Strategies for Reducing Polypharmacy in Senior Care

Marcy A. Metzgar

Polypharmacy is a serious concern among adults, and especially among seniors. Although polypharmacy is preventable, it is a significant contributor to morbidity and mortality.¹ Polypharmacy generally is defined as taking multiple medications or more medications than are medically necessary (including over-the-counter drugs and supplements).

About 98 percent of seniors take five or more medications, and estimates suggest that anywhere from 13 percent to 74 percent of residents in skilled nursing facilities and long-term care settings take nine medications or more.² Further, approximately 59 percent of residents in these settings take a potentially inappropriate medication based on STOPP/START criteria (STOPP = screening tool of older persons’ potentially inappropriate prescriptions; START = screening tool to alert doctors to right treatment).³

Seniors have a higher rate of polypharmacy because of increased numbers of comorbid conditions, newer medications that effectively treat more medical conditions, and practice guidelines that often recommend multidrug regimens.⁴ Other common risk factors for polypharmacy include availability of over-the-counter products, disjointed care, and lack of data sharing among health systems.⁵

These risk factors, alone or combined, can produce adverse effects, such as poor medication adherence, drug–drug interactions, medication errors, and adverse drug reactions. These effects may subsequently result in a decreased quality of life, falls, hip fractures, vision and cognition impairment (including confusion and delirium), and urinary incontinence, which may lead to preventable emergency department visits and hospitalizations.⁶

Adverse effects can be further compounded in a prescribing cascade, in which "an adverse reaction to one drug goes unrecognized or misinterpreted, causing the healthcare provider to inappropriately [prescribe] a second drug to treat signs and symptoms. This can lead to potentially dangerous situations and overprescribing."⁷

To avoid overprescribing, providers should:

• Look at seniors' overall medical profiles when prescribing medications.
• Evaluate each medication for its usefulness by considering factors such as the senior's life expectancy, care goals, and the length of time until benefits manifest.
• Keep dosing schedules as simple as possible and limit the number of medication changes.
• When possible, avoid prescribing high-risk medications, such as sedatives/anxiolytics, narcotics, anticholinergics medications, and certain cardiovascular drugs.⁸

Providers also can use screening tools and guidelines to identify polypharmacy in seniors, assess potential safety risks, and assist with deprescribing. Deprescribing is the process of identifying and intentionally stopping a medication or reducing its dose to improve an individual's health or reduce the risk of adverse side effects.

When deprescribing medications for seniors, an article in U.S. Pharmacist advocates for a team-based approach that involves physicians, pharmacists, and nurses and focuses on planning, coordination, and communication. The article also notes that the care team should educate residents and their families/caregivers about the risks of polypharmacy and the possibility of deprescribing.⁹

A productive approach to deprescribing involves a five-step approach:

1. Review all medications and the indications for each of them.
2. Determine the harms associated with each medication.
3. Assess each medication for the potential to deprescribe it.
4. Prioritize the medications according to what should be deprescribed before others.
5. Implement and monitor the approach.¹⁰

When making medication changes, providers should always document the reason for doing so as well as the outcome of the change in the patient's health record. It's important to also keep in mind that a medication change in an electronic health record does not automatically get sent to the patient's pharmacy, so it's important for providers to ensure the pharmacy is aware of it.¹¹

When seeing and evaluating seniors, providers can use these methods to minimize polypharmacy:

• Conduct a thorough medication review and reconciliation and review dosages. Work with seniors and their families/caregivers to get a current and accurate list of medications.
• Assess for drug–drug interactions.
• Monitor for adverse drug withdrawal events.
• Identify any drug-related problems.
• Teach seniors about potential side effects, including when to seek help.
• Inform seniors of any dietary restrictions necessitated by a specific medication.
• Explore nonpharmacological interventions, such as dietary changes and behavioral modification strategies.
• Use tapering approaches.
• Reduce pill burden to improve seniors' ability to adhere to treatment regimens.¹²

The prevalence of polypharmacy is a resident safety issue in senior care facilities. It can produce significant adverse effects and reduced functional capacity. Reducing polypharmacy and avoiding inappropriate medications is a common goal in senior care, regardless of the setting. Healthcare providers can use resources and interventions to target seniors and prescribing practices associated with higher adverse drug events.

Resources

• Agency for Healthcare Research and Quality: Patient Safety Primer: Deprescribing as a Patient Safety Strategy
• American Family Physician: Polypharmacy: Evaluating Risks and Deprescribing
• Institute for Healthcare Improvement: Guide to Using the 4Ms in the Care of Older Adults in Hospitals and Ambulatory Care Practices

Endnotes

¹ Wang, K. A., Camargo, M., & Veluswamy, R. R. (2013). Evidence-based strategies to reduce polypharmacy: A review. OA Elderly Medicine, 1(1), 6.

² Earl, T. R., Katapodis, N. D., Schneiderman, S. R., & Shoemaker-Hunt, S. J. (2020). Using deprescribing practices and the screening tool of older persons' potentially inappropriate prescriptions criteria to reduce harm and preventable adverse drug events in older adults. Journal of Patient Safety, 16(3S Suppl 1), S23-S35. doi: 10.1097/PTS.0000000000000747; Hoel, R. W., Giddings Connolly, R. M., & Takahashi, P. Y. (2021, January 1). Polypharmacy management in older patients. Mayo Clinic Proceedings, 96(1), P242-256. doi: https://doi.org/10.1016/j.mayocp.2020.06.012

³ Hoel, et al., Polypharmacy management in older patients.

⁴ Brookes, L., & Scott, I. A. (2013). Deprescribing in clinical practice: Reducing polypharmacy in older patients. Medscape. Retrieved from www.medscape.com/viewarticle/814861_1

⁵ Takhar, S., & Nelson, N. (2021, October 27). Patient safety primer: Deprescribing as a patient safety strategy. Agency for Healthcare Research and Quality. Retrieved from https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy

⁶ Shah, B., & Hajjar, E. (2012). Polypharmacy, adverse drug reactions and geriatric syndromes. Clinics in Geriatric Medicine, 28, 173-186.

⁷ Woodruff, K. (2010). Preventing polypharmacy in older adults. American Nurse Today, 5(10). Retrieved from www.myamericannurse.com/preventing-polypharmacy-in-older-adults/

⁸ Saljoughian, M. (2019). Polypharmacy and drug adherence in elderly patients. U.S. Pharmacist, 44(7), 33-36. Retrieved from www.uspharmacist.com/article/polypharmacy-and-drug-adherence-in-elderly-patients; Dahal, R., & Bista, S. (2023, February 20 [Last updated]). Strategies to reduce polypharmacy in the elderly. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from www.ncbi.nlm.nih.gov/books/NBK574550/; Woodruff, Preventing polypharmacy in older adults.

⁹ Saljoughian, Polypharmacy and drug adherence in elderly patients.

¹⁰ Takhar, et al., Patient safety primer: Deprescribing as a patient safety strategy.

¹¹ Ibid.

¹² Ibid; Farrell, B., Shamji, S., Monahan, A., & Merkley, V. F. (2013). Reducing polypharmacy in the elderly. Canadian Pharmacists Journal, 146(5), 243–244; Woodruff, Preventing polypharmacy in older adults.

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