Why is polypharmacy common in elderly patients?

According to the Centers for Disease Control and Prevention (CDC), nearly 85% of older adults have at least one chronic health condition, and 60% have at least two, directly linking age with multimorbidity. This prevalence of complex health issues provides crucial insight into the question: why is polypharmacy common in elderly patients?

Quick Summary

Polypharmacy in elderly patients is common due to the increased prevalence of multiple chronic conditions, which often leads to fragmented care from different specialists. Age-related physiological changes affect drug metabolism, while clinical guidelines and non-prescription medication use further complicate regimens, increasing health risks.

Key Points

• Multimorbidity: The presence of multiple chronic health conditions is the leading cause of polypharmacy in older adults, as each condition often requires separate medications.

• Fragmented Care: Seeing multiple doctors from different specialties without a single coordinating provider can lead to conflicting prescriptions and a lack of oversight regarding total medication burden.

• Age-Related Physiology: Changes in liver and kidney function, as well as body composition, alter how drugs are processed, increasing the risk of adverse effects and making polypharmacy more dangerous for seniors.

• Lack of Deprescribing: The medication list for an elderly patient often grows but rarely shrinks, as health providers and patients fail to review and discontinue unnecessary or outdated prescriptions.

• Hidden Medications: The use of over-the-counter drugs, supplements, and herbal remedies often goes unreported to physicians, adding to the total number of medications and increasing the risk of harmful drug interactions.

• Safety through Review: Regular, comprehensive medication reviews involving all healthcare providers and the patient are crucial for identifying and correcting problematic medication regimens.

The complex issue of polypharmacy in geriatric care

More than one-third of older adults in the U.S. use five or more medications, illustrating just one facet of the complex issue of polypharmacy. This phenomenon, which poses significant risks, prompts the critical question: why is polypharmacy common in elderly patients? The issue stems from a combination of factors related to health, healthcare systems, and the aging process itself.

The root of the problem: multimorbidity

The single biggest driver of polypharmacy in seniors is the high rate of multimorbidity, which is the simultaneous presence of two or more chronic diseases. As people age, the likelihood of developing conditions like hypertension, diabetes, heart failure, arthritis, and osteoporosis increases. Each condition comes with its own set of recommended medications, and when combined, they create a complex regimen. For example, a single patient might take medication for blood pressure, another for diabetes management, and an anti-inflammatory for joint pain. Each medication may be clinically indicated individually, but together, they constitute polypharmacy.

The fragmented healthcare system

A patient with multiple chronic conditions often sees numerous healthcare providers—a primary care physician, a cardiologist, an endocrinologist, and a rheumatologist, among others. In a fragmented healthcare system, communication between these specialists can be poor or non-existent. Each doctor may prescribe a new medication without a complete understanding of the patient's entire medication list, including over-the-counter (OTC) drugs and supplements. This lack of a central, coordinated view of the patient's care often leads to therapeutic duplication or the prescription of drugs that interact negatively with one another.

Age-related physiological changes

The aging body undergoes a series of changes that can impact how medications are processed, stored, and eliminated. Known as altered pharmacokinetics and pharmacodynamics, these changes include:

• Decreased kidney function: The kidneys' ability to filter waste and drugs from the blood declines with age, meaning medications stay in the body longer and can build up to toxic levels.
• Decreased liver function: The liver metabolizes drugs, and its efficiency decreases over time, also leading to a buildup of medication.
• Changes in body composition: Seniors often have a higher percentage of body fat and less lean muscle mass. This alters how fat-soluble drugs are stored and how water-soluble drugs are distributed throughout the body.
• Increased drug sensitivity: The central nervous system and other organs can become more sensitive to medication effects, increasing the risk of side effects like confusion, dizziness, and sedation.

The role of clinical practice guidelines

Clinical practice guidelines, which are designed to standardize and improve care for specific diseases, can unintentionally promote polypharmacy. These guidelines focus on treating a single condition and often recommend the use of multiple drugs for optimal management. When a patient has several conditions, following each guideline can result in an ever-expanding medication list. While well-intentioned, this approach can sometimes prioritize single-disease management over the holistic health of the older patient, who might struggle with the side effects and complexity of so many drugs.

Non-prescription medications and supplements

Polypharmacy isn't limited to prescription medications. Many older adults take a variety of over-the-counter drugs, herbal supplements, and vitamins without informing their healthcare providers. These products can interact with prescriptions, altering their effectiveness or causing adverse reactions. A patient might take an NSAID for pain, an herbal supplement for sleep, and a vitamin supplement, all of which contribute to their overall medication burden.

