Which of the following indicates that an elderly client has been affected by polypharmacy?

Polypharmacy

Polypharmacy is often defined as a medication count of five or more medications.137,138 Because patients with CKD take on average 8 medications, and those on dialysis take between 10 and 12, polypharmacy is possibly one of the largest issues in renal medicine. In older populations, polypharmacy is associated with increased mortality, adverse drug events and drug interactions, falls and other GSs, low medication adherence, and greater health care costs.139 Safe medication prescribing in older adults with CKD is complicated not only by the number of medications and presence of comorbidities, but also by the altered pharmacokinetics and pharmacodynamics in the setting of advancing age and presence of CKD. The combination of age-related changes and CKD places older patients at increased risk of drug accumulation and higher potential for adverse drug effects.140,141 Evidence to guide prescribing is severely limited because a large proportion of clinical trials excluded those older than 65 years, and therefore treatment decisions were often based on evidence extrapolated from other patient groups.142–144 As a general guide, clinicians are advised to consider multiple factors listed inTable 84.5. Drugs that have a narrow therapeutic index and/or high toxicity levels should only be used when other alternatives are not available, and individuals should be monitored carefully.145

Several tools can identify medications in which the risks of use in older adults often outweigh the benefits or identify medications that have been omitted but are likely to benefit the individual. The most widely used tools include the Beers Criteria,146 Screening Tool to Alert doctors to the Right Treatment (START),147 and Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP).148 START focuses on ensuring that medications that are indicated, and likely to provide benefit, are not omitted in error, whereas the Beers Criteria and STOPP focus more on minimizing the exposure to medications for which the risks outweigh potential benefits. The 2015 Beers Criteria are divided into five sections—medications to avoid in most older adults, medications to avoid in older adults with specific diseases or syndromes, medications to be used with caution in older adults, potentially clinically important drug-drug interactions, and medications to avoid or adjust dose in older adults based on kidney function. The combined STOPP-START criteria, recently updated,149 have been shown to improve medication appropriateness significantly and reduce adverse outcomes from potentially inappropriate medications.150 Incorporating the Beers criteria and STOPP-START criteria into a daily drug prescription review process can maximize the efficiency and safety of pharmacotherapy and minimize the number of errors in the administration of drugs to older patients with CKD.

Epidemiology

Polypharmacy is an important health issue among the US population, especially the elderly. Currently, people aged 65 years and older make up 13% of US population, and they use 33% of prescription drugs.2 By 2040, this will increase to 25% of population, using 50% of prescription medications2 (Fig. 9.2). Approximately, 82% of adults living in the United States take at least one medication in a given week.4 The prevalence of polypharmacy in the elderly across various healthcare settings has been reported in the literature (Table 9.1).5–7 Among the elderly, 87.7% use at least one medication.8 The prevalence of polypharmacy among the elderly in the United States is 35.8%.8 Patients over 65 years of age take on average 2–6 prescribed medications and 1–3.4 nonprescribed medications.9 Polypharmacy and associated adverse outcomes were recognized as a safety concern in the Healthy People 2000 Final Review (National Center for Health Statistics, 2001).1

Elderly patients are at an increased risk for ADEs and drug interactions.10–12 ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year.13 Nearly 5% of hospitalized patients experience an ADE.13 Table 9.2 presents the rate and percentage of ADEs for certain diseases.14 Many factors contribute to ADEs in the elderly (Fig. 9.3), one such factor being the number of medications prescribed.15 An estimated one-third of elderly persons will experience an adverse reaction to medication for a given year.16 Furthermore, past research has confirmed an association between polypharmacy and ADEs and drug interactions.17 The potential for an adverse event increases as the number of prescribed drugs increases. Elderly patients prescribed with two medications have a 6% chance of experiencing an adverse event, compared with 50% for patients prescribed with five drugs and 100% for patients prescribed with eight or more drugs.18 One such adverse event among the elderly that results from polypharmacy is impaired mobility.19,20

