Polypharmacy in the Elderly - Part 1: The Problem

Polypharmacy is generally defined as the use of at least five prescription medications. Rarely are patients, particularly the elderly (from 62 to 85 years), asked about the over-the-counter (OTC) medications that they use. Yet, OTC medications are medications that are considered safe and effective for use by the general public and hence do not require a prescription from a physician. However, they are drugs. They are a type of self-care and the elderly are prone to using them, often for financial reasons. Polypharmacy then, must include OTC medications.

The most commonly used OTC medications by the elderly include aspirin, acetaminophen and ibuprofen.  OTC medications can be grouped into seven areas: allergy, analgesics, anti-fungals, cold or cough or flu, upper and lower gastrointestinal tract and skin products. It is essential when dealing with the elderly that all (prescribed and OTC) medications be noted.

A study1 of 13,869 adults, 65 years and older, in the National Health & Nutrition Examination Survey found that between 1988 and 2010, the median number of prescribed medications used by them increased from 2 to 4 and the number taking 5 or more prescriptions went from 12.8% to almost 40%. There was an association between the use of 5 or more medications with body mass index, a higher income to poverty ratio, previous smoking and race. The researchers noted that older adults on multiple medications, when compared with those on fewer medications had worse health status and appeared to be a ‘vulnerable population’.

Adverse Events

The elderly respond differently to medication than young adults with both drug metabolism and drug clearance affected. With each new or OTC medication added, the elderly are at increased risk of drug-drug interactions and adverse effects. Thirty percent of hospital admissions for the elderly are related to toxic effects of drugs. As a cause of death, medication-related problems, if ranked as a disease, would rank as the fifth leading cause of death in the USA. In the year 2000, it was calculated that medication-related problems cost over $100 billion annually with medical errors causing a further $85 billion.2

Polypharmacy is of concern. With the increasing use of medications, prescribed and OTC, there is an increased risk of potentially inappropriate medications that have been linked to long-term negative physical and cognitive functioning, adverse drug reactions, reduced adherence to prescribed medication, higher financial costs, drug-drug interactions, drug duplication, and taking inappropriate therapy.3 Increased medication usage may also be linked to poor functional status, a decline in nutritional status and reduced cognitive capacity.4 It has also been associated with increased rates of morbidity, hospitalizations and mortality.

The medication categories that are most likely to be involved in adverse reactions include5

  • antibiotics
  • anticholinergics
  • anticoagulants
  • benzodiazepines
  • cardiovascular medications
  • diuretics
  • hypoglycemics
  • non-steroidal anti-inflammatories
  • opiods
  • steroids

Polypharmacy is increasing. In 2000, Kaufmanand colleagues6 canvassed adults in the USA and found that among the 2590 participants, aged 18 and above,

  • 81% used at least one medication in the preceding week
  • 50% took at least 1 prescribed medication
  • 7% took 5 or more prescribed medications

In 2005, about 53% of older adults were taking five or more prescription medications regularly. By 2010 that percentage had increased to 76%.

When you include the 30% of seniors who use complementary and alternate medicine (CAM), supplements and herbal medications to the mix of those using prescribed and OTC medications, the risk of adverse reactions is greatly increased. A survey found that one in four did not report to their health care provider that they were taking OTC supplements or herbs.7 Thus, one in six seniors in the USA is at risk for a major drug-drug interaction. The risk of adverse reactions increases with each additional medication that is prescribed.

Qato and colleagues 8 found that in 2005-2006, 8.4% of older adults were at risk for a major drug interaction. The percentage increased to 15.1% by 2010-2011. In that same 5-year time period, the use of

  • prescription medication increased by 4%
  • polypharmacy increased from 30.6 to 35.6%
  • dietary supplements increased by 12% from 53% to 67%
  • OTC medications declined from 44% to 18%.

