Polypharmacy in the Elderly

Increased meds raises the risk of drug interactions and adverse side effects.

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Learning Scope #347
1 contact hour
Expires Dec. 6, 2012

You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

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The goal of this CE offering is to review the latest evidence about the use of multiple medications - polypharmacy - in older adults and the nurse's role in avoiding problems associated with medication regimes that are too aggressive or unwarranted. After reading this article, you will be able to:

1. Describe the hazards of using multiple medications in the elderly.
2. Discuss methods to reduce the potential hazards of medication therapy.
3. Describe ways to participate in the thoughtful assessment of medication regimes.
4. Discuss various ways to act as a patient advocate, including helping patients discontinue medications if needed.

AS PEOPLE AGE, they become more susceptible to chronic illnesses. As a result, they are often prescribed drugs to treat those illnesses and may end up taking a plethora of medications. With the increased use of medications comes the increased risk of drug interactions, side effects and adverse reactions.

Polypharmacy has many definitions. It has been defined as "the excessive or unnecessary use of medication," and the use of more than five medications.1 Others define it as taking a medication for no therapeutic reason, taking more than one medication for the same condition or taking medications to treat side effects of other medications.

Definitions of the elderly and an older adult are elusive. Experts point out the definition of the older adult is often culturally related, changes over time and may hold different definitions depending on the subject matter.

Taking into account the vagueness of the definitions of polypharmacy and the older adult, this article focuses on multiple medication use by adults, concentrating on the impact these medications have on adults as they grow older, and the nurse's role in avoiding harm from inappropriate medication use.

Cause for Concern

A large part of nursing practice is the administration of medications, including the assessment for the desired effect, looking for untoward or side effects, and educating patients about their safe use. Nurses are taught the actions of medications on the body (pharmacodynamics), as well as how the body processes the medication (pharmacokinetics).

Population statistics show the number of older adults is growing. Between 1900 and 2000, the total U.S. population tripled; however, the population of people ages 65 and older increased more than tenfold. The number of people 65 years and older is estimated to reach 55 million by 2020 and 80 million by 2040.2 Due to the changes in demographics, surveillance of medication regimes is becoming an integral part of nursing care for older adults in all healthcare settings.

Nurses are faced with numerous challenges when addressing the medication regimes for their older patients. The use of multiple medications, the presence of coexisting illnesses and the normal physiological changes associated with aging places older people at increased risk for adverse drug reactions (ADRs). Nurses need to have a good understanding of the factors that put the elderly at increased risk for ADRs, and work with care providers to assure patient safety when it comes to medication management.3

Various examples exist in the literature when polypharmacy has come into question. For example, in one study, the use of medication was shown to have no therapeutic benefit. Researchers took 102 patients with dementia ages 67-100 who were on antipsychotic medications and divided them into two groups: One group of 51 patients continued their antipsychotic medications as prescribed, and the second group of 51 patients had their antipsychotic medication discontinued. After 12 months, the researchers found there were no significant differences in the two groups in the patients' cognitive ability or behaviors commonly observed in individuals with dementia.4

In another study, researchers found the use of multiple medications may not result in better outcomes than the use of only one. Researchers investigating the use of multiple medications used to treat schizophrenia found care providers prescribed more than one medication 47 percent of the time, including the use of more than one antipsychotic medication, or the addition of an antidepressant, mood stabilizer, anti-anxiety medication and drug to treat extrapyramidal symptoms. However, there was lack of evidence to support certain combination therapies.5

Need-to-Know Info

Processes need to be developed for the accurate appraisal of individuals' medication regimes, including an understanding of the interactions of these medications. Regular and vigilant assessment for polypharmacy in older patients is crucial. Check for the possibility of polypharmacy.

Polypharmacy can be a result of:

• failure of the patient or the caregiver to discontinue medications as intended by the prescribing provider;
• prescribing of medication by multiple providers;
• failure of the provider to regularly review the medication profile;
• using multiple pharmacies; and
• poor compliance with medication regimes.6

Watch Out for PIMs

The identification of potentially inappropriate medications (PIMs) for use in the older population is a vital part of medication management.7 The best known list of medications deemed inappropriate for use in the elderly is the Beers list, originally created in 1991 and revised in 2003.

The medications on the Beers list are those that have evidence to support they cause side effects due to the physiological changes of aging, and for which better therapeutic alternatives exist.

Some of the medications on the Beers list are CNS depressants that can cause sedation and cognitive impairment, resulting in problems with self-care and falls. Anticholinergics, such as diphenhydramine (Benadryl) and amitriptyline (Elavil), are also included as they are known to cause cognitive problems, constipation and urinary retention.

The complete Beers list can be accessed at www.dcri.org/trial-participation/the-beers-list.

Nonlinear Pharmacokinetics

Pharmacokinetics, or what the body does to a drug, includes the processes of absorption, distribution, metabolism and elimination, and how long these processes take.8 Using linear pharmacokinetics thinking assumes if you double the dosage of a medication, you would expect double the amount of the medication to be present in the blood.

Thinking nonlinear pharmacokinetics assumes the amount of medication in the blood when the dosage is doubled may increase to a greater amount, depending on the other medications the individual is taking.

