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 is generally defined as taking multiple medications or more medications than are medically necessary (including over-the-counter drugs and supplements).
Estimates suggest that anywhere from 13 percent to 74 percent of residents in skilled nursing facilities and long-term care 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’ prescriptions; START = screening tool to alert to right treatment).3
Because of increased numbers of comorbid conditions, newer medications that effectively treat more medical conditions, and practice guidelines that often recommend multidrug regimens, seniors have a higher rate of polypharmacy.4 Seniors take more medications to control multiple chronic diseases and may have greater difficulty metabolizing them, both of which can produce unfavorable adverse effects.
Some of these adverse effects include poor medication adherence, drug–drug interactions, medication errors, and adverse drug reactions. These effects may subsequently result in falls, hip fractures, cognitive impairment including confusion and delirium, and urinary incontinence, which account for a significant percentage of potentially preventable emergency department visits and hospitalizations.5
Adverse effects can be further compounded in a prescribing cascade, in which an adverse reaction to one drug goes unrecognized or misinterpreted, causing a healthcare provider to inappropriately prescribe another drug to treat signs and symptoms. This can lead to potentially dangerous situations and overprescribing.6
To avoid overprescribing, providers should look at a senior’s overall medical profile when prescribing medications instead of prescribing for certain therapies. They should evaluate each medication for its utility by considering factors such as the senior’s life expectancy, care goals, and the length of time until benefits manifest.7 Providers also should minimize the number of medications prescribed for seniors, keep the dosing schedule as simple as possible, and limit the number of medication changes.
The following screening tools and guidelines are available to help providers evaluate and discontinue medications that are potentially inappropriate for seniors:
- START8
- STOPP9
- Beers Criteria for Potentially Inappropriate Medication Use in Older Adults10
Deprescribing is when providers identify and intentionally stop a medication or reduce its dose to improve an individual’s health or reduce the risk of adverse side effects. A team-based approach involving physicians, pharmacists, and nurses is optimal when deprescribing medications for seniors. Discontinuing a medication should involve proper planning, communicating, and coordinating with the senior and the nursing staff. The nursing staff can help monitor the senior for beneficial or harmful effects from tapering or stopping medications. Seniors and families should also be educated about the dangers of polypharmacy so they are aware that a medication may be discontinued if it harms or no longer benefits them.11
Providers can follow these steps when deprescribing:
- Avoid medications that are inappropriate for seniors because of adverse effects, lack of efficacy, and/or potential for interactions.
- Discontinue medications when the harms outweigh the benefits in the context of the senior’s care goals, life expectancy, and/or preferences.12
When seeing and evaluating seniors, providers can use these methods to minimize polypharmacy:
- Scrutinize medication lists during every patient visit and review the dosages. Have seniors bring all of their medications to the office and review them together.
- 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 call the office or seek emergency 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.13
The prevalence of polypharmacy in senior care is a resident safety issue. 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.
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 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: www.medscape.com/viewarticle/814861_1
3 Ibid.
4 Brookes, L., & Scott, I. A. (2013). Deprescribing in clinical practice: Reducing polypharmacy in older patients. Medscape. Retrieved from https://www.medscape.com/viewarticle/814861_1
5 Shah, B., & Hajjar, E. (2012). Polypharmacy, adverse drug reactions and geriatric syndromes. Clinics in Geriatric Medicine, 28:173-186.
6 Woodruff, K. (2010). Preventing polypharmacy in older adults. American Nurse Today, 5(10). Retrieved from www.myamericannurse.com/preventing-polypharmacy-in-older-adults/
7 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
8 Barry, P. J., Gallagher, P., Ryan, C., & O’Mahony, D. (2007). START (screening tool to alert doctors to the right treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing, 36(6):632-638.
9 Gallagher, P., & O’Mahony, D. (2008). STOPP (screening tool of older persons’ potentially inappropriate prescriptions): Application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing, 37(6):673-679.
10 American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674–694. DOI: https://doi.org/10.1111/jgs.15767
11 Saljoughian, Polypharmacy and drug adherence in elderly patients.
12 McGrath, K., Hajjar, E. R., Kumar, C., Hwang, C., & Salzman, B. (2017). Deprescribing: A simple method for reducing polypharmacy. The Journal of Family Practice, 66(7):436-445.
13 Farrell, B., Shamji, S., Monahan, A., & Merkley, V. F. (2013). Reducing polypharmacy in the elderly. Canadian Pharmacists Journal, 146(5):243-244.