Lack of consistent medication review

Medication lists tend to grow over time, but they don't always shrink. A drug prescribed for a short-term issue may never be discontinued. Patients might also continue taking medications prescribed by a long-past specialist. Without a regular, comprehensive medication review—a process called deprescribing—unnecessary or potentially harmful medications can accumulate. Deprescribing is a structured process of reducing or stopping medications that are no longer beneficial or may be causing harm.

Managing polypharmacy: strategies for safer care

Mitigating the risks of polypharmacy requires a proactive, patient-centered approach. Both patients and healthcare providers must work together to ensure a safe and effective medication plan.

• Maintain a complete medication list: Keep an up-to-date list of all medications, including prescriptions, OTC drugs, vitamins, and supplements. Share this with every healthcare provider at every visit.
• Regular medication reviews: Have a physician or pharmacist conduct a full medication review at least once a year, or whenever a new medication is added. The goal is to evaluate if each drug is still necessary.
• Centralize care: Whenever possible, use a single pharmacy and a primary care physician who can coordinate care among different specialists.
• Deprescribing protocols: Ask about the possibility of deprescribing if a medication is no longer beneficial or is causing adverse effects.

Contribution to Polypharmacy	Strategy for Mitigation
Multimorbidity	Coordinate care to use fewer drugs for multiple conditions.
Fragmented Care	Designate a lead physician to oversee all prescriptions.
Age-Related Changes	Adjust dosages and monitor for side effects regularly.
Single-Disease Guidelines	Deprescribe unnecessary medication and prioritize patient-centered goals.
Non-Prescription Drugs	Document all OTCs, vitamins, and supplements in the medication list.
Unchecked Accumulation	Conduct regular, comprehensive medication reviews.

Steps for an effective medication review

1. Bring all medications: Gather all prescription bottles, OTCs, and supplements to the appointment. This ensures the most accurate and complete picture.
2. Discuss medication goals: Talk with your doctor about what each medication is for and whether it is still achieving its intended purpose.
3. Identify unnecessary drugs: Work with your doctor to identify any medications that are no longer necessary or are causing side effects that outweigh the benefits.
4. Create a schedule: Simplify the medication schedule as much as possible to improve adherence and reduce confusion.
5. Develop a long-term plan: Establish a plan for future medication reviews and communication to prevent polypharmacy from reoccurring.

For more information on understanding medication interactions and safe use, a valuable resource is MedlinePlus from the U.S. National Library of Medicine, which provides in-depth articles and tools. You can find more at their website https://medlineplus.gov/druginformation.html.

Conclusion

The commonality of polypharmacy in elderly patients is not a simple issue but rather a systemic one rooted in complex health profiles and healthcare delivery systems. Recognizing the physiological changes of aging, addressing poor communication between specialists, and actively managing medication lists are all essential steps toward safer, more effective care. By empowering patients and their caregivers with knowledge and promoting a coordinated approach to healthcare, the risks associated with polypharmacy can be significantly reduced, leading to better overall health and quality of life for seniors.

Frequently Asked Questions

What is considered polypharmacy?

Polypharmacy is generally defined as the use of five or more medications on a regular basis. It can also refer to the use of more medications than are clinically necessary, regardless of the number.

What are the biggest risks of polypharmacy for the elderly?

The biggest risks include increased adverse drug reactions, drug-drug interactions, a higher risk of falls, cognitive impairment, medication non-adherence, and a decline in overall physical and mental function.

How can families help manage an elderly patient's polypharmacy?

Families can help by maintaining an accurate, up-to-date list of all medications, accompanying the patient to doctor's appointments, asking questions about each medication's purpose, and facilitating regular medication reviews.

What is deprescribing?

Deprescribing is the supervised process of systematically reducing or stopping medications that may no longer be beneficial or could be causing harm. It is a key strategy for managing polypharmacy.

Should over-the-counter medications be included in a medication list?

Yes, absolutely. All over-the-counter medications, herbal supplements, and vitamins should be included on the medication list. They can cause significant interactions with prescription drugs and must be reviewed by healthcare providers.

How often should an elderly patient have their medications reviewed?

An elderly patient's medications should be reviewed at least annually. Reviews should also occur whenever a new medication is prescribed or if the patient experiences new or worsening symptoms.

Is polypharmacy always dangerous?

While polypharmacy significantly increases risks, it is not inherently dangerous. In some cases, it may be medically necessary to manage multiple complex conditions. The key is ensuring that all medications are appropriate, necessary, and effectively managed to minimize risk.