Mobility, the ability to move around in one’s environment, is the essential capacity for his or her survival. Mobility problems are most common among older adults, and the likelihood of reduced mobility and related consequences increase with polypharmacy. Consequences of reduced mobility resulting from polypharmacy are shown in Box 9.2. Elderly patients are especially vulnerable to adverse mobility events due to age-related physiologic changes resulting from the absorption, distribution, metabolism, and elimination of drugs. Montiel-Luque et al. examined polypharmacy effects on health-related quality-of-life variables in older patients and found that mobility was affected in 54.9% of the patients.21 Herr et al. reported that having polypharmacy, in addition to frailty, markedly increases the risk of mortality. This study showed that frail people with excessive polypharmacy of 10 drugs or more were six times more likely to die.22 This emphasizes the importance of polypharmacy among those with impaired mobility for the rehabilitation team.

Polypharmacy

Polypharmacy is common among older adults with multimorbidity because clinicians prescribe a group of evidence-based medications oriented to each disease; this often results in a risky accumulation. Each guideline is supported by evidence, but there is no guideline that addresses medication regimens for multiple concurrent diseases and their aggregated effects.23 “Quality indicators,” which are frequently used to assess the quality of care, are often based on clinical guidelines; they may implicitly reinforce incentives for clinicians to prescribe guideline-based medications irrespective of the total number of medications the patient is taking. Although most CVD guidelines acknowledge that clinical judgment is needed to integrate evidence-based standards with each patient's idiosyncrasies and complexities, they do not provide a refined strategy to achieve or access such tailored care.1 Consequently, the concept of individualizing guideline-based CVD care is often more theoretical than real, especially because a divergence from guideline recommendations may be (mis)interpreted (e.g., by insurers) as substandard care (and potentially vulnerable to punitive repercussions, such as nonremuneration or insinuations of negligence) rather than appropriate care. Similarly, CV adherence initiatives such as “get with the guidelines”24 implicitly encourage cardiologists to prioritize full regimens of CV medications without explicit modifications that adjust for comorbidities and patient complexity.

The Sloan survey shows that 44% of older men and 57% of older women received five or more prescription medications,25 a finding typical among those with CVD. Consequences are often dangerous. Common scenarios include patients who might receive multiple medications for hypertension despite a context of poor gait, poor nutrition, sarcopenia, and falls. Similarly, many patients with CHD and AF may be prescribed aspirin, P2Y12 inhibitors, and warfarin despite a history of epistaxis or other bleeding pathologies. Most CVD patients are also taking medications to control cholesterol levels or diabetes, enhance memory, relieve the pain of arthritis, help prostate disorders, provide bladder control, relieve anxiety or insomnia, and benefit many other typical comorbidities, compounding the risks for adverse drug reactions, poor adherence, and exorbitant costs.25

The safety risks associated with mounting numbers of medications in old age are compounded by age-related changes in pharmacokinetics and pharmacokinetics (see alsoChapter 8). Pharmacokinetics refers to the processing of a drug by the body, which encompasses absorption, distribution, metabolism, and excretion.25 Pharmacodynamics relates to the actions of drugs on the body.25 Both are significantly affected by aging effects on body composition, metabolism, and vulnerability to adverse sequelae. Because most cardiac medications are absorbed by passive diffusion, gastrointestinal aging has only minor effects on absorption. Distribution is more affected by age. Medications that are distributed predominantly in skeletal muscle (e.g., digoxin) must be adjusted for age-related lean tissue atrophy, particularly among women, in whom lean mass is usually less than men. Weight is also usually lower in older adults, and weight-based dosage adjustments are indicated for many medications (e.g., low-molecular weight heparin (LMWH]). The most significant age changes of pharmacokinetics are related to metabolism and excretion. Changes in renal metabolism are especially significant. In general, the glomerular filtration rate (GFR) is lower in older women than men, and decreases about 10% per decade in both sexes.26 By age 80 years, the GFR is typically one half to two thirds of that in younger adults. This reduction can be masked by overestimation of the GFR using the Modified Diet in Renal Disease formula and the Chronic Kidney Disease Epidemiology Collaboration. The Cockroft-Gault is the preferred GFR equation; it accounts for age, sex, and weight, and characterizes a linear decrease of renal function. The dosage of many medications cleared by the kidney must be reduced in old age, such as digoxin, LMWH, glycoprotein IIb or IIIa inhibitors, and direct oral anticoagulants (DOACs) (see alsoChapter 98).

