Strategies to Reduce Polypharmacy in Older Adults

Function

Polypharmacy can result from both patient- and system-driven factors. Patient-related factors include multiple comorbid conditions that require various medications and management by multiple specialists, a lack of a designated primary provider, residing in long-term care facilities, and psychiatric or psychosocial issues. Older adults living in long-term facilities typically have multiple medical problems requiring multiple medical regimens.

Patients with mental health issues are often on antipsychotic or psychiatric medications that sometimes require additional medications to mitigate their side effects. System-related factors often include automatic medication refills, inadequate medication reconciliation, poor care transitions, and prescribing medications solely to meet quality metrics rather than addressing the individual patient's requirements. In addition, primary care physicians often face time constraints that limit their ability to counsel patients and thoroughly address multiple issues during visits.

Polypharmacy serves as a nidus for adverse clinical outcomes. This practice can lead to a delayed return to work, additional medication costs, and unintentional drug-drug interactions. Clinical guidelines often recommend combining multiple medications for a single disease process. Older adults often have multiple comorbid conditions requiring multiple medications. The prevalence of polypharmacy in older adults is high in all healthcare settings across all countries. Studies also indicate that approximately over 50% of older adults are taking more than 1 medication that is not clinically indicated.[2] 

Polypharmacy significantly impacts older adults, contributing to poor medication compliance, drug interactions, medication errors, and avoidable adverse drug events (ADEs), which can lead to additional complications. ADEs can harm patients, increasing morbidity and mortality even with the usual drug doses. ADEs also have high financial implications. Polypharmacy is thus recognized as an expensive practice that costs the Centers for Medicare and Medicaid Services around 50 billion dollars annually.[3]

As individuals age, metabolism and drug clearance changes increase the risk of adverse effects, further heightened by the use of multiple medications. Older adults can be susceptible to medications, leading to unwanted adverse effects. These effects can be intensified when multiple drugs produce similar physiological responses due to their synergistic effects, potentially causing ADEs not typically associated with individual medications. This situation can lead to a prescribing cascade, where ADEs are misinterpreted as new issues, resulting in additional medications being prescribed.[4] Moreover, interactions between OTC and herbal medications with prescribed drugs can further exacerbate adverse events.

Issues of Concern

Polypharmacy presents significant concerns for both patients and the healthcare system. Polypharmacy can cause vision and cognition impairment in older adults, which can further impair compliance, reduce the quality of life, and increase the risk of falls. Polypharmacy is an independent risk factor for ADEs such as hip fractures. Other complications of polypharmacy include frailty, disability, and delirium, potentially leading to multiple preventable hospital or clinic visits, prolonged hospitalizations, and long-term care placement, adding to healthcare costs.[5]

Understanding and avoiding high-risk medications in older adults is crucial. Alternatives should be considered when possible. Below are some medications that require careful use in this population.

Anticholinergics

Anticholinergic medications can cause delirium, memory loss, hallucinations, blurry vision, constipation, dry mouth, elevated body temperature, and increased risk of falls. These drugs can also precipitate acute angle-closure glaucoma and urinary retention. First-generation antihistamines, such as chlorpheniramine, hydroxyzine, promethazine, meclizine, and diphenhydramine; antiparkinsonian drugs, such as benztropine and trihexyphenidyl; skeletal muscle relaxants, such as cyclobenzaprine and methocarbamol; antidepressants, such as amitriptyline, desipramine, nortriptyline, and paroxetine; antimuscarinics, such as oxybutynin, solifenacin, trospium, and tolterodine; antipsychotics, such as chlorpromazine, clozapine, olanzapine, and thioridazine; and antispasmodics, such as scopolamine, hyoscyamine, and atropine, are commonly prescribed medications with anticholinergic properties. 

Sedative or Anxiolytic Agents

Sedatives and anxiolytics can cause confusion, falls, fractures, respiratory failure, and dependence. Examples of sedatives include benzodiazepines, such as diazepam, lorazepam, alprazolam, temazepam, and chlordiazepoxide, and barbiturates, such as phenobarbital and pentobarbital.

Narcotics

Narcotics can cause dependency, confusion, constipation, falls, and respiratory failure. Hydrocodone, morphine, oxycodone, fentanyl, and tramadol are commonly used drugs for pain.

Cardiovascular Medications

Central α-agonists such as clonidine and methyldopa can lead to sedation and hypotension. Peripheral α-1 blockers such as prazosin, doxazosin, and terazosin and the immediate-release formulation of the calcium channel blocker nifedipine can cause hypotension. Digoxin increases the risk of cardiotoxicity and heart blocks. Dipyridamole increases the risk of orthostatic hypotension. 

