The Prescription Dilemma – Navigating Polypharmacy in the Elderly

‘Medications? I have a lot, doctor.’

Puan Siti brings out a large transparent plastic bag, bigger than my face.

It is filled with different packets of medications. White pills, yellow pills, blue pills- of all different shapes and sizes.

One would think she was selling candy.

She points to me ‘This big yellow pill – I take in the morning. Then this white tablet, I take in the morning and at night.’ ‘I think this is for gout, and this is for my blood pressure.’

There are easily 7-8 tablets that she takes in a day at different timing.

These tablets do not count supplements and vitamins.

Does this sound familiar?

This is a regular sight for healthcare practitioners to see, not just in Malaysia but globally.

What is Polypharmacy?

We hear this word thrown around quite commonly, especially in the community of those who care for the elderly. It is defined as the usage of 5 or more medications concurrently.

As we age, the number of comorbidities tends to increase, including conditions like high blood pressure, type 2 diabetes mellitus (T2DM), and high cholesterol, among others. Additionally, dementia and Alzheimer’s Disease are prevalent among the elderly, often remaining undiagnosed until the later stages.

A study done in 2018 found that nearly half (40.6%) of Malaysians above 60 years old had multiple comorbidities. Among the 3966 Malaysian adults they interviewed, they found that 27.7% had T2DM, 50.1% were diagnosed with hypertension, and 41.8% had high cholesterol.

It is expected to rise as the years go by.

Multiple factors come into play, including lifestyle, diet, exercise, stress, smoking and alcohol.

Another study found that people who consume 28% or more of their calories from ultra-processed foods face a heightened risk of developing dementia.

Why is this a concern?

The presence of multiple underlying diseases can significantly affect an individual’s functioning, independence, overall quality of life, and life expectancy.

It is every elderly person’s desire to achieve the highest possible quality of life as they age.

More medication is good…. No?

Medications are prescribed with the sole purpose of treating medical illnesses.

Antihypertensives treat hypertension.

Insulin-lowering medications treat diabetes mellitus.

We take our medication to prevent our disease from progressing and reduce the risk of complications from the illness.

However, too many medications may paradoxically have a negative impact on one’s health.

Problematic polypharmacy is defined as the usage of multiple medications in a way that causes more harm than good to the patient.

Problematic Polypharmacy

What does problematic pharmacy entail?

Renal impairment, reduced renal function

As we age, medications take a longer time to be broken down in our liver. Some might not even be fully broken down.

Our kidneys cannot filter out toxins and drugs as effectively as before. Hence, this may cause the elderly to be more prone to side effects.

Increased Hospitalisations

3-10% of hospitalisations are related to adverse effects of medications.

The higher the amount of medications one takes, the higher the risk of an adverse drug event (ADE).

Thus, there is an increased risk of hospitalisations. Most of which is due to an unintentional drug overdose.

Drug-drug interactions

Some medications have a stronger effect (synergistic effect) when combined together, which may cause significant side effects.

For example, consuming NSAIDS (ibuprofen, mefenamic acid) and warfarin (an anti-clotting medication) together can increase the risk of bleeding.

Prescribing cascade

This is an important factor to take note of.

Side effects from medications may be interpreted as a new medical condition, which would then cause a new medication to be added to the regime.

This is a classical example, Mr. Abu comes to the clinic complaining of gout symptoms. The natural thing to do would be to prescribe medication to treat it.

‘It would make sense for him to develop gout at this age.’

However, further history would reveal that he was recently diagnosed with heart failure and was

prescribed a thiazide diuretic.

A side effect of thiazide is gout.

It turns out, his toe pain started shortly after taking thiazide.

Hence, it is essential to bring along a list of all medications to doctor visits – review medications and potential side effects.

The Delicate Balance

‘Should I just stop taking medications then? What is the point?’

Before we jump the gun and use this as an excuse to miss our doctor’s appointments and miss our medications, it is important to understand that medications are not the culprit.

We walk a tightrope between over-prescribing and under-prescribing (giving too many medications versus giving too little).