Polypharmacy

Polypharmacy (use of multiple medications in a single individual) has been positively associated with increasing age, multiple diseases, and disability. The use of multiple medications has been shown to increase nursing home placement, difficulty with ambulation, admissions to the hospital, and mortality.1 Several components contribute to the incidence of polypharmacy. Sometimes, the use of many medications is the right thing for patients to control their diseases and ensure a better quality of life. However, there are risks associated with polypharmacy. When a person consumes more drugs, then drug interactions happen with increased frequency. These interactions may include the increase or decrease in effectiveness of one drug. Changes in effectiveness are caused by another or a more pronounced manifestation of an adverse event due to the elder taking two drugs that have a similar side effect profile. In addition, sometimes new medications are introduced for the specific reason of offsetting a troublesome effect caused by another. Providing new medications may be appropriate, but this scenario often occurs because the problem is not recognized as drug-induced. Risk factors that contribute to polypharmacy include the use of multiple physicians with different specialties who may prescribe similar medications, the use of multiple pharmacies, and the fact that elders often have multiple conditions requiring medication therapy. In addition, inappropriate medication reconciliation upon discharge from the hospital is also a risk factor. The prevalence of polypharmacy post-hospital discharge has been shown to be higher than at the time of admission.2

Polypharmacy and Medication Optimization

Polypharmacy is a highly prevalent and complex geriatric syndrome that has been defined in a number of different ways. The simplest definition is the use of multiple medications. More recent definitions include the concepts of increased regimen complexity and use of potentially inappropriate medications. More complex medical regimens may be difficult for older adults to follow correctly and can lead to poorer compliance with prescribed therapy. Risk of drug interactions increases exponentially with increased numbers of medications. Use of inappropriate medications can lead to untoward side effects and other negative outcomes (O'Connor et al., 2012). Rates of potentially inappropriate medication prescription among older adults are high, with approximately 25% of more than 272,000 in one study being on these types of drugs in the perioperative period (Finlayson et al., 2011). The ultimate goal is to optimize pharmacotherapy and minimize risk in older adults using medications.The practice of medication reconciliation during hospitalization and clinical evaluation has become a common practice and is an important step in helping to reduce or eliminate polypharmacy in geriatric patients. During this process, all medications including prescription and non-prescription medications are assessed. Clinical indications for each medicine are verified, and response determined. Ideally, medications without a clear clinical indication should be discontinued. Potentially inappropriate medications should also be identified, and safer agents substituted if possible. In addition, medication underuse can occur with elderly patients, and it is important to recognize when medications may be clinically indicated based on guidelines or other evidence-based practice.

In 1993 the late Dr. Mark Beers convened a consensus panel to develop a list of potentially inappropriate medications for use in older adults in nursing home settings. This original list has been updated and expanded to include all older adults and is no longer limited by location or type of clinical care.The AGS has recently published a revised version of the Beers criteria (American Geriatrics Society Beers Criteria Update Expert Panel, 2015). This is a highly evidence-based document that categorizes medications into different groups based on characteristics and considerations for use in older adults. The most recent version includes information regarding level of evidence used to make recommendations, and overall strength of the recommendation from the expert panel. This document is being maintained and updated on a regular basis as new data emerge. It is important that urologists be familiar with the Beers criteria and the concept of potentially inappropriate medications (PIMs). This can help them to make more informed decisions about medication use in older adults, which can help improve the care they provide (Griebling et al., 2016;Steinman et al., 2015). Identification of alternate medications or treatment strategies may be helpful in this regard (Hanlon et al., 2015).

