What Is Polypharmacy, And Why Is My 72 Year Old Parent Taking 11 Medications?

How Polypharmacy Happens

Polypharmacy does not usually result from a single physician making a series of poor decisions. It accumulates gradually across time, across medical specialties, and across healthcare transitions, in ways that are predictable once you understand the structure of how older adults receive care.

Multiple specialists, each prescribing for their domain. An older adult with heart disease, diabetes, arthritis, depression, and osteoporosis may see a cardiologist, an endocrinologist, a rheumatologist, a psychiatrist, and an orthopedist, in addition to their primary care physician. Each specialist prescribes for their area of expertise. None of them has a complete view of everything the others have prescribed. The primary care physician is theoretically the integrator of the full medication list, but in a 15 minute appointment managing multiple active problems, a comprehensive medication review across all specialist prescriptions rarely happens thoroughly.

The prescribing cascade. One of the most insidious mechanisms of polypharmacy is the prescribing cascade, where a side effect of one medication is misidentified as a new medical condition and treated with an additional medication, whose side effect is then treated with another, and so on.

A classic example: a patient is prescribed an NSAID for arthritis pain. The NSAID causes increased blood pressure. A physician who does not connect the blood pressure elevation to the NSAID prescribes an antihypertensive. The antihypertensive causes ankle swelling. A physician prescribes a diuretic for the ankle swelling. The diuretic causes gout. A physician prescribes allopurinol for the gout. The patient is now on four medications where one, the NSAID, was the root cause.

Reluctance to deprescribe. Stopping a medication that a physician did not prescribe, or that was started by a specialist, carries perceived risk that starting a new medication does not. A physician who stops a medication and the patient deteriorates carries the liability for that decision. A physician who continues a medication that is no longer necessary is following the path of least resistance. The result is medication lists that grow over time without a systematic process for removing medications that are no longer serving the patient.

Transitions of care. Hospital discharges, rehabilitation stays, and transfers between care settings are moments where medication lists are frequently modified, and where new medications are added to treat acute hospital conditions without a clear plan for stopping them when the acute condition resolves. Studies consistently show that medication reconciliation at care transitions is one of the highest risk points for medication errors in older adults.

Why Polypharmacy Is a Patient Safety Issue

The risks of polypharmacy are well documented and clinically significant.

Drug interactions increase exponentially with the number of medications. A patient on two medications has one possible drug pair to interact. A patient on five medications has ten possible pairs. A patient on ten medications has 45 possible pairs. The probability of at least one clinically significant interaction rises substantially with each medication added to the regimen.

Adverse drug events are the leading cause of hospitalization in older adults. Approximately 30 percent of hospital admissions in patients over 65 are related to adverse drug events, many of which are preventable through medication review and rationalization.

Cognitive impairment, falls, and functional decline are associated with polypharmacy. Medications with anticholinergic effects, which include many antihistamines, bladder medications, antidepressants, and antipsychotics, are particularly problematic in older adults because they impair cognitive function and increase fall risk. The Beers Criteria, a list of medications that are potentially inappropriate in older adults, was developed specifically to address the problem of medications that are commonly prescribed to older adults but carry risks that outweigh their benefits in this population.

Adherence becomes impossible. A patient on 11 medications cannot reliably manage a complex regimen of different doses at different times with different food requirements and different side effect profiles. The complexity of the regimen itself becomes a source of errors, missed doses, and double doses.

What a Medication Therapy Management Review Does

Medication Therapy Management, MTM, is a clinical service specifically designed to address polypharmacy in older adults and other complex patients. At Fairview, Dr. Mike provides comprehensive MTM reviews that include:

A complete review of every medication the patient is taking, prescription, OTC, and supplements, with evaluation of whether each medication is still necessary, whether the dose is appropriate, whether better alternatives exist, and whether any medications in the list are interacting with each other or contributing to symptoms the patient is experiencing.

Identification of prescribing cascade situations, where a medication side effect has been treated as a new condition rather than addressed by reconsidering the causative medication.

A prioritized medication action plan communicated to the patient and to the prescribing physicians, with specific recommendations for medications to consider stopping, doses to consider reducing, and interactions to monitor.

A simplified medication schedule that reduces the complexity of the daily regimen to the extent possible.

This review is particularly valuable after a hospitalization or care transition, when medication lists are most likely to have grown beyond what the patient actually needs.

What You Can Do for an Aging Parent on Multiple Medications

Request a comprehensive medication review. Ask your parent’s primary care physician for a formal medication reconciliation appointment, not just a routine follow up, but a dedicated appointment with the specific agenda of reviewing every medication on the list.

Bring every medication to the appointment.

Every prescription bottle, every OTC product, every vitamin, every supplement, every herbal product. Put them all in a bag and bring them. This is called a ”brown bag review” and it is one of the most effective tools available for identifying medication problems that a review of the medical record alone would miss, because the medical record frequently does not capture OTC medications and supplements.

Ask specifically about the Beers Criteria medications. The American Geriatrics Society publishes the Beers Criteria, a list of medications considered potentially inappropriate in adults over 65 because their risk benefit profile is unfavorable in older patients. Ask your parent’s physician whether any medications on their list appear on the Beers Criteria and whether safer alternatives are available.

Ask about each medication’s continued necessity. For every medication on the list ask: Why is this still being taken? Is the condition it was prescribed for still active? What would happen if we stopped it?

Consider an MTM consultation with a pharmacist. Medication Therapy Management is specifically designed for complex patients with multiple medications and is covered by Medicare Part D for qualifying patients. An MTM consultation with a clinical pharmacist provides a level of medication review depth that a busy physician appointment often cannot.

This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.