The prevalence of conditions requiring multiple medications makes polypharmacy, which is typically defined as more than four medications, common in the older patient population. Nine or more medications are considered to be serious. A geriatrician at Duke University advises clinicians who treat older adults to be on the lookout for any warning signs of possible drug interaction issues so they can address them before they develop into more serious health issues.
This article examines potential issues, such as age-related changes in medication response and noncompliance with medication regimens, that could arise from older adults taking multiple medications.
How Aging Affects Response to Drugs
Drugs affect older people differently than they do younger people. While most drug absorption rates remain constant with age, aging changes the body’s water and fat composition: fat stores rise while total body water levels fall. These modifications may affect the therapeutic drug levels, resulting in higher concentrations of water-soluble drugs and longer half-lives of fat-soluble drugs.
Also, because the liver metabolizes many drugs, such age-related changes as reduced hepatic blood flow and liver size alter drug clearance. Drug elimination also may be affected by age-related decreases in renal blood flow, kidney size, and glomerular filtration rates, as well as changes stemming from chronic diseases.
Digoxin and a few other medications are also bound to plasma proteins, meaning that only the unbound or free portion of the drug is biologically active. Decreases in serum albumin levels, which are frequent in older adults who are malnourished, severely disabled, or suffering from chronic illnesses, can therefore result in higher drug blood levels. Therefore, older patients may be more sensitive to some drugs and less sensitive to others.
Adverse Reactions to Drugs
Adverse reactions are frequent in older adults and frequently present differently than in younger patients. In ambulatory older adults, an estimated 35% of adverse drug reactions occur annually; 29% of these reactions necessitate hospitalization or medical attention. Furthermore, some adverse reactions are mistakenly labeled as health issues. For instance, falls, dementia, and urinary incontinence are common in the elderly and can result from a health problem or a medication.
In a prescribing cascade, an adverse reaction to one drug goes unrecognized or misinterpreted, causing the healthcare provider to inappropriately subscribe a second drug to treat signs and symptoms. This may result in risky circumstances and overprescribing.
Dietary and Herbal Preparations
Dietary supplements (such as vitamin and mineral supplements) and herbal preparations have become popular. Examples include ginkgo biloba, St. John’s wort, echinacea, ginseng, garlic, saw palmetto, kava, and valerian root are promoted for their purported use in preventing or treating various health problems, including depression and the common cold. After learning about these precautions from friends, family, or the media, a person might begin to take them. And because they’re available OTC, patients may not think they should mention them to healthcare providers. However, there is a risk that these preparations will interact negatively with other prescribed medications. So be sure to ask the patient about all preparations—not just prescription drugs—he or she is taking.
Poor Adherence to the Medication Regimen
It is a persistent issue with older adults to not follow their medication regimen. Most patients are motivated to take their medications as directed, but some patients may not because they don’t understand, they’re unsure of what to do, or they simply forget. However, for elderly patients with impaired vision or poor manual dexterity, cutting tablets in half to reduce the dosage may be difficult or impossible. In other situations, prescribers may advise patients to do this.
Additionally, some patients may attribute negative side effects to a medication and, without consulting the doctor, reduce or stop taking it. Those who have vision problems might find it challenging to read the prescription label. Patients with financial difficulties or those who have fixed incomes may choose to take medication at lower doses than recommended in order to extend their supply, or they may choose not to fill a prescription at all.
Methods to Help Older Adults Avoid Polypharmacy
Be Cautious When Deprescribing Medications
Little believes that although deprescribing has been shown to improve patient outcomes, it’s a complex matter that requires a management process. “We think deprescribing is safe as long as it’s an individualized process done systematically,” she says, “and it requires the efforts of the entire care team to be done correctly. Chronic disease management is not ‘one size fits all.’ Life expectancy, functional status, clinical targets that change with age—all of these factors play a significant role in determining the best course of treatment for each patient.”
Get An Accurate List of Medications
According to Little, it can be very difficult to even obtain an accurate list of medications. “I work hard to find out everything a patient takes, and how and when they take it. I also need to know how they administer medication and the protocol they follow. Sometimes, patients come up with ingenious ways to keep track of how much medication they need to take. One patient marked an “X” on the bottle lids for each tablet he needed to take each day. It is crucial to be aware of every prescription that has been filled as well as the system that has been used, to see if any changes need to be made to increase compliance and safety. Even those without memory issues may accidentally take too many pills at once or forget to take any at all. Knowing these crucial details requires extensive research, and managing them effectively frequently necessitates the assistance of multiple care team members.”
Reorganize the Medication List
Normally, medications entered into a patient’s electronic health record (EHR) are listed in alphabetical order, but Little suggests grouping medications by condition or use. She rearranges the list according to the condition for which they were prescribed, for example., blood pressure, anticholinergic, pain control, antidepressants. “This grouping enables me to quickly determine whether I can combine and use one medication to treat two conditions, or deprescribe a medication that may be interfering with another and posing issues.”
Identify Inappropriate and Incorrect Prescriptions
Little asserts that problems with polypharmacy can occasionally be the result of prescribing the incorrect drugs for a patient’s condition or a patient’s ignorance of the need to stop taking one drug when beginning to take another. “A patient may be on two medications for one indication prescribed by two different physicians,” she says, adding that some patients who subscribe to mail order medications may continue to receive bulk shipments after their physician has changed a prescription, creating confusion. about what they should actually be taking.
Watch for Signs of Potential Issues
According to Little, PCPs should look for signs of polypharmacy problems during the annual wellness exam and, if necessary, consider referring elderly patients to a geriatric medicine specialist.
Summary
Remind elderly patients to refrain from sharing medications and dispose of unused medications properly to address the issue of multiple medications. Additionally, if necessary, assist seniors in producing memory aids. For instance, advise seniors to incorporate medication management into their daily routines or to use color-coded charts, automatic dispensers with bells, or voice-activated message services to help them remember to take their medications.
