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| EDITORIAL |
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| Year : 2017 | Volume
: 4
| Issue : 1 | Page : 1-3 |
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Polypharmacy among elderly: Need for awareness and caution
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| Date of Web Publication | 20-Jun-2017 |
Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jgmh.jgmh_15_17
How to cite this article:
Grover S. Polypharmacy among elderly: Need for awareness and caution. J Geriatr Ment Health 2017;4:1-3 |
| Introduction | |  |
Polypharmacy can be a significant health hazard when used inappropriately. Among the various age groups, polypharmacy is a significant issue among elderly. Among elderly, polypharmacy is a rule rather than the exception. Polypharmacy is not limited to the specialty of psychiatry alone but is prevalent throughout the practice of medicine. Polypharmacy is often associated with an increased risk of adverse effects of medications, as well as drug interactions, poor medication adherence, and higher cost of treatment.[1]
| What is Polypharmacy? | | |
Although polypharmacy is practised quite often, there is a lack of consensus definition for polypharmacy. Simply stating, polypharmacy is understood as prescribing >1 medication for the same individual. This definition is solely based on the count of medications irrespective of clinical indications and conditions suffered by the patient.[2] However, this simple definition has been questioned because this does not specify short-term or long-term use, for the same or multiple conditions, for managing illness or side effects, etc., It is also not known as to the concurrent use of how many medications is considered as polypharmacy. Different thresholds have been used to assess polypharmacy. Some of the authors use thresholds of 3, 4, 5, or 10 medications to evaluate polypharmacy.[1]
In relation to psychiatry and use of psychotropic medications, one of the operational definitions of polypharmacy includes the use of two or more psychotropics in the same patient [3] or use of ≥2 medications from the same chemical class or medications having the same pharmacological effect to manage the same condition.[4] Polypharmacy is further categorized as same class polypharmacy, multi-class polypharmacy, adjuvant polypharmacy (use of medication to manage side effects of another medication from a different class), augmentation polypharmacy (use of second medications in lower than the usual doses to enhance the therapeutic effect of the first medication), and total polypharmacy.[3]
However, all these definitions are confusing and do not provide much guidance as to what is correct and what is incorrect. To overcome such limitations some people have tried to categorize polypharmacy as appropriate and problematic polypharmacy.[1] Appropriate polypharmacy is understood as the use of >1 medication in a single person for complex medical ailments or for multiple medical conditions, who have been tried on optimal doses of medicines as per the available best evidence. Polypharmacy in such a scenario is used as a last resort with the aim of improving and maintain the quality of life.[1] Polypharmacy is considered as problematic, when it is not based on evidence, the risk of harm outweigh benefits, the combination is hazardous because of drug-drug interactions, there is unacceptable pill burdenpolypharmacy leads to poor medication adherence and additional medications are used to manage side effects of other medicines where alternative solutions can be considered to reduce the prescription of number of medicine.[1] Further, different criteria have also been proposed to evaluate inappropriate prescription of medications, this include the Beers criteria for potentially inappropriate use of medications in elderly,[5] French consensus panel list,[6] consensus-approved clinical indicators of preventable drug-related morbidities,[7] improving prescribing in the elderly tool,[8] McLeod criteria,[9] and Norwegian General Practice criteria.[10]
| How Common is Polypharmacy? | | |
Over the years, there is an increase in the rates of polypharmacy in most parts of the world. Data from England, Sweden, United States, Scotland, etc., suggest that there is a significant increase in polypharmacy in general, in the last decade or so.[1],[11],[12] Studies have shown that compared to adult population, the rate of polypharmacy is higher among elderly. A Swedish study showed that the average number of medications used per person was 3.4; however, among people aged 70–79 years, the average number of medications was 5.[11] One of the studies reported that in the year 2010, 16.4% of elderly patients aged 65 years or above were receiving 10 or more medications.[13] A study from the United States showed that among community-dwelling people aged 57–85 years, 29% were receiving 5 or more prescription medications, with a higher number of medications associated with increasing age and female gender.[12] A systematic review which evaluated the data on potentially inappropriate medication use in older adults living in nursing homes showed the potentially inappropriate medication use was 43.2%, with an increase in the prevalence from 30.3% in studies published during 1990–1999 to 49.8% in studies published after 2005.[14] Studies among elderly patients with various physical disorders suggest that polypharmacy is associated with cognitive decline [15] and higher depressive symptoms.[16]
Limited data are available in terms of psychotropic polypharmacy among elderly. A study from the United States which evaluated the rates of psychotropic polypharmacy (defined as concurrent use of two or more psychotropic medications) in a nationally representative sample of elderly (aged >65 years) patients with Parkinson's disease estimated the prevalence of polypharmacy to be 26.3% and 21.3% among nursing home residents and home health setting, respectively.[17] Studies have shown that potentially inappropriate prescription are significantly higher among those receiving psychotropic medications when compared with those not receiving psychotropics medications.[18] Studies which have evaluated potentially inappropriate drug prescription among nursing home elderly residents suggest that long-acting benzodiazepines, antipsychotics, and antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) from most of the inappropriate drug prescriptions.[19] Further, it is suggested that these are associated with adverse events such as falls and associated fractures among elderly.[19]
| What are the Reasons for Polypharmacy? | | |
One of the often cited reasons for the increase in polypharmacy is recommendations of various treatment guidelines. These guidelines are often based on the available evidence in patients suffering from a single disorder and comorbidity issues are often not addressed by these guidelines.[1],[20] However, in real clinical practice, most often patients have >1 disorder/disease, and accordingly, when clinicians follow guidelines for these individual disorders and try to manage patients accordingly, this necessarily results in polypharmacy.[1],[20] Further, for certain conditions, for example, mania, polypharmacy is recommended as first-line management by the various treatment guidelines.
