2. 2
This module is part of the sfCare approach
PowerPoint
Presentation
8.5 x 11
Poster
Patient
Handout
3. 3
1. Identify the factors that contribute to polypharmacy
2. Explain the consequences of problematic
polypharmacy
3. Describe a structured approach to the detection of
problematic polypharmacy
4. Apply general strategies to limit problematic
polypharmacy
5. Apply a senior friendly care approach to
polypharmacy
Objectives
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
4. 4
While there is no consensus definition for polypharmacy, most
studies have used a numerical threshold of 5 or more medications
per day
What is polypharmacy?
1. JAMA 2017;318(17):1728
2. Duerden M, et al. Prescriber 2014;25:44-47
Approximately 40% of older
adults take 5-9 medications1
Approximately 18% of older
adults take 10 or more
medications2
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
5. 5
Medication optimization ensures benefits outweigh risks
Takes into consideration impact on outcomes important to the
older adult, such as
• Improving the duration and quality of life
• Symptom control
• Prevention
It is evidence-based
Appropriate versus problematic polypharmacy
JAMA 2017;318(17):1728
Duerden M, et al. Prescriber 2014;25:44-47
Appropriate Polypharmacy
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
6. 6
Appropriate versus problematic polypharmacy
JAMA 2017;318(17):1728
Duerden M, et al. Prescriber 2014;25:44-47
Problematic Polypharmacy
Risk of harm exceeds the
potential benefits or
coexists with the
benefits
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
7. 7
Impact of polypharmacy on the older adult
1. adverse drug reactions
2. drug interactions
3. cost
4. risk of non adherence
5. risk of medication errors
6. Precipitate or exacerbate geriatric syndromes
The following risks accompany polypharmacy: Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
8. 8
Impact of polypharmacy on the older adult
Falls
Functional impairment
Cognitive impairment
Urinary incontinence
Impaired nutrition
Dehydration
Constipation
Geriatric syndromes Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
9. 9
Risk factors for polypharmacy
=
Increasedrisk
of
problematic
polypharmacy
OR
harmful
medication
effects
+
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
10. 10
Risk factors for polypharmacy
Multiple medical problems/multiple medications
Treatment guideline-based prescribing
• Promotes multiple medications
• Conditions for deprescribing uncertain
ADRs and prescribing cascade
• An adverse reaction to one drug may go unrecognized/
misinterpreted
• Healthcare provider inappropriately prescribes a second drug
to treat signs/symptoms
Infrequent medication review
• There is a lack of incentive to deprescribe
• Unnecessary drugs or doses not adjusted
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
11. 11
Taffet GE, Physiology of aging. In: Cassel CK, Leipzig RM, Cohen HJ, et al [eds]. Geriatric Medicine: An
Evidence-Based Approach, 4th ed. New York, Springer, 2003
Risk factors for polypharmacy
Reduced Homeostatic Mechanisms & Organ Dysfunction
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
A decline in physiologic reserves associated with aging causes the
older adult to become less resilient to various causes of stress
such as acute illness or injury, or the effects that medications have
on the body.
The combination of increased stressors and a decrease in
physiologic reserve can lead to adverse outcomes such as
hospitalization or death.
12. 12
Risk factors for polypharmacy
Pharmacokinetics
changes
• Absorption
• Distribution
• Metabolism (liver)
• Excretion (kidney)
Changes in how the
body
acts on the drug
Pharmacodynamics
changes
• Changes in receptor
binding
• ↓ # of receptors and
receptor activity
• ↑↓ Drug efficacy
• ↑ Toxicity / ADRs
Changes in how the
drug
acts on the body
Changes in
physiology
with aging:
• ↑ body fat
• ↓ body water
• ↓ albumin
• ↓ liver
metabolism
• ↓ renal
function
Reduced homeostatic mechanisms and organ dysfunction
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
13. 13
Risk factors for polypharmacy
Characteristics of frailty
Unintended weight loss due to
inadequate nutrition
Slow walking speed
Impaired grip strength
Exhaustion
Self reported decline in activity
levels
Frailty
Older people are vulnerable to medication-
related problems associated with frailty.
Robust Pre-frail Frail
0 1-2 ≥3
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
14. 14
Risk factors for polypharmacy
Older age
Multiple medical problems (or geriatric syndromes)
Taking multiple medications
Multiple psychosocial problems
One or more sensory impairments (vision, hearing)
New onset urinary or fecal incontinence
Decrease in functional status
Change in mental status- cognition/affect
Disruptive behavior or personality changes
Frequent falls
Frailty (cont.)