For example, a 75-year-old male with underlying osteoarthritis, type 2 diabetes mellitus, hypertension, high cholesterol and dementia would require at least 10 medications in total.

Every individual requires an individualised regimen, tailored specifically to them. Their age, comorbidities, level of cognitive function, level of independence, patient education and support (financially and physically) need to be taken into account.

This requires follow-ups and conversations with his/her doctor and their carer.

During a follow-up

Medication list
Patient education
Response to medication
Potential side effects

Are assessed and tweaked accordingly.

Careful consideration in substituting or discontinuing medications can be done.

The Deprescribing Debate

The rule of thumb is simple: discontinue medications that cause more harm than benefit.

How?

It is easier said than done. However, it is possible and attainable.

Work together with your doctor to identify and stop medications that will, as a whole, be able to bring you one step closer to your goals.

Comorbidities, level of cognitive function, degree of independence (ADL), life expectancy and views on medications are all taken into account.

The majority of medications can cause neuropsychiatric effects like altered consciousness or mood changes.

This is particularly important in elderly persons with dementia or Alzheimer’s disease.

Deprescribing and optimising medications can significantly diminish adverse drug effects and enhance outcomes for all patients, especially those with cognitive impairment and deficits.

By carefully reviewing and adjusting medication regimens, healthcare providers can improve overall patient well-being and ensure safer and more effective treatment approaches.

Why is Deprescribing So Hard?

Reluctance from the Elderly Person

There is a fear of going against the ‘original’ plan, despite being taught about side effects and further harm upon continuing medication

Time

Time is precious. Most (if not all) doctors would love to sit down and explore their patients’ history, counsel them and work together with them and their carers to formulate goals and plans. Unfortunately, most doctors may not have enough time to educate patients. They have to see many patients in a day and may subconsciously want to ‘clear’ as many patients as possible.

Multiple prescribers

Most patients go to see multiple doctors. Hence, most patients with multiple prescribers may be reluctant for one doctor to stop medications prescribed by another.

Pill Organisers – Dependable or Dangerous?

Like Puan Siti, an average elderly takes at least 6 medications daily. With multiple medications to take at different timings, it can be easy to forget to take them consistently.

Pill organisers were designed to fill in the gap.

However, research actually shows that they may do more harm than good.

The Paradox

Pill organisers help us remember to take our medication.

A study done at the University of East Anglia found that elderly citizens who transitioned from taking medication directly to using pill organisers experienced more adverse effects, like hypoglycemia (low blood sugar), falls and increased hospitalisations.

Doesn’t the outcome seem contradictory to its purpose? Why do the elderly, who now take their medications on time and regularly, experience these medical issues?

It is because patients who switch to pill organisers now start to take the proper and full dose of their medications.

Prior to that, they were unintentionally not taking medications as they should.

These happen during the transitioning stage.

Transitioning to using pill organisers ought to be carefully discussed with our doctor.

Improper packaging

Moreover, some pills and medications tend to be affected by environmental factors like heat, light and humidity. Some medications need to be stored with silica gel packets to remove humidity, in air-tight packaging, or in special forms containers that prevent the passage of light.

Pill organisers may not be suitable for storing such medications.

Preventing Complications from Pill Organisers

Although pill organisers are effective in ensuring adherence and compliance, there are pitfalls that could potentially worsen an older person’s health and well-being.

The elderly need to be monitored for adverse effects from medications and have their medications adjusted accordingly.

This is to prevent complications like hospitalisations.

The Ultimate Goal

Maintaining independence is a universal desire among the elderly.

This is the end goal for every elderly person. To live life as pain-free and illness-free as possible. To hold our grandchildren and grow old with our spouse.

To be able to look back on our life and proudly say ‘I have lived a fulfilled life. I have done it!’

‘Matters Most’ represents the pivotal and most significant ‘M’ in the 5Ms of geriatric care- emphasises preserving independence in life.

It takes into account one’s own health outcome goals and personal preferences.

There is no ‘one-size-fits-all’.

Let us not deny our elderly that goal and desire.

References

https://www.scielo.br/j/rsp/a/wWq6LsHNFnRSD4Snj6WgqSC/?lang=en&format=pdf