I talk with Dr Lishan Liu, an Elderly Care Medicine Registrar at Chester, about Polypharmacy in the older patient. Lishan has previously undertaken work investigating Polypharmacy and Potentially Inappropriate Medications (PIM) amongst patients on Elderly Care wards and the application of a tool to help with improving prescribing. Whatever speciality you work in, with the exception of paediatrics, you will likely regularly encounter patients at risk from Polypharmacy.
The World Health Organisation has predicted that the number of people over the age of 65 will reach 1.5 billion by the year 2050 and the majority of health burden coming from chronic, non-communicable diseases (1). Patients in this age group will typically have increasingly complex health needs and are at risk of both Polypharmacy and Potentially Inappropriate Medications (PIMs).
The term Polypharmacy refers to a patient on multiple medications. No consensus exists for exactly how many this would be, perhaps the best way to consider it is the use of more medication than is clinically justified (2). Potentially Inappropriate Medications encompasses not only those that are over-prescribed but the under-prescription and mis-prescription of medications (3). Though we aim to prescribe based upon evidence, occasionally the combined best practice for multiple conditions may not be the best practice for the individual patient. There are situations, however, when polypharmacy is appropriate and we may find ourselves adding to the prescription rather than removing.
The exact rate of polypharmacy varies (4, 7, 12). The consequences of polypharmacy and PIMs include hospital admissions, falls, delirium and adverse drug reactions (ADRs) (5-7). There have even been associations made between polypharmacy and an increased mortality risk (10). Those residing within community care facilities are at even greater risk as are patients with cognitive decline or poor renal function (11). Over 40% of patients within these facilities may be taking inappropriate medications (12). This places them at risk of not only adverse drug reactions but hospital admissions as well (11). With vigilance toward medication reviews, these admission may well be preventable. NICE (National Institute for Health and Care Excellence) recommend that there should be policies in place for residents of care facilities to have regular medication reviews (13)
When these patients are admitted to hospital or engage with other providers in the community, it provides the opportunity to review their medications for appropriate and inappropriate prescriptions. For some patients, this can be a large and complicated challenge.
Multiple tools currently exist to help us review medication. Two commonly investigated criteria are the Beer’s Criteria and the STOPP/START criteria.
The Beer’s criteria is a tool produced by the American Geriatrics Society and was updated in 2015 (8). The criteria divides PIMs into three groups:
- Medication to avoid in older adults regardless of diseases or conditions,
- Medication considered potentially inappropriate when used in older adults with certain diseases or syndromes,
- Medication that should be used with caution
One drawback for the Beer’s criteria when applying to UK practice is that often these medications are not actually prescribed.
The STOPP/START criteria (9) would be more commonly used in the UK. STOPP stands for Screening Tool of Older Person’s Prescriptions. START stands for Screening Tool to Alert to the Right Treatment. This combined tool is important when conducting a medication review because reviewing medication is not just about stopping medications but also starting the correct ones when indicated. The criteria look at indicators for PIMs that include:
- Drug reactions with either other drugs or disease processes
- Therapeutic duplication
- Treatment duration
- Drugs that could lead to cognitive decline and falls
The START element predominantly focuses on errors of omission and provides the opportunity to reduce potential morbidity from underlying disease states that may have been neglected previously.
Is one tool better than the other? Some evidence, though from small studies, suggests that STOPP/START may be more effective at detecting PIMs that contribute to hospital admissions than Beer’s Criteria (9). In reality, these are tools and should be used alongside clinical decision making. If your place of work does use such tools, then it is worth familiarising yourself with how they work and if you are unsure, ask someone to explain it to you or ask a senior for advice. At the time of writing this piece, the evidence linking such interventions to more patient-centred outcomes such as morbidity, hospital admissions and mortality is sadly lacking in quality. An observation backed by the Cochrane Review (10)
7 Steps for a Medication Review
Conducting a medication review can be challenging, especially for junior doctors. We don’t want to cause harm to patients or sometimes be chastised by our seniors for making a mistake. Sometimes it will feel easier to maintain status quo rather than make alterations. If you embark upon a medication review then it is worth reading the 7 steps outlined by SIGN (www.polypharmacy.scot.nhs.uk/7-steps). These steps allow a structured review.