Several factors are known to be associated with frailty:
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
15. 15
Risk factors for polypharmacy
With acute illness, usual medications can cause
unanticipated harm
With any change in medications or change in dose, adverse
effects can result
Acute illness or changes to medication can lead to
problematic polypharmacy
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Riskfactors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
16. 16
Challenges in detecting polypharmacy
Problems due to medications may occur
• Without any changes to the medication
• Advancing age
• Coincident with acute illness or symptoms
ADRs masquerade as age-related changes
• Atypical presentation of adverse effects
• Side effects difficult to interpret, may go unreported
• Prescribing cascade
Infrequent Medication Review
• There is a lack of incentive to deprescribe
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
17. 17
Detecting problematic polypharmacy
Problematic polypharmacy can present in atypical ways, such as …
Exaggerated medication effects
Loss of medication’s effect
Problems with taking medication
New or worsening symptoms or conditions
Decline in functional and self-care abilities
Decline in mobility
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
Confusion and falls are important clues that resilience is
compromised in an older adult and should prompt a search for
causes, including medications!
18. 18
Addressing polypharmacy
Assess medication list with an available tool
Explicit criteria – list of
potentially inappropriate
medications
Implicit criteria or
comprehensive assessment
Medication assessment
framework
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
19. 19
Addressing polypharmacy
STOPP/START
Explicit criteria – lists of potentially inappropriate medications
(PIM), for example
Suggests drugs to avoid and drugs to use
High alert medications
anticholinergic activity
Benzodiazepines
Tricyclic antidepressants
Warfarin
NSAIDs
Fluoxetine
Digoxin
Oxybutynin
Age and Aging 2015; 44(2):2013-218
J Am Geriatr Soc 2019;67(4):674-694
Suggests drugs to avoid and highlights high alert medications / patients
High alert patients
Impaired renal function
Impaired cognition or senses
Falls
Hypotension
Diabetes
Parkinson’s disease
Poor nutrition
Beers Criteria List
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
20. 20
DEBRIDE Tool
Dose and frequency
Effects
Benefit
Risk
Indication
Drug monitoring
Expectations
Medication
Appropriate Index
(MAI)
No TEARS
ARMOR
7-Step Review Process…
Gokula M, Homes H. Clin Geriatr Med 28 (2012) 323–341
DEBRIDE: Medication reviews in long-term care and supportive living. Alberta
http://www.cpsa.ca/medication-reviews-long-term-care-supportive-living-physicians-perspective/
MAI: Hanlon JT, et al. MAI J Clin Epidemiol. 1992;45:1045–51
No TEARS: BMJ 2004;329:434
ARMOR: Haque R. Ann Long-Term Care 2009;17:26-30
Other
Medication
Assessment
Frameworks
Medication assessment frameworks
Addressing polypharmacy
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
21. 21
Addressing polypharmacy
Implicit criteria or comprehensive assessment
Health status
Prognosis and goals of care
Benefit – risk assessment of each medication and
overall combination of medications
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
22. 22
Addressing polypharmacy
1. Assess risk for polypharmacy
2. Annual review of medications in all older adults
3. Inform caregivers of medication changes to increase the
chance of detecting problems as soon as possible
4. Chose medications with the fewest side effects
5. Stop unnecessary medications
6. Consider the impact of medications on quality of life
7. Consider the person’s ability to take medications and
remember to take them
Limiting potential harms Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
23. 23
Addressing polypharmacy
1. Recognize
the Need
A practical guide to stopping medication…
2. Reduce or
Stop
to stop a
medicine
one medicine
at a time
3. Taper
Medicine
when
appropriate
4. Check for
Benefit or Harm
after each
medicine has
been stopped
With the
person’s
consent, view
the
discontinuation
process as a trial
At the next
scheduled visit
review progress,
then either:
Maintain
(at half dose)
Continue to
taper (e.g.
quarter
dose)
Stop
Time taken to
taper may vary
from days to
weeks to
months
If symptoms
worsen, may
need to
reinstate the
medication
At the first
visit, halve the
dose
Frank C, Weir E. CMAJ 2014;186(18):1369-1376
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
24. 24
Case study: Mary
Mary is 85 years old and has 4 chronic
conditions that require 9 medications.
No changes to her medications for 5
years.
One month ago a new medication was
started. Soon after that, she began to
feel unsteady when walking and has
been incontinent of urine on 2
occasions because she is not able to
get to the bathroom fast enough. One
week ago, she fell but only sustained
some bruising of her arm.
She is mystified by these new
problems and wonders if she is getting
old and whether she can stay in her
own apartment. She wonders if she
should report these problems to her
daughter.
