Firstly, do no harm!
Doctors must use the medicines correctly for co-existing diseases and avoid risks often associated with multiple medicine usages such as side effects, drug/ drug interactions, drug/ disease interactions, and inappropriate dosing.
Using inappropriate medicine, and polypharmacy are extremely common among the elderly.
What is polypharmacy? Is it necessary?
Polypharmacy occurs when a person is taking many different medicines at the same time. Usually, taking more than five drugs is called polypharmacy, while high-risk polypharmacy is taking over ten medicines.
It often happens when a person has many chronic diseases, such as diabetes, high blood pressure, high cholesterol, heart failure, osteoporosis, and may or may not have symptoms such as pain or sleeplessness, requiring long-term treatment. Chronic diseases and symptoms accumulate with age; for this reason, almost 40% of the elderly take polypharmacy.
Polypharmacy is often necessary but can be more harmful than helpful to the patient. Therefore, the doctors regularly monitor the patient’s treatment.
What harm can polypharmacy do to elderly patients?
Polypharmacy can cause increased 0drug side-effects, drug interactions, prescribing cascade, and higher costs. Polypharmacy can cause poor quality of life, including weakness, decreased mobility, confusion, and loss of memory.
What questions does a doctor ask himself when treating the old?
“Is my patient taking too many medicines?” Increasing age needs more symptomatic relief and prevention of disease-related complications. Therefore, more drugs are prescribed.
“Is the cognitive function of the patient normal, or will he need a supervised treatment?”
Which are the inappropriate medicines?
In polypharmacy, a patient may use some potentially inappropriate medicines. Specific medicines which on taking outweigh the benefits are considered as inappropriate, especially when the safer alternatives are present. Additionally, the appropriateness of drug therapy is dependent on treatment goals. For instance, giving painkillers directly through the mouth to a patient of acidity is inappropriate.
What is a prescribing cascade?
Prescribing cascade is defined as using medicines to treat the side effects of other medicines. Side effects of drugs are frequently misinterpreted as a new problem, triggering more prescriptions, a process is known as a prescribing cascade or multi-step waterfall.
For instance, a patient taking the drug to lower blood pressure develops swollen ankles, so the doctor prescribes a diuretic. The diuretic causes potassium deficiency, resulting in medicine to treat low potassium. However, it can trigger nausea which is treated with an anti-vomiting drug, which can cause confusion, which, in turn, is treated with more medicines.
What are the fixed drug combinations?
These are medicines with two or more drugs given in one capsule to ensure patient compliance. However, doctors are not happy with these combinations, as all patients get the same dosage, and this can cause problems in very sick or very emaciated patients.
What are the risks of polypharmacy?
The use of many different medicines, at the same time, can lead to mistakes in taking them correctly.
Doctors may not know what other medicines their patients are taking, leading to prescribing errors. For example, a similar type of medicine, by a different company, may be prescribed by another doctor.
Medicine may not work well when used with other medicines that hamper its effectiveness. It is known as a drug-drug interaction. Like taking calcium tablets with iron capsules.
A medication used to treat one disease may have an opposite result on the another. For instance, painkillers may increase blood pressure and worsen kidney function, and therefore, should not be used by patient with high blood pressure or kidney problems.
How are medicines stopped in an elderly patient?
Withdrawing medicines is a process carried out by a doctor after consideration of treatment goals, benefits and risks, and medical ethics. For example, blood-thinning medicines, given to an elderly patient with cardiac bypass, have to be stopped before any other major surgery.
Optimising medicines: Where to start?
The doctor and patient have to agree on a course of treatment. Does the patient have any problems or concerns about taking medicines? How does he take the medicines, by himself, or a caregiver, family member help him? Does the patient buy and stock his medicines? In a prescription, does the doctor write the most important medicine first, and so on? How often does his doctor review the medicines: quarterly or half-yearly? Can the elderly patient afford to buy all the medicines prescribed to him? Does he strictly follow all instructions? Does the chemist substitute the medicines leading to confusion? Is the patient buying generic drugs as currently advised?
Increased healthcare costs
Polypharmacy contributes to health care costs to both the patient, and the public healthcare system, in which the elderly are treated free. The question every doctor needs to ask is: are these drugs necessary for their elderly patient? Is it possible to reduce the number of prescribed drugs? Does polypharmacy affect the elderly patient’s appetite and nutritional status, enough to be given expensive diet supplements?
End of life issues
Healthcare providers must consider the need of reducing medications in frail older adults or patients approaching the end of life. Lastly, the human right of the elderly to refuse treatment must be given due credence.