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Practice Management

Doctors and other health care professionals need to address a growing problem with inappropriate polypharmacy BY JOHN SCHIESZER

It may be time for physicians to conduct yearly medication reviews with their patients aged 65 years or older to collaboratively assess whether the benefits of each of their medications outweighs the harms, according to Michelle S. Keller, PhD, MPH, assistant professor of medicine at Cedars-Sinai Medical Center in Los Angeles, California.

Research shows that the prevalence of inappropriate polypharmacy is increasing, with the pandemic possibly adding to the problem. Inappropriate polypharmacy is at the root of a high percentage of emergency room visits by older adults due to adverse drug events.

Inappropriate polypharmacy is the use of more medications than medically necessary or the use of multiple drugs that can cause harmful interactions. Patients aged 65 years or older commonly have multiple comorbidities and are under the care of a variety of clinicians. A clinician may prescribe a new drug without being aware of other drugs a patient is taking. Older adults can be especially prone to harm from inappropriate polypharmacy because of changes in how they metabolize and excrete drugs. Physicians need to engage patients in thorough discussions about the prescription medications

and over-the-counter (OTC) products, including dietary supplements and minerals, they are taking.

Psychotropic drugs Various factors are contributing to a rising incidence of inappropriate polypharmacy. “It is due to increased use of psychotropic medications such as benzodiazepines, antidepressants, and opioids, and the increased use of preventive medications such as statins,” Dr Keller said. “While all of these medications can have important clinical benefit, it is really critical that physicians assess regularly which medications are still helpful depending on an individual’s life expectancy, comorbid conditions, and overall medication regimen.”

Geriatrician John Morley, MD, of Saint Louis University in Missouri, said it appears the pandemic has only added to the problem. “The reality is that people with COVID pain have a whole series of side effects. They are given drugs and doctors forget to stop the drugs,” Dr Morley said.

Currently, the biggest concern is with anticholinergic drugs. Anticholinergics, which have been linked to dementia, are prescribed for many conditions common in older adults, such as depression, urinary incontinence, irritable bowel syndrome, and Parkinson’s disease. Further, many OTC sleep aids and allergy medicines contain anticholinergic agents.

Belinda Vicioso, MD, a professor of geriatric medicine at UT Southwestern Medical Center in Dallas, Texas, said inappropriate polypharmacy continues to increase unabated for several reasons. “With the advent of direct-to-consumer advertising, shortened face-toface visits, and disjointed subspecialty care that is often not patient centered,

polypharmacy is more common than ever,” Dr Vicioso said.

Caroline Harada, MD, an associate professor in the Division of Gerontology, Geriatrics, and Palliative Care in the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, said it is crucial to involve the patient in all conversations about polypharmacy, something that has traditionally not been done. “As a geriatrician, by far the most helpful thing I do for patients is review their medication lists and start a conversation with my patient about which medications may be doing more harm than good,” Dr Harada said. “There are times when we have ‘cured’ a patient’s cognitive impairment or tendency to fall simply by stopping harmful medications such as benzodiazepines, anticholinergics, and opioids.”

Movement toward deprescribing There is a growing movement toward deprescribing to combat inappropriate polypharmacy. Deprescribing is a thoughtful and collaborative process of stopping or reducing the dose of a medication, Dr Keller said. The goal is to make sure that all of a patient’s drugs are medically appropriate and the patient is not taking one medication to combat the effects of another.

“We use this term intentionally because in recent years we’ve seen physicians abruptly stop medications such as opioids, which has led to severe withdrawal effects and adverse outcomes such as increased suicides,” Dr Keller said. “Deprescribing should always include a conversation between the patient and the clinician to discuss the reasons for deprescribing and the process of slowly stopping or reducing the medication.”

Deprescribing takes work, thought, and collaboration with patients and families, but it is a worthwhile undertaking, Dr Vicioso said. Dementia symptoms often improve and patients become more mobile, he added.

At Dr Keller’s institution, staff are working on various research projects in the inpatient and outpatient settings to help clinicians identify patients at highest risk for polypharmacy-related events to implement new deprescribing programs. One project involves sending educational materials about benzodiazepines to patients at elevated risk of benzodiazepine-related adverse events and letters from patients’ primary care provider urging patients to make an appointment to discuss these medications.

“Through this simple intervention, we found that 35% of patients were eventually able to stop taking their benzodiazepines completely,” Dr Keller said. “We’re working on publishing these results and are also expanding the project. We recently mailed these education pamphlets and letters to more than 300 patients.” ■

Older adults are particularly vulnerable because they often have multiple medical problems and see a variety of specialists.

Clinicians might prescribe a new drug without knowing about other drugs a patient is taking.