2.4 POLYPHARMACY IN THE ELDERLY
2.4.2 Dangers of Polypharmacy
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The trend of multiple drugs usage will likely increase in the future as a result of an increasing burden of chronic disease and success of researchers who develop new drugs. Increased educational efforts concerning the hazards of multiple drug therapy should be directed to physicians who prescribe drugs for the elderly and to consumers who use drugs. A high priority should be placed on the development of computer systems to aid physicians in prescribing more appropriately for older people and to aid pharmacists who monitor drug therapy of their patients (Stewart, 1990).
Often, the result is that similar compounds are used simultaneously, for example two or more benzodiazepines or antipsychotics: or drugs with similar properties are used concurrently, for example a number of drugs with anti-cholinergic properties.
Polypharmacy increases the risk of prescribing errors and needs to be addressed (Burgess, 1997). Studies have shown that on average elderly people took three to four different medications (both prescribed and aT C) (FIP Lisbon Congress, 1994).
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Use of contraindicated drugs i.e. prescribing of medications that are inappropriate for a particular condition (e.g. use of a beta-blocker such as propranolol for patients with heart failure, which can worsen the condition; use of anticoagulants in patients with active peptic ulcer disease).
Use of inappropriate dosages (e.g., excessive doses of the more potent diuretics, which can produce postural hypotension and precipitate falls in the elderly).
Use of drugs to treat adverse drug reactions, thus exacerbating the polypharmacy spiral (e.g., use of levodopa to treat Parkinson's-like side effects produced by major tranquilizers) (Lipton and Lee, 1988).
Multiple drug use in the elderly results in iatrogenic illness, drug-drug interactions, and decreased medication compliance. Although warnings concerning the use of multiple medications in the elderly are sounded frequently, pressures to prescribe even more drugs will continue in the future. This is expected because research will enhance the physician's ability to identify diseases in the elderly and expand the physician's armamentarium of therapeutic modalities. A constant concerted effort by physicians and other health care professionals caring for the elderly will be essential to restrict the number of medications prescribed. It will be necessary to develop medications with more precise mechanisms of action, consider whether a drug is necessary and employ more careful assessment of benefit-to-risk ratios when prescribing drugs in order to partly offset the increased use of medication in the elderly.
Four of every five elderly people have at least one chronic illness (Stewart, 1990). In the future new advances in diagnostic techniques will enhance our abilities to identify disease in the elderly. Disease that would have gone unrecognized several years ago could now be detected through innovative diagnostic techniques such as magnetic resonance imaging, position emission tomography, radioimmunoassay, and monoclonal antibody labeling. In the future, the percentage of elderly people with diagnosed illness will increase and physicians will feel impelled to treat many of those chronic conditions with medication.
In 1965, clinicians treating patients with hypertension had only a limited supply of
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drugs, such as reserpine, hydralazine, and guanethidine at their disposal to treat this condition. Today there is an impressive array of agents available to control hypertension such as diuretics, beta-blockers, calcium-channel blockers, adrenergic blockers, and angiotensin-converting enzyme inhibitors (SAMF, 1997). In addition, there are many other drugs awaiting approval by the Food and Drug Administration, of the USA. Twenty-five years ago there was no effective treatment for Parkinson's disease; today we have levodopa, amantadine and bromocriptine, which are useful for controlling this condition. Many similar examples could be cited (Stewart, 1990).
Thus the number of drugs used would be likely to increase because of an increase in the number of diseases, better diagnostic skills, improved health screening and better drug development. On the other hand, drug use would decrease because of the introduction of "better" drugs, more preventative therapy, better computing technology to prevent duplication of medication, along with education and monitoring by pharmacists. Health professionals need to appreciate that "life is a terminal condition" and those in our care, need to accept the inevitabilities of advancing years with wisdom and compassion, rather than with inappropriate medications and technologies (Mallet, 1996).
Pharmacists take a drug history related to the diagnosis and are cautious if a patient indicated that all drugs they had tried had failed. Non-drug alternatives should be considered and drugs to treat ADRs should be avoided. Using a drug that could treat more than one disease and avoiding multiple ingredient preparations should be considered. Use of single daily dosage regimens and limiting the use of "as required"
medications could also be advised (FIP Lisbon Congress, 1994).
A focused systematic intervention by the primary care physician can often remedy the problem of polypharmacy in older patients. Such an approach includes medication disclosure, drug identification, side effect recognition, treatment review, and a thoughtful, well-monitored reduction in the numbers and doses of medicines. By developing skillful prescribing habits, the physician can resolve drug side effects, prevent future adverse reactions, reduce pharmacy expenditures, and improve medication compliance. The poly-pharmacy situation in the management of elderly patients is gloomy, but it can be vastly improved through prudent prescribing.
Drug reloted problems among geriatric ouJ-patients at a public sector hospital: An intervention study
Guidelines to simplify a drug regImen appears in the 'Prescribing guidelines for geriatrics' (Appendix 4).
Multiple disease states frequently require additional medication. This can generally be monitored by the prescriber and the pharmacist, but the situation is complicated when the patient buys or is given non-prescription medication for minor ailments, or when the patient attends hospital out-patient clinics as well as seeing his or her doctor.
One solution to the problem is to educate the patient or a caregiver about the importance of maintaining a medication record card, which the patient should show to the health care worker at every visit (Osman, 1996).
Drug relllled problems among geriatric out-patients at a public sector hospital: An intervention study