Polypharmacy in Seniors: The New Health Crisis

By Cynthia Chioma Nwaubani, PharmD, BCGP | CEO & Founder | PharmD Live

Background on Polypharmacy in Seniors

The population of persons 65 years and older is rapidly increasing. Approximately 49 million Americans are age 65 and older, and for the next 19 years,10,000 people will turn 65 every day. Projections estimate that the population of older adults will almost double to 80 million by 2030.¹ Twenty percent of Americans will be older than 65 years, and this Silver Tsunami will remain relatively stable through 2050. 

The senior population is highly diverse and heterogeneous regarding demographics, health characteristics, and status. Several factors such as public health measures, advances in medical technology, promotion of a healthy lifestyle, and improvements in living conditions have contributed to the decline in mortality rate and longevity in seniors², hence the increase in the senior population.

Normal aging is a diverse and complex process. It’s associated with physiological and pathological changes that place people at risk of sensory impairments, such as difficulties with hearing and vision, and multimorbidity³ that includes multiple chronic diseases, among them cardiovascular disease, stroke, and diabetes. Multimorbid patients are likely to have decreased quality of life, lower mobility and functional ability due to chronic conditions, and higher healthcare expenditures. 

Multiple comorbidities require complex therapeutic medications, sometimes from different prescribers. The situation leaves patients vulnerable to “medication overload,” also known as polypharmacy. As a result, we see a high degree of polypharmacy at the intersection of multimorbidity and aging. 

According to the Agency for Healthcare Research and Quality, polypharmacy is likely the most substantial risk factor for Adverse Drug Events (ADEs). ADEs represent the fourth leading cause of death in the United States and cost up to $130 billion annually. The consequences of polypharmacy can be dangerous and can include severe adverse drug reactions, unintentional overdose, and death.

What is Polypharmacy?

Polypharmacy definitions slightly vary from one source to another, so there isn’t a standard or universal definition despite its prevalence. Science and medical professionals often define polypharmacy as:

• The routine and concurrent patient use of five or more medications—including prescription, over-the-counter (OTC), herbals, and supplements. In certain multimorbid patients, polypharmacy may be necessary for short and longer terms. 

Polypharmacy may also refer to medications that do not have a specific current indication:

• they may duplicate other medications, or 
• are not therapeutically effective for the condition for which it was prescribed⁴. 

Simply put, polypharmacy occurs when the patient uses multiple medications that are not necessary and have the potential to do more harm than good.

The World Health Organization⁵ reports categories of polypharmacy as appropriate and inappropriate:

  “Appropriate polypharmacy is present, when:

(a) all medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient; 

(b) therapeutic objectives are actually being achieved, or there is a reasonable chance they will be achieved in the future; 

(c) medication therapy has been optimized to minimize the risk of adverse drug reactions (ADRs); and 

(d) the patient is motivated and able to take all medicines as intended.” 

“Inappropriate polypharmacy is present, when one or more medicines are prescribed that are not or no longer needed, either because: 

(a) there is no evidence-based indication, the indication has expired, or the dose is unnecessarily high; 

(b) one or more medicines fail to achieve the therapeutic objectives they are intended to achieve; 

c) one, or the combination of several medicines cause ADRs or put the patient at a high risk of ADRs, or 

(d) the patient is not willing or able to take one or more medicines as intended.”

Polypharmacy is also classified based on degree: 

• no polypharmacy (patient on less than 2 medications), 
• minor polypharmacy (2 to 3 medications), 
• moderate polypharmacy (4 to 5 medications), and 
• major polypharmacy (more than 5 medications)⁶.

According to a cross-sectional study of the Centers for Disease Control and Prevention’s Survey from 2009 to 2016, which included over 2 billion geriatric patient visits to ambulatory physicians, polypharmacy was common 65% of the time. Most senior patients over 65 years experienced some degree of moderate and major polypharmacy. A significant proportion of these patients with polypharmacy were also prescribed high-risk medications.⁷

Other categorizations of polypharmacy include chronic polypharmacy (continuous patient exposure to polypharmacy) and persistent (frequent polypharmacy) and, a pseudo-polypharmacy patient may be taking more medications than they really are.⁸

Prevalence of Polypharmacy

Polypharmacy is a significant and rapidly growing public health issue occurring in all US health area settings. The prevalence of polypharmacy reported in several literature sources varies between 10% to 90%:

• Estimates are that roughly 90% of seniors aged 65 and older take at least one medication
• 42% take 5 or more medications, and 
• at least 18% are on10 or more drugs chronically. 

Based on the US prescription drug data analysis, polypharmacy rates are steadily on the increase⁹:

• From 1994 to 2014, the proportion of older adults taking 5+ medications tripled from 13.8 percent to 42.4 percent, and 
• at this rate of increase, almost half of the older population could be affected by polypharmacy by 2030.

