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Deprescribing Polypharmacy: The Real War on Drugs

Polypharmacy is a term used to describe a patient taking at least five or more medications, however the definition has been revised to also include the use of one or more inappropriate medications (Halli-Tierney et al., 2019; Schneider & Koretz, 2022). It is more commonly seen in older adults and populations at risk, such as persons with disabilities, as these patient groups are likely to experience chronic disease therefore require more medication. Other risk factors for polypharmacy include being diagnosed with multiple conditions managed by multiple providers, having severe mental illness, and living in a long-term care facility (Halli-Tierney et al., 2019). Approximately 75% of individuals aged 50 to 65 years use prescription medications and 91% of those aged 80 years and older (Schneider & Koretz, 2022). Research data has shown that in the United States (U.S.) over a span of 30 years (1988-2018), the percentage of Americans prescribed five or more medications rose from 4% to 11%. In older adults aged 65 years or over, the percentages significantly increase from 13.8% to 41.9%. Up to 91% of older adults in long-term care facilities use at least five medications daily (Halli-Tierney et al., 2019; Schneider & Koretz, 2022). Polypharmacy has been linked to a variety of poor health outcomes such as an increased risk of death, falls, drug interactions, hospitalization, and decreased patient compliance (Delara et al., 2022). An individual managing multiple medications can experience financial burden dealing with increased drug costs (“The dangers of polypharmacy and the case for deprescribing in older adults”, 2021). Patients also face extreme stress being prescribed multiple medications who need to fully understand the purpose of their prescribed medications from provider(s), acquiring refills, correct dosage timing, and recognize potential side effects. In this article, we will discuss polypharmacy over multiple patient populations and current methods and research to address this issue.


Polypharmacy in Older Adults

In adults aged 40 to 59 years, commonly used medications are lipid-lowering medications, and ACE inhibitors (lower blood pressure) in combination (“Angiotensin-converting enzyme (ACE) inhibitors”, n.d.; Hales et al., 2019). Adults aged 60 to 79 years most commonly use lipid-lowering, anti-diabetic, and beta-blocker (lower stress on the heart and blood vessels) medications (“Beta blockers”, 2022). The diagnosis of multiple conditions is highly prevalent in older adults (65 years old and above) (“Age”, 2022; Pazan & Wehling, 2021). This high prevalence of multiple diagnoses usually leads to older adults being prescribed multiple medications. Pazan and Wehling (2021) investigated the prevalence of polypharmacy in older age groups (65 to 74 years) from approximately 34,000 older adults in over 17 countries. The following age groups (75 to 84 years, and 85 years and older) were found to have a prevalence of 25.3%, 36.4%, and 46.5% respectively. The authors also investigated polypharmacy (defined by 5 or more medications) reported in skilled nursing home facilities which appeared in 38.1% to 49.7% of residents and 10.6% to 65% of residents reported use of 10 or more medications (Pazan & Wehling, 2021). Polypharmacy in older adults is at an increased risk of medication-related problems as adverse drug reactions made up 90% of hospitalized older adults in the U.S. and Europe (Beezer et al., 2022).


Figure 1. Percentage of U.S. workforce suffering from polypharmacy (“The dangers of polypharmacy”, n.d.)

Polypharmacy in Type 2 Diabetes

Remeilli et al. (2022) investigated the prevalence and effect of polypharmacy in older adults diagnosed with Type 2 Diabetes (DM2) by performing a systematic review over 9 studies globally (U.S., Europe, Canada, Taiwan, Kurdistan). Results indicated the average prevalence of polypharmacy was 64% in older adults with DM2 and the authors postulated polypharmacy may be associated with increased risk of issues with blood sugar control, lower blood sugar levels (hypoglycemia), and accidental falls (Remelli et al., 2022). In conclusion, a higher prevalence of polypharmacy can be partially due to individuals with DM2 often suffering from other comorbidities which require the use of other medications. The literature also highlights the relationship between the total number of medications used and the management of DM2, with a majority of studies reporting higher rates of poor blood sugar control and low blood sugar episodes in older adults with DM2 with a higher number of medications taken. These findings of inadequate blood sugar control are postulated to be a result of the overuse of anti-diabetic medication in older adults, creating imbalances in blood sugar control and risk of low blood sugar episodes. The results also indicate a risk of adverse drug reactions in older adults with DM2 causing negative health outcomes such as falls, hospitalization, decreased quality of life and function.


