Polypharmacy; A Case-based Primer on the Practice in the Geriatric Population
Michael J. Schuh, PharmD, MBA, FAPhA,1 Haya S. Kaseer, PharmD,2 Robert P. Shannon, MD, FAAHPM,3 and Jessica A. Peterson, PharmD4
1 Department of Pharmacy, School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, FL
2 University of Florida, College of Pharmacy, Gainesville, FL
3Department of Family and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, FL
4 Maine Medical Center, Portland, ME
Address correspondence to: Michael J. Schuh, PharmD, MBA, FAPhA Mayo Clinic 4500 San Pablo Road Jacksonville, FL 32224 Phone: (904) 953-2673 Email: [email protected]
Abstract
Polypharmacy in the geriatric population is challenging for all caretakers involved. Those patients often have a variety of comorbid medical conditions requiring numerous medications. On occasion, these medications are no longer consistent with the treatment goals and can cause serious side effects. Geriatric patients may benefit from the expertise of pharmacists who are well-trained in pharmacology, pharmacokinetics and pharmacodynamics working in collaboration with primary physicians in both the inpatient and outpatient setting. The authors present a case-based primer on the principles of polypharmacy in the geriatric population.
Introduction to Polypharmacy
Polypharmacy is simply defined as “the administration of multiple medications concomitantly or the administration of excessive medications.”1 Approximately 61 percent of individuals older than 65 take at least one prescription medication, and most are taking an average of three, exclusive of over-the-counter (OTC) medications or supplements.2 Another recent analysis found the prevalence of polypharmacy in the United States (defined as ≥8 medications) was 15.7 percent; females had a higher rate of polypharmacy than males. Polypharmacy is most dominant in the southern region of the United States. Between 1988 and 2010, multiple medication use increased dramatically. The median number of prescription medications used in adults aged ≥ 65 has doubled, and the proportion of adults taking five medications or more has tripled from 12.8 percent to 39.0 percent.3,4
Clinical practice guidelines often recommend several medications to treat chronic disease. Consequently, an elderly patient with at least two medical conditions, such as hypertension and diabetes, will often be on more than five medications.5
Polypharmacy in the Elderly
Polypharmacy in the elderly is associated with increased healthcare expenses and emergency room visits.6 Geriatric patients are at increased risk for adverse drug events due to drug interactions, altered drug metabolism, or absorption from declining organ function. Medications also contribute to increased fall risk in geriatric patients. It is estimated that 1 in 3 older adults fall annually, associated with increased emergent care visits, increased cost, and death. Reducing polypharmacy can reduce the number of falls and subsequent debility.7
Many elderly patients take medications without a clear indication. Often, drugs are not routinely assessed for continued need. Examples include long term use of proton pump inhibitors for a history of acid reflux, xanthine oxidase inhibitors for a distant episode of gout, and hormone replacement therapy in patients long past menopause. Studies of community-based older patients have documented an average of one unnecessary drug per patient, including drugs with no identifiable current indication or those that provide marginal benefit for the disease indication.8
Additionally, the elderly often self-medicate, sometimes preferring supplements for health and medical conditions.9 A recent study showed analgesics, vitamins and dietary supplements are commonly self-administered by older adults. Dietary supplements may be viewed as benign by patients and providers, but can have major interactions with prescription medications. This view is problematic in the setting of polypharmacy and decreased organ function, and increases the risk for drug interactions and adverse effects.10
Patient Centered Medical Home/Beers Criteria
The Patient Centered Medical Home (PCMH) is a healthcare delivery model recognized to improve the quality and efficiency of care while responding to each patient’s unique needs. This model focuses on a team approach, incorporating physicians, nurses, social workers, and pharmacists. The PCMH provides comprehensive, patient-centered care, including acute care, chronic condition management, and preventative services to patients from childhood to end of life.11,12
The Beers Criteria is an evidence-based list of medications from The American Geriatric Society which helps identify the risk level of certain medications that can cause harm to elderly patients. The list includes common drug-drug interactions associated with harmful outcomes, and identifies drugs to avoid in patients with kidney impairment. A clinician can use this list to monitor medication use and recommend discontinuation, dose adjustments, and/or increased monitoring.13
Pharmacy Medication Management: The Evolving Role of Pharmacist
Numerous studies demonstrate the benefits of clinical pharmacist interventions in the setting of polypharmacy.7, 14,15,16, 17 Medication therapy management (MTM) clinically integrates pharmacists in the PCMH in a variety of practice models. Physicians may be time-limited during office visits and unable to address polypharmacy or conduct comprehensive medication reviews. MTM is a comprehensive, patient-centered service that can enhance therapeutic outcomes while ensuring individualized care. MTM provides face to face patient education to review medication use, simplify medication regimens, and improve adherence.
