Anna (68-year-old female) was hospitalized after a fall, bringing along 14 medications she routinely takes at home. During the medication history review, it was revealed that she is taking seven vitamins and minerals based on friends’ advice. Upon examining her blood pressure medications, a concerning issue was identified – duplication of hydrochlorothiazide, one in combination with ramipril and another one prescribed by a different doctor. This raises concerns of potential polypharmacy, involving duplicate and/or unnecessary medications.
Defining polypharmacy
Polypharmacy is commonly defined as the concurrent use of five or more medications, encompassing both prescribed and over-the-counter products, by a single individual. In 2014, 66 per cent of Canadians over the age of 65 took at least five different prescription medications. Polypharmacy is particularly prevalent among older adults. Multiple medical conditions are likely associated with complex medication regimens.
In 2014, 66 per cent of Canadians over the age of 65 took at least five different prescription medications.
Untangling possible causes of polypharmacy
With the advancement in healthcare, there is an expanding array of treatment options available for medication therapy management of medical conditions, potentially contributing to polypharmacy. Fragmented communication within the healthcare team may lead to patients with multiple medical conditions receiving prescriptions from different prescribers, resulting in drug therapy problems (e.g., duplication of therapy, drug-drug interactions, etc.). Lack of coordination among healthcare providers is particularly problematic during transitions of care, such as, when patients are transferred from hospitals to long-term care facilities or home, and vice versa. Mis- or lack of care coordination/communication between the healthcare team and the patient (and/or family) may also trigger a prescribing cascade and missed opportunities for deprescribing. A prescribing cascade occurs when side effects are misinterpreted as new health conditions, leading to additional prescriptions and a subsequent cycle of escalating treatments. This also highlights the important consideration of deprescribing, a systematic process of reducing or stopping medications that may no longer be necessary or may be causing harm, in mitigating polypharmacy associated risks. Sometimes, the complexities of polypharmacy may be augmented with self-medicating practices without a comprehensive understanding of risks-versus-benefits, side effects, and/or potential interactions among medications (as in Anna’s case above).
Deprescribing emerges as a cornerstone solution in mitigating polypharmacy.
Exploring consequences of polypharmacy
Polypharmacy is associated with an elevated risk of adverse drug events (ADEs) and ADE-related healthcare visits. The susceptibility of the aging population to ADEs is heightened by physiological changes in how their bodies process and respond to medications. The complex interplay of multiple medications also escalates the risk of drug-drug interactions, a frequent cause of preventable ADEs, and medication-related hospitalizations. Non-adherence to medication regimens was often linked to the complexity of drug regimens and the presence of polypharmacy, which may lead to potential disease progression, treatment failure, hospitalization, and life-threatening ADEs. In addition, functional decline, cognitive impairment, falls, and urinary incontinence in older adults have been linked to polypharmacy. Finally, polypharmacy contributes to increased healthcare costs for both patients and the healthcare system due to preventable emergency visits and hospitalizations, while also raising individual out-of-pocket expenses for unnecessary medication use.
Addressing polypharmacy
Embracing patient-centered care is paramount. Actively involving patients in decision-making processes, coupled with systematic medication reviews and patient education, will support tailored prescribing practices. Transparent communication between healthcare providers and patients by fostering interprofessional collaboration will enhance care coordination, prevent therapy duplication, minimize drug interactions, and optimize the overall medication therapy management.
Resources and Selected Tools
Deprescribing emerges as a cornerstone solution in mitigating polypharmacy. Regular deprescribing considerations/assessments integrated into patient care will allow healthcare providers to personalize medication regimens, minimizing the risk of potential ADEs and drug interactions. Online platforms, such as Deprescribing.org and DeprescribingNetwork.ca offer valuable resources and guidance with evidence-based information to assist healthcare professionals and patients in the deprescribing process. Choosing Wisely Canada is another valuable resource for clinicians and patients, prompting discussions about the risks, harms, and benefits of tests and treatment options. This initiative is designed to empower patients to make informed and effective care decisions while supporting healthcare providers in delivering personalized and evidence-based care. Furthermore, leveraging specialized tools that were developed based on the Beers Criteria ® and the Screening Tool of Older Persons’ Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria can better support prescribing decisions. The Beers Criteria ®, developed by the American Geriatrics Society, provides insights into medications inappropriate for older adults, aiding in risk identification. The STOPP/START criteria offer explicit recommendations for stopping or starting specific medications in older adults, with comprehensive considerations in both inappropriate prescriptions and underprescribing situations. These tools play an active role in safely reducing polypharmacy, fostering deprescribing, and facilitating patients in attaining optimized clinical and financial benefits.
By Jasmina Jovanovic and Certina Ho
Jasmina Jovanovic is a PharmD Student at the Leslie Dan Faculty of Pharmacy, University of Toronto; and Certina Ho is an Assistant Professor at the Department of Psychiatry and Leslie Dan Faculty of Pharmacy, University of Toronto.