What’s going through your
mind?
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
25. 25
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case
+
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
26. 26
Is Mary at risk of problematic polypharmacy?
4 chronic
conditions that
require 9
medications:
Prescribing
cascade and
increasing
polypharmacy
Problematic
medications left
unchanged
Risk of further
decline in health
status
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Identify the risk factors in Mary’s case Objectives
Whatis
Polypharmacy?
ImpactfortheOlder
Person
Risk Factors
Detecting
Addressing
CaseStudy
Summary
SeniorFriendly
Approach
Questions
27. 27
New acute
condition may
have:
Compromised
her homeostatic
mechanisms; or
Worsened her
already impaired
organ function
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
28. 28
New health
problems
not attributed to
medications:
• Urinary
incontinence, via
decreased mobility
• Fall
• Confusion: Mary is
unsure if episodes
should be reported
to daughter
• Psychological
distress: Mary is
worried about
ability to live
independently
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
29. 29
Recently been
prescribed a new
medication for a new
condition/acute illness
• Usual medications
have caused
unanticipated harm
• Recent medications
were not
communicated to
Mary’s daughter,
leading to
insufficient health
monitoring and
reporting
• No recent
medication review
+
Multiple medical
problems/ multiple
medications
Reduced
homeostatic
mechanisms and
organ dysfunction
AND/
OR
Frailty
Acute illness or
change to
medications
Is Mary at risk of problematic polypharmacy?
Identify the risk factors in Mary’s case Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
30. 30
Case study: Mary - resolution
Finally, apply the Medication Review Framework
(DEBRIDE) to determine if Mary can benefit from de-
prescribing.
Dose and frequency - Is the dose and frequency correct based
on age and organ function?
Effects - Have the known side effects been considered?
Benefit - Will Mary benefit from treatment given goals of care?
Risk - Is the medication considered a high risk medication?
Indication - Is the indication for the new medication clear and valid?
Drug monitoring - Is a monitoring plan in place to assessbenefit
and harm?
Expectations - Are the expectations of benefit to be achieved
realistic?
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Casestudy
Summary
Seniorfriendly
approach
Questions
31. 31
Summary
Polypharmacy is common ≥ 65 years
due to multiple conditions requiring medications
polypharmacy can be appropriate or problematic
Risk of harm increases with # medications, frailty, and illness
inconvenience ……hospitalization………..death
Medication appropriateness may change over time
decline in functional reserves of organs (frailty)
maintenance medications may become harmful
medication changes result in adverse effects or new drug-
interactions
Medication appropriateness may change with acute illness
loss of physiologic reserve causes medications to have an
enhanced effect
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
32. 32
Summary
medication problems can occur without a change in
medications
tools are available to structure the medication
assessment process
each patient is unique, medication decisions require
clinical judgement
all care providers can contribute to medication problem
identification and reporting
Recognizing problematic polypharmacy is difficult
Benefit/harm ratio can change in an instant or gradually over time.
Regular medication review provides an opportunity to detect
problems, adjust doses based on changing physiology and consider
medication deprescribing.
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
33. 33
Summary
1. Assess polypharmacy risk
2. Annual review of medications in all older adults
3. Inform caregivers of medication changes to increase the
chance of detecting problems as soon as possible
4. Chose medications with the fewest side effects
5. Stop unnecessary medications
6. Consider the impact of medications on quality of life
7. Consider the person’s ability to take medications and
remember to take them
Strategies to limit the potential harms due to
polypharmacy
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
34. 34
The senior friendly approach
How all healthcare providers can address
polypharmacy using a senior friendly care approach
• Leadership-supported medication
reviews
• Providing staff and patient education
• Changes in condition prompt a
medication review – regardless of
patient age
• Medications are meeting the older
adult’s goals
• Facilitate medication reviews
• Medication reminder systems to
increase adherence
Organizational Support
Emotional &
Behavioural Environment
Ethics in Clinical Care
and Research
Physical Environment
Processes
of Care
Organizational
Support
Ethics in Clinical
Care and Research
Processes
of Care
Emotional &
Behavioural
Environment
Physical
Environment
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
35. 35
Which of the strategies to limit
the potential harms due to
polypharmacy (slide 33) are you
already using in your practice?
What are some of the barriers
to implementing strategies to
limit the potential harms due to
polypharmacy (slide 33)?
What is one strategy that you
can implement moving
forward?
Discussion questions
Objectives
Whatis
polypharmacy?
Impactfortheolder
adult
Risk factors
Detecting
Addressing
Case study
Summary
Seniorfriendly
approach
Questions
36. The sfCare Learning Series received support from the Regional Geriatric Programs
of Ontario, through funding provided by the Ministry of Health and Long-Term Care.