Polypharmacy in Heart Failure

The treatment of heart failure typically requires the prescription of multiple medications, leaving patients at risk of polypharmacy over the globe (Beezer et al., 2022). A systematic review performed by Beezer et al. (2022) investigated the prevalence of polypharmacy in patients (ages 18 years and older) diagnosed with heart failure in 22 studies. The prevalence of polypharmacy in this patient population ranged from 17.2% to 99%, as 19 out of the 22 studies stated reports of polypharmacy among adults with heart failure. The authors also found evidence that polypharmacy within these studies was associated with various issues and harm in patients, such as inappropriate prescription of medications, poor patient prognosis, decreased patient adherence to medications, and hospitalization. The authors concluded that further evidence is needed to further understand polypharmacy in specific types and stages of heart failure but state that research in heart failure treatment evolves with novel medications to improve patient outcomes, and can in actuality cause an increase in polypharmacy in patients with heart failure.


Figure 2. Polypharmacy infographic with patient case example (“The problem of polypharmacy: When less is more”, 2016)

Proposed Solutions and Research in Polypharmacy

An individual that is prescribed 10 or more daily medications is three times more likely to be hospitalized compared to individuals using 1 to 3 daily medications (Reeve, 2021). Literature reviews emphasize providers to focus more on patient-centered care that is led by the needs and preferences of a patient versus only focusing on the disease or illness (Muth et al., 2019; Reeve, 2021). Reeve (2021) states that The School for Advancing Generalist Expertise (SAGE) 5 Steps consultation model illustrates principles for providers to follow to tailor care to the patient to avoid issues of polypharmacy and inappropriate prescribing of medications:


The consultation seeks to describe, identify and support health as a resource for daily living. This is achieved by focusing on the goals of health care to support daily living. Even where medicines are the primary interest of the clinician the consultation focuses on the Goals of care, the Gaps in care (outstanding needs), and individual Grasp (expectations) of the health care—including mediation—that they are using.


The specific five steps are:


Goals of care: The clinician explores a biographical account of living with illness along with the goals for, gaps in, and grasp of care.


Exploration: The clinician works out the illness experience with reference to the patient's story, the clinician's contextual knowledge, and biomedical knowledge (including guidelines).


Tailored Explanation: The clinician takes responsibility for (co-) constructing and sharing with the patient an explanation of what is happening and why.


Safety Net: The clinician's responsibility to identify and address risk.


Impact: The ultimate test of the interpretation (knowledge constructed) lies in following up with the patient and assessing the impact of the decision.


Researchers also recommend the use of a patient questionnaire that focuses on medication use, issues, experiences with specific medications, and concerns and expectations with their care and medication use (Muth et al., 2019). The use of a questionnaire serves as an interaction assessment between provider and patient to conduct a thorough evaluation of the patient’s needs to appropriately prescribe medications. A medication review between provider and patient is also recommended for continuity of care to confirm if specific medications are appropriate for the patient.


Figure 3. Step process for appropriate polypharmacy ("Scottish Government Polypharmacy Model of Care Group", 2018)

Conclusion

Overall the prevalence of polypharmacy in research ranges from 4% to 96.5% depending on age, definition of polypharmacy in literature, and healthcare settings (Pazan & Wehling, 2021). Up to 80% of patient cases with a family provider suffer from multiple comorbidities (Muth et al., 2019). Financially, polypharmacy carries an extreme burden on patients with rising medical costs with additional prescribed medications. It is predicted that over the 2020-2030 period, polypharmacy will cost an additional 62 billion dollars in the U.S. health system (“The dangers of polypharmacy”, n.d.). The risk of adverse reactions and medication errors increases with higher prescribing (Delara et al., 2022). Polypharmacy has the potential to cause negative health outcomes such as adverse drug reactions, increase risk of falls, hospitalization, and in severe cases death (Beezer et al., 2022; Delara et al., 2022; Pazan & Wehling, 2021). These drug adverse events can cause more sickness and potentially death than a majority of chronic diseases (“The dangers of polypharmacy”, n.d.). Current research efforts to mitigate polypharmacy recommend providers to focus more on individualized management, evaluating the patient themselves concerning goals and expectations with disease treatment as well as performing a routine medical review between provider and patient (Muth et al., 2019; Reeve, 2021). These efforts attempt to decrease the lack of communication between provider and patient to correct errors in inappropriate prescription of medications. Future research is needed to provide specific guidelines and solutions for polypharmacy in specific disease stages (i.e. acute, subacute, and chronic) and patients with multiple comorbidities.


