Am I taking too many pills?
Polypharmacy refers to the effects of taking multiple medications concurrently to manage coexisting health problems. Often, polypharmacy becomes problematic especially when patients are prescribed too many drugs by different healthcare providers working independently of each other. Also, drug-drug interactions can occur if no single provider oversees the patient's complete medications list.
Among older adults, polypharmacy is an especially common problem: about 50 per cent of patients older than age 65 take five or more medications; 10 per cent of them take ten or more drugs. These agents include both prescription and over-the-counter preparations, such as supplements and herbal products.
An estimated 35 per cent of older adults experience an adverse drug reaction each year; one-third of these reactions require special care. What's more, some adverse reactions are identified incorrectly as health problems. For example, fatigue and confusion are common in the elderly and can result from a health problem or a medication effect. In a prescribing cascade, an adverse reaction to one drug goes misinterpreted, causing the provider to inappropriately prescribe a second drug to treat the new signs and symptoms. This can lead to a potentially worse situation and overprescribing.
How ageing affects the response to drugs
Older persons react differently to medications than younger people:
1. Although stomach and bowel absorption for most drugs does not change with age, ageing alters body fat and water composition: fat stores increase while total body water decreases. These changes can affect drug levels, causing greater concentrations of water-soluble medicines and longer lasting effect of fat-soluble ones.
2. Because the liver clears out many drugs, age-related liver changes, like reduced liver size and blood flow, could slow drug elimination.
3. Elimination through the kidneys could become affected by age-related decrease in kidney size and filtration rate.
4. Certain drugs are bound to blood proteins so that only the unbound portion of the drug is biologically active. Therefore, a decrease in the manufacturing of those proteins commonly seen with chronic illnesses, malnutrition, or physical debilitation, could lead to higher drug levels.
Supplements and herbal preparations:
Ginkgo biloba, St John's wort, echinacea, ginseng, etc are promoted for their purported use in preventing or treating various problems. A person may start taking these preparations and because they're available over-the-counter, he/she may not think about mentioning them to their providers. Yet these preparations can interact with prescribed medications and lead to serious adverse effects.
Poor adherence to the medication regimen:
It is seen hand-in-hand with polypharmacy and could well compound it. Unfortunately, it is an ongoing problem among older adults.
Although most patients are motivated to take their medications as prescribed, some may fail to comply due to lack of understanding or forgetfulness. In other cases, prescribers may advise a patient to cut tablets in half to lower the dosage, but this task may be difficult for elderly patients with decreased vision or poor manual dexterity. Also, some patients may attribute unpleasant symptoms to a medication and, without consulting the prescriber, decrease the dosage or even stop it. Patients with financial problems or who live on a fixed income may decide to take lower-than-prescribed dosages to extend their supply or may not fill a prescription at all.
How can polypharmacy be reduced?
• Information: Patients and providers should work together on generating an accurate list of all medications, including generic and brand names, with dosages and frequencies. Healthcare givers should provide, but patients should also actively seek, information about each drug, including its alternative names, appearance, purpose, potential side effects, and interactions with food or other pills.
• Organisation: Patients should avoid sharing medication; they ought to store them in a secure location or refrigerate them if necessary. Old/expired ones should be disposed of properly. If appropriate, providers could help patients establish memory aids, for instance, linking drug intake to daily routine, use of weekly pill distributors, or voice-activated smartphone messages.
Finally, three critical things to add:
1. Patient care should be directed by a limited number of healthcare providers.
2. All medications should be filled at one pharmacy.
3. Family should be involved in the medication reconciliation and administration process, especially with frail patients or complex dosing regimen.
• Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women's Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients' care recognition awards.
The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article.