Polypharmacy in Elderly Patients: A Pervasive Problem

Because current health care practice focuses on diagnosing and prescribing, the need to taper, reduce, or discontinue inappropriate medication therapy receives relatively little attention.

Few clinical guidelines cover drug deprescribing, and this lack of evidence-based direction contributes to prescribers’ hesitancy or reluctance to touch treatment regimens that may have originated from a different practice setting.

But failure to deprescribe medications that are contributing to adverse side effects can have serious consequences, explained Thomas R. Clark, RPh, MHS, CGP, executive director of the Commission for Certification in Geriatric Pharmacy, in an exclusive interview with Pharmacy Times.

As a general rule of thumb, “the more medication a patient takes, the greater the risk of adverse drug reactions and interactions,” Dr. Clark said.

Where to focus deprescribing

In an effort to help guide clinicians on describing for elderly patients in particular, a recent study published in PLOS One compiled and prioritized drug classes where deprescribing guidelines would have the most benefit.

The authors noted that elderly patients are particularly vulnerable to polypharmacy and inappropriate medication use because of comorbidities, multiple prescribers, and the comparably small amount of training clinicians receive in geriatric medicine.

To form a list of medication classes on which to focus deprescribing guidelines, the researchers employed a literature review, an expert panel to develop a survey, and 3 survey rounds to seek consensus on prioritized drug classes.

Panel participants included 3 pharmacists, 2 family physicians, and 1 social scientist, while survey participants included 36 pharmacists, 19 physicians, and 10 nurse practitioners.

Top priority drug classes that emerged from the survey rounds were benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors.

How to reduce polypharmacy

Dr. Clark noted that older adults often fall victim to the “prescribing cascade” that occurs when “new symptoms end up being treated with a new drug instead of discontinuing or changing the offending drug that is causing the symptom.”

Polypharmacy can also cause or contribute to what he called “geriatric syndromes” such as falls, delirium, constipation, and urinary incontinence.

Health-system pharmacists can help reduce this polypharmacy in 2 key ways.

First, Dr. Clark said, “they can help assure that older adults do not continue medications after discharge that they were only given for treatment or prevention of a problem in the hospital.”

Second, a patient’s duration of stay at the hospital presents a good opportunity “to review all the medications that are being taken and identify and resolve numerous medication-related issues,” he noted.

The study authors concluded that overtreatment “occur[s] through the full spectrum of primary care,” so the development of evidence-based deprescribing guidelines, and subsequent inclusion of those guidelines in all chronic disease management practices, “should be a priority in the care of the elderly.”