MTM focuses on improving the quality of care in elderly patients, utilizing clinical guidelines and patient goals. The pharmacist reviews the patient’s medications, counsels the patient on proper administration and management of side effects, and educates the patient on non- pharmacological interventions. The pharmacist identifies potential concerns, and reviews the medical and relevant drug history to suggest a plan that meets the patient’s goals. After composing the recommendations, the pharmacist discusses modifications with the physician to improve quality of life and prevent potential complications.
The role of the pharmacist is especially significant in chronic disease management. The pharmacist ensures that the patient understands short-term and long-term treatment goals, therapeutic monitoring, and possible adverse effects, and can alleviate patient knowledge gaps in understanding when complex treatments have been initiated by multiple physicians.18
Medication Reconciliation
Medication errors frequently occur during transitions of care. Errors result when patients can’t recall home medications, and when records are unavailable. Medication reconciliation is a required process of creating a medication list for a patient during transitions of care. Medication reconciliation reduces the incidence and severity of medication errors during both prescribing and dispensing. Maintaining an up-to-date list and accounting for medication changes at every appointment helps to reduce inadvertent medication errors, and harm to the patient.19,20
Screening tools are helpful in preventing medication errors in the elderly. The screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria recognize the dual nature of inappropriate prescribing by including a list of potentially inappropriate medications (STOPP criteria) and potential prescribing omissions (START criteria).21 Potentially inappropriate medications identified by STOPP criteria include digoxin, beta blocker with history of COPD, TCA with dementia, long-acting benzodiazepines, and prolonged use of first generation antihistamines.22 Potential prescribing omissions, defined as treatments indicated but not prescribed, by START criteria include ACE inhibitor following acute myocardial infarction, ACE inhibitor in chronic heart failure with no existing contraindications, statin therapy in patients with documented history of cardiovascular events, and ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy.23 There is no evidence that using the START/STOPP criteria reduces morbidity, mortality, or cost in the geriatric population. However, these criteria may identify opportunities for better patient prescribing practices.24
Comprehensive Geriatric Assessment
The geriatric assessment is a multidimensional tool intended to gather information on the medical, psychological, social, and functional abilities and restrictions of the elderly population. Areas to assess include current symptoms and their functional influence, current medications along with indications and effects, past allergies and medical conditions, recent life changes, current caregiver network, measure of cognitive function, nutritional status, and services required. It is important to inquire about demographics, patient’s chief complaint and present illness, past medical history, social history, daily nutritional health, physical activity, sleep hygiene, and recreational activities. It is useful to perform regular physical examinations and laboratory tests, and a thorough review of systems for every elderly patient.25
Opioids and Controlled Substance Treatment Plans
Opioids are listed on the Beers Criteria due to increased risk for falls, fractures, and potential interaction with other psychotropic medications. Despite this recommendation, elderly patients are frequently prescribed chronic opioids for nonmalignant pain. The use of prescription opioids has increased in older adults in the United States.26, 27, 28 The elderly are at risk for adverse drug events due to opioid use, and they are not immune to opioid misuse and overdose. Compassionate care requires a delicate balance of undertreating pain and inappropriate prescribing. If opioids are deemed appropriate for long term use, providers must discuss benefits and risks, including side effects and potential for dependence or addiction.
Controlled Substance Treatment Plans should be formulated between the patient and physician, including goals of treatment, with a schedule for periodic evaluations. Non-pharmacologic treatments should be considered as alternatives or in conjunction with medications. Treatment plans should outline appropriate medication use and define medication misuse. Providers should address other medications that can interact with opioids and efforts should be made to minimize other central nervous system (CNS) modulating medications.28
Palliative Care
Polypharmacy is common in patients at end of life. There is little guidance on appropriate discontinuation of medications in the setting of palliative care. The pharmacist and members of the palliative care interdisciplinary team should focus the conversation on the wishes of the patient and family, and create a plan of care consistent with the notion of “assess, anticipate and alleviate suffering.” All modalities aimed at comfort, including those on the Beers Criteria should be considered and offered; all other treatments should become elective or discontinued.29 Continuing unnecessary medications can increase harm to patients and add to the burden of polypharmacy, and providers should highlight the disadvantages of continuing medications.30 Medications such as aspirin or statins are particularly important in palliative care discussions.