Most guidelines for medications were developed using linear pharmacokinetics, that is by investigating that medication only, not it in conjunction with other medications. When a medication dosage is increased, nurses need to review it in conjunction with other medications the person is on, including over-the-counter medications, as well as vitamins, herbals and botanicals, looking for possible drug interactions that could increase the likelihood of an increase in the amount of medication in the blood.9

Use an Ethical Approach

Nurses can work with care providers to evaluate medication regimes by using the ethical principles of beneficence, non-maleficence and autonomy.10

Beneficence is assessing the likelihood of benefit. Nurses can work with care providers to determine whether there is an evidence-based benefit of trying a certain medication in a particular patient, and then determining whether there is any overall benefit to that individual. Analyze clinical trial evidence closely for conclusions relevant to older people. Review the dosage with age-related clinical trial data (if available), as well as the patient's health status, paying particular attention to age-related physiological changes such as hepatic and renal function. Finally, closely monitor the patient for efficacy and the development of adverse effects.

Nonmaleficence is determining what adverse effects are likely in a particular patient, given her age, comorbidities and other medications. Nurses can work with care providers to balance the risk of taking a particular medication against the efficacy of a medication before a decision is made to prescribe a particular medication. Avoid polypharmacy if possible.

Autonomy is an evaluation of what the older person wants. Some older adults may be more concerned about issues such as independence and side effects of medications than their therapeutic value. Listen to what patients tell you about their concerns. Promote that an individual patient's wishes be taken into account when a medication is under consideration.

Use the LIGHT Approach

Nurses can advocate for the use of the LIGHT approach when working with patients and their care providers on appropriate medication regimes.11 This approach uses a benefits focus and suggests medications be reviewed in LIGHT of:

  • Life expectancy by estimating the average life expectancy of the patient based on age and health status;
  • Impact of other conditions such as the aging process, syndromes related to aging, and other illnesses or chronic conditions;
  • Goals the patient might have, as well as the goals of care;
  • Helping the patient prioritize and develop a care plan with you that meets the patient's preferences for care; and
  • Time required to determine whether the patient has received benefit from the medication.

Brown Bag Medication Review

During a Brown Bag Medication Review, patients are asked to bring all their medications, including over-the-counter medications, vitamins, supplements and other botanicals, in for a review and discussion. Reviewing medications in this way helps:

• answer questions and assist patients in taking medications correctly;
• verify what is being taken and how much; and
• identify errors in administration and/or assess the possibility of drug interactions.

Download a free Brown Bag Medication Review toolkit courtesy of the Ohio Patient Safety Institute from http://www.ohiopatientsafety.org/meds/default.htm.

Apply Deprescribing Rules

One way to avoid polypharmacy is to identify medications that might be candidates for discontinuation or deprescribing.4 When determining whether a medication can be deprescribed, use the same approach used when prescribing medication but in reverse. When medications are prescribed, the target symptoms and indications for the medication are first reviewed, then the medication's risk and benefits, followed by the patient's acceptance of the treatment. After the medication is prescribed, it is monitored for effectiveness.

In deprescribing, first monitor how effective the medication has been, communicate with the patient about her observations, evaluate whether the medication is of low benefit or high risk, and then determine whether or not the medication should be discontinued. When you critically look at medications in this way, you might find a particular medication is no long needed, or the risks of taking the medication outweigh its benefits.

When deprescribing a medication, be sure to work with the care provider to reduce the possibility of adverse events that result from withdrawing medications, including those of emotional or psychological withdrawal. Help the patient understand how to discontinue the medication slowly or by using a taper if needed.

If a patient does not want a certain inappropriate medication to be discontinued and the care provider decides to discontinue the medication anyway, the nurse's role shifts to assessing the patient for symptoms and providing reassurance.

Being a Patient Advocate

Advocate for the patient if you believe the patient is on an inappropriate group of medications or ineffective medications, or is being overmedicated. Listen to what your patients tell you about their concerns, particularly if they believe a certain medication should be discontinued. Determine how the decision to discontinue fits with other treatment goals. In addition, conduct a critical review of the medications your patients are on, using what you have learned in this article. Share this information with the prescribing provider, outlining your reasons for discontinuation.

Other ways to work as a patient advocate include the following:

 • Encourage patients to consolidate their care with a single primary care provider. Multiple providers may not be aware of each other and may prescribe medications that interact with one another.

• In some organized way, go through medication with your patients, help them identify what they are taking and determine whether they have written medication instructions they can understand. Remember to include over-the-counter medicines, vitamins, supplements and other botanicals.

• Enlist the help of others if your patients need it.

• Review all acute changes in each patient (such as a fall or confusion) as a potential adverse drug reaction. Adverse drug effects may go unrecognized in the elderly because of their nonspecific nature.

Aging individuals are more susceptible to develop chronic illnesses and thus be prescribed medication that may lead polypharmacy. In the advocacy role, nurses need to review their patients' medication regimes, determine which, if any, medications can be discontinued, and work with care providers and patients in determining the most effective and safe approach to medication management.

Online Resources
American Geriatric Society: http://www.americangeriatrics.org/
CDC-Healthy Aging: www.cdc.gov/aging
NIH-Senior Health: http://www.nihseniorhealth.gov/
AHRQ-Improving the Health Care of Older Americans: www.ahrq.gov/research/olderam

To view the Course Outline and take the test online, click here.

For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click
here.

References for this article can be accessed here 

Joan M. Lorenz is nurse manager at Sheridan VA Medical Center, Sheridan, WY.




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