V1 July 2019
Editor's Notes
We have developed a comprehensive set of materials for each of 7 topics. Each topic has a PPT Presentation, a Patient Awareness poster, and Patient handout
By the end of this module, the learner will be able to
Identify the factors that contribute to polypharmacy
Explain the consequences of problematic polypharmacy
Describe a structured approach to the detection of problematic polypharmacy
Apply general strategies to limit problematic polypharmacy
Apply a senior friendly care approach to polypharmacy
What is polypharmacy and why does it affect older people?
Polypharmacy occurs when a person is taking more than 1 medication at a time – usually multiple long-term medications at the same time. This can happen when a person has multiple chronic conditions such as diabetes, high blood pressure, or heart failure or symptoms such as pain or insomnia requiring long-term treatment with medication.
The actual number of medications that need to be taken at the same time to qualify as polypharmacy cannot be stated exactly, but in general the potential for harm increases with the number of medications taken.
Polypharmacy is common in those > 65 years old because chronic diseases and symptoms can accumulate with age
Studies show that up to 40% of older adults take between 5-9 medications and up to 18% take 10 or more medications daily.
Polypharmacy may be appropriate or problematic, depending on the clinical context and the degree of effectiveness of each medication and how well medications are tolerated.
The main drivers of medication use are:
Medications are important since they improve both the quantity and quality of life. A person with several chronic diseases receiving medications for each disease will inevitably take multiple medications, for example, a person with diabetes, high blood pressure, and heart failure or a person who has symptoms such as pain or insomnia or a person receiving medications for prevention of a disease such as osteoporosis will have polypharmacy. Hence, having multiple co-morbidities increases the likelihood of being prescribed multiple medications.
The availability of disease treatment guidelines that recommend a cocktail of medications to manage the condition will promote polypharmacy. Therefore, patients with more than one disease, called multimorbidity, are definitely at increased risk of polypharmacy.
Appropriate polypharmacy is when the use of medications has been optimized and prescribed according to best evidence and produces many health benefits with no or only minimal side effects.
Problematic polypharmacy occurs when medications are not optimized, leading to actual or potential harm from medication, which tips the balance of the benefits and harms, so that harm exceeds the benefits.
Polypharmacy may result in:
Adverse drug events can occur as a result of taking multiple medications. For instance, rather than experiencing the anticipated effect of a medication and no side effects, the older adult may experience the side effects associated with the medication. Side effects may manifest in a variety of ways based on the pharmacologic action of the medication. For example: a medication that lowers blood glucose, may lower it too much, causing hypoglycemia; or a medication that lowers blood pressure may cause hypotension or dizziness or a fall; a medication that can cause loss of electrolytes may cause a severe loss of electrolytes resulting in problems with the heart or brain.
Drug interactions may result in an altered response to the drug, (either an enhanced pharmacologic effect leading to toxicity or a reduced effect leading to treatment failure).
Cost and pill burden are other concerns that can arise due to taking multiple medications. Pill burden can imply that the older adult finds it difficult to manage their medications due to complicated dosing schedules (such as every second day or once a week) or the need to take medications multiple times per day or experiencing upset stomach when swallowing multiple medications at the same time.
Medication nonadherence can result from taking multiple medications, since the older adult may forget to take them or may mix up the timing of the dose or the frequency of the dose or take extra pills on occasion. Other reasons for a lack of adherence could be dysphagia, causing a person to avoid the medications that are hard to swallow.
Geriatric syndromes can occur as a consequence of polypharmacy, related to an adverse drug event or a drug interaction.
The major geriatric syndromes include:
falls (e.g. due to balance problems, impaired reflexes, hypotension)
functional impairment, i.e., inability to perform activities of daily living
cognitive impairment
urinary incontinence
impaired nutrition (e.g. dry mouth affecting ability to eat). Many medications have anticholinergic or antihistamine effects which cause dry mouth.
dehydration due to insufficient eating and drinking or over-diuresis from diuretic medications
constipation is a common side effect of medications, especially opioids and iron
A Recipe for Problematic Polypharmacy in Older Adults. Polypharmacy may become problematic in older adults under these conditions:
The presence of multiple medical problems and taking multiple medications
And
Reduced homeostatic mechanisms, due to a decrease in physiologic reserve or the presence of organ dysfunction, especially renal impairment
And
The presence of frailty or factors associated with frailty
And/or
Acute illness or medication changes (including adding new medications or increasing the dose of existing medications)
These factors can lead to problematic polypharmacy in an older adult and should be kept in mind when reviewing a patient’s medication regimen.
