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Polypharmacy in Elderly Patients: The March Goes On and On
Accepted Manuscript Polypharmacy in elderly patients: The march goes on and on Joseph S. Alpert, MD PII:
S0002-9343(17)30327-3
DOI:
10.1016/j.amjmed.2017.03.012
Reference:
AJM 13995
To appear in:
The American Journal of Medicine
Received Date: 17 March 2017 Accepted Date: 22 March 2017
Please cite this article as: Alpert JS, Polypharmacy in elderly patients: The march goes on and on, The American Journal of Medicine (2017), doi: 10.1016/j.amjmed.2017.03.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Polypharmacy in elderly patients: The march goes on and on Joseph S. Alpert, MD
Editor in Chief, The American Journal of Medicine Funding: none; CofI: none
RI PT
Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ;
EP
TE D
M AN U
SC
Polypharmacy is a major public health problem in the US and abroad. Although there is no standard definition of polypharmacy, I see and recognize it every day in the out-patient and in-patient environment. A typical example that I saw yesterday was an 84 year old man admitted to our internal medicine service for worsening heart failure. He had a list of 14 different medicines that he claimed to be ingesting each day. This list even included two different beta blockers! In addition, he was taking significant quantities of an over the counter non-steroidal anti-inflammatory agent which had caused deterioration of his renal function and was a major factor in his worsening heart failure. I see patients like this literally every day, and I believe that the readers of this editorial will concur: Polypharmacy is as common as dirt (!!) and it leads to a multitude of potentially dangerous adverse reactions many of which result in hospitalization. Polypharmacy is not just a problem in the US; it rears its ugly head in all resource rich countries where patients, particularly elderly individuals, have ready access to prescription and over the counter drugs.
AC C
The extent and implications of polypharmacy were extensively reviewed in 2007 by Hajjar et al1. They reviewed the MEDLINE database (1986-June 2007) and the International Pharmaceutical Abstracts (1986-June 2007) and found 21 articles dealing with polypharmacy in elderly patients. These studies consistently documented the multiplicity of negatives associated with geriatric polypharmacy: Large numbers of adverse events, potentially dangerous drug-drug interactions, increased morbidity and mortality directly related to excessive consumption of multiple pharmaceutical products, increased cognitive dysfunction and urinary incontinence, and augmented balance problems with associated increased risk for falls. This is truly a frightening collection of negative consequences.
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
Today, almost all physicians in the US and abroad recognize polypharmacy as a major health problem, and so one would expect that following the review of Hajjar et al and others1-6, there would have been serious attempts to decrease the use of too many drugs in elderly patients. Unfortunately, the situation has not improved. In this issue of The American Journal of Medicine, Morin et al report on the burden of polypharmacy in Sweden, a country with an outstanding, universal, national health service. All drugs prescribed in the country are followed in the Swedish Prescribed Drug Register. Consequently, it is possible to track how many drugs any one Swedish citizen is taking or supposed to be taking. Morin et al identified more than 500,000 older adults (>65 years) who died in Sweden between 2007 and 20132. They reviewed their drug prescription history for the last 12 months of their lives. Over that short period of time, the percentage of patients taking 10 or more drugs rose from 30.3% to 47.2%. In other words, during the last year of their life, nearly half of the citizens of Sweden who died were taking 10 or more drugs, truly a frightening statistic when one considers the possible negative consequences of polypharmacy in elderly individuals.
EP
TE D
A second important observation in the study of Morin et al was that many of the drugs prescribed were given for long-term preventive therapy, for example, statins or anti-hypertensive medications. Given that many of these patients were chronically and severely ill and not expected to live for many more years, the value of preventive medicine at that stage of life is clearly questionable. For example, it is likely that moderate hypertension will not harm an elderly patient with end-stage disease. Therefore, an aggressive antihypertensive medication program in such a patient is not needed.
