Using multiple physicians or pharmacists can result in a lack of coordinated care, missed medication interactions, and overlooked contraindications.
The CDC and the National Institutes of Health define polypharmacy as consuming 5 or more medications daily.1,2 Polypharmacy is an important health issue with significant impacts on disease burden and health care costs. Although multiple medications are commonly necessary to manage acute and chronic health conditions, polypharmacy can lead to harm. The estimated prevalence of polypharmacy is 37% for the general population and up to 65% for those who are 65 years and older.3,4 Patients with polypharmacy have a 50% chance of having an adverse drug interaction. Additionally, polypharmacy accounts for almost 30% of all hospital admissions.5 Polypharmacy is associated with a significant health care burden of approximately $50 billion annually in the US alone, and it is on the rise.3
Contributing Factors
Polypharmacy can occur in a range of situations, often overlapping. Patient-related factors include age, health conditions, multiple morbidities, chronic conditions, and living in a long-term care facility.6 Self-medication is also a contributing factor, when patients add medications to their regimen without consulting a health care professional. Such products can include vitamins, herbs, and cough/cold treatments, leading to an increased risk of adverse effects.
Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center in Denver. She has more than 30 years’ experience as a community pharmacist and works as a clinical medical writer based in Homosassa, Florida.
The use of multiple physicians and pharmacies can result in a lack of coordinated care, leading to missed medication interactions or contraindications, heightening the dangers of polypharmacy. Similarly, a prescribing cascade occurs when one drug is administered and causes an adverse effect, which is misinterpreted as a new condition, leading to a new prescription. To avoid prescribing cascades, pharmacists can ask questions such as whether the precipitating drug is still indicated, whether the treatment can be altered, and whether the benefits of the prescribing cascade outweigh the risks.7
System-level factors can also lead to polypharmacy. Failures at the system level include inadequately updated medical records, automated refills, and prescribing to achieve quality metrics instead of individualizing therapy.6 Transitions of care are also a common source of medication errors, including polypharmacy.
Finally, direct-to-consumer advertising can also lead to polypharmacy. Patients often see a commercial or advertisement and inquire about it with their physician, who may prescribe it even when it is not the patient’s best option.8
The Dangers of Polypharmacy
Polypharmacy is not inherently bad and may even be necessary for some patients with multiple chronic conditions. However, the potential for not taking medications as directed increases with the number of medications prescribed. Additionally, polypharmacy increases the risk of drug-drug and drug-disease interactions, as well as adverse drug events, cognitive impairment, falls, hospitalizations, and prescribing errors.
Polypharmacy is also associated with cognitive impairment in older adults. Factors that increase the risk of polypharmacy-related cognitive impairment include advanced age, multiple comorbidities, low socioeconomic status, and low education. Evidence from one study showed that patients receiving polypharmacy are almost 3 times more likely to develop cognitive impairment, even after adjusting for other factors.9
Interventions
Detecting inappropriate polypharmacy and optimizing medication regimens is crucial to enhancing patient outcomes. Interventions to improve polypharmacy can improve medication appropriateness, reduce improperly prescribed medications, and reduce prescribing omissions.
A patient-centered deprescribing strategy involves a stepwise approach that includes obtaining a comprehensive medical history, identifying potentially inappropriate medications, determining the necessity of each medication, planning and execution of medication withdrawal, and monitoring.10
A comprehensive medication review (CMR) is a systematic process of collecting patient-specific data, assessing medication therapies to determine medication-related problems, and creating a plan to resolve them through shared decision-making. A CMR is designed to help patients improve their medication knowledge and their health.
Many tools are also available to help identify and reduce inappropriate polypharmacy, with explicit criteria for appropriate prescribing:
Conclusion
Medication-related problems, including inappropriate polypharmacy, are a massive public health issue in the US. Anyone who uses prescription medications, nonprescription medications, dietary supplements, and/or herbal supplements may benefit from consulting a pharmacist, especially if they take several medications or have multiple health conditions.
Pharmacists provide services in all settings in which medications are provided. Although different settings require different services, pharmacists are always responsible for ensuring that the medication is right for the patient and their condition, thereby supporting positive patient outcomes.
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