Factors that influence polypharmacy:
Treatment guidelines may recommend multiple therapies for one condition. These guidelines are based on studies conducted in adult patients with a single disease. Patients with multimorbidity and frail older adults are excluded from these clinical trials, creating an evidence gap in addressing medication use in older patients with multimorbidity or frail older adults. Clinicians must carefully evaluate the risk-benefit of each medication and work collaboratively with patients to ensure that medication regimens fit patient preferences and goals of care.
Clinical guidelines promote the addition of medications, but do not address the conditions for stopping or lowering the dose, i.e., deprescribing. Medications that were appropriately prescribed years earlier may be less effective or may be causing harm in old age, owing to a decline in renal function, the presence of new diseases, impaired homeostatic mechanisms or an increased sensitivity to the effects of medications.
Adverse drug reactions may go unrecognized because the presentation of the adverse effect is atypical (for example, the presenting symptom may be confusion, which is not a characteristic effect of the drug or the symptom may occur commonly in older adults regardless of medication use, such as: weakness, blurred vision, dizziness, dry mouth or constipation. Failure to appreciate the adverse effect of a drug may result in a new drug being prescribed to address the symptom. This is called a prescribing cascade and is a common cause of problematic polypharmacy.
Infrequent review of medications may cause medications to continue unnecessarily or continue without necessary dose adjustment to account for age-related changes in the body.
The impact of medications or illness on homeostatic mechanisms and brain function are magnified in older adults, especially frail older adults. Medications that were tolerated when the person was younger may not be tolerated in older age.
Older adults have changes in how the body acts on the drug and how the drug acts on the body. Healthcare professionals who are familiar with medications, (i.e., physicians, pharmacists and nurses) should consider these factors when prescribing and monitoring the effects of medications.
Aging is associated with many changes in physiology and body composition. These changes can alter how medications affect an older adult compared to a younger adult. Since most medications are studied in young and middle-aged adults, prescribers are less certain how a medication will affect an older adult.
Key changes in the body include
Increase in body fat relative to weight
Decrease in the amount of body water
A decrease in serum albumin, which is important for binding medications in serum
A decrease in liver metabolism, resulting in less drug metabolism and a higher serum drug concentration
A decrease in kidney function, resulting in reduced elimination of a medication by the kidneys and a higher serum drug concentration
Changes to the ways in which medications act in the body are classified under two categories, pharmacokinetics and pharmacodynamics.
The term pharmacokinetic implies the presence of the drug in the body, which is influenced by:
Absorption from the intestinal tract - unaltered by age alone
Distribution throughout the body, due to altered physiology (i.e. in body water and body fat)
Metabolism (liver) via enzymes called the P450 system, a common method of eliminating medications from the body
Excretion (via the kidney), a common route of drug elimination from the body
These changes can be measured or implied by evaluating the concentration of drug in the body
The term pharmacodynamics implies the action a drug has on the body, which is influenced by a number of factors such as receptor binding affinity of a drug to its receptor. Pharmacodynamic changes cannot be measured by the concentration of a drug in the body. These changes may be felt or observed (such as sedation, confusion, sense of balance, or dizziness) or may be measured by a change in a physiologic parameter such as blood pressure, heart rate, respiratory rate, or nerve reflexes. Changes in pharmacodynamics are common in older adults, manifesting as greater drug potency or efficacy, or greater drug toxicity and adverse drug reactions.
Frailty is a risk factor for polypharmacy to become problematic.
Frailty is characterized by deficits in the following areas:
Unintended weight loss (as a result of inadequate nutrition)
Slow walking speed (due to mobility or balance problems)
Impaired grip strength (indicating a decline in muscle mass and strength and general physical weakness)
Exhaustion (or fatigue indicating a reduced ability to meet physical challenges of the day)
Self-reported decline in activity levels (suggesting an inability to fully participate in life events or cope with stress)
Older adults who have none of these characteristics are considered robust.
Individuals with 1 or 2 of these features are considered pre-frail
Individuals who have 3 or more of these features are considered frail
A frail older adult has accumulated significant health deficits and is at increased risk of dying compared to a non-frail older adult
Several factors are known to be associated with frailty:
Older age
Multiple medical problems (or geriatric syndromes)
Taking multiple medications
Multiple psychosocial problems
One or more sensory impairments (vision, hearing)
New onset urinary or fecal incontinence
Decrease in functional status
Change in mental status- cognition/affect
Disruptive behavior or personality changes
Frequent falls
Having one of the associated factors does not make a person frail. However, having several of these factors or in combination with the frailty characteristics from the previous slide increases the likelihood of being considered frail and needing support from caregivers, needing multiple medications to mange multiple conditions and experiencing problems due to polypharmacy.
