Our eagerness to provide relief with a pill to swallow and a glass of water to wash it down has led to an epidemic of polypharmacy—the use of multiple drugs, including supplements to manage health conditions (some of which are drug-induced). Some attribute the emergence of polypharmacy to a broken healthcare system of rushed doctor visits and direct drug promotion to patients, "ill-equipped to make rational decisions about what to take, what not to take, and when." The elderly are most at risk of suffering from polypharmacy due to declining health. Even for patients without cognitive decline, managing multiple medications increases the likelihood of non-compliance and improper use.
New research from the University of Pittsburgh School of Medicine suggests that advanced illness is a strong predictor of polypharmacy, which means that hospice patients are a vulnerable population. Yael Schenker, M.D, M.A.S., and chief investigator explained that patients with an advanced illness often, “...experience what is called a ‘prescribing cascade’ when the side effects of drugs result in more prescriptions.” The solution becomes part of the problem as patients confront “symptom burden,” in the form of depression, nausea, fatigue, and a host of other undesirable side effects. Upon admission into hospice, the average patient may take as many as 20 medications daily. Near the end of life, symptom relief takes precedence as care goals shift from curing to maximizing comfort. In Schenker’s study measuring quality of life, the consensus was clear: Patients taking more daily medications reported lower quality of life and greater symptom burden than those taking fewer medications.
Polypharmacy costs patients more than personal comfort. Studies repeatedly demonstrate a positive relationship between polypharmacy and adverse drug events (ADEs) or injuries resulting from pharmaceutical intervention, including adverse drug reactions (ADRs). Injurious falls are one common ADE associated with polypharmacy. A 2019 study found that risk increased by “2% for each additional drug, in a remarkably linear fashion.” 1 in every 30 urgent hospital admissions of patients aged 65 and older is related to an ADR. At one point the financial burden of ADRs was estimated to be as high as 30.1 billion dollars annually. Natural pharmacokinetic and pharmacodynamic changes affect how medications are metabolized in the aging body. Current clinical guidelines for medications are often based on evidence derived from younger and healthier populations using a single disease model that does not put into consideration the co-morbidities of older adults.
If the problem stems from overprescribing than the answer is to deprescribe. Major health organizations are taking note—including the Center for Medicare and Medicaid Services (CMS). In their 2017 Long-Term Care Conditions of Participation, CMS advised that patients discontinue “all unnecessary medications.” Tools such as STOPP/START and PresQuipp help clinicians deprescribe. The Good Palliative Geriatric Practice Algorithm discontinues all non-life saving medications where there is an absence of evidence justifying use in the elderly. Patients reported an 88% improvement in their quality of life when medications were systematically discontinued using such tools. When in doubt, talk with the patient. Consider their unique circumstances and discuss care preferences before automatically reaching for the prescription pad.
Medications are powerful tools that must be used appropriately in vulnerable patient populations to reap maximum benefit and avoid exacerbating existing health problems or causing new ones. In hospice, fewer drugs mean more—more comfort, more compliance, more safety. Stop being prescription happy and focus on making patients happy instead.
Barclay, Kelsey, et al. “Polypharmacy in the Elderly: How to Reduce Adverse Drug Events.” Clinician Reviews, 4 Feb. 2019, pp.38-44., https://www.mdedge.com/clinicianreviews/article/157265/geriatrics/polypharmacy-elderly-how-reduce-adverse-drug-events.
Brody, Jane E. “The Hidden Drug Epidemic Among Older People.” The New York Times, The New York Times, 16 Dec. 2019, www.nytimes.com/2019/12/16/well/live/the-hidden-drug-epidemic-among-older-people.html.
“Hospice Facts & Figures.” NHPCO, July 3, 2019, https://www.nhpco.org/research
Mangin, Dee, et al. “International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action.” Drugs & Aging, Springer International Publishing, July 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6061397/.
Morin, Lucas, et al. “Polypharmacy and Injurious Falls in Older Adults: a Nationwide Nested Case-Control Study.” Clinical Epidemiology, Dove, 24 June 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598933/.
Schenker, Yael, et al. “Associations Between Polypharmacy, Symptom Burden, and Quality of Life in Patients with Advanced, Life-Limiting Illness.” Journal of General Internal Medicine, vol. 34, no. 4, Apr. 2019, pp. 559–566., doi:10.1007/s11606-019-04837-7.
Sultana, Janet, et al. “Clinical and Economic Burden of Adverse Drug Reactions.” Journal of Pharmacology & Pharmacotherapeutics, Medknow Publications & Media Pvt Ltd, Dec. 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853675/