POLYPHARMACY IN THE ELDERLY - more medications may be used caused by under-
POLYPHARMACY
- the act of taking many medications (many drugs)
- the use of more than 5 medications, some of
which may be clinically inappropriate
- “concurrent use of several drugs” (ANA, 1990)
PREVALENCE
 As much as 25% of the overall population
(Chumney et al., 2006)
 For those >65 years old, prevalence increases to
50%
 Prevalence may also be dependent on
comorbidity
–More drugs among diabetics than age or
sex matched non-diabetics (Good, 2002)
–Other predictors include number of starting
drugs, CAD, diabetes, and use of
medications without indications (Veehof et
al. 2000)
The Typical Older Adult….
 Takes 4 to 5 prescription and 2 OTC drugs
at a time; fills 12 – 17 prescriptions/year
 Is on fixed income, whose main source of
income is Social Security
 Spends an average of 27% of budget for
medications
 In ambulatory: 2 – 4 prescription drugs
 In long term care: 2 – 10 prescription
drugs
RISK FACTORS TO POLYPHARMACY
CHRONIC ILLNESSES
-sometimes require different drugs to address each
symptom
UNDERUTILIZATION
- underprescribing of medications
treatment
PHYSICIAN FACTORS
 Presuming patient expects prescription
medication and no medication review
 Prescribing without sufficient investigation of
clinical situation
 Unclear, complex, incomplete instruction; not
simplifying the regimen
 Ordering automatic refills
 Lack of knowledge of geriatric clinical
pharmacology……inappropriate prescribing
SPECIALTY PHYSICIANS
 different healthcare providers prescribe different
drugs
PATIENT FACTORS
 Seeing multiple physicians and pharmacies
 Hoarding of medications
 Inaccurate reporting of ALL medicines
concurrently being taken
 Assuming that when medication starts, they can
continue indefinitely
 Changes in daily habits
 Changes in cognition, depression, insufficient
funds, declining function, living alone
MEDICATION ERRORS
- taking a wrong medication or the wrong dose at
the wrong time or for the wrong purpose
IMPLICATIONS OF POLYPHARMACY
Polypharmacy leads to…
 Adverse drug reactions
 Drug-drug interactions
 Decreased medication compliance
 Poor quality of life
 Unnecessary drug expense - occurs when two or more drugs are taken
concurrently
- as the number of medications taken increases, so
ADVERSE DRUG REACTIONS does the risk for drug-drug interaction
- a detrimental response to a given medication that IATROGENIC PROBLEMS
is undesired, unintended, or unexpected in  Anticholinergics: confusion; orthostatic
recommended doses hypotension; dry mouth; blurred vision; urinary
- a higher level of care is usually required to treat retention
the adverse events  Tricyclics: confusion and unstable gait
- has been shown to increase the risk of mortality &  Antiemetics: confusion; orthostatic hypotension;
nursing home placement in the geriatric population blurred vision; falls; dry mouth; urinary
- Fifth leading cause of death in older adults retention
- Falls from orthostatic hypotension  Digoxin: toxicity
- Confusion and disorientation  H2 Blockers: confusion
- Hepatic toxicity  Benzodiazepines: CNS toxicity
- Renal toxicity
 Narcotics: constipation; “start low; go slow”
CLINICAL MANIFESTATIONS OF ADR’s
NON-ADHERENCE
 Nausea
- the extent to which the patients are not willing to
 Constipation follow the instruction
 GI bleeding - deemed complicated and expensive
 Urinary incontinence INCREASED INCIDENCE OF
 Muscle aches HOSPITALIZATION
- usually a result of ADR’s and non-adherence
 Sexual dysfunction
- may also result from complications from:
 Insomnia  Electrolyte imbalances
 Confusion  Gastrointestinal bleeding
 Dizziness  Hip fractures (associated with falls)
 Orthostatic hypotension EFFECTS OF PHYSIOLOGIC AGING
 Falls ALTERED PHARMACOKINETICS &
PHARMACODYNAMICS
CONSEQUENCES OF ADR’S suppression and exaggeration response to other
Drug-drug interactions
medications
Drug-disease interactions
PHARMACOKINETICS
Drug-food interactions Absorption
Drug side effects
 Delayed gastric emptying; decreased gastric
Drug toxicity
acidity; decreased splanchic blood flow
DRUG-DRUG INTERACTION
Drug Distribution
 Higher percentage of fat; decreased total body
water; decreased plasma albumin concentration
PHARMACODYNAMICS
 Serum Concentration
 Change in body composition changes serum
concentration of water-soluble drugs
 Change in fat mass affect concentration of fat-
soluble medications
 Drug Clearance
 Altered liver metabolism; decreased renal
excretion of drugs
INTERVENTIONS AND STRATEGIES FOR
CARE
1. Be knowledgeable about drug therapy and the
medications the individual patient is taking
- a good starting point is to become familiar
with the medications that have been
identified as problematic (i.e. medications
with high potential for adverse reactions)
*Vigilance in monitoring for adverse
reactions.
2. Obtain a comprehensive medication profile
- ask for the name of the drug, purpose,
dose, and administration parameters for each
medication
3. Monitor kidney function (serum blood urea
nitrogen (BUN) and creatinine)
- excretion of most drugs depends on
adequately functioning kidneys
4. Monitor liver function (AST, ALT, ALP, &
Bilirubin)
ENHANCING COMPLIANCE
 Improve provider-patient communication so that
older adults can become more adept at self-care.
Patient need more time from physicians and
pharmacists than is typically available, and with
older patients the time needed can be
substantial. Health-illiterate patients especially
suffer and could use simpler, easily
understandable information.
 Pill sharing among older adults should be
discouraged.
 Assess other remedies (natural homeopathic,
herbal, and cultural) that older adults may also
be using.
 Support systems such as medication event
monitoring systems (MEMS), pill boxes, and
prepoured medications, friendly calls, and pill
counts might improve compliance.
 At least yearly, and more often if indicated, ask
older adult patients to bring in all medications
for review:
o prescription and over-the-counter drugs
o vitamins
o supplements
o herbal preparations and review the need
for each medication