Factors that influence polypharmacy:
During an acute illness the person’s usual medications may cause unanticipated problems; possibly due to worsening organ function or dehydration during the illness. Once the person recovers, the usual medications can typically be restarted without problems.
Change in medications or dose can cause adverse effects
Detecting problematic polypharmacy can be challenging for a number of reasons, which will be described in the next part of the presentation.
Problems due to medications may occur:
Without any changes to the medication. When medications have been well tolerated for many years, clinicians may overlook medications as the cause of the new symptoms or acute change in health status.
Advancing age may result in changes in physiology over time, changing the context for prescribing medications in an older adult (i.e., then versus now). For example, safer choices may be available for an older adult, or the dose may need to be reduced to accommodate changes in organ function, or the medication may not be beneficial when life expectancy is shortened.
Problems with usual medications may occur with acute illness or onset of a new symptom. For example, medications to lower blood pressure or to lower blood glucose may cause excessive effects during an acute illness, or a new medication to treat an acute illness may interact with existing medications.
Adverse drug reactions can masquerade as normal aging and as a result, adverse events may be mistakenly attributed to normal aging rather than a drug reaction and go unrecognized. There are several reason that this might occur:
Medication side effects may present in older adults in an atypical way compared to the expected manifestation in a younger person (for example a medication that causes sedation in a younger person may cause confusion in an older adult), causing the problem to be misdiagnosed, leaving problematic medications unchanged.
Older adults may have some cognitive impairment or may become confused as a result of illness or due to a medication side effect, making it difficult for the person to attribute the problem they are experiencing to a adverse drug event and report the problem to their caregivers and health care providers.
When medication side effects are not attributed to medication, a new medication may be started to treat the problem or symptom. This situation is called a prescribing cascade. The risk of a prescribing cascade is increased when the presenting symptoms are atypical or non-specific, making the problem difficult to interpret and target a medication as the cause. For example, symptoms such as weakness, blurred vision, dizziness, dry mouth or constipation may be assessed as being age-related, but could be caused by a medication. Prescribing cascades increase the number of medications taken (polypharmacy) and can result in problematic polypharmacy.
Infrequent medication reviews results in fewer opportunities to optimize medications. Medications may go unchanged for years. As a result, adverse effects may not be detected and problematic polypharmacy may persist for years.
There is a lack of incentive to deprescribe medications in older adults for fear of destabilizing the patient’s health status. Also, some patients are reluctant to have their medication tapered or discontinued, feeling that it is essential to their well being.
Problematic polypharmacy can manifest in subtle or dramatic ways.
Clinicians should monitor for:
Exaggerated medication effects due to impairment in normal physiology or synergy between two medications that have the same effect (e.g. sedation, hypotension), or
Loss of a medication’s effect due inhibition by another medication
Problems with taking medication: difficulty swallowing, a complicated dosing schedule, missing doses due to memory impairment
A new symptom or condition such as falls, confusion, urinary incontinence, dry mouth, or constipation. It is important to note that confusion and falls are important clues that resilience is compromised in an older adult and should prompt a search for causes, including medications
A decline in functional and self-care ability including activities of daily living
A decline in mobility, due to weakness, fatigue, balance or vision problems, or impaired reflexes
Given that multimorbidity and polypharmacy are inevitable in older adults, what tools are available to identify problematic polypharmacy?
For each medication that is prescribed, clinicians should assess its appropriateness in terms of anticipated efficacy and side effects.
When choosing medications to prescribe, those with high efficacy and low side effects are preferred if available.
Three types of tools or approaches are available:
List of potentially inappropriate medications (PIMs) that are to be avoided in older adults if possible. Examples, the Beers List. These lists are referred to as “explicit appropriateness criteria”
A comprehensive assessment of an individual’s situation, taking into account their health status, prognosis, and goals of care, and an assessment of the benefits and risks with each medication and the combination of medications. This type of approach is referred to as “implicit appropriateness criteria”
Medication appropriateness frameworks, involve a structured approach to assessing appropriateness, example, DEBRIDE
26 list of potentially inappropriate medications have been published. Two of the most well-known lists are the STOPP/START criteria and the Beers List
STOPP: Screening Tool of Older People’s potentially inappropriate Prescriptions, provides lists of medications that are potentially inappropriate in persons aged ≥ 65 years, categorized by system in the body, such as the cardiovascular system or the nervous system.
