PRACTICE RECOMMENDATIONS
• Consider the possibility that an adverse drug effect—rather than a new condition—is at play when a patient taking multiple medications develops a new symptom. C
• Use an online interaction checker, which can be accessed via a smart phone or tablet, to check for potential drug-drug interactions in patients on multiple medications. C
• Cross-check patients’ medications with a list of their medical problems, with the goal of discontinuing any drug that duplicates the action of another or is age-inappropriate, ineffective, or not indicated for the condition for which it was prescribed. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Older adults are taking more medications than ever before. Nearly 9 out of 10 US residents who are 60 years of age or older take at least one prescription drug, more than a third take 5 to 9 medications, and 12% take 10 or more.1
The increase is largely driven by newer medications to effectively treat a variety of medical conditions, and by practice guidelines that often recommend multidrug regimens.2
As a result, the term “polypharmacy,” which once referred to a specific number of medications, is now used more broadly to mean “a large number” of drugs.
From a safety standpoint, the number of medications a patient takes matters. The risk of adverse drug effects and dangerous drug-drug interactions increases significantly when an individual takes ≥5 medications.3
More than 4.5 million adverse drug effects occur each year in the United States, and nearly three quarters of them are initially evaluated in outpatient settings.4 Research suggests that about 80% of the time, these adverse effects are not recognized as such by the patient’s physician. So instead of discontinuing the offending medication, physicians treat the drug-related symptoms by adding yet another medication—a phenomenon known as “the prescribing cascade.”5
This review can help you safeguard older patients taking multiple medications by recognizing and responding to drug-related problems, identifying drugs that can be safely eliminated (or, in some cases, drugs that should be added), and checking regularly to ensure that the medication regimen is appropriate and up to date.
CASE Mrs. R, a 79-year-old woman who recently moved to town, is brought to your office by her daughter and son-in-law. The patient has a hard time reporting her medical history, but her daughter tells you her mother has chronic obstructive pulmonary disease (COPD), heart failure, type 2 diabetes, and mild urinary incontinence, and was recently diagnosed with early dementia.
Mrs. R’s daughter has brought in a bagful of medications, but she’s not sure which ones her mother takes regularly. The medications are an albuterol inhaler, alprazolam, digoxin, diphenhydramine, donepezil, furosemide, glargine insulin, guaifenesin, levothyroxine, metformin, extended-release metoprolol, naproxen, omeprazole, simvastatin, tolterodine, and zolpidem—a total of 16 different drugs.
If Mrs. R were your patient, how would you manage her multidrug regimen?
Start with a medication review
The first step in evaluating a patient’s medication regimen is to find out whether the drugs in the patient’s possession and/or in the medical record are the ones he or she is actually taking. Ask older patients who haven’t brought in their medications, or the caregiver of a confused patient, to bring them to the next visit.
The next step: Determine whether the medication regimen is right for the patient.
Polypharmacy may be indicated
Despite the risks associated with polypharmacy, do not assume that it is inappropriate. For some conditions, multiple medications are routinely recommended. Patients with heart failure, for example, have been shown to have better outcomes when they take 3 to 5 medications, including beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and diuretics.2
Some treatment guidelines also call for multiple medications. Achieving the more stringent blood pressure goals recommended in the Seventh Report of the Joint National Committee on Prevention, for instance, often requires 2 or more antihypertensive agents.6 In many cases, however, patients end up taking more drugs than necessary.
Is the patient taking the right drugs?
Medication reconciliation (determining whether the treatment regimen is appropriate for the patient’s diagnoses) is the way to find out.
The most widely recommended approach to medication reconciliation is to create a table and do a systematic review.7 List all the patient’s medical conditions in the first column and all current medications in the second column. Use the third column to note whether each medication is one the patient should be on, based not only on his or her medical conditions and other drugs being taken but also on current renal and hepatic function and body size, and contraindications.