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Submitted by Anita Kumar on 14 October 2020
Risk of polypharmacy in the elderly

Polypharmacy in the elderly is a growing concern and can even cause harm to the patient. Dr. Anita Kumar explains the risks associated with polypharmacy, the symptoms to watch out for and the way forward for patients and their caregivers.    

Polypharmacy is an issue that requires addressing because people unknowingly follow polypharmacy and do not recognize the potential harm it may cause. In recent times, polypharmacy has emerged as a public health issue and a concern globally. However, it is important to differentiate between appropriate and inappropriate polypharmacy. This is even more imperative in the elderly population who have several co-morbidities and higher instances of multiple prescriptions.

What is Polypharmacy?

Polypharmacy is the simultaneous use of multiple medications. Although there is no universal definition of polypharmacy yet, it is routinely defined as the use of five or more medications simultaneously. Vulnerable patient groups often include older patients above the age of 65 years and patients who are living alone or in care homes. An average elderly patient has about 6-8 prescription medications in a day.  

Why are the elderly more prone to polypharmacy?

The pharmacodynamic and pharmacokinetic properties of medication may work differently in the elderly than in healthy middle-aged adults.  This means the way the body utilizes the drugs is different in the elderly as compared to the young. Often elderly patients have decreased liver or kidney function which can impair drug absorption and elimination. Aging in itself causes metabolic changes and reduced drug clearance.

What are the common reasons for polypharmacy?

  • One of the common causes is self-medication without complete understanding or knowledge of the uses/risks/adverse drug reactions of the medications. This includes the use of supplements, over-the-counter drugs, homeopathic, ayurvedic, and herbal remedies.
  • Several elderly persons suffer from various chronic conditions. Different specialists give their prescriptions and counter-interactions of the multiple prescriptions is not taken into consideration.
  • Complete information of previous medical history may not be provided to the consulting doctor. Due to this lack of awareness, unknowingly, medications may be repeated or dosages increased.
  • Besides allopathic doctors, patients consult practitioners from various fields of alternative and complementary therapies concurrently.

What are the potential risks associated with polypharmacy in the elderly?

The elderly are susceptible to events such as drug-drug interactions, higher risk of falls, adverse drug reactions, cognitive impairment, non-adherence, and poor nutrition. Polypharmacy can increase the risk of adverse events. These can range from mild to severe (such as rashes, redness, itching, blisters, dizziness, vomiting, diarrhea, headache, hallucinations, anaphylaxis, death, etc.) and can vary at onset of event.

Certain medications (like benzodiazepines) can increase the risk of falls, which can be very detrimental in the elderly. Another dangerous side-effect is cognitive impairment which can lead to patients forgetting to take their regular medications or not adhering to the timely regimen. Some medications show adverse drug reactions when consumed with certain other medications the result of which can be dangerous.

How can one recognize effects of polypharmacy?

As a doctor, it’s not possible to say just by looking at the patient. One needs to do a complete examination of the patient, review all past medical history, cross-check for drug interactions, and dosages before coming to any conclusion. For this reason, patients are advised to bring all their medical files with them at a consultation.

Speaking to the primary care provider may also hold clues to the diagnosis.  Many symptoms are vague and are not recognized easily by a caregiver such as loss of appetite, increased slowness, lethargy, drowsiness, generalized weakness, confusion, low mood, etc. The caregiver may pick up on these symptoms but may not be able to point towards polypharmacy as the cause.

Related Reading: 12 Confusing and Overlappying Symptoms in the Elderly

Why is Polypharmacy a concern?

This is an alarming issue especially in India where there is easy access to drugs. Self-medication is a serious concern for the masses, along with the use of alternative and complementary medications, all without the consult or consent of their doctor. Over the counter drugs and non-prescription medications provide temporary relief which leads to delayed diagnosis. Non-adherence to prescription directions, discontinuation, and skipping of pills are additional factors. Often side effects that occur are trivialized and go unreported.

Must Read: Drug Interactions of Common Heart Medications Part 1 and Part 2

How can one avoid effects of polypharmacy?

  • Well to start with strictly follow the doctor’s prescription. Even a minor drug consumption should first be consulted with your respective doctor, be it a pain killer or vitamin.
  • Whenever you have a doctor’s consult, carry all your medications and prescriptions with you to show him/her. If you have any doubts or side-effects, discuss them openly.
  • If you are dealing with multiple specialists, it can also be helpful to discuss the entire medication regime with your family doctor.
  • When a new medication is prescribed, pay attention to the instructions on when and how to take the medications. If you are unclear, feel free to ask your doctor to repeat the instructions. Writing them down is a great way to make sure you don’t forget later.
  • As an caregiver, you will want to ensure that your patient strictly adheres to the regimen. To ensure the independence of the elderly, one can provide labeled pillboxes (also available in colours) to the patient. Setting an alarm on the phone to remind the elderly of the time when they have to take their medications is another simple way to ensure timely pill intake.
  • As a doctor, checking the patient’s medications and symptoms/signs if any thoroughly at every visit is important. Eliminating duplicate medications, reviewing dosages, explaining possible side-effects, assessing for drug-drug interactions are all ways to reduce and eliminate incidences of polypharmacy. Such practices will help in reducing hospitalizations, unwanted adverse events, and costs to both patients and the healthcare system.

Related Reading: Drug Interactions of Diabetes Medications and Medicines that alter blood glucose levels

Increasing awareness of polypharmacy can decrease prospective issues in the elderly. Remember the key is not unprescribing or underprescribing but prescribing adequate and appropriate medications that do not counteract with each other.

Dr. Anita Kumar, MSc MBBS MIPH MD[resident-geriatrics] 
MGM Hospital, Kamothe, Navi Mumbai.