START: Screening Tool to Alert doctors to Right Treatments, provides lists of medications that should be considered for people ≥ 65 years of age, where no contraindication exists. (i.e. medications that are appropriate, indicated)
The Beers List contains tables of medications to avoid based on the drug category (e.g. certain analgesics) or medications to avoid based on disease (e.g. in the presence of renal impairment) or medication combinations to avoid due to the risk of a drug-drug interaction.
The Beers Criteria List describes:
high alert medication's to use with caution: e.g. medications with anticholinergic activity, benzodiazepines, tricyclic antidepressants (TCA), warfarin, NSAIDs, fluoxetine, digoxin, oxybutynin
And
High alert patients who require extra caution when prescribing any medication. These patients have conditions such as renal impairment, cognitive impairment, deficits of the senses, falls, hypotension, diabetes, Parkinson’s disease or who have poor nutrition
These lists are recommendations only. They help prescribers avoid drugs that may cause harm. However, in some situations it may be appropriate to prescribe a medication which is on the Beers Criteria List. When reviewing a patient’s medication profile, clinicians should be alert to the use of a medication on the Beers Criteria List and consider an alternate, especially if harm is detected.
Several conceptual frameworks are available to help clinicians review a patient’s medications and determine appropriateness. A few examples are listed on this slide.
DEBRIDE - 7- step review process
Medication Appropriate Index (MAI)
No TEARS
ARMOR
A systematic approach to reviewing each medication and all medications together helps to optimize medication therapy. A thorough medication review conducted periodically can help to avoid problems with medications. A number of medication review frameworks are available. A 7-step framework is described on this slide.
Indication
Is there a clear indication and is it still valid?
Benefit
Will the patient benefit from the treatment, e.g. therapies at the end-of-life and treatments with long lead time to take effect?
3. Dose and frequency
Is the dose and frequency correct?
4. Side effects
Are there known or potential side-effects?
Are there potential drug-drug or drug-disease interactions?
5. Drug Monitoring
Is therapeutic drug monitoring required and up-to-date?
6. Risk medications
Has special attention been given to high-risk medications?
(All psychoactive medications, antihypertensives and diuretics, Insulin, Warfarin)
7. Expectations
Are the treatments aligned with the patient’s goals of care?
What opportunities do we have to identify problematic polypharmacy?
Problematic polypharmacy may be identified as a result of events that require medical attention or at the time of a scheduled review of medications:
A change in health status, often an acute change or critical incident that requires acute treatment in the emergency department or hospital or doctor’s office visit, such as a fall or a new symptom like dizziness that prompts a re-evaluation of all medication taken. Alternatively, a gradual decline is detected by the older adult or their caregivers.
An acute illness, like an infection causing pneumonia or a urinary tract infection requiring medical attention.
A functional decline has occurred, such as impaired mobility or impaired cognition or loss of ability to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) requiring re-evaluation of the person’s living arrangements.
A new or worsening symptom is reported by the person or identified by caregivers and reported to the doctor or other healthcare provider.
At the time of a periodic medication review by the pharmacist or prescriber.
To empower the older adult and their family members or other caregivers to participate in limiting the potential harms from polypharmacy, the following should be considered and acted on:
Identify problematic polypharmacy opportunities
Assess polypharmacy risk (5 to 9 medications = moderate risk, or 10 or more = greater risk
Are mediations reviewed by the pharmacist and primary care provider at least annually and after discharge from hospital to determine appropriateness and optimize the medication regimen? Consider that medications that were appropriate when prescribed years ago, may not be appropriate years later due to changes in physiology.
Are caregivers aware when mediation changes occur so that they may help to monitor for adverse effects and report problems as soon as possible?
When selecting medication from the available choices, do the selected medications have the lowest side effect profile?
When medications are no longer necessary or are causing problems, or are unlikely to achieve their intended benefit due to a shortened life expectancy, are they tapered or discontinued?
Are medications having a negative impact on the person’s quality of life?
Is the person able to take their medications (e.g., issues related to swallowing problems) and remember to take their medications?
Deprescribing may be an important aspect when optimizing medications in older adults. The All Wales Medicine strategy group has proposed a simple approach, which includes:
Reducing the dose or stopping one medication at a time
Tapering rather than stopping abruptly if possible
Monitoring for benefit or harm after each medication has been tapered or stopped
The patient must be an integral partner in any decision to taper or stop a medication.
Here is an example of a person who has problematic polypharmacy.
Mary is 85 years old and has 4 chronic conditions that require 9 medications. There have been no changes to her medications for 5 years.