The researchers identified the 20 most commonly used supplements and the 20 most commonly prescribed medications for the elderly. Among the latter, the researchers classified 15 possible interactions as either major or life-threatening. Among the supplements, there was potentially, 93 drug-drug interactions. While many of the medications prescribed are done so according to the guidelines, the researchers were greatly concerned about the potential for adverse drug interactions.

Another study 9 of the elderly found a 72.3% prevalence of polypharmacy among the subjects. Further,

  • 16.2% took two or more herbal products
  • 26.2% took two or more vitamin/mineral supplements
  • 6.9% took two or more nutraceuticals
  • 46.2% were at risk of least one potential drug-drug interaction
  • 31.5% were at risk of one herbal-supplement interaction.

Polypharmacy leads to an increase in adverse effects including constipation, confusion,  cognitive and functional impairment, dementia, depression, falls,  hip fractures, immobility, urinary incontinence, weight loss and hospitalizations.2,5,10

Health Literacy in the Elderly

Health literacy is also a major concern with the elderly. The National Academy of Medicine defines health literacy as an individual’s capacity to obtain, process and understand basic health information and services needed to make the appropriate health decisions. Recent research 11 reinforced the concept that health literacy declines with age, that health literacy is higher for women than men and above all, that compared to whites, racial and ethnic minorities have lower health literacy.

The Health Literacy and Cognitive Function among Older Adults Study found that one in five patients aged 55 to 74 were unable to manage everyday tasks related to health care decisions, including that of medications. 12 Health literacy is linked to cognitive ability. Minorities, low educational levels and multiple morbidities tended to be indicative of low health literacy. The study found that

  • 24% took more than the recommended dose of the OTC product
  • 46% used more than one product containing the same active ingredient, risking an overdose.

The 2003 National Assessment of Adult Literacy found that 59% of people over the age of 65 had basic or below basic health literacy.

                                                                                                                                                         . . . to be continued

References

  1. Charlesworth CJ, Smit E et al. Polypharmacy among adults aged 65 years and older in the United States: 1988-2010. J Gerontol A Biol Sci Med Sci. 2015 Aug;70(8):989-95. doi: 10.1093/gerona/glv013.
  2. Fick DM, Cooper J, et al. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003;163:2716-2724 http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/757456. Accessed March 2017.
  3. Steinman MA Polypharmacy -- time to get beyond numbers JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2015.8597
  4. Jyrkkä J, Enlund H, et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 2011 May; 20(5):514-22. DOI: 10.1002/pds.2116
  5. Woodruff K. Preventing polypharmacy in older adults. Am Nurs Today. 2010;5(10)
  6. Kaufman DW, Kelly JP et al. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002 Jan 16;287(3):337-44.
  7. Jou J and Johnson PJ Nondisclosure of complementary and alternative medicine use to primary care physicians: Findings from the 2012 national health interview survey JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2015.8593.
  8. Qato DM, Wilder J et al. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-482. doi:10.1001/jamainternmed.2015.8581
  9. Loya AM, González-Stuart A, Rivera JO. Prevalence of polypharmacy, polyherbacy, nutritional supplement use and potential product interactions among older adults living on the United States-Mexico border: a descriptive, questionnaire-based study.  Drugs Aging. 2009;26(5):423-36. doi: 10.2165/00002512-200926050-00006.
  10. Gómez Aguirre N, Caudevilla Martínez A et al. Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness. Rev Clin Esp. 2017 Feb 16. pii: S0014-2565(17)30026-7. doi: 10.1016/j.rce.2016.12.013.
  11. Rikard RV, Thompson MS et al. Examining health literacy disparities in the United States: a third look at the National Assessment of Adult Literacy (NAAL) BMC Public Health 2016; 16(1): 975 . doi:  10.1186/s12889-016-3621-9
  12. Wolf MS, Curtis LM et al. Literacy, cognitive function, and health: Results of the LitCog study. J Gen Int Med, 2012; 27 (10), 1300-1307. doi:10.1007/s11606-012-2079-4