Introduction

Polypharmacy, or use of multiple medications, is common among older adults with multiple chronic conditions and carries high risk of unwanted drug interactions and reactions.1,2,3 Adverse drug reactions are responsible for a quarter of acute geriatric hospital admissions and occur in 35% of community-dwelling older adults.2,3 Beyond simply posing a high “pill burden” to older adults, use of multiple medications often results in patients receiving duplicate medications, without an appropriate clinical indication, prescribed on multiple dosing schedules from multiple prescribers and filled at multiple pharmacies. For vulnerable elders with existing cognitive impairment and difficulty completing instrumental activities of daily living, negative outcomes are likely.2 Multiple medications can lead to changes in older adults’ cognitive status, physical function, and predispose them to developing harmful geriatric syndromes, such as delirium, frailty, falls, fractures, and repeat hospitalization.1,3 Patients at highest risk of negative effects from polypharmacy include individuals over age 85, patients with renal impairment, patients with low body weight and poor nutrition, patients diagnosed with six or more chronic diseases, patients taking over 12 dosages of medications daily, and individuals with a history of adverse drug reactions.2

Interprofessional Assessment and Collaborative Interventions

Health care providers will need to consider each patient’s unique physical, psychological, and social profile when planning and adjusting a medication regimen. While all older adults are at risk of experiencing adverse drug events given normal age-related changes in the body’s drug metabolism, individuals with decreased renal function, decreased cardiac output, and inadequate hydration are at higher risk of poor outcomes.2,3 Patients taking multiple medications that work on similar receptors and end organs, such as those targeting the central nervous system and anticholinergic medications, are also at increased risk of impaired function and falls.1,3 Seeing as patients with multiple chronic illnesses may be seeking care from multiple specialists, providers and pharmacists may not be aware of all medications that the patient is taking. Herbal supplements and over-the-counter products are also frequently omitted from patient reports of medications taken at home.2 Patients may also not be taking medications as prescribed or may not be adherent to dosing and frequency. Nonadherence to complex medication regimens is common among older adults, with 50% of elders reportedly missing prescribed doses of medication on a regular basis.3 If providers do not see an improvement in the patient’s condition for these reasons, they are more likely to prescribe a higher dosage or a new medication with a similar mechanism that is unnecessary.2

Nurses can play a key role in collecting a thorough medication history from patients and completing accurate medication reconciliation at each visit.3 Nurses can also aid in evaluating patients’ knowledge of why a given medication was prescribed and how it should be taken. Prescribing providers and pharmacists should also be involved in medication reconciliation to confirm that each medication is still indicated given the patient’s present health status. It is also essential that all current dosages are deemed therapeutic and that no significant drug-drug or drug-disease interactions are suspected.Use of the Beers criteria and the ARMOR (Assess, Review, Minimize, Optimize, Reassess) tool are also effective in evaluating and minimizing polypharmacy in older adults.1,2 Providers should also consider whether  nonpharmacologic therapy, such as diet modification and exercise, is a more appropriate treatment than medication in some cases.3 Nurses providing discharge instructions should assess patients for understanding of medications, provide both written and verbal instructions on administration, and ask for a return demonstration if necessary. Family members and caregivers are also encouraged to be involved in education surrounding patients’ multiple medications and to assist their loved one in taking these medications properly.3 Visiting nurses and home health aides can assist patient in organizing medications at home by using pillboxes, calendars, or cell phone alarms, to boost medication adherence and simplify medication regimens.3 Social workers can arrange for assistance at home to increase patient’s adherence to medications if indicated. Encouraging frequent communication with the prescribing provider and interprofessional team will be essential to ensure that patients taking multiple medications on a daily basis do not experience dangerous and unnecessary medical complications.3

Interprofessional contacts for this topic:

Primary care providers

Acute care providers

Pharmacists

Registered nurses

Home health aides

Social workers

Link to the following evidence-based protocols:

Age-related changes

Medication

References

1Hilmer, S. N., & Gnjidic, D. (2009). The effects of polypharmacy in older adults. Clinical Pharmacology & Therapeutics, 85(1), 86-88.

2Planton, J., & Edlund, B. J. (2010). Strategies for reducing polypharmacy in older adults. Journal of Gerontological Nursing, 36(1), 8-12.

3Hajjar, E. R., Cafiero, A. C., & Hanlon, J. T. (2007). Polypharmacy in elderly patients. The American Journal of Geriatric Pharmacotherapy, 5(4), 345-351.