, and drug interactions. Teach-back methods can help ensure comprehension.
- Implement deprescribing protocols. Clinical guidelines and decision support tools can help prescribers identify and safely discontinue potentially inappropriate medications.
- Maintain accurate records. Utilize electronic health records (EHRs) to maintain a single, up-to-date medication list that is accessible to all involved providers.
- Assess patient goals. Involve patients and their families in discussions about treatment goals. For some, reducing the pill burden to improve quality of life might be more important than aggressively treating every single symptom.
Conclusion
While polypharmacy can affect any individual with complex health needs, older adults represent the population at greatest risk for polypharmacy due to the accumulation of chronic diseases and age-related physiological changes. Factors like multimorbidity, multiple prescribers, and use of over-the-counter products exacerbate this risk. By promoting a team-based approach, implementing strategic deprescribing, and improving communication and patient education, healthcare providers can significantly reduce the potential for adverse drug events and improve the overall well-being of high-risk individuals. For more information, visit the National Institutes of Health (NIH) website for resources on medication safety and healthy aging here.