Polypharmacy

Polypharmacy is defined simply as the use of multiple medications. There is no standardized threshold to define what constitutes “multiple medications”; however, a threshold of at least five medications commonly is accepted. Using this definition, surveys estimate that polypharmacy occurs in roughly 20% to 30% of older adults, with half of older adults using nonprescription medications concurrently.31,42 On average, community-dwelling older adults take four prescription medications daily.27 Averages are higher in populations with more comorbidities and greater frailty. The average number of medications for residents in assisted living facilities is six,5 and this number increases to eight medications daily for nursing home residents.16

The presence of polypharmacy itself does not denote inappropriate or incorrect use of medications, because older adults with more than one chronic medical condition typically require polypharmacy to manage their conditions. Indeed, three medications commonly are needed to manage symptoms of heart failure or control blood pressure to meet national guidelines. Clients with type 2 diabetes often require at least two medications for effective glucose control. Multi-ingredient combination tablets or capsules have been developed to address these and other examples of appropriate polypharmacy. In contrast, inappropriate polypharmacy can result from inattentive prescribing, lack of follow-up of medication use, or clients pressuring their physicians to prescribe a medication, for example.

Despite the cause of polypharmacy, the end result is that clients who take multiple medications are at higher risk of experiencing medication-related problems (MRPs), such as adverse drug reactions or drug interactions. Problems often result in increased utilization of health-care resources, from additional office visits to hospitalization or nursing home placement. Because of the potential for untoward outcomes related to polypharmacy, gerontology practitioners must be prudent in applying clinical guidelines to client care. In many cases, aggressive attempts to abide by clinical guidelines are not appropriate for certain gerontological clients. The frailty or robustness of each client must be taken into account as part of the risk and benefit assessment, along with consideration of the cost and complexity of the regimen. These latter two issues are addressed next.

The economic burden caused by polypharmacy presents a source of complications for older adults. Older adults who live on a fixed income often have difficulty affording their medications. They might choose not to fill a prescription or perhaps will cut tablets in half or skip doses to make the prescription last until the end of the month. The negative outcomes that can result from such behaviors are readily apparent.

Finally, polypharmacy makes it challenging for many clients to take their medications as instructed and continue to take medications over time. The more medications a person takes, the more complex the medication regimen likely becomes and the greater the risk of taking a medication at the wrong time, forgetting a dose, or otherwise skipping medication doses (i.e., increased risk of nonadherence to the medication regimen, discussed in the next section). Adherence is highest with once- or twice-daily dosing instructions, and decreases significantly with three or four daily doses.13 Thus, medications that are dosed just once or twice daily are desirable. Pharmaceutical manufacturers wisely strive to develop long-acting formulations of existing drugs or new molecular entities with once-daily dosing properties for this reason. A common dilemma arises when there is a choice between a higher-cost, once-daily product and a less expensive generic drug that requires multiple daily doses and quite possibly has more side effects. The increased cost of the newer, once-daily product often is justified based on fewer side effects and greater likelihood of medication adherence.

The complexity of a medication regimen is further increased in the presence of polypharmacy, because of medications that must be taken at certain times of day or in a certain manner. For example, while most medications can be taken in the morning, some are more effective at bedtime. Some need to be taken 1 hour before a meal (i.e., on an empty stomach), others with food. When one adds to the mix the potential physical, psychological, or emotional medication adherence barriers faced by many older adults, it becomes easy to see how polypharmacy can adversely affect the ability of an older adult to adhere to his or her medication regimen. The important topic of medication adherence is discussed in more detail in the next section.

Supplements

Polypharmacy with nutritional supplements is to be avoided, just as polypharmacy with medications in PC and end-of-life (EOL) care can increase the burden on the patient without significant benefit. Only those nutritional supplements essential to the patient’s well-being should be continued. In most cases of patients imminently dying, almost all nutritional supplements can be discontinued except for those giving specific symptom relief. Patients and families must be a part of this decision-making process because they may hold strong beliefs about what supplements are essential for their well-being. These supplements can be continued unless the patient is having difficulty swallowing them or if they are contributing to distressing symptoms or contraindicated (e.g., fish oil in a patient with the potential for bleeding or actively bleeding).