AC C
Recognition of the problems associated with polypharmacy is widespread. Solutions to this problem are much less commonly recognized. In the review of Hajjar et al, a number of interventions were observed to be of modest benefit in reducing the number of prescription drugs in elderly patients who were identified as victims of polypharmacy. One study cited by them involved supplying a medicine grid to residents who were discharging patients3. The grid showed the full number of medications and the times of administration of these drugs. Once the residents saw the complexity of their patients’ medical protocols, significant reductions occurred in the number of medications and the frequency of administration. Several other studies employed letters to patients requesting
ACCEPTED MANUSCRIPT
that they review their medication list with their primary care doctor or consult with their pharmacist about the number and nature of their prescribed medications4,5,6. Each of these studies documented a reduction in the number and complexity of the medications prescribed.
SC
RI PT
Perhaps, the most effective approach is for each of us who see patients on a daily basis to review patient medications carefully and eliminate as many unnecessary and duplicative agents as possible. In my own practice, I review all of the patient’s medications with them at each visit, and I see this as one of the most important components of that individual’s visit with me.
M AN U
As always, I welcome comments to this editorial on our blog at amjmed.org.
Bibliography
AC C
EP
TE D
1. Hajjar ER, Cafiero AC, Hanlon JT: Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007; 5: 5345-351. 2. Morin L, Vetrano DL, Rizzuto D, Calderon-Larrangaga A, Fastbom J, Johnell K: Choosing wisely? Measuring the burden of medications in older adults near the end of life: Nationwide, longitudinal, cohort study. Am J Med 2007; 3. Muir AJ, Sanders LL, Wilkinson WE, Schmader K. Reducing medication regimen complexity. A controlled trial. J Gen Intern Med. 2004; 16:77-82. 4. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25: 1636-1645. 5. Fillit HM, Futterman R, Orland BI, et al. Polypharmacy management in Medicare managed care: Changes in prescribing by primary care physicians resulting from a program promoting medication reviews. Am J Manag Care. 1999;5: 587-594. 6. Fick DM, Maclean JR, Rodriguez NA, et al. A randomized study to decrease the use of potentially inappropriate medications among communitydwelling older adults in a southeastern managed care organization. Am J Manag Care. 2004;10: 761-768.
S0002-9343(17)30327-3
DOI:
10.1016/j.amjmed.2017.03.012
Reference:
AJM 13995
To appear in:
The American Journal of Medicine
Received Date: 17 March 2017 Accepted Date: 22 March 2017
Please cite this article as: Alpert JS, Polypharmacy in elderly patients: The march goes on and on, The American Journal of Medicine (2017), doi: 10.1016/j.amjmed.2017.03.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Polypharmacy in elderly patients: The march goes on and on Joseph S. Alpert, MD
Editor in Chief, The American Journal of Medicine Funding: none; CofI: none
RI PT
Professor of Medicine, University of Arizona College of Medicine, Tucson, AZ;
EP
TE D
M AN U
SC
Polypharmacy is a major public health problem in the US and abroad. Although there is no standard definition of polypharmacy, I see and recognize it every day in the out-patient and in-patient environment. A typical example that I saw yesterday was an 84 year old man admitted to our internal medicine service for worsening heart failure. He had a list of 14 different medicines that he claimed to be ingesting each day. This list even included two different beta blockers! In addition, he was taking significant quantities of an over the counter non-steroidal anti-inflammatory agent which had caused deterioration of his renal function and was a major factor in his worsening heart failure. I see patients like this literally every day, and I believe that the readers of this editorial will concur: Polypharmacy is as common as dirt (!!) and it leads to a multitude of potentially dangerous adverse reactions many of which result in hospitalization. Polypharmacy is not just a problem in the US; it rears its ugly head in all resource rich countries where patients, particularly elderly individuals, have ready access to prescription and over the counter drugs.
AC C
The extent and implications of polypharmacy were extensively reviewed in 2007 by Hajjar et al1. They reviewed the MEDLINE database (1986-June 2007) and the International Pharmaceutical Abstracts (1986-June 2007) and found 21 articles dealing with polypharmacy in elderly patients. These studies consistently documented the multiplicity of negatives associated with geriatric polypharmacy: Large numbers of adverse events, potentially dangerous drug-drug interactions, increased morbidity and mortality directly related to excessive consumption of multiple pharmaceutical products, increased cognitive dysfunction and urinary incontinence, and augmented balance problems with associated increased risk for falls. This is truly a frightening collection of negative consequences.