| What is Known About Polypharmacy from India? | | |
There are limited data on polypharmacy among elderly in India. A study, which used the 'study on Global Ageing and Adult Health' data reported that polypharmacy (use of 4 or more medications) among elderly (aged 60 or more) was 4.2%. Polypharmacy was more common among individuals who were much older. Various risk factors identified for polypharmacy were poor self-rated health, diabetes mellitus, depression, and hypertension.[21] Another clinic-based study that evaluated the prescription of 100 elderly patients reported that they were receiving a mean of 7.61 (standard deviation [SD]-3.37) medications at admission and 5.48 (SD-2.46) medications at discharge, with more than half of the patients receiving 5–9 medications. In terms of drug interactions, 53.69% and 52.91% potential drug-drug interactions were observed at the time of admission and at discharge.[22]
| Real-life Scenario in India | | |
In India, most of the patients receive medical care in the private sector.[23] The lack of integrated care for elderly in this country promotes polypharmacy. It is very common that patients with multiple physical ailments visits different specialists, who prescribe medications based on the abnormality detected in their domain. Many a times, individual specialist treatment results in duplication of prescription of medications or prescription of different medications by different specialists for the same set of symptoms. It is also not uncommon to come across, use of psychotropics, especially benzodiazepines, zolpidem class of drugs and SSRIs by nonmental health professionals, without clear indications. Benzodiazepines are part of many prescriptions of cardiologist or those managing patients with hypertension. At times, these medications are prescribed among elderly in usual adult doses who are not able to tolerate these medications. This kind of polypharmacy often leads to “prescribing cascades,” in which signs and symptoms of adverse drug reactions due to polypharmacy are misinterpreted as a disease and a new medication is added to the existing regimen to treat the new condition. However, this leads to further drug interactions and worsens the situation and creating another prescribing cascade.[24]
| What to Do? | | |
The first and foremost thing to overcome the problem of polypharmacy is becoming aware about and recognizing the same. The signs and symptoms of polypharmacy arising as a result of adverse drug reactions can include features of tiredness, drowsiness or excessive sleep, reduced alertness, constipation, diarrhea, or incontinence, anorexia, confusion, falls, depression or lack of interest in usual activities, weakness, tremors, visual or auditory hallucinations, anxiety or excitability, and/or dizziness.[24] Some of these symptoms may be actually misinterpreted as depression or a part of dementia. Often, a wash out period is helpful in clarifying the clinical dilemma.
Accordingly, while evaluating elderly patients presenting with mental symptoms, it is very important to evaluate the prescription(s) and inquire about use of over the counter medications and drugs of abuse. The independent diagnosis of depression or anxiety disorder must only be considered when the potential role of medications received by patients has been ruled out. While prescribing psychotropics among elderly, clinicians should first make sure that patient is not on any psychotropic medications from any other specialist. Further, clinicians should preferably use monotherapy. Various psychotropics to be used must be selected after considering the possible drug interactions with the existing medications in the patient's prescription. A good liaison must be established with the patient's other specialists to discuss starting of psychotropics and possibility of discontinuation of unnecessary medications. Medication regimens must be kept simple, and multiple dosing must be avoided. Patients and their caregivers must be educated about the available treatment, possible positive effects of the newer medication, potential adverse effects, drug-drug interactions, drug-disease interaction, and required monitoring must also be discussed. Before increasing the dose or adding a new medication, always evaluate the medication compliance of the patient. Needless to say, the paying capacity of the patient must be taken into account while prescribing. Whenever a new medication is added to the existing regiment, the frequency of follow-ups must be increased to monitor the patient more closely.[3] The general principle of prescription of “start low and go slow” must be followed. If the patient fails to respond to a medication after being used in adequate doses for adequate duration, discontinuation of medication should be considered. Hopefully, these strategies will help in minimizing inappropriate polypharmacy and causing harm to the elderly patients.
Considering the fact that there is a lack of data on polypharmacy from India, there is a need to carry out research in this area to enhance the knowledge of the prescribers and making them aware about the risks of polypharmacy. There is also a need of continuing medical education programs for clinicians to make them aware about adverse consequences of polypharmacy so that this can be avoided.
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