Polypharmacy in the Elderly – Part 2: The Solution

This, part 2, concludes the two-part series on polypharmacy in the elderly. Part 1 outlined the increasing problem of medications used by the elderly – both prescribed and OTC.

Monitoring polypharmacy

There is one further complication when dealing with the elderly. It may be that they feel they are wasting a health care provider’s (HCP) time; or they may feel that the situation is not serious enough to warrant a visit to their HCP; or they seek advice from friends to the extent that they are known to not only take medication that has been prescribed for themselves but also medication that has been prescribed for their friends. Multiple medications increase the risk for interactions. Further, an increase in the number of chronic conditions will result in an additional requirement for medications.

As Steinman1 stated, it is time to systematize the process. Periodical assessment of each patient’s medications is required as well as an evaluation of the reasonableness of the regimen.

The easiest tools that are readily available include the Beers criteria and the STOPP-START criteria. The Beers criteria provides a list of medications that should be avoided in adults 60 years and over, as well as medications that should not be used in the elderly who have specific medical conditions. The Beers criteria cannot be applied to individuals who are frail or considerably older than 65.

STOPP is the Screening Tool of Older Person's Potentially Inappropriate Prescriptions and START is the Screening Tool to Alert doctors to the Right Treatment. A meta-analysis of four studies2 that included 1925 adults found that use of this criteria reduced potentially inappropriate medications (PIMs) and was associated with reduced number of

  • falls
  • episodes of delirium
  • hospital length of stay
  • emergency and primary care visits
  • medication costs

Using Beers criteria, a study3 of 7,132 elderly individuals found that 27.6% were prescribed at least one PIM. An increasing number of both medications and prescribers was significantly associated with PIMs as was female gender and older age. Another study4 in New Zealand found that using the Beers criteria, the rate of at least one PIM being prescribed was 40.9%. The Beers criteria can be used to identify PIM for elderly dental patients. A study involving elderly dental patients found that 56.9% given prescriptions for 1 and 28.3% were given prescriptions for 2 or more Beers criteria medications which would impact both oral health care and patient safety.5

HCP use of the updated Beers criteria6 would help

  • titrate to the lowest effective dose of medication
  • monitor for adverse reactions
  • treat withdrawal symptoms

A comparison7 of the Beers and STOPP criteria found that while both were effective in determining PIMs, each set of criteria differed in the profile of PIMs. Hence the researchers suggested that both tools should be used in a complementary manner. A systematic review and meta-analysis of randomized controlled studies using STOPP-START found that it was superior in detecting PIMs.2 The latest comparison8 of both versions of STOPP-START and the 2012 updated version of Beers on 1615 prescriptions found that

  • the prevalence of elderly taking 5 medications was 72.9%
  • the median number of medications taken by a patients was 7.1
  • 28.4% of the elderly took 10 medications on a regular basis
  • the most frequent PIM was related to benzodiazepines

 PIM was identified by

  • STOPP version 1 at 18.7% with a potential prescribing omission at 34.7%
  • Beers at 37.3%
  • STOPP version 2 at 40.4% with a potential prescribing omission at 21.8%

STOPP verison 2, identified the number of medications taken, insomnia and the presence of a psychological disorder as risk factors for a PIM.

The end result of use of these criteria to identify age-inappropriate medications would be an improvement in the quality of prescribing, reduced risk of adverse events, enhanced patient outcomes, and optimized use of resources.

Patient’s Role

Monitoring prescribed medications is insufficient. It becomes necessary to ask patients to keep a complete list (and not depend on their memory) of every medication, prescribed, OTC, supplement and herbal, CAM, that they take noting name, quantity, dosage, frequency, any possible effects. While non-disclosure is common among patients who use CAM, the most common reason for non-disclosure was the lack of inquiry by HCP.

Patients too have a role to play. They should be advised to

  • take only those medications that are prescribed and exactly as indicated
  • avoid sharing medications
  • use memory aids to remind them when and how to take their medications
  • store medications in a cool, dry, secure place away from sunlight
  • dispose of outdated or unused medications properly
  • use only one pharmacy to fill their prescriptions
  • keep a list of their health care providers and their contact information
  • keep an updated list of all prescribed, OTC, supplements and herbal medications that they are taking together with the name, purpose, dosage, dosing frequency, reason for taking, generic and brand names.

It would also be helpful if patients kept a list of medications that

  • had been tried and discontinued
  • ∙that caused side effects with a comment about the kind of side effects incurred

Unless electronic records are available, patients should be encouraged to document major health problems, surgeries, chronic conditions,  treatments that worked and those that failed (consider that some asthma medications make asthma worse).

The asthma educator can help patients to link the taking of medication with daily rituals as well as discuss the side effects and which ones warrants a call to their health care provider. This is particularly important when starting a new medication. For asthma medications, it is critical to ensure that patients use the correct inhalation technique. Incorrect technique may unnecessarily result in an increased dosage with increased side effects based on the assumption that the initial dose was ineffective. The elderly patient should be encouraged to bring all their medications in once a year for a pharmacist to ensure that they are taking the appropriate medications. In effect, the team approach to treatment also applies to evaluating both the OTC and the prescribed medications for an individual patient.

Abbreviations:  

CAM       complementary and alternate medicine
HCP        health care provider
OTC        over the counter medications
PIM         potentially inappropriate medication
START    Screening Tool to Alert doctors to the Right Treatment
STOPP    Screening Tool of Older Person's Potentially Inappropriate Prescriptions

References

  1. Steinman MA Polypharmacy -- time to get beyond numbers JAMA Intern Med 2016; DOI: 10.1001/jamainternmed.2015.8597
  2. Hill-Taylor B, Walsh KA et al. Effectiveness of the STOPP/START (Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies. J Clin Pharm Ther. 2016 Apr;41(2):158-69. doi: 10.1111.
  3. Lim YJ, Kim HY, et al. Potentially inappropriate medications by Beers Criteria in older outpatients: Prevalence and Risk Factors. Korean J Fam Med. 2016 Nov;37(6):329-333. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122664/   Accessed March 2017.
  4. Narayan SW, Nishtala PS. Prevalence of potentially inappropriate medicine use in older New Zealanders: a population-level study using the updated 2012 Beers criteria. J Eval Clin Pract. 2015;21:633–641
  5. Skaar DD, O'Connor H. Using the Beers criteria to identify potentially inappropriate medication use by older adult dental patients. J Am Dent Assoc. 2017 Mar 8. pii: S0002-8177(17)30077-6. doi: 10.1016/j.adaj.2017.01.020.  Abstract.
  6. 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.
  7. Blanco-Reina E, Ariza-Zafra G et al. 2012 American Geriatrics Society Beers criteria: enhanced applicability for detecting potentially inappropriate medications in European older adults? A comparison with the Screening Tool of Older Person's Potentially Inappropriate Prescriptions. J Am Geriatr Soc. 2014 Jul;62(7):1217-23. doi: 10.1111/jgs.12891.
  8. Blanco-Reina E, García-Merino MR, et al. Assessing potentially inappropriate prescribing in community-dwelling older patients using the updated version of STOPP-START criteria: A comparison of profiles and prevalences with respect to the original version. PLoS One. 2016 Dec 1;11(12):e0167586. doi: 10.1371/journal.pone.0167586.