79 years old woman suffering from 5 chronic diseases: high blood pressure, type 2 diabetes, osteoporosis, osteoarthritis and lung disease. Based on good practices recommandations, this patient is given 12 different medications.
In the elderly, many pathologies such as those mentioned above justify the combination of several drugs for an optimal treatment. These associations improved the prognosis of diseases that would otherwise be associated with a premature mortality.
However, is polymedication in seniors still necessary, or even safe?
We will see in this article that this is not always the case.
We will see that polypharmacy is a problem of public health that is recognized and well-documented. Let’s quote the cases in the United States, where 30% of hospitalizations of elderly people are related to the consumption of medication and to their undesirable effects.
Polymedication is a growing phenomenon, which can be explained in particular by the increase of chronic diseases and increase of life expectancy.
What is polymedication ?
From a quantity point of view, polymedication corresponds taking 3 or more drugs simultaneously. Others consider that it is the simultaneous intake of 5 drugs or more.
From a quality point of view, polymedication is the usage of inappropriate drugs or drugs that are not clinically indicated.
Types of polymedication
1) Simultaneous polymedication: this is the average number of medications taken on a given day.
2) Cumulative polymedication: it is the sum of all the drugs administered during a given period, most often 3 months.
3) Continuous polymedication: these are medications taken on a prolonged and regular basis.
The nature of polymedication
According to literature, the diseases the most frequently responsible for consultations (and therefore subject to prescriptions) concern the cardiovascular systems, the central nervous system, digestive pathologies and the osteoarticular system.
Circumstances favouring polymedication
Certain circumstances favour polymedication. For example, an elderly person that consults several doctors and obtains so many prescriptions without informing the prescriber of what has already been prescribed. Or a senior that deals with different community pharmacies that do not share their pharmaceutical files. Self-medication, that is taking medications without a prescription of the doctor, can also promote polymedication.
Polymedication in CHSLDs
On the other hand, it is well known that polymedication is common among seniors in CHSLDs. They consume an average of 14 medications. This situation is more worrisome as it is a fragile population, both in terms of the side effects of medication and of physiological changes in these patients that reduces the elimination of medication and thus increase their toxicity.
The consequences of the polypharmacy
It is well established that polymedication can alter the quality of life of seniors while percipitating a functional decline. It is clearly associated with an increased risk of adverse effects, overdoses, drug interactions and making errors of taking medication. It can entail a decrease in therapeutic compliance.
The polypharmacy is also associated to an increased occurrence of falls and femoral fractures in the elderly. It should be noted that the use of antidepressants, benzodiazepines and of diuretics is often the cause of falls in seniors.
Associated with the physiological changes of aging, polymedication increases the risk of morbidity and even mortality.
The economic costs
Not only does polymedication have an impact on the life of a patient, but it also generates economic costs. Hospitalizations caused by adverse drug reactions contribute to increased costs and decreased the efficiency of care.
Paths to improve prescription
The MAI (Medication Appropriateness Index) criteria enables to question oneself on the indication, accuracy, modalities, dosage, interactions between drugs, the presence of double prescription as well as the duration of a treatment.
Secondly, the use of a computerized prescription assistance system can improve prescription quality by reporting dangerous interactions and inappropriate dosages.
Thirdly, the management by a multidisciplinary geriatric team is also the opportunity to review the patient’s overall treatment.
Lastly, the presence of a clinic pharmacist in a multidisciplinary team brings an increased value to the measures cited above.
Conclusion
Polymedication is the taking of several drugs and is measured in three different ways. Multiple consultations and self-medication can promote polypharmacy. This here brings about many adverse consequences on an individual level (e.g. functional decline, adverse effects, drug interactions, falls, etc.) and on an economic level.
We also have seen ways to improve the prescribing such as the MAI criteria or a computerized prescription assistance system.
It may also be wise to look for alternatives to medication prescriptions (e.g. nutrition).
Along the same lines, we have the right to ask ourselves “ Should we treat everything, all the time and until when ? ”
It is therefore to be hoped that doctors and pharmacists will come to deprescribe medications that are not appropriate, while teaming up with elderly patients.