In simple terms, “polypharmacy” refers to the use of multiple (“poly”) medications (“pharmacy”). A “polypharmacy patient” then, is one who has been prescribed and is taking multiple medications for multiple conditions.
Although an analysis of more than 100 articles shows no consensus definition of the term, its authors found the highest percentage of references to polypharmacy as a numerical definition of five or more medications daily. This is also the criteria used by the World Health Organization (WHO).
In addition to the term being most commonly used to describe the number of prescriptions being taken, polypharmacy has become a term used to indicate that a patient may be on too many or unnecessary medications.
Here are seven things to know about polypharmacy, and why close monitoring of patients who take five or more medications is critical to their safety and care.
1. It’s on the rise
A 2015 report found that the number of Americans who regularly took at least five prescription drugs nearly doubled between 2000 and 2012, from 8% to 15%. Although in some cases, this may be appropriate for the patient, a more than double increase is reason for pause. Why is the increase so sharp? Are all of these medicines really indicated? Are they being prescribed as an easy alternative to dietary or lifestyle changes? Further, is each medication working as intended?
These questions deserve serious discussion between clinicians and patients, yet there is often little time for such conversations in the ambulatory or hospital setting. This may be one reason that polypharmacy has increased.
2. Puts elderly patients at greater risk
Given that many older patients have one or conditions being treated with medication, it’s no surprise that polypharmacy is more common in older patients. But here’s the issue to be concerned about: As a normal part of aging, kidney and liver function decline, making it harder for the body to flush itself of medications and other toxins in the body as we get older. The result for elderly people is that medications can build up in their systems faster than they would in a healthy, younger person. Multiply this physiological fact of aging with seven, nine, or more medications, and you run the risk of an elderly patient having a greater buildup of medications in their system. This puts the patient at risk for adverse events, side effects, and other negative outcomes.
Older polypharmacy patients are also at greater risk due to the fact that they have lower lean body mass, and often reduced hearing, vision, cognition, and mobility.[1]
3. Increases the risk of adverse drug events (ADEs) and drug-drug interactions
Given the combination of conditions treated, and number of medications polypharmacy patients take, the opportunity for an ADE is higher. Do the math: if the number of medications a patient takes is five, ten, or fifteen, the opportunity that he or she will experience an adverse event increases significantly. The elderly are particularly vulnerable. In one study of 1,000 elderly patients where the occurrence of polypharmacy was 70%, the incidence of ADEs was 10.5%.
4. Opens the possibility to "prescribing cascades”
A prescribing cascade develops when an ADE, often a side effect, is misinterpreted as a new medical condition and additional drug therapy is then prescribed to treat it, instead of removing or reducing the dosage of the medication creating the adverse event. This happens with unfortunate frequency.
For example, a patient experiences a significant increase in pain and begins to take over the counter NSAIDs to help alleviate it. After using the NSAID for a few weeks, the patient begins experiencing an upset stomach and heartburn-type symptoms, leading to her physician prescribing an H2 blocker of PPI[2] instead of digging deeper to identify these as side effects of the NSAID.
5. Ups the opportunity for non-adherence
Imagine trying to manage the regimen and refill schedule of eight, ten, or twelve medications. Now imagine you are 79, live alone, and have arthritis which makes it difficult to open pill bottles and fill pill trays.
Polypharmacy has been associated with non-adherence in older adults because, quite simply, it’s complicated for them to manage. Non-adherence rates in community dwelling older adult has been reported between 43%-100%, depending on the study design.[3] More pills equals more complicated regimen to take/refill, and if you don’t have a caregiver or family member to help you, it’s highly likely you will have difficulty complying with the regimen.
6. Increases the risk of functional status decline in older patients
Studies indicate that polypharmacy is associated with functional decline in older patients. A Women's Health and Aging Study found that use of five or more medications was associated with a reduced ability to perform independent activities of daily living.[4] A prospective cohort of approximately 300 older adults found that patients taking 10 or more medications had diminished functional capacity and trouble performing daily tasks.[5] Providers and other clinicians must give thought to how prescribing multiple medications will impact the patient’s quality of life - not just manage their condition or cure them.
7. “Deprescribing” is a growing movement
After six not so positive points, I thought I’d leave you with some good news: Many physicians have begun adopting a philosophy of “deprescribing.” Step-down methods, tools, and new approaches are used with patients to remove or reduce doses of medicines that are inappropriate, duplicative, or unnecessary. Including a clinical pharmacist in the conversation is often part of the process.
Physician-led initiatives such as Choosing Wisely offer clinicians educational modules and tools that help patients and families ask the right questions about medications. And the publicly-available Beers Criteria is list of overused and potentially unsafe drugs for seniors that patients can check against when their parent or other elderly loved one is prescribed a new medicine.
[1] Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383–389. doi: 10.2147/CIA.S2468. [PMC free article]
[2] 3 Classic Prescribing Cascades, https://www.meded101.com/3-classic-examples-of-the-prescribing-cascade/
[3] Clinical Consequences of Polypharmacy in the Elderly, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3864987/
[4] Crenstil V, Ricks MO, Xue QL, Fried LP. A pharmacoepidemiologic study of community-dwelling, disabled older women: factors associated with medication use. Am J Geriatr Pharmacother. 2010;8:215–224. [PubMed]
[5] Jyrkka J, Enlund H, Lavikainen P, et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 2010;20:514–522. [PubMed]
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