Other Common Pharmaceutical Agents

Pharmacological agents frequently combined with other drugs, potentially causing ADEs, include the following:

• Long-acting sulfonylureas, which increase the risk of hypoglycemia
• Metoclopramide, which carries a risk of extrapyramidal adverse effects
• Testosterone hormone supplements, which elevate the risk of cardiac events
• Nitrofurantoin, which can lead to lung and liver toxicity
• Proton pump inhibitors, which are associated with an increased risk of bone fractures, pneumonia, and Clostridium difficile diarrhea.
• Nonsteroidal anti-inflammatory medications, which may cause renal failure, gastrointestinal bleeding, and high blood pressure

A thorough review of patient factors and potential drug interactions must be accomplished before combining these agents with other medications.

Clinical Significance

Detecting polypharmacy and optimizing medication regimens are critical in the comprehensive care of older adults. These practices help reduce preventable ADEs such as falls, drug-drug interactions, impaired cognition, hip fractures, rate of hospitalizations, and overall healthcare utilization and costs. Avoiding polypharmacy enhances the patient's health status and quality of life while improving patient and caregiver satisfaction. However, the potential benefits of medical therapies, whether for treating, curing, slowing disease progression, or alleviating symptoms, should not be overlooked. Each treatment should be evaluated through a risk-benefit discussion tailored to the individual patient.

When used appropriately, medical therapies can improve quality of life, prevent recurrent hospital admissions, and decrease morbidity and mortality. Balancing the benefits and risks of these therapies presents both a significant challenge and an opportunity for prescribers. Effective strategies to mitigate polypharmacy include developing user-friendly tools, identifying barriers, and educating healthcare practitioners.

Enhancing Healthcare Team Outcomes

Healthcare outcomes may be enhanced through judicious prescribing methods and by taking steps to identify and deprescribe the medications posing more harm compared to the benefit. When prescribing a new medication, the long-term goals of the patient or caregiver must be understood, and a thorough discussion of the medication's benefits and risks should occur. The rationale for use, alternative therapies such as preventative or nonpharmacological options, life expectancy, affordability, and patient compliance should be considered. Prompt follow-up should be ensured to assess safety and effectiveness at each visit. Medications should be continued long-term only if clear benefits are demonstrated and no significant harm is identified.

The first step in mitigating this risk is implementing screening tools to identify and assess the safety of polypharmacy in older adults. The tools that may be used in various settings are described below. 

NO TEARS

The NO TEARS tool may be used to review medications and help with medication reconciliation.[6] The 7 components of the NO TEARS tool are as follows:

• Need an indication: Each medication's indication and duration, along with the intended treatment duration, appropriate dosing, and other nonpharmacological options, should be reviewed at every visit. 
• Open questions: Patients should be asked open-ended questions about their understanding of medications. These questions should include indications, compliance, and issues such as understanding the drug's benefits and adverse effects. 
• Tests and monitoring: Patients' conditions should be assessed based on clinical findings and laboratory results. 
• Evidence and guidelines: The appropriateness of a medication should be reviewed based on current evidence and guidelines. Diagnostic tests appropriate for the disease should be ordered. 
• Adverse events: Any adverse drug reaction should be noted. 
• Risk reduction or prevention: Risks associated with modifying medication combinations, including the potential for falls, opportunistic infections, and adverse effects, should be assessed.
• Simplification and switches: Medical treatment should be simplified with medication reconciliation and proper transition of care.

Hyperpharmacotherapy Assessment Tool

The Hyperpharmacotherapy Assessment Tool delineates 6 goals and helps prescribers reduce polypharmacy in long-term care facilities. The first goal is to monitor the number of medications used, including OTC drugs, herbal supplements, and vitamins. The second goal is to decrease inappropriate drug use, achieved by assessing medication efficacy, addressing the treatment goals and disease status, finding effective but lower-cost drugs, and considering alternative nondrug therapy. The third goal is to decrease inappropriate pharmacotherapy. The fourth goal is to optimize the dosing regimen. The fifth goal is to organize the sources of medicine acquisition. The last and sixth goal is to educate the patient about the medications, which should be revisited in every patient encounter. This tool is easy to use and effective in addressing patient compliance. 

Beers Criteria

The Beers Criteria is a widely used set of criteria that provides an evidence-based approach to improve prescription drug selection. Using the Beers Criteria educates prescribers on drug appropriateness, clinically important drug-drug interactions, and health outcomes. The Beers Criteria lists high-risk medications that should be avoided or used cautiously at reduced dosages, along with possible alternatives. This approach helps to minimize the use of inappropriate medications in older adults. The details can be reviewed in the 2019 Updated American Geriatrics Society Beers Criteria.[7][8]

Screening Tool of Older Persons' Potentially Inappropriate Prescriptions

The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) identifies drug interactions, duplicate therapies, and inappropriate prescription medication use in older adults.[9] This tool also helps pinpoint medications that may need to be discontinued or adjusted to improve patient safety. Regular use of STOPP can enhance medication management and reduce the risk of ADEs in older individuals.

