When a man in his 70s recently arrived at the UCI Health SeniorHealth Center for a medication review, his daughter pulled out a five-page spreadsheet listing all his prescriptions.
Tatyana Gurvich, PharmD, a clinical pharmacist who specializes in geriatrics, was stunned. “I was impressed because she was so organized, but as I looked through the number of medications and duplications, I was also horrified. I asked her how it had gotten to this point.”
The woman explained that her dad was taking medications for a number of chronic illnesses when he was admitted to a community hospital for treatment. All the medications he brought with him were bagged and taken away. Once he was discharged, he was given a list of new prescriptions, then as they were leaving, another staff member returned his bag of old medications.
“He ended up with three times as many meds as he needed because nobody actually went through everything and told him to throw all the old stuff away,” Gurvich says. “Adverse events in hospitals are all too real especially when there is a transition of care like going from hospital to home or hospital to a nursing facility."
This phenomenon is known as polypharmacy, defined as the regular use of multiple drugs — typically five or more — often to treat multiple chronic conditions. It is a serious and growing public health concern among older adults because the risk of adverse effects or even life-threatening symptoms increases as the number of medications multiples. Several studies have shown that polypharmacy is closely associated with falls, fractures, kidney impairment, frailty, cognitive dysfunction and hospitalization.
That’s why Gurvich and the geriatricians of the SeniorHealth Center make it a point to consider not only each patient’s medical conditions but also the drugs they are taking for them. “Medication lists need to be reviewed at every transition-of-care event to make sure that everything is being prescribed appropriately,” she says.
According to the U.S. Centers for Disease Control and Prevention, 83% of adults in their 60s and 70s reported using at least one prescription drug in the previous 30 days and about one-third used five or more.
Other studies have shown that:
But Gurvich, a board-certified geriatric pharmacist in the UCI School of Medicine’s Division of Geriatric Medicine and Gerontology, says any medication can be high-risk if used in an inappropriate way or leads to an adverse event that impacts the person’s quality of life.
“There are certain high-risk medications that we don’t want older adults to be on,” she says. “However, sometimes they may be taking fewer than five medications. If there are several high-risk ones on that smaller list, that would also be polypharmacy.”
Whether it’s pharmacy students, medical students or physicians, Gurvich teaches others to look deeper.
“It may be that a particular drug is inappropriate or the dosage is too high or too low,” she says. “You have to see whether each medication is an appropriate choice for the patient.”
What is the risk?
While polypharmacy is not inherently bad and may be necessary for a person with multiple chronic conditions, there are five main areas physicians should consider:
- Medication cascades, or prescribing another medication to treat side effects from the first medication. “For example, you go to the doctor because you’re depressed and you’re given an antidepressant,” Gurvich says. “Over the next few weeks, it causes anxiety and maybe a little insomnia. So, you go back to the doctor and you’re given a sleep or anti-anxiety medication.”
- Drug interaction, as when one medication makes another medication ineffective or, conversely, one medication amplifies the other one and its potential to cause toxicity.
- Quality of life, or the impact of taking a large number of drugs on a daily basis. “If you take a water pill in the morning, does that mean you can’t go out to lunch with friends because you need to be near a toilet?” she says. “Or do you take a medication that makes you so dizzy that you can’t participate in your exercise class?”
- Compliance. Can a person with cognitive impairment remember to take all their medications? Will they need a caregiver's assistance?
- Expense. The cost of multiple medications may also impact quality of life and a patient’s ability to do other activities. “Even with Medicare Part D, every medication has a co-pay, which can range from a few dollars to $20 or $40 and more,” says Gurvich. “Multiply that by 20 medications and it becomes a significant financial burden.”
What can older patients do?
If you are 60 years or older and managing multiple chronic medical conditions, you may want to seek out a geriatrician — a primary care provider who specializes in treating older adults.
- Selecting a geriatrician. Interview a few physicians to find one you feel will listen to your concerns.
“When you have baby, most people interview a few pediatricians before they choose one,” says Gurvich. “It’s the same kind of process. That’s the level of care you should take to find a good geriatrician.”
- Get an annual medication review. Bring all your medications in their original containers, including over-the-counter drugs, vitamins, herbal supplements, cannabis, etc.
“Roughly 25% of older adults don’t tell their doctors about additional drugs and supplements they are taking and most doctors don’t ask about them,” Gurvich says. These, too, may have unexpected interactions."
Providing the prescription containers allows your doctor to see the dosage and ingredients of each medication. It also shows how many additional prescribers there are, how many pharmacies a patient has been to, how old each prescription is and whether it has expired.
"If a patient tells me that they are taking this blood pressure medicine every day and I look at the vial and see that it’s a year old and appears to be full, it gives me an idea of how compliant or noncompliant the patient is in managing their condition,” Gurvich says. “Or if I look inside and see three or four different colored pills mixed together, it shows how much confusion exists in the patient’s regimen.
- Ask about medication side effects. You should also be alert for any signs of adverse reactions and interactions with other drugs you are taking. The most common are dizziness, depression, increased falls and cognitive impairment. Medications most commonly associated with adverse effects and drug interactions are those used for asthma, colds and allergies, anxiety, depression and insomnia.
The American Geriatrics Society (AGS) publishes a comprehensive review of medications called the Beers Criteria®, which includes a list of those that are poorly tolerated by older adults and whose use is linked to adverse outcomes. The AGS patient-centered website is a trusted source for up-to-date information and advice on health and aging including medications.
“It also lists many over-the-counter drugs that are high-risk for seniors and should be considered just as important as prescription medications,” Gurvich adds.
At the Seniorhealth Center, each patient’s prescription and medication history is reviewed regularly by the physicians and healthcare providers.
"Our patients with complex, chronic conditions can also schedule a comprehensive consultation with our Health Assessment Program for Seniors (HAPS)," she says. "Our team reviews medical records, prescriptions, current living situations and more to identify key issues."
Patients may also have their medications reviewed in person or through videoconferencing services, free of charge.
“Diagnosing and treating polypharmacy goes far beyond numbers, says Gurvich, who is also an assistant professor of clinical pharmacy at the USC School of Pharmacy. "It means looking at each person, their health goals and the risk vs. benefit of each medication to help them get back on the path to a healthier, happier life.”