Strategies for lowering the risks of polypharmacy
Polypharmacy is a common problem encountered by clinicians caring for the elderly. It is encountered in all care settings, ranging from outpatient to long-term care, where it is particularly linked with falls and other associated problems. Polypharmacy refers to the use of multiple medications by a patient. The term is used when too many forms of medication are used by a patient, more drugs are prescribed than clinically warranted, or even when all prescribed medications are clinically indicated but there are too many to take (“pill burden”). This has a potential to cause higher adverse drug reactions (ADRs) and drug-drug interactions (DDIs).
It is very common for those over age 65 to have more than one chronic condition, and thus be on more than one medication. According to the National Council on Patient Information and Education, 40 percent of seniors are unable to read prescription labels, and 67 percent are unable to understand information given to them. Given those statistics, it is likely that many elderly persons are not taking their medications properly. While using the right drugs properly can alleviate symptoms, cure infection and disease, and improve quality of life, there can also be negative consequences, such as:
- Adverse drug reactions.
- Drug-to-drug interactions.
- Noncompliance with the drug regimen.
- Decline of quality of life or functional ability.
- Deterioration in mental status.
Polypharmacy-related problems add significant costs to the healthcare system, having a financial impact on patients as well as institutions, according to research. Duplication and redundancy of medications are common. Regulatory issues, particularly in LTC settings, also can influence prescribing patterns.
Lack of proper indications, inappropriate dosage and subclinical toxicities of medications are common observations. “Prescribing cascade” is a known problem, where a medication results in an adverse drug event (ADE) that is mistaken as a separate diagnosis and treated with more medications, which puts the patients at risk for additional ADEs. It is common to see nine or more medications prescribed to elderly patients transferred for subacute rehabilitation from hospitals to nursing homes. These medications are prescribed by multiple providers at different times for different reasons. One such common example is medications started for a patient during a hospital stay by consultants and hospitalists that are not re-evaluated for appropriateness after discharge from the hospital by the physician in charge of care of that patient.
Powerful Prevention Strategies
Some current strategies available to address this complex issue include “START” (Screening Tool to Alert doctors to the Right Treatment) and “STOPP” (Screening Tool of Older Person’s potentially inappropriate Prescriptions) criteria. START is an effort to help prevent omission of important appropriate medications and is organized by organ system. STOPP criteria are a useful guide to identify potentially inappropriate medications (PIMs), particularly in the hospital setting.
In addition, a multidisciplinary expert panel recently developed a consensus agreement on a list of laboratory findings and medication combinations to help detect potential ADPs in nursing home residents. Researchers (Zhan et al.) have published modified Beers Criteria to develop a list of potentially harmful medications in community-dwelling elderly persons. A cross-sectional database study identified older patients receiving medications included in the Health plan Employer Data and Information Set (HEDIS 2006) criteria, using national data from Veterans Affairs. The HEDIS 2006 criteria was derived from the medications thought to be the most problematic in the elderly. Results for the HEDIS 2006 measure were similar to those of the 1997 Beers Criteria.
The ARMOR Tool
The ARMOR Tool (Assess, Review, Minimize, Optimize and Reassess) is an attempt to consolidate these recommendations into a functional and interactive tool. It takes into account the patient’s clinical profile and functional status and tries to balance evidence-based practice with altered physiological reserves. ARMOR is an effort to approach polypharmacy in a systematic and organized fashion. Restoring and maintaining functional status are the primary outcome goals. This tool also emphasizes quality of life as a key factor for making decisions on changing or discontinuing medications. Use of a certain medication is weighed against its impact on primary biological functions such as bladder, bowel and appetite. Functional status and mobility is held up as the essential final outcome measure for any medication change using ARMOR.
Implementation of the use of this tool requires a multidisciplinary approach. Teams should include the medical director, director of nursing, pharmacist, physical/occupational therapy director, recreational therapist and social worker. The application of this tool has led to significant reduction in polypharmacy, reduced cost of care and marked decrease in hospitalizations. Falls and behaviors with potential of harm to self and other residents show a decline in frequency. Similar impact is seen in usage of psychotropic medications. Quality indicators further validate this trend.
ARMOR is a stepwise process for the assessment of a geriatric patient who is: 1) receiving nine or more medications; (2) seen for initial assessment; (3) seen for falls and/or behaviors; and/or (4) admitted for rehabilitation.
The ARMOR tool has been used for the following: subacute geriatric rehabilitation, outpatient comprehensive geriatric assessment, evaluation of multiple falls, behavior assessment in LTC, evaluation of delirium, GDR in LTC, and unexplained functional decline in LTC.
Facilities that have implemented the use of ARMOR report a consistent decline in the use of nine or more medications and a reduction in falls and behaviors with harm to self. The number of hospital admissions, geriatric psychiatry admissions and consultations have also declined. Use of antipsychotics and antidepressants has been reduced.
A systematic approach with ARMOR is able to effectively improve patient care and outcomes.