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
Today, almost all physicians in the US and abroad recognize polypharmacy as a major health problem, and so one would expect that following the review of Hajjar et al and others1-6, there would have been serious attempts to decrease the use of too many drugs in elderly patients. Unfortunately, the situation has not improved. In this issue of The American Journal of Medicine, Morin et al report on the burden of polypharmacy in Sweden, a country with an outstanding, universal, national health service. All drugs prescribed in the country are followed in the Swedish Prescribed Drug Register. Consequently, it is possible to track how many drugs any one Swedish citizen is taking or supposed to be taking. Morin et al identified more than 500,000 older adults (>65 years) who died in Sweden between 2007 and 20132. They reviewed their drug prescription history for the last 12 months of their lives. Over that short period of time, the percentage of patients taking 10 or more drugs rose from 30.3% to 47.2%. In other words, during the last year of their life, nearly half of the citizens of Sweden who died were taking 10 or more drugs, truly a frightening statistic when one considers the possible negative consequences of polypharmacy in elderly individuals.
EP
TE D
A second important observation in the study of Morin et al was that many of the drugs prescribed were given for long-term preventive therapy, for example, statins or anti-hypertensive medications. Given that many of these patients were chronically and severely ill and not expected to live for many more years, the value of preventive medicine at that stage of life is clearly questionable. For example, it is likely that moderate hypertension will not harm an elderly patient with end-stage disease. Therefore, an aggressive antihypertensive medication program in such a patient is not needed.
AC C
Recognition of the problems associated with polypharmacy is widespread. Solutions to this problem are much less commonly recognized. In the review of Hajjar et al, a number of interventions were observed to be of modest benefit in reducing the number of prescription drugs in elderly patients who were identified as victims of polypharmacy. One study cited by them involved supplying a medicine grid to residents who were discharging patients3. The grid showed the full number of medications and the times of administration of these drugs. Once the residents saw the complexity of their patients’ medical protocols, significant reductions occurred in the number of medications and the frequency of administration. Several other studies employed letters to patients requesting
ACCEPTED MANUSCRIPT
that they review their medication list with their primary care doctor or consult with their pharmacist about the number and nature of their prescribed medications4,5,6. Each of these studies documented a reduction in the number and complexity of the medications prescribed.
SC
RI PT
Perhaps, the most effective approach is for each of us who see patients on a daily basis to review patient medications carefully and eliminate as many unnecessary and duplicative agents as possible. In my own practice, I review all of the patient’s medications with them at each visit, and I see this as one of the most important components of that individual’s visit with me.
M AN U
As always, I welcome comments to this editorial on our blog at amjmed.org.
Bibliography
AC C
EP
TE D
1. Hajjar ER, Cafiero AC, Hanlon JT: Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007; 5: 5345-351. 2. Morin L, Vetrano DL, Rizzuto D, Calderon-Larrangaga A, Fastbom J, Johnell K: Choosing wisely? Measuring the burden of medications in older adults near the end of life: Nationwide, longitudinal, cohort study. Am J Med 2007; 3. Muir AJ, Sanders LL, Wilkinson WE, Schmader K. Reducing medication regimen complexity. A controlled trial. J Gen Intern Med. 2004; 16:77-82. 4. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25: 1636-1645. 5. Fillit HM, Futterman R, Orland BI, et al. Polypharmacy management in Medicare managed care: Changes in prescribing by primary care physicians resulting from a program promoting medication reviews. Am J Manag Care. 1999;5: 587-594. 6. Fick DM, Maclean JR, Rodriguez NA, et al. A randomized study to decrease the use of potentially inappropriate medications among communitydwelling older adults in a southeastern managed care organization. Am J Manag Care. 2004;10: 761-768.