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Table of Contents
EDITORIAL
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 127-129

Conundrum of polypharmacy in geriatrics: Less is better than more


Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission07-Mar-2021
Date of Decision08-Mar-2021
Date of Acceptance10-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
V Rajesh
Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_60_21

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How to cite this article:
Rajesh V, Rao M. Conundrum of polypharmacy in geriatrics: Less is better than more. Cancer Res Stat Treat 2021;4:127-9

How to cite this URL:
Rajesh V, Rao M. Conundrum of polypharmacy in geriatrics: Less is better than more. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Apr 23];4:127-9. Available from: https://www.crstonline.com/text.asp?2021/4/1/127/312120



Polypharmacy is the use of multiple medications by an individual. The number of medications that constitutes polypharmacy is debatable and varies from two to five.[1] The term “polypharmacy” is often used interchangeably with the phrase, “inappropriate drug use.” Besides this, there are various other definitions of polypharmacy, and this makes it difficult to realize the impact of the problem.[2] Potentially inappropriate medication (PIM) is the use of medicines that cause more harm than benefit, especially when safer alternative drugs can be used instead. Polypharmacy can result in PIM. Polypharmacy poses a major challenge to the physicians when prescribing drugs, particularly in case of geriatric patients diagnosed with cancer.[3] In 2011, there were about 104 million people aged more than 60 years; in the past few years, this number has rapidly increased. It is estimated that by 2050, the proportion of the geriatric population will be 20% greater than that of those aged below 15 years.[4] More than 90% of the patients with chronic conditions are prescribed five or more medications. This situation calls for greater consideration and focus of the health-care providers on older adults, who take multiple drugs and are at a greater risk for developing complications like adverse reactions, drug–food and drug–drug interactions.[5]

There are a number of consequences of polypharmacy. It can lead to a decrease in the patients' quality of life, increase in the issues related to mobility, increase in mortality and risk of adverse events, readmission, and increased length of hospital stay. Additionally, it can lead to decreased physician functionality and productivity, occurrence of medication error, and economic burden on the health-care system.[6] The Beers Criteria is a list of guidelines utilized in the identification of the use of inappropriate medications in people aged more than 65 years. These criteria can help the clinicians to rationally prescribe medications to the geriatric patients.[7]

Polypharmacy requires extensive research and understanding for prescribing ideal drug therapies to the patients according to their individual needs. Noronha et al.[8] conducted a prospective observational study on potentially inappropriate use of medications and polypharmacy in geriatric patients with cancer in India. The goal of their study was to raise awareness about the scope of the problem and to encourage the clinicians to consider safe prescription practices when treating their patients. Noronha et al.'s study was aimed at understanding the relationship of polypharmacy and PIM with the outcomes in older Indian patients with cancer and determining the optimal peri-chemotherapy supportive care medication regimen. In this study, the authors enrolled and assessed 285 patients at a geriatric oncology clinic. The data on the medications, including over-the-counter drugs, were collected from the patients and their caregivers. In case of combination medication, the total number of individual constituent medications was considered. They did not consider alternative or traditional medications when counting the total number of medications. The median age of the study population was 70 years; 80% of the patients were men, 77% of the patients had comorbidities. All the patients had solid malignancies, with lung cancers being the most common (39%), followed by gastrointestinal (36%) cancers. Polypharmacy was noted in 55% of the patients, and excessive polypharmacy was noted in 13%. Unindicated medications, such as vitamins and calcium, were being taken by 21% of the patients, and 24% of the patients were taking alternative medications (ayurvedic/homeopathic). About 80% of the patients were taking proton pump inhibitors and the pain killer, tramadol, and in many of the cases, these could be PIMs. Peri-chemotherapy supportive care medications like intravenous antihistamines, histamine H2 blockers, and steroids were being used potentially inappropriately in 52% of the cases. Overall, four out of five patients were using PIMs, which is alarming. Therefore, the issue of polypharmacy demands attention. Although Noronha et al.'s study highlighted the issue of polypharmacy and PIM use in the older Indian patients with cancer, they did not evaluate the clinical outcome of chemotherapy and polypharmacy.[8] Such studies are therefore needed at the national level to assess the true extent and impact of polypharmacy in older patients with cancer. There have been several studies focused on this issue that highlight the extent of polypharmacy in various settings.

In a prospective observational study, Subeesh et al. reported their findings on 344 older patients. The mean age of their cohort was 72.9 ± 6.5 years. The mean length of hospital stay was found to be around 10 days. The average number of drugs prescribed was 9.68 (±1.94), with minimum of 5 drugs and a maximum of 14 drugs. The use of PIMs was observed in around 52% (110) of the participants. The authors concluded that polypharmacy and use of PIMs were highly prevalent.[9]

A cross-sectional study by Rakesh et al. reported polypharmacy in the prescriptions of around 66.19% of the patients. The highest number of patients with polypharmacy was observed in the age group of 70–79 years. A considerable proportion of patients were prescribed drugs that could be avoided as per the Beers Criteria. Inappropriate prescriptions were also observed in the geriatric patients.[10] Romskaug et al. suggested that a better model for handling polypharmacy involves clinical evaluation and thorough drug reviews carried out by health-care professionals in cooperation with the patients' family physicians.[11]


  Methods for Handling The Issues of Polypharmacy Top


The key to solving the problem of polypharmacy is the careful evaluation of the patients' medication regimen and discontinuation of medications that are unnecessary for their condition. This is known as “deprescribing,” and is defined as, “the systematic process of identifying and discontinuing drugs in instances in which the existing or potential harms outweigh the existing or potential benefits within the context of an individual patient's care goals, current level of functioning, life expectancy, values, and preferences.” Scott et al.[12] recommended a five-step process for deprescribing, which involves collecting all the information related to the medication the patient is using (step 1), evaluating the risk of drug-induced problems (step 2), checking whether the drug should be discontinued (step 3), prioritizing medications to be discontinued (step 4), and implementing the recommendations and monitoring the patient (step 5).