Specialty-based
Geriatrics: Geriatric patients are often cared for by multiple specialists. When care is not coordinated between each provider, patients are at risk for polypharmacy, duplications in therapy, drug interactions and increased side effects.31
Oncology: Cancer progression and treatment affect the overall quality of life, functioning, and life expectancy of older adults. Polypharmacy is a serious concern in cancer patients.32 Chemotherapy agents are associated with several adverse effects, including gastrointestinal abnormalities, peripheral neuropathy, hand and foot syndrome, and hypersensitivity reactions. In the setting of polypharmacy, toxicity and adverse effects may increase due to drug-drug interactions or metabolism-induced complications. This can lead to lack of adherence, treatment failure and suffering. A patient’s medications should be evaluated thoroughly to avoid therapeutic barriers and adverse consequences. Neurology & Psychiatry: With each amendment of the Beers Criteria, there is a greater focus on antipsychotics, benzodiazepines, tricyclic antidepressants, opioids, and other CNS-impacting agents. Polypharmacy with multiple of these medications is risky and dangerous.28 When managing mental health and controlling pain in the elderly, it is imperative to evaluate each patient’s medications and ensure the use of CNS-impacting agents is limited to what is truly needed. Subjective assessment of a patient’s mental and pain status is essential to manage these medications, including listening to caregivers in patients with cognitive impairment.
Cardiology: Hypertension, atrial fibrillation, and heart failure are some chronic disease states commonly seen in the geriatric population necessitating the use of anti-hypertensives, nitrates, antiplatelets drugs, and anticoagulants. Cardiac medications have risks of bleeding, orthostatic hypotension, bradycardia, and falls that are often seen in the geriatric population. Therefore, polypharmacy requires special attention to ensure appropriate medications are prescribed, and adverse effects are managed. Patient education and monitoring are crucial to achieving treatment goals.
Case Introduction
Case #1
Demonstrates the diversity of symptoms resulting from polypharmacy. Illustrates how fragmented care contributes to polypharmacy. Shows the “multiplier effect” of iatrogenic symptoms.
A 64-year-old female presented to her pulmonologist for evaluation of dyspnea. Her medications included diclofenac, cyclobenzaprine, and hydrocodone/acetaminophen from her chronic pain physician, clonazepam, nortriptyline, and duloxetine from her psychiatrist, and topiramate, gabapentin, and cetirizine from her primary care physician. The patient also had chronic renal disease, cognitive impairment, six falls over several months, anxiety, mydriasis, episodes of sweating, nausea, and occasional myoclonic jerks and tremor. She was unmotivated to exercise or socially engage, was anemic, and gained 20 pounds over the last year.
Case #2
Illustrates the importance of screening for potential medication-medication and medication-nutrition interactions. Demonstrates the importance of respecting a patient’s autonomy and goals of care. Identifies necessary dose modifications in the setting of impaired renal function.
A 71-year-old female was referred for a comprehensive medication review with a pharmacist by her family physician. Her chief concerns included feeling fatigued and depressed. She reported dizziness, nausea, acid reflux, and “wanted to stay in bed all day.” Her blood pressure was significantly elevated with systolic readings in the 170-180’s.
Her past medical history was significant for undifferentiated connective tissue disease, uncontrolled hypertension, renal dysfunction, and hypothyroidism. Current medications include apixaban, atorvastatin, calcium carbonate, carvedilol, chlorthalidone, hydralazine, hydroxychloroquine, levothyroxine, nitrofurantoin, prednisone, spironolactone, tramadol, ferrous sulfate, and vitamin B complex.
Thyroid-stimulating hormone and calcium levels were elevated. Patient reported taking her levothyroxine one hour apart from her ferrous sulfate. She wished to stop as many medications as possible and was not agreeable to starting additional medications for hypertension.
Case #3
Illustrates the positive impact of de-prescribing. Demonstrates role of judicious and appropriate use of comfort medications even if on the Beers Criteria list. Shows the need for earlier palliative care interventions.
A 76-year-old female who was in transit from Virginia to St. Augustine, Florida was seen in the palliative medicine clinic following an overnight observation in the emergency department for acute altered mental status superimposed on advanced dementia, renal impairment, hypertension, hyperlipidemia, osteoarthritis, sarcopenia, anemia, weight loss, acute urinary retention, and constipation. She was on several medications including a diuretic, a statin, and donepezil. The patient was hallucinating intermittently, frequently agitated, and seemed to be in pain. Beyond “sundowning,” she had sleep-wake cycle disruption. The physical exam showed advanced dementia with poor functional capacity: she was wheelchair bound and incontinent of urine and feces with very little verbal capacity.
