by Greg McKenzie © Copyright 2016
Polypharmacy
Greg's articles

Polypharmacy: Pitfall Of Ageing

Do you take a prescribed medication? Chances are you do, and those chances increase with age as prescription medication is not only on the rise in all age groups but is almost in the stratosphere with the elderly.

According to co-authors Rohan Elliott and Jane Booth of a report for the Centre for Medicine Use and Safety at Monash University “older people are the largest users of medicines”. That makes sense, of course. As we become older age and disease-related changes in heart, kidney and liver function require medicinal management.

Multiple medical issues require multiple medications and that can lead to problems. “Polypharmacy” is the new buzz word in medical treatment of older people. My spellcheck refuses to recognise it but a quick look around the media and medical journals will bring up a plethora of information.

Polypharmacy is roughly defined by taking five or more medications concurrently. A 2009-2010 survey of 4,500 Australians living in the community and aged 75 years or older found 66% took five or more medications; over 20% took ten or more.

Older people often suffer multiple “comorbidities” This grave-sounding term simply means a number of medical conditions that co-exist independently in the same person. For instance someone may suffer insomnia and anxiety, or diabetes and high blood pressure at the same time. Each condition is often treated with prescription medication, usually not always by the same physician.

Older people living in residential retirement villages and aged care facilities take higher levels of medication. A more recent survey showed up to 95% of residents were prescribed five or more medications and an average of 7-10 per resident. That’s a lot of pills. Whether living at home with a carer or independently, or in residential care that’s quite a responsibility to track dosages, brands and other confusing aspects of medication.

One third of older community-living Australians self-report difficulty in removing meds from packaging, reading meds labels and achieving correct dosages with puffers and patches. Some simply have difficulty swallowing pills and capsules let alone the difficulty in understanding instructions, confusion over different brand names, and remembering to take meds at all. Others share, borrow and hoard meds.

Starting to add up to quite a stew, isn’t it? When you consider that patients don’t always tell their doctor everything they are taking, and the doctor often doesn’t ask, you can see why Dr Caleb Alexander, co-director of the John Hopkins Centre for Drug Effectiveness and Safety and co-author of a JAMA Internal Medicine report that’s been making a splash in the media lately advocates for a “brown bag” review of all medications (including prescribed and over-the-counter, herbal and dietary supplements) by doctor and patient. He says patients should simply bring every single pill tablet, etc they take to their doctor for a coordinated review of their medication management.

In such a review with one of his patients he found they had accumulated four or five bottles of the same drug from different brands and were taking several times the dosage recommended.

Does it matter?

It sure does. The Monash review of papers on the subject found that inaccurate medication histories, sub-optimal medication management, complex medication regimes and non-adherence to those regimes was contributing to adverse drug-to-drug and drug-to-disease interactions and increased hospitalisations.

Even in hospitals, where improved monitoring of medical regimes and updated systems for their management are being implemented a study found 75% of elderly patients arrive with inaccurate GP medication lists that flowed on to unintended discrepancies on hospital charts.

Improved public health care, including access to a wider variety of medications on pharmaceutical benefits means more medications are prescribed than ever. Statins, or cholesterol-lowering drugs are the most rapidly rising prescribed drug. Factor in increasing life expectancy. Australians are living longer; by 2050 one in four of us are expected to be over 65. Older Australians currently account for 13% of the population but receive twice the meds per GP encounter than people under 25.

The heavy reliance on medications for older people is often unaccompanied by evidence to support it. For instance, in clinical cancer trials, only 20% of subjects are over 70, and only 9% are over 75. In effect, elderly people are being prescribed medications in ever increasing amounts yet they are not really evidence-based on trials targeted at the elderly. Even when included in studies, those elderly participants are usually healthier than typical for similar elderly aged people in the general population. There are few guidelines for the treatment of comorbidities, decisions are often extrapolated from studies of younger people, or made on just the professional judgement of practitioners.

There is a phenomenon known as the “prescribing cascade”. This is where one medication’s side effects are treated by another drug, and that further drug’s side effects are treated by another, and so on. For instance, cardiovascular drugs, opiods and sedatives can lead to dizziness, often treated by prescribing prochlorperazine, known for increasing hospitalisation for hip fracture. Anti-psychotic meds also lead to increasing hospitalisation for hip fracture.

As people live longer, they experience more multiple chronic disease, treated by medication regimes that grow ever more complex and intensive. The ultimate side effect of all this is rising polypharmacy and its unfortunate consequences. 14% of older people suffer impaired physical functioning due to polypharmacy: slower walking, poorer balance and grip, frailty, delirium and falls. A study of older community-dwelling Australian men found a threshold for increasing falls and mortality at 4.5 meds taken concurrently. At 5.5 concurrent meds and beyond, disability and frailty rose sharply. It concluded that every medication added to a regime increased risk of mortality, falls, disability and frailty.

Phew! I’m not a doctor or pharmacist but in reviewing studies and statistics on the growing problem of polypharmacy I can see that taking measures to decrease medication and a better flow of information between patients and doctors can help this problem. Sometimes an alternative medication might reduce the negatives of polypharmacy. In Dr Alexander’s study, he found the most common combination in his elderly patients was a statin (Zocor) and a blood pressure medication (Norvasc). Now, Zocor (like most statins) causes muscle pain and weakness which is heightened by Norvasc so a better combination could be sought amongst these drug types to reduce side effects.

I’m 60 now, and don’t take any medications. I don’t mean to be smug about this, perhaps I’m lucky, perhaps my years of exercise and good nutrition have helped. I do know that older people should evaluate their use of medication in conjunction with a knowledgeable and sympathetic doctor. One of the clients I train in my personal training business is 78, and healthy and fit. Let’s call him Jim. Jim takes a medication for kidney stones he sometimes suffers and a statin for cholesterol-lowering. He has been complaining of shoulder pain and we concluded that the statin was most likely responsible. I encouraged Jim to get a full blood lipid profile to see if his cholesterol was now within reasonable bounds of normal so he could discontinue its use with his doctor’s advice. He also decided to have a scan of his shoulder which revealed a tear in the supraspinatus tendon. Aha!

The cholesterol reading came back at 5.6 which is just above normal so he has the option of ceasing use of the statin which might have been contributing to shoulder pain also. We have modified his training and include particular strengthening and stretching exercises for his damaged rotator cuff.

I guess the moral of the story is to be well-informed about your physical condition and the medication regime you are on. It should be reviewed periodically by a single physician, particularly if different specialists are prescribing different medications and may not be aware of the full picture.

I didn’t cover the use of herbal and dietary supplements and aspirin which can all impact on medication regimes.

We’ll cover that next.