Bibliographical References

Age. (Reviewed 2022). National Institutes of Health. Retrieved February 25 2023 from https://www.nih.gov/nih-style-guide/age Angiotensin-converting enzyme (ACE) inhibitors. (n.d.) Mayo Clinic. Retrieved February 25 2023 from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/ace-inhibitors/art-20047480 Beezer, J., Al Hatrushi, M., Husband, A., Kurdi, A., & Forsyth, P. (2022). Polypharmacy definition and prevalence in heart failure: a systematic review. Heart failure reviews, 27(2), 465–492. https://doi.org/10.1007/s10741-021-10135-4 Beta blockers. (Reviewed 2022). National Health Service. Retrieved February 25 2023 from https://www.nhs.uk/conditions/beta-blockers/ Delara, M., Murray, L., Jafari, B., Bahji, A., Goodarzi, Z., Kirkham, J., Chowdhury, M., & Seitz, D. P. (2022). Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis. BMC geriatrics, 22(1), 601. https://doi.org/10.1186/s12877-022-03279-x Hales C.M., Servais, J., Martin, C.B., Kohen, D. (2019) Prescription drug use among adults aged 40–79 in the United States and Canada. National Center for Health Statistics, Centers for Disease Control and Prevention. Retrieved February 25, 2023 from https://www.cdc.gov/nchs/products/databriefs/db347.htm Halli-Tierney, A. D., Scarbrough, C., & Carroll, D. (2019). Polypharmacy: Evaluating Risks and Deprescribing. American family physician, 100(1), 32–38. Muth, C., Blom, J. W., Smith, S. M., Johnell, K., Gonzalez-Gonzalez, A. I., Nguyen, T. S., Brueckle, M. S., Cesari, M., Tinetti, M. E., & Valderas, J. M. (2019). Evidence supporting the best clinical management of patients with multimorbidity and polypharmacy: a systematic guideline review and expert consensus. Journal of internal medicine, 285(3), 272–288. https://doi.org/10.1111/joim.12842 Pazan, F., & Wehling, M. (2021). Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. European geriatric medicine, 12(3), 443–452. https://doi.org/10.1007/s41999-021-00479-3 Reeve J. (2021). Avoiding harm: Tackling problematic polypharmacy through strengthening expert generalist practice. British journal of clinical pharmacology, 87(1), 76–83. https://doi.org/10.1111/bcp.14531 Remelli, F., Ceresini, M. G., Trevisan, C., Noale, M., & Volpato, S. (2022). Prevalence and impact of polypharmacy in older patients with type 2 diabetes. Aging clinical and experimental research, 34(9), 1969–1983. https://doi.org/10.1007/s40520-022-02165-1 Schneider, E., & Koretz, B. K. (2022). Polypharmacy: A Continuing Challenge to Clinicians. Clinics in geriatric medicine, 38(4), xi–xiii. https://doi.org/10.1016/j.cger.2022.07.010 The dangers of polypharmacy. (n.d.). Optum. Retrieved March 3 2023 from https://www.optum.com/business/insights/pharmacy-care-services/page.hub.polypharmacy-risk-factors.html The dangers of polypharmacy and the case for deprescribing in older adults. (2021). National Institute on Aging. Retrieved March 3 2023 from https://www.nia.nih.gov/news/dangers-polypharmacy-and-case-deprescribing-older-adults

Visual Sources

Cover Image: Barrett, K., Lucas, E., Alexander, G.C. (2016). How polypharmacy has become a medical burden worldwide. [Image]. The pharmaceutical journal. Retrieved February 25 2023 from https://pharmaceutical-journal.com/article/opinion/how-polypharmacy-has-become-a-medical-burden-worldwide Figure 1: The dangers of polypharmacy. (n.d.). [Image]. Optum. Retrieved March 3 2023 from https://www.optum.com/business/insights/pharmacy-care-services/page.hub.polypharmacy-risk-factors.html Figure 2: The problem of polypharmacy: When less is more. (2016). [Image]. Health eSystems. Retrieved February 27 2023 from https://healthesystems.com/infographics/ Figure 3: Scottish Government Polypharmacy Model of Care Group. [Image]. Polypharmacy guidance, realistic prescribing. 3rd edn. Edinburgh: Scottish Government, 2018. Available from: https:// www.therapeutics.scot.nhs.uk/wp-content/ uploads/2018/09/Polypharmacy- Guidance-2018.pdf


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