The key principles of conservative prescribing[13] are as follows:

  1. It is necessary to consider options other than drugs (one can consider prevention, non-drug therapies, and treatment of the underlying causes)
  2. It is also necessary to be more strategic when prescribing medications, be cautious when using unproven drugs, adjourn any non-urgent therapies, start the treatment with a single new drug at a time, and avoid any unwarranted switching of drugs
  3. It is essential that we be extremely vigilant about the development of various adverse effects, such as withdrawal syndromes and drug reactions, and inform the patients about the possibility of occurrence of such events
  4. It is also important to be cautious and skeptical about the use of new drugs and seek objective information. One should wait for the drugs to have spent adequate time on the market and be skeptical about the surrogate outcomes. Additionally, it is important to avoid being lured by the elegant molecular pharmacology and stretching indications and beware of selective reporting of drug trials
  5. It is necessary to work with the patients toward a common goal. One must not readily comply with the drug requests from the patients and must consider non-adherence before adding new drugs to the regimen, discontinue the use of unnecessary drugs, avoid restarting drug treatments that have previously been unsuccessful, and respect the patients' apprehensions about drug use
  6. Lastly, it is essential to take into account the long-term and wider impacts of drug use by weighing the long-term outcomes and recognizing the questionable benefits of the new drugs.


Polypharmacy is widely prevalent among geriatric patients with cancer due to various reasons, including severity of the disease and its symptoms. As a result of the diversity of the population and the underrepresentation of the older patients with cancer in the clinical trials, our understanding of polypharmacy is not substantial. Health-care providers have to recognize this lack of information and take initiative to include the geriatric patients in the clinical trials. Teamwork is another critical need of the hour to improve our understanding about the medications that need to be routinely reconsidered in the context of each individual patient. Various tools and criteria, such as the Beers Criteria, Medication Appropriateness Index, and START (screening tool to alert doctors to the right treatment), should be used to assess polypharmacy in routine practice and appropriate measures should be taken to limit the adverse reactions, drug–drug interactions, non-adherence to medications, morbidity, and mortality.



 
  References Top

1.
Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017;17:230.  Back to cited text no. 1
    
2.
Rakesh KB, Chowta MN, Shenoy AK, Shastry R, Pai SB. Evaluation of polypharmacy and appropriateness of prescription in geriatric patients: A cross-sectional study at a tertiary care hospital. Indian J Pharmacol 2017;49:16-20.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Sharma M, Loh KP, Nightingale G, Mohile SG, Holmes HM. Polypharmacy and potentially inappropriate medication use in geriatric oncology. J Geriatr Oncol 2016;7:346-53.  Back to cited text no. 3
    
4.
Tripathi, P. Share of population over age of 60 in India projected to increase to 20% in 2050: UN. (T. E. Times, Ed.) India; 2019.  Back to cited text no. 4
    
5.
Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018;9:CD008165.  Back to cited text no. 5
    
6.
Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: Evaluating risks and deprescribing. Am Fam Physician 2019;100:32-8.  Back to cited text no. 6
    
7.
Salbu RL, Feuer J. A closer look at the 2015 beers criteria. J Pharm Pract 2017;30:419-24.  Back to cited text no. 7
    
8.
Noronha V, Ramaswamy A, Gattani S, Castelino R, Krishnamurthy MN, Menon N, et al. Polypharmacy and potentially inappropriate medication use in older Indian patients with cancer-Analysis of a prospective observational study. Cancer Res Stat Treat 2021;4:67-73.  Back to cited text no. 8
  [Full text]  
9.
Subeesh VK, Gouri N, Beulah ET, Shivashankar V. A prospective observational study on polypharmacy in geriatrics at a private corporate hospital. J Appl Pharm Sci 2017;7:162-7.  Back to cited text no. 9
    
10.
Rakesh KB, Chowta MN, Shenoy AK, Shastry R, Pai SB. Evaluation of polypharmacy and appropriateness of prescription in geriatric patients: A cross-sectional study at a tertiary care hospital. Indian J Pharmacol 2017;49:16-20.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Romskaug R, Skovlund E, Straand J, Molden E, Kersten H, Pitkala KH, et al. Effect of clinical geriatric assessments and collaborative medication reviews by geriatrician and family physician for improving health-related quality of life in home-dwelling older patients receiving polypharmacy: A cluster randomized clinical trial. JAMA Intern Med 2020;180:181-9.  Back to cited text no. 11
    
12.
Scott I, Anderson K, Freeman C. Review of structured guides for deprescribing. Eur J Hosp Pharm 2017;24:51-7.  Back to cited text no. 12
    
13.
Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med 2011;171:1433-40.  Back to cited text no. 13
    




 

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