Medication Appropriateness Index

This index is not drug-specific, but it provides a scoring method and shows a positive correlation between a high score and drug-related hospital admissions. Regularly applying this index can help identify potentially problematic medications and guide adjustments to improve patient safety.[10][11]

Anticholinergic Drug Scale

This tool is useful for older patients in nursing homes, hospitals, and community settings. This list provides the 117 medications that have anticholinergic effects, affecting cognition, functional activity, falls, hospital readmission, and mortality.[12]

Nursing, Allied Health, and Interprofessional Team Interventions

The study published by Zarowitz et al showed that pharmacist intervention twice a year, identifying and managing high-risk drugs in patients, decreased polypharmacy. The pharmacist also educated the physicians and patients about drug safety and ways to deprescribe medications. The first intervention led to a 67% reduction in polypharmacy and 39% after the second intervention.[13]

Deprescribing involves systematically identifying and discontinuing medications where the potential risks outweigh the benefits or where the benefits are unclear. The primary goals are to reduce the adverse effects of polypharmacy and improve medication compliance and clinical outcomes.[14] This process relies on interprofessional collaboration and addressing the patient's current needs and care goals. Primary care physicians should obtain a detailed history, including a complete list of all medications, and compare it with current medical issues. Patients should be asked open-ended questions about all prescription drugs, OTC medications, and home herbal remedies.

The proper indication for each medication and reasons for deprescribing should be assessed based on risk-benefit analysis, ADEs, and patient or caregiver goals, as deprescribing methods vary, depending on these goals. Prescribers should clearly state the indications for each medication and update the patient's problem list when possible. Medications with the highest risk should be deprescribed first. Clear instructions about the deprescribed medication should be provided to the patient or caregiver, and short-interval follow-ups should be scheduled. Dose reduction or discontinuation should occur one medication at a time to assess response accurately. Close monitoring and gradual tapering are required, as some drugs can cause withdrawal symptoms.[15]

A deprescribing protocol should be adopted in a few scenarios, including: [16]

• New symptoms due to ADEs
• Presence of terminal illness, dementia, or extreme frailty with complete dependence in all aspects of care
• High-risk medications
• Preventative medications with no clear-cut benefit

The study by Laursen J et al identified that a lack of communication among healthcare providers and specialists and challenges in managing polypharmacy are significant barriers to withdrawing unnecessary medications.[17] In addition, patients on chronic medications may be reluctant to discontinue them due to fears of exacerbating their chronic conditions. Automatic refills may also create confusion and delay the deprescribing process.

Interphysician collaboration and effective communication with patients and their caregivers or families should help formulate a more focused plan for deprescribing. The study by Zarowitz recommends a rational approach to drug discontinuation, which includes screening for modifiable risk factors such as multiple prescribers and pharmacies, drug response monitoring, and identifying high-risk medications. Inappropriate medication discontinuation can lead to disease exacerbation and unnecessary hospital admissions.[18]

Drug discontinuation to improve the quality of life should not compromise the stability of chronic conditions. Deprescribing medications requires considerable time, and making multiple changes at once can create confusion, especially in older adults. The primary strategy to reduce polypharmacy is to regularly review the patient's medication regimen in light of their clinical status and care goals at each visit, if possible. The potential risks of each medication should be evaluated, and benefits should be assessed based on clinical trials and compared with controls.[19] 

Nursing, Allied Health, and Interprofessional Team Monitoring

Considering the growing number of older adults and the prevalence of chronic diseases associated with aging, healthcare practitioners must be vigilant and strategic in managing multiple medications. Balancing the benefits and risks of multiple medications associated with polypharmacy is essential for effective management.

All patients should be assessed by healthcare providers, including clinicians, nurses, and pharmacists, during each visit, whether inpatient, outpatient, or home-based. Coordinated care among providers, patients, and caregivers is crucial. Effective coordination requires a thorough understanding of the patient's complex chronic conditions and responses to changes in drug therapy. Regularly evaluating how adding or discontinuing medications affects other treatments and chronic conditions is essential.

Shared decision-making between patients or caregivers and the interprofessional healthcare team is essential. Timely intervention can reduce the number of medications, improve patient outcomes, enhance safety and satisfaction, and lower overall costs for patients and healthcare facilities. A 2022 cross-sectional survey revealed that older adults were more involved in shared decision-making compared to their younger counterparts.[20] These strategies serve as guidance to augment clinical judgment, but decisions should always be patient-centric when possible.

Interprofessional team members should progress beyond solely following disease management guidelines to consider the patient's holistic picture, including comorbid conditions and care goals. The focus should be on improving overall health status and activities of daily living. The American Geriatrics Society, American Society of Health-System Pharmacists, and American Psychiatric Association recommend assessing the need for new medications, regularly reviewing existing medications, and deprescribing when appropriate.[21]