Resolution of Case Presentations
Case #1
The clinical pharmacist MTM suggestions:
Taper to stop the scheduled clonazepam and use lorazepam only for acute anxiety attacks. Clonazepam has an extended half-life in the elderly and through accumulation is additive with other CNS depressants, contributing to fall risk, depression, respiratory depression and dyspnea. Taper down gabapentin and topiramate doses since glomerular filtration rate (GFR) is 50 mL/min, to prevent reduced cognition and additive CNS/respiratory depression. Minimize all serotonergic medications if possible, (duloxetine, cyclobenzaprine, nortriptyline) as patient exhibited possible signs of serotonin toxicity. Consider recommended sleep hygiene protocol or alternative agents for depression/sleep; current therapy may be ineffective. Dyspnea may be multifactorial. Deconditioning, added weight, and respiratory depression from multiple medications are likely contributory factors. Refer patient to the pain rehabilitation clinic (PRC) for overall taper of pain and CNS depressive medications to lowest possible dose or discontinuation.
The pulmonologist suggested that the patient and her primary physicians follow the pharmacist recommendations. After enrollment into a PRC, the above recommendations were followed, and following the 21-day program, the total prescription and over-the counter medication count was reduced from 19 to 7.
Case #2
The clinical pharmacist MTM suggestions:
Maximize doses of current antihypertensives instead of adding additional agents. Recommended home blood pressure monitoring, lifestyle modifications, and appointment with registered dietician. Separate levothyroxine and ferrous sulfate administration by at least four hours. Recheck Thyroid-Stimulating Hormone (TSH) in six weeks. Take tramadol only as needed. Tramadol requires dosing adjustments in patients with impaired renal function. The active metabolite of tramadol is excreted in the kidney and the half-life may be prolonged in patients with renal dysfunction, leading to increased CNS depression, somnolence and fatigue. Augment analgesia with acetaminophen if needed. Elevated calcium may contribute to nausea. Stop calcium carbonate use for reflux symptoms. Utilize non-pharmacologic methods or ranitidine. Check parathyroid hormone. Consider withdrawal of chlorthalidone if serum calcium is still elevated. Nitrofurantoin is not recommended with patient’s current renal function impairment; however, she was convinced this medication prevented UTIs which reoccurred whenever she discontinued use in the past. Therefore, in this case it was continued. Consider wean off prednisone which can contribute to CNS symptoms and increase blood pressure. Patient was unsure of clinical indication or efficacy.
After discussion with the primary provider, the patient’s hydralazine dose was increased. Patient reduced tramadol use and added acetaminophen. She had a consultation with a registered dietician and blood pressure normalized. Repeat TSH was within normal limits.
Case #3
Fortunately, despite the advanced dementia, the patient had valid documentation of advance care planning including designation of healthcare surrogate and a living will declaring her wish to “allow a natural death” while focusing on comfort care. Deprescibing is a thoughtful process of discontinuing medications especially pertinent in the case when the patient’s survival time wanes.33 After discussion with the family on the risk/benefit ratio, potential for drug-induced harm, and ways to stay consistent with her primary goal of comfort, the family concurred that she no longer needed the diuretic, statin or donepezil; hence, all were discontinued.
To attend to the patient’s agitation and sleep/wake cycle disruption, a very low dose of quetiapine was combined with low dose mirtazapine at bedtime. Oxycodone for arthritic pain was offered simultaneously with constipation mitigation strategies, and a referral for hospice was accomplished. She perked up cognitively for a few days and then died with her family at her side. While the patient’s wishes were articulated on paper, she was not afforded timely counsel to focus earlier on comfort goals, exposing her to potential missed opportunities of life, pain, and existential suffering.
Authors’ Recommendations:
Evaluate and treat the problems that the patient declares important. Review completely the medication list for safety and efficacy. Create plan of care consistent with patient/surrogate goals. Assess benefits versus burdens, alternatives and probabilities of reaching individual goals. Recommend for or against implementation, continuation or discontinuation. Reassess periodically for achievement of goals. Ask for help at every step in the process as needed.
Conclusion
Polypharmacy in geriatric patients is a common issue leading to poorer health outcomes, increased costs and decreased quality of life. Primary care providers need to be aware of the unique characteristics of the geriatric population, including altered organ function, impaired drug clearance, and cognitive impairment. Providers should also attempt to advocate and coordinate the multiple recommendations from specialist providers in the geriatric population. A multidisciplinary approach, utilizing all the specialized skill sets of various healthcare providers, including pharmacists and palliative care physicians, can be helpful in identifying medication related issues, managing polypharmacy, and streamlining regimens for patients’ preference and treatment goals. Ultimately, the patient’s treatment goals should be respected while maintaining the safest and most efficacious care possible.
