To fully understand the topic of polypharmacy, we must first get clear on the definition of the term, which can vary dramatically. We’ve consulted several sources to provide the most comprehensive working definition available, but first, let’s look at the history and evolution of the term.
To break it down to its simplest use, the word “polypharmacy” refers to the use of multiple medications. It follows then that a “polypharmacy patient” is one who has been prescribed and is taking multiple medications for multiple conditions. Let’s review what literature reveals about the nuances of the definition.
A U.S. Pharmacist article illuminates the challenges with defining polypharmacy:
“Although no concrete definition of the term exists, polypharmacy has come to mean the use of several (usually five or more) medications on a daily basis, with the possibility that these may not all be clinically necessary.”
The authors of a BMC Geriatrics article led a systematic review of polypharmacy definitions. They determined that “the most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily.”
The World Health Organization (WHO) backs up this definition and furthers it with more detail. WHO has defined what qualifies as a "medication” in its definition, stating,
“Polypharmacy is often defined as the routine use of five or more medications. This includes over-the-counter, prescription and/or traditional and complementary medicines used by a patient.”
In addition to the term being most used to describe the number of prescriptions being taken, polypharmacy is sometimes used to indicate that a patient may be on too many or unnecessary medications. In fact, many physicians have begun adopting a philosophy of “deprescribing.” In these cases, step-down methods, tools, and new approaches are used with patients to remove or reduce doses of medicines that are inappropriate, duplicative, or unnecessary. Involving a clinical pharmacist in the conversation is often part of the process of deprescribing.
As with any medication regimen, there are both benefits and risks associated with polypharmacy. To be sure, when it’s medically necessary, patients taking multiple medications — even five or more daily — can benefit greatly from the proper mix. In fact, adhering to the best mix of medications can help manage chronic conditions, treat ailments, and improve a patient's quality of life. In other words, no small benefit.
However, there’s a big caveat. The key to achieving such benefits is through “intelligent polypharmacy,” which relies on access to accurate data about prescriptions. Alternative terms for intelligent polypharmacy also include “rational polypharmacy,” “targeted polypharmacy,” "evidence-based polypharmacy,” and “combination pharmacotherapy.”
While it may seem straightforward, there are many factors that can stand in the way of attaining the benefits associated with polypharmacy. Ideally, effective polypharmacy should boil down to the same guidelines that should exist for any medication regimen: patient- and condition-specific medication selection together with effective review of interaction risks and ongoing medication management, reconciliation, and deprescribing (where appropriate). All these steps help ensure optimization of the regimen.
Although the number of medications a patient is taking is an important consideration for effective medication management, it’s not the most important factor. To truly optimize the regimen, you’ll need an understanding of the value of each medication individually and the role it plays within the regimen in helping realize health and wellness goals. Sound prescribing decisions will make this consideration a higher priority.
There are several risks associated with polypharmacy. Here, we examine three of the main ones:
Now that you have an understanding of the definition of polypharmacy and what the research has said about guidelines for mitigating risks, let’s take a closer look at the recent trends and developments related to the topic.
When it comes to understanding the depth and breadth of polypharmacy’s impact on older adults, one needs to look no further than the statistics. The numbers we’ve cited from recent sources create a narrative that words alone don’t quite capture. Let’s examine a few:
67% of older people – A study published in JAMA Internal Medicine found that the number of older people taking five or more prescription drugs, over-the-counter medications, and supplements is about 67% — a figure that, like many alarming polypharmacy metrics, is on the rise.
150,000 premature American deaths and more than 4.6 million hospitalizations – The Lown Institute, in an April 2019 report, estimated that polypharmacy — which Lown essentially refers to as “medication overload” — would result in 150,000 premature American deaths and more than 4.6 million hospitalizations over the next decade. “[Medication overload] will reduce the quality of life for millions more. Strong, coordinated, and immediate action is needed to stem the tide of this epidemic, which harms people of all ages, but especially older generations.”
A 58% risk of ADEs – In a study, polypharmacy was shown to increase the risk of adverse drug events, or ADEs, from 13%, which is associated with taking two medications, to 58%, which is associated with five drugs. When patients are taking seven or more medications, the risk of ADEs surpasses 80%.In fact, The Lown Institute notes that the risk of an ADE increases by 7–10% with each medication.