The 5 Patient Populations at Most Risk for Polypharmacy

1. Geriatric patients with certain chronic diseases: diabetes, depression, heart disease, hypertension, HIV, shortness of breath, and pain were linked significantly to polypharmacy and excessive polypharmacy in various observational studies.^10,11 
2. Patients in long-term care facilities whose rate of polypharmacy is about 50% higher than older adults living in the community.¹²
3. Geriatric cancer patients: 84% of older cancer patients are on 5 or more medications.^13,14
4. Low-income seniors: Dual-eligibles (patients on both Medicare and Medicaid) have a 25% higher rate of multiple chronic conditions, which increases their polypharmacy risk.¹⁵
5. Patients with limited health literacy and numeracy are at risk.

Drivers of Polypharmacy

A broad array of driving forces explain the rapid increase in polypharmacy, some of which include:

• Increased multimorbidity due to the aging population 
• Care fragmentation, which precipitates a lack of communication and coordination between different healthcare teams 
• Disease-specific clinical guidelines which often encourage the use of several medications to treat one medical condition ¹⁶
• Patients who self-medicate without accurately understanding potential risks. 
• Patients visiting different physicians, facilities, and pharmacies and prescribed multiple medications 

Adverse Outcomes Associated with Polypharmacy 

Several studies have shown the association of polypharmacy with multiple adverse consequences and worsening overall health. The risk of an adverse drug reaction increases exponentially with each new medication added to a patient’s regimen. Older adults taking 5 or more medications are at least 88% more likely to seek outpatient care for an adverse drug event than those taking just 1 or 2 medications.

There’s an 82% risk of an adverse drug event occurring when placing patients on 7 or more medications. Polypharmacy contributes to cost increases for both the patient and the payers and can increase medical costs by approximately 30%.¹⁷ 

Potential negative effects of polypharmacy include the following: 

• Higher risk of adverse drug events (ADE) and other safety events such as falls.
• Nonadherence to medications, as patients on 4+ medications are 35% more likely to not adhere to their regimen.¹⁸ 
• Increased health care utilization 
• Frailty¹⁸– a multidimensional syndrome characterized by a non-resilient state and increased vulnerability in older adults 
• Cognitive and functional impairment
• Increased mortality¹⁹ 
• Increased medical cost¹⁷

Strategies to Prevent Polypharmacy 

• Implement medication management and screening system to identify and resolve drug-drug and drug-disease interactions resulting from polypharmacy, which may include a routine and thorough review of the older adult’s medication profile and regular patient engagements in-between visits. 
• Target high-risk and high-cost patients most likely to develop drug-related problems to ensure meeting previously established therapeutic endpoints while discontinuing all unnecessary medications. 
• Maintain an accurate and up-to-date patient medication list in the EHR and ensure that all prescribed medications have a valid indication. 
• A stepwise approach to prescribing: 
  • Prescribe the fewest possible medications, the most uncomplicated dosing regimen, at the lowest dose and then titrate slowly. 
  • Avoid initiating potentially harmful medications based on the Beer’s^® Criteria or concurrent use of 3 or more central nervous system (CNS) medications that may result in falls. 
  • Consider goals of care and life expectancy of patients and non-pharmacological alternative treatment strategies. 
• Avoid prescribing cascade-initiating new medications to combat the potential side effects of other medications.
• Implement a team approach that involves the patient/caregivers, the pharmacist, and other care team members to ensure access to the pharmacist for medication-related questions, medication counseling, and reinforcement of the care plan instructions. 
• Ensure accurate and complete medication reconciliation during care transitions, including proper communication handoffs to prevent medication discrepancies, potential ADEs, and treatment failures.

Conclusion 

The rates of prescription drug use and adverse drug events have both increased dramatically over the past decade. The number of people older than 65 years is growing in the United States, and polypharmacy is prevalent in the elderly population. 

Caring for senior patients can be challenging due to multiple chronic conditions requiring complex medication regimens, hence the importance of medication optimization in comprehensive geriatric care to prevent adverse drug events resulting from polypharmacy. 

When evaluating and caring for an older patient, consider any new symptoms drug-related until proven otherwise. This strategy will help decrease prescribing cascades and other adverse outcomes associated with polypharmacy. 

While polypharmacy may be appropriate for some patients, there should be a balance between over-prescribing and under-prescribing, medication appropriateness, patient’s life expectancy, and care goals. 

Polypharmacy management is multi-faceted, necessitating a team-based approach where all stakeholders-physicians, pharmacists, nurses, and other health care professionals play a vital role in driving change that will result in positive patient outcomes. 

Medication overload is a public health crisis and requires a systemic and evidence-based approach to mitigate the risks associated with polypharmacy. Advanced data analytics, innovative clinical strategies, practice standards, and implementation resources for medication optimization can reduce risk.

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About the author

References:

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