One month ago a new medication was stated. Soon after that, she began to feel unsteady when walking and has been incontinent of urine on 2 occasions because she is not able to get to the bathroom fast enough. One week ago, she fell but only sustained some bruising of her arm.
She is mystified by these new problems and wonders if she is getting old and whether she can stay in her own apartment. She wonders if she should report these problems to her daughter.
multiple medical conditions ( 4 plus a new one)
multiple medications (9 plus a new one)
Read slide.
New condition may have compromised homeostatic mechanisms or worsened already impaired organ function, affecting the action of existing medications or the new medication.
indicators of frailty (impaired mobility and falls)
indicators that are associated with frailty (advancing age, new onset urinary incontinence, decrease in functional status, change in mental status- e.g. confusion/indecision about reporting her symptoms to her daughter)
may have reduced physiologic homeostasis (impaired mobility and falls)
developed a new condition or illness requiring changes to her medications. This may cause a new potential drug interaction.
has not had her medications reviewed regularly for appropriateness. Changes in organ function over time may require that medications or dose of medications be modified.
Let’s apply the mediation review framework to Mary’s case. The answers to these questions may improve prescribing appropriateness.
Reflective questions:
Is the indication for the new medication clear and valid?
Will the patient benefit from treatment, given goals of care?
Is the dose and frequency correct based on age and organ function?
Have the known side effects be considered?
Is a monitoring plan in place to assess benefit and harm?
Is the medication considered a high risk medication?
Are the expectations of benefit to be achieved realistic?
Are there opportunities for deprescribing
Taper and discontinue unnecessary or harmful medications
Polypharmacy is common in persons ≥ 65 years
due to multiple conditions requiring medications
polypharmacy can appropriate or problematic
Risk of harm increases with # meds, frailty, and illness. Harm can range from:
inconvenience ……hospitalization………..death
Medication appropriateness may change over time
decline in functional reserves of organs (frailty)
maintenance medications may become harmful if organ function declines
medication changes may result in adverse effects or new drug-interactions
Medication appropriateness may change with acute illness
loss of physiologic reserve during illness may cause medications to have an enhanced effect
Recognizing problematic polypharmacy is difficult to do
medication problems can occur without a change in medications
tools are available to structure the medication assessment process
each patient is unique, medication decisions require clinical judgement
all care providers can contribute to medication problem identification and report
Benefit/harm ratio can change in an instant or gradually over time.
Regular medication review provides an opportunity to detect problems, adjust doses based on changing physiology and consider medication deprescribing.
To empower the older adult and their family members or other caregivers to participate in limiting the potential harms from polypharmacy, the following should be considered and acted on.
Assess polypharmacy risk (5 to 9 medications = moderate risk or 10 or more = greater risk
Are mediations reviewed by the pharmacist and primary care provider at least annually and after discharge from hospital to determine appropriateness and optimize the medication regimen? Consider that medications that were appropriate when prescribed years ago, may not be appropriate years later due to changes in physiology.
Are caregivers aware when mediation changes occur so that they may help to monitor for adverse effects and report problems as soon as possible?
When selecting medication from the available choices, do the selected medications have the lowest side effect profile?
When medications are no longer necessary or are causing problems, or are unlikely achieve their intended benefit due to a shortened life expectancy, are they tapered or discontinued?
Are medications having a negative impact on the person’s quality of life?
Is the person able to take their medications (e.g., issues related to swallowing problems) and remember to take their medications?
All the content we have covered today has been around the processes of care for polypharmacy.
This slide provides an overview of all the other components of a senior friendly approach to address polypharmacy. In order to address polypharmacy we need more than just adequate processes of care, such as:
Organizational support: Ask leaders to support the delivery of senior-friendly care with respect to medications by removing barriers to care, and providing education for staff, patients and caregivers.
Emotional and Behavioural Environment: Confusion and falls are not due to age! Changes in condition should prompt a search for cause which includes a review of all medications – just as you would for adults of all ages.
Ethics in Clinical Care and Research: Ensure that medications are meeting the older adult’s goals. Involve caregivers, especially for vulnerable older adults.
Physical Environment: Remove barriers to medication reviews such as the transportation of the older adult and all of their medications, by performing the review in the older adult’s home. Encourage the use of a medication reminder system if appropriate to facilitate adherence to the medication administration schedule.
Options for discussion:
Brainstorm as a large group
Think independently, pair off and discuss, come back and share with the large group
Round-robin style discussion so that all voices are heard
The sfCare Learning Series received support from the Regional Geriatric Programs of Ontario, through funding provided by the Ministry of Health and Long-Term Care.
You can access more sfCare materials at www.rgptoronto.ca
