The dangers of polypharmacy, or too many prescription drugs
In her mid 70s, Argie, a widowed former teacher, began feeling poorly. She was tired. Her stomach hurt. Sometimes she got agitated. And she seemed forgetful.
Worried, her grown children urged the woman, who asked that only her first name be used for privacy reasons, to consult a memory specialist in Baltimore, not far from her home.
Argie’s cognitive powers, the doctor concluded, were reasonably good. But her medicine cabinet was a real hazard: She was taking 21 different prescription drugs, for diabetes, high blood pressure and her kidneys. After an assessment by a team that included a clinical pharmacy specialist well versed in drug interactions, she’s now down to eight.
“Every time I went in to a doctor, they gave me another pill,” Argie said. She’s now less confused. Less agitated. Less nauseated. She said cognitive challenges are manageable, and she’s more energetic and steadier on her feet.
That overload of drugs, known as polypharmacy, can be dangerous at any age but it’s particularly hazardous for elderly people, who often have multiple health conditions and whose bodies may not handle meds the same way they did when they were younger, said Nicole Brandt, a leading expert on geriatric prescribing at the University of Maryland.
That can aggravate or cause a host of harms ranging from heart and blood pressure problems to being groggy or unsteady, which increases the risk for falls. Too many drugs and interactions can raise the risk of dementia, or worsen the confusion and memory fog of someone who already has some cognitive decline, experts in aging and medicine said. Or, as in Argie’s case, all those drugs can make a mild impairment appear far more serious.
Too many pills, too many interactions
“You have to be really, really strategic about how you prescribe medications, because you might be worsening other things in the long run or the short run,” said Jonathan Watanabe, chair of the Department of Clinical Pharmacy at the University of California at San Francisco and an expert in geriatric prescribing. Not only can patients get drugs that interact, they may end up taking a medicine longer than the prescriber intended. “It gets sort of stuck on their patient profile in perpetuity,” he said.
The dangers of polypharmacy are well recognized. The American Geriatrics Society has set criteria for safe prescribing. Other medical groups have promoted a model for “age-friendly” care. Doctors, nurses and other providers are supposed to be more deliberate about “medication reconciliation,” meaning checking everything a patient takes. Yet overprescribing and the harms it causes persist, researchers have found.
In theory, electronic health records were supposed to flag inappropriate medications and interactions and they are certainly more helpful than handwritten charts stuffed in file cabinets in multiple doctors’ offices and hospitals, said Michael Steinman, a geriatrician at UCSF who specializes in prescribing for clinically complex older adults. But years after electronic health records were introduced, the cardiologist at Hospital A still may not see all the medicines the urologist at Hospital B and the rheumatologist at Hospital C have prescribed. And none of the providers may know about over-the-counter-pills, vitamins or other supplements, he said.
“It becomes this huge morass, and it’s very difficult to figure out what a given person is actually putting in their mouth, and to make sure that everyone has a common understanding,” Steinman said.
Care transitions, say from a nursing home to a hospital or vice versa, are high risk times for many reasons, and risks multiply because the two settings use totally different electronic record systems, said Alice Bonner, a nurse practitioner who has worked on national models for safe prescribing. It gets even more challenging if the patient’s first language is not English.
“You’re on these different systems. They’re capturing the data differently about your meds, and that’s when things get messed up,” said Bonner, who spent years caring for elderly patients before moving to research and policy. Talking to the patient helps, but it’s also time consuming and complex.
“Are they able to take their medications as prescribed? Is their regimen too complicated? Does it need to be simplified? Do they understand the dosing? Do they understand the different drugs?” she said. For instance, if a patient doesn’t realize their Lasix, a brand name drug prescribed for congestive heart failure and other conditions, is the same thing as furosemide, the generic, they might end up taking both.
Medication reconciliation
Ideally, health providers do undertake “medication reconciliation,” to figure out what’s helpful and what’s not. That’s what helped Argie. But outside of leading health care systems, it doesn’t always happen. And even in a top-notch system, things can still be missed.
“People accrue medicines, right? Especially if they’re seeing multiple providers, that medicine list just grows,” said Susan Parks, director of geriatric medicine at Thomas Jefferson University in Philadelphia. Patients there are given a marked brown bag to bring in everything they take, prescription and non, so it can all be assessed. Some drugs are “deprescribed,” with explanation and reassurance that the patient is better without them. And sometimes patients and providers weigh trade-offs. For instance, a patient might want to stay on a drug for incontinence despite some chance of dizziness or confusion. And providers can then help minimize risks.
But sometimes, instead of a careful effort to deprescribe, the opposite happens. A prescription pile-on.
That’s what happened to Julie Cusick. After her longtime partner left her, she was 60 years old and on her own, and dealing with emotional fallout from a very difficult relationship. She was already on a bunch of meds for a chronic lung condition, but at least four specialists prescribed new drugs for what appeared to be worsening psychiatric, cognitive and assorted other conditions — and then a car accident made everything worse.
“They bombarded her with all these meds. One on top of another after another,” said her sister, Joanne Cusick, a nurse. When she continued to decline and get more confused, they added yet more drugs, including one for dementia and two antipsychotics, which the sisters later learned should never be given together.
Her sister knew something was wrong, but at first, she didn’t focus on all those bottles of medicine. “I’m an ICU nurse! Not a psychiatric nurse!” she said.
A geriatric psychiatrist finally figured out that she was neither demented nor psychotic and gradually peeled away unneeded medications. Her pulmonologist is trying to wean her from some, maybe all, of the lung drugs she has taken for years.
“Before, I would stare into space,” Julie Cusick said. Now, she reports being alert and engaged, living on her own but in a setting where seniors or people with disabilities can get help if needed. She takes classes at a senior center, goes to the gym, and has made new friends.
Barriers to fixing the problem
But there’s a shortage of geriatricians in the United States, a shortage of psychiatrists, and certainly a shortage of geriatric psychiatrists. And not everyone’s sister is a nurse. That means much drug oversight is done in primary care settings. And while awareness of polypharmacy has grown, barriers to fixing it remain. Doctors don’t always have time or incentives to do a thorough review. And patients often go to an appointment expecting to get a prescription — not to have one taken away.
There are some new approaches that experts hope will address these issues, including, perhaps, artificial intelligence tools in the near future. The Center for Medicare and Medicaid Innovation funded research at the University of Hawaii that showed that incorporating pharmacists in hospital inpatient teams for high risk patients and then connecting the patient to the right community pharmacist helps — but it has never been widely implemented or funded in either Republican or Democratic administrations, said Karen Pellegrin, who led that “Pharm2Pharm” study.
A lot of patients could benefit, she believes, including her own father in his final months of life. He had several complicated conditions, and it was tough to manage his blood thinners and aspirin — which can be risky together — and a bunch of other things.
Pellegrin doesn’t blame his death after a stroke on a single error or drug interaction. Everybody, she said, followed the standard of care.
“Unfortunately, that standard of care isn’t the best available care,” she added. The best care would have included something like Pharm2Pharm, with pharmacists making sure he had the right meds, at the right times, both in an out of the hospital.
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