Conclusion

MDT has been a success story in both the treatment of M. leprae infection and the mobilization of many people involved in treatment, surveillance and leprosy control programs. In 1982 MDT was implemented in endemic areas and since then more than 90% of registered cases have received treatment, 14 million patients have been cured and global prevalence has declined.

The current treatment for leprosy reactions is still not optimal, with a significant number of patients not responding to prednisolone and some ENL patients requiring chronic thalidomide therapy. Researchers are still looking for different immunosuppressant drugs with efficacy in the treatment of reactions (e.g. azathioprine and ciclosporin A).

The stigma associated with the diagnosis of leprosy is still a very real problem and the management of someone with the disease should include discussion of their psychosocial status and education for the patient and their family.

Pharmacotherapy

Polypharmacy, the treatment with many medicines for the same condition, is extremely common in the elderly.56 Older patients are at higher risk for polypharmacy because of the increased rates of chronic and co-morbid medical illness in this age group. Thus concurrent use of multiple drugs does not necessarily connote inappropriate prescribing; it may in fact be sensible. Regardless, polypharmacy puts the elderly at increased risk for multiple adverse outcomes, including adverse drug reactions, falls, hospitalizations, nursing home placement, malnutrition, pneumonia, and death.57–59

The four key concepts relevant to polypharmacy in the elderly are the “prescribing cascade,” the effects of aging, altered pharmacokinetics and pharmacodynamcis, and multiple co-morbidities.3 The “prescribing cascade” begins when an adverse drug reaction is misinterpreted as a new medical condition, for which another drug is then prescribed, placing the patient at risk of developing additional adverse effects relating to this potentially unnecessary treatment.60 Age-related changes may exacerbate medication side effects in the elderly. Of particular concern are side effects like orthostatic hypotension, anticholinergic reactions, parkinsonism, sedation, and cardiac conduction disturbances. Changes in metabolism, distribution, and excretion that occur with aging result in longer half-lives, increased or decreased drug effects, and increased occurrence of drug toxicity. All of these issues need to be taken into consideration with the increased medical co-morbidities in the older population, which at times necessitates the use of multiple medications.

One of the primary goals of the consultant is to prevent polypharmacy and its associated negative outcomes. One of the first and most critical steps of any geriatric psychiatry consultation should be a careful and detailed review of current medications and all recent medication changes, including both psychotropic and nonpsychotropic agents as well as over-the-counter medications. A new medication should be added only when there is a clear indication for its use; one should consider nonpharmacologic treatments when appropriate. When starting new medications, one should start with low doses and slowly titrate them to achieve a therapeutic response. Many clinicians will stop titration too soon, thus giving the patient an inadequate trial of a medication; this is also a negative outcome. Hence, remember the adage “start low, go slow, but go all the way.”

Medications and Substances

Polypharmacy is a serious problem in older adults, and the use of multiple medications also contributes to insomnia. Prescription medications known to be related to insomnia include antidepressants, such as bupropion, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOs), and tricyclic antidepressants (TCAs) except for amitriptyline and venlafaxine.36 Other medications prescribed for medical conditions that are associated with insomnia include bronchodilators, beta-blockers, central nervous system (CNS) stimulants, gastrointestinal drugs, and cardiovascular drugs. Concomitant use of several types of medication (polypharmacy) further increases the risk of sleep disturbances in this age group. Adjustment of the timing and dosing and the contraindications between medications in elderly persons can lead to improvements in their sleep.36

Moderate alcohol consumption in elderly persons has been related to sleep disturbances including insomnia and sleep-disordered breathing (SDB).37 Other substances known to be related to insomnia include caffeine and nicotine. Although the effects of these substances are yet to be investigated in the elderly population, it is unlikely that they would not also disrupt sleep in the elderly.