In general, the discussion about polypharmacy revolves around “older adults,” defined as those at least 65 years of age. Let’s review some of the most commonly discussed challenges, including adverse effects, medication adherence issues, and — most recently — the impacts of the COVID-19 pandemic.
Because the aging process naturally makes one more vulnerable to adverse effects, any discussion of polypharmacy challenges inherently leads back to the elderly, even though people of any age can be polypharmacy patients. When kidney and liver function decline as a normal part of the aging process, it’s harder for the body to flush itself of medications and other toxins in the body as we get older. As a result, medications accumulate faster in the system of an older patient than they would in a healthy, younger person.
When this normal aspect of growing older is amplified with seven, nine, or more medications, this puts the patient at risk for negative outcomes, such as adverse events or side effects.
In addition, polypharmacy has been associated with non-adherence in older adults because, quite simply, it’s complicated for them to manage. This can inevitably lead to some dangerous outcomes: Patients are more likely to experience adverse drug events (e.g., drug reactions, allergic reactions, overdoses, and missed doses) when they struggle with medication management — especially when the number of medications increases.
Also, older patients are more likely to experience adverse drug events. It gets even more complicated when a medication regimen undergoes changes — this scenario puts patients in particular danger of experiencing adverse drug events. When a regimen becomes more complex with the introduction of additional and new medications, it becomes more difficult to develop and maintain a medication routine.
And changes to a regimen are not often well informed. Often patients receive prescriptions from multiple prescribers who do not have access to or effectively review a patient's medication regimen prior to making changes to it, and this raises the risk for some of the previously mentioned adverse drug events. Many times, prescribers and pharmacies don’t communicate about those patients they have in common. Even when the prescribers and pharmacists have the best intentions, they can be deterred by a lack of time, resources, and information to reliably piece together an accurate medication list for patients.
Another contributing factor that increases the risk of adverse effects is the failure to perform medication reconciliation post-discharge (MRP), which can result in medications remaining a part of a regimen for longer than necessary. Failure to adequately and consistently perform medication reconciliation is one of the quickest paths to patient and caregiver confusion about the proper medications a patient should take. Such confusion can lead to medication errors and harm. In contrast, proper medication reconciliation helps to decrease or eliminate medication discrepancies.
Lastly, with more patients using dietary supplements, the risks associated with them is generating increased attention — an article in the Evidence-Based Complementary and Alternative Medicine journal states, cases of excessive or inappropriate use of herbal dietary supplements have even led some to coin the term “polyherbacy,” a designation associated with some of the health problems associated with polypharmacy.
Along with adverse effects and their corresponding danger, polypharmacy also comes with the aforementioned medication adherence challenges. Let’s examine why that is in more detail.
Fortunately, the healthcare industry has made concerted efforts to develop tools that can help tackle the challenges inherent to polypharmacy. One important way they are tackling the challenges is through deprescribing, defined as using step-down methods and tools to remove or reduce doses of medicines that are inappropriate, duplicative, or unnecessary.
By using one or more of the following tools, your organization can help safely reduce polypharmacy, increase deprescribing, and help patients achieve substantial clinical and financial benefits.
“The MAI is designed to allow rating of 10 explicit criteria to determine whether a given medication is appropriate for an individual. The ten criteria of the MAI, worded as questions, pertain to the individual patient and drug in question.”
Each criterion is rated on a three-point Likert scale. When added up, the resulting score is intended to determine the level of inappropriateness, with a score of 0, meaning the drug is appropriate, and 18 representing maximal inappropriateness.
“… compendium of medications potentially to avoid or consider with caution because they often present an unfavorable balance of benefits and harms for older people.”
With the STOPP/START criteria, clinicians can potentially decrease polypharmacy by improving medication appropriateness.“Unlike the Beers Criteria, STOPP and START criteria provide guidance on inappropriate medications as well as medications that are underprescribed.”
Tools are not the only effective means of preventing or better managing polypharmacy — physicians themselves can adopt better practices as well. Let’s review some ways they play a role.
Even though medications are typically recommended by well-intentioned providers or clinicians, the sheer number of them increases the potential for drug-drug interactions, side effects, and other adverse events. It’s the volume and frequency that make it imperative for physicians to consider ways to prevent or at least improve the management of patient polypharmacy.
