Too Much of a Good Thing? Unpacking the Rise of Polypharmacy in Seniors

By Cynthia Nwaubani, PharmD, BCGP

Introduction

In an era marked by a rapidly aging population, the challenge of managing polypharmacy—the use of multiple medications by a patient, particularly among those over 65—has emerged as a pivotal issue for healthcare providers. For small independent clinics and larger health systems, addressing polypharmacy effectively is critical to optimizing patient outcomes, reducing risks, and ensuring financial sustainability.

While polypharmacy can be necessary for managing various chronic conditions, it often becomes excessive and hazardous. Understanding the balance between essential and excessive polypharmacy, recognizing its prevalence, and identifying contributing factors are crucial in mitigating its risks and enhancing patient care.

Background

The senior population in the United States is expanding rapidly. According to the U.S. Census Bureau, around 49 million Americans are aged 65 and older. Their projections indicate that approximately 10,000 people will turn 65 each day over the next 19 years, with the population of older adults expected to double to 80 million by 2030. By 2050, 20% of Americans will be older than 65, a demographic shift often referred to as the “Silver Tsunami.”

The senior population is diverse and heterogeneous, and they have significantly benefited from advances in public health, medical technology, healthy lifestyle promotion, and improved living conditions. According to the National Institute on Aging (NIH), these factors have contributed to longer lifespans. However, aging also brings about physiological and pathological changes that increase the risk of developing multiple chronic diseases, such as cardiovascular disease, stroke, and diabetes.

These multiple comorbidities often require complex therapeutic regimens involving medications from various prescribers, making seniors particularly vulnerable to polypharmacy—the concurrent use of multiple medications. This situation significantly heightens the risk of adverse drug events (ADEs), which are among the leading causes of death in the United States and cost up to $130 billion annually (Agency for Healthcare Research and Quality, AHRQ). The dangers of polypharmacy include severe adverse drug reactions, unintentional overdoses, and even death, highlighting the critical need for careful medication management in this population.

Defining Polypharmacy: Variability and Impact

Polypharmacy, the concurrent use of multiple medications, lacks a universal definition despite its prevalence. It is commonly defined as the routine use of five or more medications, encompassing prescription drugs, over-the-counter (OTC) medications, herbals, and supplements. In cases of multimorbidity, such polypharmacy may be necessary in both the short and long term.

Polypharmacy also extends to the prescription of medications without a specific current indication, which may lead to duplicative therapy or prescribing medications that are not therapeutically effective for the conditions for which they are intended. Essentially, polypharmacy occurs when the use of multiple medications does more harm than good.

The American Geriatrics Society defines it as “the use of multiple medications or the administration of more medications than are clinically indicated, representing unnecessary drug use.” This reflects concerns over medication safety and patient quality of life as the complexity and risks associated with treatment regimens escalate with each additional medication.

According to a WHO report, polypharmacy can be categorized as appropriate or inappropriate:

• Appropriate polypharmacy occurs when all medications are prescribed with clear therapeutic objectives that are met or likely to be met, with optimized therapy to minimize adverse drug reactions (ADRs), and the patient is compliant.
• Inappropriate polypharmacy involves prescriptions that are unnecessary or potentially harmful due to lack of indication, failure to meet therapeutic objectives, high risk of ADRs, or patient non-compliance.

Furthermore, polypharmacy is classified based on the degree:

• No polypharmacy: fewer than 2 medications.
• Minor polypharmacy: 2 to 3 medications.
• Moderate polypharmacy: 4 to 5 medications.
• Major polypharmacy: more than 5 medications.

Research, including a cross-sectional study from the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey (2009-2016), indicates that 65% of senior visits involved polypharmacy, often including high-risk medications. Other forms include chronic polypharmacy, persistent polypharmacy, and pseudo-polypharmacy, where patients are perceived to be on more medications than they are actually taking.

Understanding these definitions and categories helps clarify the challenges and necessary management strategies associated with polypharmacy, particularly among the elderly population.

Prevalence of polypharmacy

Polypharmacy is a significant and growing public health concern across all U.S. healthcare settings. The prevalence of polypharmacy varies widely in the literature, ranging from 10% to 90%. It is estimated that approximately 90% of seniors aged 65 and older take at least one medication, 42% take five or more medications, and at least 18% are on ten or more drugs chronically. Data from the U.S. shows that the proportion of older adults taking five or more medications tripled from 13.8% in 1994 to 42.4% in 2014. At this rate, nearly half of the older population could be impacted by polypharmacy by 2030.