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31. Rambhade S, Chakarborty A, Shrivastava A, et al. A Survey on Polypharmacy and Use of Inappropriate Medications. Toxicol Int. 2012 Jan-Apr;19(1):68-73.
32. Lichtman S, Hurria A, Jacobsen P. Geriatric oncology: an overview. J Clin Oncol. 2014 Aug 20;32(24):2521-2. 33. Pruskowski J. Fast Facts and concepts # 321 [Internet]. 2016 Sep [cited 2017 Jul 10]. Available from: https://www.mypcnow.org/copy-of-fast-fact-320. accessed July 10, 2017. CME Questions & Answers (circle one answer) Return by September 1, 2020 BY EMAIL: [email protected]
1. Which of the following most accurately describes polypharmacy? a. Polypharmacy has a higher prevalence in female patients b. Polypharmacy is a condition defined as taking greater than three medications. c. Polypharmacy is easy to recognize. d. Polypharmacy occurs at a higher rate in the Northwestern region of the United States.
2. Which statement is most accurate in regards to the Beers Criteria? a. The Beers Criteria is a list of drugs to absolutely avoid in the geriatric population. b. Drugs on the Beers Criteria list need to be avoided as a priority even in the setting of palliative care. c. The Beers Criteria is an evidence-based list to help clinicians identify the risk level of medications. d. The Beers Criteria lists alcohol-drug interactions as a strategy to moderate geriatric alcohol consumption.
3. Medication Therapy Management is best described as: a. It is a federally mandated program of the Affordable Care Act. b. Another governmental intrusion of health care professionals into primary care. c. A strategy that has been shown to be beneficial in the setting of polypharmacy. d. A shifting of responsibility of care to the pharmacists.
4. Whose job is it to ensure optimal care? a. The pharmacist b. The patient c. The family d. The physician e. All of the above
5. In caring for a geriatric patient with multi-morbidity and polypharmacy, which strategies are reasonable? a. Reduction of dose b. Elimination of the medication c. In-patient or outpatient Pain Rehabilitation/treatment d. Medication Therapy Management consultation e. All of the above
6. Which of the following is true regarding benzodiazepines in geriatric patients? a. Benzodiazepines must be avoided in geriatric patients as mandated by recent federal mandates. b. Benzodiazepines can be used when the patient is appropriately evaluated, and the clinical indication is clearly noted while used for the shortest duration and at the lowest dose. c. Benzodiazepines should never be used in palliative care unless the patient is enrolled in hospice. d. Benzodiazepine prescriptions should only be written by psychiatrists.
7. When treating patients for a given problem (for example; hypertension), it is reasonable and preferable) to escalate the dose of a single medication rather than adding another medication: a. Never b. Most of the time c. Some of the time. d. Only when necessary.
(test continued on next page) 8. An 80-year-old patient with acquired hypothyroidism cannot seem to keep her TSH in the therapeutic zone (too high). A gastroenterologist recently added a new suggestion to her treatment of non-specific non-ulcer dyspepsia. Which is the culprit? a. Ranitidine b. Famotidine c. Cimetidine d. Aluminum Hydroxide/Magnesium Carbonate
9. A 92 year-old gentlemen with advanced dementia who is now nonverbal, bed bound, incontinent of bowel and bladder has recently stopped swallowing. Fortunately, his advance care plan/living will (which is well written and previously documented in the electronic health record) states that comfort measures as deemed by spouse, doctors, and hospice team are to be maximized. Treatments to consider include: a. Morphine elixir for respiratory distress and pain. b. Benzodiazepines for agitation. c. Non-pharmacological strategies. d. Massage & aromatherapy e. All palliative strategies even if on Beers Criteria f. All of the above
10. Screening tools to assist clinicians include: a. START/STOPP b. MAYBE c. Beers Criteria d. Controlled Substance Agreements
EVALUATION: 1. What will you do differently as a result of this information? ______2. How will you apply what you learned to your practice? ______
Please evaluate this article. Circle one number using this scale: 1= Strongly Agree to 5= Strongly Disagree The article met the stated objectives: 1 2 3 4 5 The article was appropriate to my practice: 1 2 3 4 5 The topic was current and well presented: 1 2 3 4 5