One of the most common interventions in health care are prescription medications. Long term care facilities in particular provide as many as 10-15 medications to a patient to include vitamin and mineral supplements. An article from the National Institute of Health points out that the quality of prescribing has long been criticized about inappropriate prescribing along with overuse of medications not clinically indicated or no longer required (Hughes & Lapone 2011).
In addition to the drug categories which could elicit harm and carry many side and adverse effects, the large quantity of medications many elderly are given, could potentially lead to medication errors. Polypharmacy is the simultaneous use of multiple drugs to treat one or more conditions. A study done in 2004 indicated polypharmacy (greater than or equal to 9 medications) occurred with 40% of the clients within nursing homes (Dwyer, Han, Woodwell, & Rechtsteiner, 2010).
The following are reasons why older adults are especially impacted by polypharmacy:
- Older individuals are at greater risk for adverse drug events (ADEs) due to metabolic changes and decreased drug clearance associated with aging; this risk is compounded by increasing the number of drugs used.
- Polypharmacy increases the potential for drug-drug interactions and for prescription of potentially inappropriate medications.
- Polypharmacy was an independent risk factor for hip fractures in older adults in one case-control study, although the number of drugs may have been an indicator of higher likelihood of exposure to specific types of drugs associated with falls (eg, central nervous system-active drugs).
- Polypharmacy increases the possibility of “prescribing cascades”. A prescribing cascade develops when an ADE is misinterpreted as a new medical condition and additional drug therapy is then prescribed to treat this medical condition.
- Use of multiple medications can lead to problems with medication adherence, compounded by visual or cognitive compromise in many older adults. (Rochon MD, 2016)
Renal function with the elderly should be closely evaluated when prescribing any medication. For those elders who appear to have stable kidney function, creatinine lab results can be inaccurate due to reduced muscle mass. To protect against potentially harmful effects of medications, a suggested best practice for prescribers may be to initiate drug therapy at significantly reduced doses and then increase/decrease based on response, side effects and drug levels.
What if we were to break the paradigm? What if when a “new” sign or symptom was present, the health care provider started by ruling out inappropriate medication administration prior to prescribing additional medication? What if when an elder came into a long term care facility, their medications were stopped? Once new baselines were established, re- introduce medication slowly and methodically as symptoms return. We may accomplish a number of things to include; discontinuing unnecessary medications, reducing dosages (or several) which should prove much easier on the patients aging systems and possibly improving their quality of life. Finally, it may reduce or eliminate an undisclosed drug problem in America – inappropriate medication use by the elder population.
Dwyer, L. L., Han, B., Woodwell, D. A., & Rechtsteiner, E. A. (2010, February 8). Polypharmacy in nursing home residents in the United States: results of the 2004 National Nursing Home Survey. – PubMed – NCBI. Retrieved February 18, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/20226393
Hughes, C. M., & Lapane, K. L. (2011). Pharmacy interventions on prescribing in nursing homes: from evidence to practice. Retrieved February 18, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110814/
Rochon MD, P. A. (2016, October 11). Drug prescribing for older adults. Retrieved February 18, 2017, from http://www.uptodate.com/contents/drug-prescribing-for-older-adults