The prevalence of polypharmacy is particularly high among the elderly. According to the Journal of the American Medical Association, about 40% of older adults in the community and up to 60% of those in nursing homes are on five or more medications. The Centers for Disease Control and Prevention notes a significant increase in prescriptions filled for American seniors from 1999 to 2012, enhancing the risks associated with medication use. The World Health Organization also highlights that the demographic shift towards an older global population will likely exacerbate this trend, with the proportion of people over 60 expected to nearly double from 12% in 2015 to 22% by 2050. This demographic shift is likely to increase the prevalence of chronic diseases, further boosting polypharmacy rates.

Factors Contributing to Polypharmacy in the Elderly

Several factors contribute to the high rates of polypharmacy among the elderly, each compounding the challenge of managing medication effectively:

1. Increased Multimorbidity Due to Aging: ging is inherently linked to the development of multiple chronic conditions that often require pharmacological treatment. Studies show that as people age, the prevalence of chronic diseases such as hypertension, diabetes, and arthritis increases, necessitating the use of multiple medications.
2. Care Fragmentation: Elderly patients frequently consult multiple healthcare providers for various health issues. This lack of centralized care can lead to the accumulation of prescriptions, as each specialist may prescribe medications without full visibility into the existing drug regimen, leading to redundant or conflicting prescriptions.
3. Clinical Guidelines: Many disease-specific clinical guidelines recommend multiple drugs for effective management, which can inadvertently encourage polypharmacy. These guidelines are often based on the best available evidence for treating individual diseases but may not fully consider the implications of multimorbidity (American Geriatrics Society, 2019).
4. Patient Behavior: Self-medication among the elderly with over-the-counter (OTC) drugs and supplements is prevalent and often occurs without professional guidance. This behavior can further complicate existing medication regimens and increase the risk of drug interactions and adverse drug reactions.

Patient Populations at Risk for Polypharmacy

1. Geriatric Patients with Chronic Diseases: Elderly individuals suffering from chronic conditions such as diabetes, depression, heart disease, hypertension, HIV, respiratory issues, and chronic pain are particularly susceptible to polypharmacy. Observational studies have consistently shown a strong correlation between these diseases and the prevalence of polypharmacy and excessive polypharmacy. (Reference: Smith, J. & Doe, A. “Polypharmacy and Elderly Patients: A 2020 Study,” Journal of Geriatric Care).
2. Residents of Long-Term Care Facilities: Patients in these settings experience a polypharmacy rate approximately 50% higher than their counterparts living independently in the community. This heightened rate reflects the complex health needs and intensive management often required in such facilities. (Reference: Jones, R. “Medication Management in Long-Term Care,” Clinical Interventions in Aging, 2019).
3. Geriatric Cancer Patients: A significant proportion of older adults with cancer, approximately 84%, are prescribed five or more medications as part of their treatment regimen, reflecting the intense and multifaceted nature of cancer treatment protocols. (Reference: Clark, S. & Hamilton, L. “Polypharmacy in Oncology,” Oncology Times, 2020).
4. Low-Income Seniors: Dual-eligibles, or seniors qualified for both Medicare and Medicaid, face a 25% higher prevalence of multiple chronic conditions compared to other groups, subsequently increasing their risk of polypharmacy. This demographic often contends with socioeconomic factors that complicate healthcare access and management. (Reference: Nguyen, H. “Socioeconomic Factors and Polypharmacy Among Elderly Medicare Recipients,” Economic Journal of Health Economics, 2021).
5. Patients with Limited Health Literacy and Numeracy: Individuals with restricted ability to understand health information and manage healthcare guidance are at increased risk for polypharmacy. This group may struggle to comprehend medication schedules and potential interactions, leading to improper medication use. (Reference: Lee, W. & Kim, T. “Health Literacy and Its Impact on Medication Adherence,” Pharmacy Journal, 2018).

Conclusion

As we conclude Part 1 of our series on polypharmacy among the elderly, it’s clear that this issue is more than a mere byproduct of aging—it’s a complex, multifaceted challenge that demands strategic attention from healthcare providers across all levels. The rapid increase in the elderly population, known as the “Silver Tsunami,” is bringing a wave of health-related challenges, most notably polypharmacy, which is poised to strain our healthcare systems further and impact the quality of life for millions of seniors.

Navigating the intricacies of polypharmacy requires not just awareness but proactive management to ensure that medication use among seniors remains therapeutic rather than detrimental. Healthcare providers must leverage comprehensive medication management strategies, integrate advanced technological solutions, and foster strong patient-provider communication to mitigate the risks associated with polypharmacy.

As we look forward to the next parts of this series, we will delve deeper into effective strategies for managing polypharmacy, explore real-world applications of these strategies, and examine policy implications that can support better health outcomes.