- Identify aims and objectives of the therapy. This involves considering what the goals of the therapy are with respect to current disease processes and prevention of future problems.
- Identify essential drug therapy. These would be drugs that need specialist advice before stopping, drugs that are essential replacement, eg hormone based therapies, or drugs that prevent rapid symptomatic decline eg drugs for Parkinson’s.
- Is the drug necessary? Some medications will have temporary indications that may have been overlooked once the indication was no longer valid, there may be medications with doses higher than normal maintenance doses (eg a loading dose that continued) or medications with limited benefit for either the patient or indication prescribed.
- Are therapeutic objectives being achieved? This involves considering whether symptomatic or biochemical/clinical targets at being met or if disease progression/exacerbation is being prevented.
- Does the patient have Adverse Drug Reactions (ADRs) or is at risk of them? These may be drug-drug or drug-disease interactions. Those at risk of adverse effects should have robust monitoring procedures. ADRs should be identified either by investigations or by symptomatic assessment. We should be mindful that some medication may have been started to combat an ADR and consider stopping both if able.
- Is the drug cost effective? Perhaps not one we as juniors would always consider. The easiest thing to do is check for generic alternatives to brand name drugs and switch when appropriate. Cost effectiveness is a balance between cost, effectiveness and convenience.
- Is the patient willing and able to take the drug therapy as intended? Firstly identify barriers to compliance whether the medication form (eg tablet vs liquid), timing of the medication and their understanding of the therapeutic objectives.
An alternative approach toward medication reviews can be found in JAMA Internal Medicine (14).
LiShan talks about blister packs or dosset boxes. These are medication management systems produced by pharmacies to aid with compliance. Usually, they are put together by a pharmacy and contain the patients medication for a week, organised into days and time of day to be taken. For those patients who may struggle with timing of medications when presented in boxes and strips, these can be a great aid. It is imperative to remember when making medication changes, your pharmacy will need time to produce the blister packs prior to discharge so get those take home medications in early!
In summary, polypharmacy and PIMs can affect a large number of patient and can represent a source of morbidity to patients. Tools exist to identify inappropriate medication and omissions that may be of benefit. A structured, step-wise approach to reviewing medications can help undertake reviews when we encounter polypharmacy and rationalise prescriptions.
Want to know more? The SIGN web page provides a lot of information and further tools to help with your reviews.
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- Global Health and Aging, World Health Organisation Publications, October 2011
- Dagli RJ, Sharma A, Polypharmacy: a global risk factor for elderly people.J Int Oral Health. 2014 Nov-Dec;6(6):i-ii.
- Fried et al, Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review.J Am Geriatr Soc. 2014 Dec;62(12):2261-72.
- Gomez C et al, Polypharmacy in the Elderly: A Marker of Increased Risk of Mortality in a Population-Based Prospective Study (NEDICES). Gerontology. 2015;61(4):301-9.
- American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.J Am Geriatr Soc. 2015 Nov;63(11):2227-46. Epub 2015 Oct 8
- O’Mahony D et al, STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015 Mar;44(2):213-8. Epub 2014 Oct 16.
- Van der Stelt et al, The Association Between Potentially Inappropriate Prescribing and Medication-Related Hospital Admissions in Older Patients: A Nested Case Control Study. Drug Saf (2016) 39:79–87
- Aldred DP et al, Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev. 2016 Feb 12;2:CD009095.
- Jokanovic N et al, Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2015 Jun 1;16(6):535.e1-12. Epub 2015 Apr 11
- Managing Medicines in Care Homes, NICE Social Care Guideline [SC1], Published: March 2014.
- Scott IA et al, Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827-34.