What is PolyPharmacy? Is it little Polly going to the Pharmacy?
Does it mean lots and lots of Pharmacies
Well, the answer is coming up…….
On December 1, 1999, the Institute of Medicine (IOM) released To Err is Human: Building a
Safer Health System,* which revealed that an estimated 44,000 to 98,000 people die annually
from medical errors (Committee on the Quality of Health Care in America, 1999). According
to the Report, “more people die in a given year as a result of medical errors than motor
vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516)”
Some journalists and newspapers ran sensational headlines with the story this was equivalent to a jumbo jet
crashing daily!
In 2016, a review from Johns Hopkins published in an article another number which was hard
to fathom. Patient safety experts, in that article, calculated that 250,000 deaths per
year were due to medical error in the US. The headline in several medical journals and
print media were as follows:
John Hopkins Study suggests medical errors are the 3rd leading cause of death in the
US.
There I got you attention. So is this true or just hyperbole.
Several medical Doctors including Dr. . Gorski a medical oncologist disagreed with the findings
and he said the following: medical errors rarely occur in isolation from
serious medical conditions. And also that: Adverse events happen even in the absence
of medical errors. Many adverse events are not preventable and do not imply medical errors
or substandard medical care.
Using data from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) between 1990
and 2016, instead of simply using insurance claims, the new study showed
a modest reduction in the death rates from AEMT in the United States from
1990 to 2016 while also observing increased mortality risk with advancing age and certain
geographic locations. The numbers they showed were about 50-80 fold smaller than the John
Hopkins review.
So you are asking yourself why is this Doctor going about this, and what does this have
to do with Polypharmacy. Polypharmacy is the administration of multiple
medications at the same time. This number can vary and can range from 5-10. In my practice
I prefer to choose the lower number. More than 5 medications is just too many medications.
I would include over-the-counter and herbal/supplements in this definition.
So what happens if you are taking too many medications:
Increases the chances of side effects and adverse events
Drug-drug interaction Poor compliance ( just too many drugs for
the older let alone the younger adults to remember, this is further compounded if the
older adults has vision problems and hearing problems and problems with cognition)
Cost Duplication of therapy ( sometimes patients stay on
drugs for too long which have the same effect and providers do not discontinue the drug,
So let me give you an example of common drugs and their interaction:
If you take Aspirin and Ibuprofen at the same time it increases your chance of bleeding.
And if you are a heart patient who is taking Aspirin because of its cardioprotective effect
and you are taking Ibuprofen at the same time it negates the positive effect.(of Aspirin)
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A survey in the United States looking at adults living in the community (aged 62 through 85
years) . In 87 % of the respondents at least one prescription medication was used. 36 % used
five or more prescription medications.
Another situation which we sometimes come across is when an older adult is transferred
from the acute hospital setting to a subacute facility. In a sample of Medicare beneficiaries
an average of 14 medications was prescribed.
So you are asking yourself why are providers prescribing so many medications. Older adults
often have multiple co-morbidities such as HTN,OA, heart failure, DM, CKD,COPD. If
you want to treat heart failure according to best practices, for heart failure alone
you may end with 3,4,5 medications. Then what if they have DM and High blood pressure. You
see WHERE I am GOING with this….The older adult will get more medication to take care of each
disease entity. Obviously, the more drugs someone is on the higher the risk of DDI and
side effects from medications. In fact in one population based study polypharmacy was
an independent risk factor for hip fractures in older adults.
Patients like you, but in particular older adults are vulnerable to what is referred
to as the prescribing cascade. This is when a medication is prescribed to treat drug-related
side effects that is mistaken for a new medical condition.
Let me give you an example. You see your doctor and you are prescribed a medication called
Amylodopine (brand name is Norvasc). It’s a medication used to treat high blood pressure.
However, a common side effect is edema, or swelling of your legs, You notice this swelling
after a couple of weeks and go a see your provider. You might be seen by somebody else
and they fail to see it as a side effect of the medication and prescribe you another medication,
namely Lasix ( a water pill) to treat your leg swelling.
Another example which you might see is that you might see your provider and you are complaining about
nausea and vomiting. They might prescribe you Metoclopromide, this an anti-nausea medication (brand name is Reglan).
You return to the practice because you develop a tremor in your upper extremities. Someone
else might mistake this tremor for the beginning of Parkinson’s disease and start you on
an anti-Parkinson’s medication. Sometimes, some drugs which have been prescribed
for several years such as cholesterol lowering drugs can be safely discontinued or tapered
off as goals of care for the older adult change and the risk of taking the drug outweigh the
benefit and there is no mortality benefit to continue taking the drug. If you are interested
in the side effects of Atorvastatin click on the link above.
Students,Nurses, providers doctors and especially patients who have worked with me in the past know that
I am pretty conservative with prescribing. I believe less is better and we should always try a
non-pharmacological approach to treat a medical problem. For example if someone comes in with
leg swelling, obviously we need to figure out why they have a leg swelling, however the initial
approach is simple. Elevate your legs, lose weight, life style changes, lower your
salt intake, try compression stockings if these approaches do not work.
One point which we do not not want to forget is when you get older there are some physiological
changes associated with normal ageing: Increased fat mass, decreased muscle mass , decreased
liver metabolism, decreased kidney excretion and decreased total body water . Because of these
changes there are certain medications an older adult SHOULD not take or take judiciously.
For example Benzodiazepines (anti-anxiety medications such as Xanax and Valium) are
associated with an increased risk of hip fracture in the older person.
Because of these aforementioned physiological changes the dose
of certain drugs have to be appropriately changed as well as frequency of these drugs.
So closing the loop on medication errors. I am not suggesting that side effects of medications
are per se medication errors, however, given the complexity and frailty of the older adults
in context of their multiple medical co-morbidities they are more likely to be a victim of an error
and Polypharmacy might be a contributing
factor.
We have to learn
to
look after
our older adults as holistic beings.
And we cannot see them as individual
organs,
the
heart,
the lungs,
the legs,
the knees,
the kidneys.And everytime they come up with a problems,
let say a heart problem we give them a heart medication,
and if they come up with a lung problem we
give them a lung medication.
We should take a step back,
look at them holistically
and then decide, together.
with them or with their caregiver
what the best treatment plan is.
And always
go with a non-pharmocological approach if that is possible.
Question of the day? How many drugs are you on? Leave your answers
and comments in the section below. And if you are interested in more videos don’t
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right here or here or here.Have a good day.Bye Bye!