polypharmacy (unecessary drug prescription)

Introduction

The administration of many drugs concurrently, usually meaning that a patient is receiving an excessive number of medications.

Unnecessary medications are common in the elderly.

Etiology

• reasons
  • lack of indication
  • lack of efficacy
  • therapeutic duplication
• agents inappropriately prescribed
  • H2 receptor antagonists
  • laxatives
  • genitourinary anticholinergic agents
  • ferrous sulfate
  • tricyclic antidepressants
  • potassium chloride
  • benzodiazepines
  • antibiotics
  • antipsychotics
  • proton pump inhibitors
  • NSAIDs
• predictors
  • multiple prescribing physicians
  • prescription of 9 or more medications
  • multiple specialists consulted with no coordination of care
  • multiple pharmacies prescribing medications
  • lack of medication reconciliation
  • lonely older adults

Epidemiology

• common with the elderly (36-44%)
• 15% of U.S. adults take >= 5 prescription medications
• 18% of elderly receive 2 or more inappropriate prescriptions
• use of statins & antiplatelet drugs increased (2005-2011)
• rural elderly often prescribed >=3 psychoactive medicationsbin a single visit (2.8 visits per 100 visits in those with a pain diagnosis)
• > 90% of Medicare patients would stop taking certain medications but believe that all their medications are necessary
• 72% of elderly with dementia are prescribed >= 5 medications, 43% >= 10 medications
  • these medications often include highly sedating & anticholinergic agents

Complications

• drug adverse effects
• drug interactions
  • older patients with HIV1 infection taking > 15 medications have lower chance of viral suppression
• inappropriate drug use
• medication noncompliance
• duplication of therapy
• medication errors
• 1 in 7 elderly with dementia who live outside nursing homes have overlapping prescriptions for >= 3 drugs that act on the central nervous system according to Medicare part D claims increasing risks for falls, respiratory depression, & cognitive impairment
• associated with risks for falls, disability, & death
• acute renal failure demonstrated by rising serum creatinine may be associated with diminished clearance of renally cleared drugs
  • with polypharmacy risk of elevated levels of renally cleared drugs increases
  • elevated gabapentin levels due to diminished clearance may manifest as dizziness

Management

• pharmacy intervention through patient education between patient visits can reduce mortality in the elderly
• successful drug discontinuation may lead to improved outcomes
• frequent, routine medication reconciliation to verify the need for a medication & the appropriate dosing
• even with guideline-recommended drugs, benefits might be affected by other conditions & drugs & effects on mortality may be unpredictable
• comprehensive geriatric assessment may reduce polypharmacy in the elderly
• lonely older adults may benefit from increased socialization
• drugs to consider deprescribing
  • docusate
  • proton pump inhibitors
  • statins for primary prevention of cardiovascular disease
  • benzodiazepines
  • beta-blockers
  • bronchodilators in the absence of confimatory spirometry
  • antimuscarinic agents for urinary incontinence
  • cholinesterase inhibitors for Alzheimer's disease
  • muscle relaxants for low back pain
  • supplements

More general terms

• inappropriate prescription

Additional terms

• Beers criteria
• medication deprescribing

Patient information

polypharmacy patient information