Journal of Gerontological Nursing

Letters to the Editor Free

Addressing Polypharmacy

Aisha Willie, RN

Click here to read the article.

To the Editor:

In the article, “Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications,” which appeared in the January 2019 issue of the Journal of Gerontological Nursing, Chou, Tong, and Brandt (2019) addressed a common and well-known issue in the older adult population. Polypharmacy is not a truly therapeutic regime; I believe it is dehumanizing and violates the rights, safety, and security of older adults. As a nurse, I am witness to the pharmaceutical abuse directed toward older adults. Although they may have several comorbidities, the fact remains that the dignity and respect for older adults seems lost when prescribing numerous medications, which increases the risk for drug interactions and multiple side effects. Chou et al. (2019) propose that a plan to deprescribe medications is an attempt to lessen polypharmacy risk.

During my nursing experience with the geriatric population, individuals who have expressed their dislike for taking so many medications account for the “92% of older adults…willing to stop one or more of their medications if their physician told them it was possible” (Chou et al., 2019, p. 10; Reeve et al., 2018). However, some drugs are beneficial to older adults. If diuretics, beta blockers, or ACE inhibitors are deprescribed, patients should be monitored closely for instances of disease rebound. Chou et al. (2019) encourage providers to look for inappropriate drugs to deprescribe first. A compassionate provider will facilitate regimens that are feasible and help older adults regain self-control of their pharmaceutical needs.

There is a higher risk for falls with polypharmacy. A nursing protocol within a nursing home setting is for caseworkers, nurses, and physicians, along with family members and clients, to review medication regimens and discuss whether some medications can be deprescribed, decreased in their dosage, or omitted from the medication list. “Patient education and team collaboration are also vital in preventing polypharmacy in older adults” (Wright, 2018, p. 10). As a nurse, I can provide bedside education to older adults and communicate with the pharmacy daily.

Reviewing medications and providing choices and the ability to make decisions enhances patients' safety and quality of care.

Aisha Willie, RN
Medgar Evers College/CUNY
Department of Nursing
Buena Vida Rehabilitation
Brooklyn, New York

References

  • Chou, J., Tong, M. & Brandt, N.J. (2019). Combating polypharmacy through deprescribing potentially inappropriate medications. Journal of Gerontological Nursing, 45(1), 9–15. doi:10.3928/00989134-20190102-01 [CrossRef]
  • Reeve, E., Wolff, J.L., Shekan, M., Bayliss, E.A., Hilmer, S.N. & Boyd, C.M. (2018). Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States. JAMA Internal Medicine, 178, 1673–1680. doi:10.1001/jamainternmed.2018.4720 [CrossRef]
  • Wright, W. (2018). Medication and fall prevention. American Journal of Nursing, 118(12), 10. doi:10.1097/01.NAJ.0000549671.51451.4c [CrossRef]

Reply:

Thank you for your insightful letter in response to our article “Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications” (Chou, Tong, & Brandt, 2019). We appreciate your support and perspective on polypharmacy as a nurse. As an interdisciplinary team, it is important that we engage our patients and their caregivers in identifying goals of care and reevaluating the medication regimen and overall plan of care.

There are an increasing number of health care systems incorporating patient-centered care through age-friendly initiatives using the framework of the 4Ms (Pelton, Fulmer, Hendrich, & Mate, 2017). The 4Ms are What Matters, Mobility, Medications, and the Mentation of older adults, serving as a driving factor for interventions (Pelton et al., 2017). The goal of age-friendly health systems is to improve the care and transition of older adults while preserving dignity and encouraging independence with the involvement of family caregivers (Pelton et al., 2017).

Polypharmacy can increase the risk of harm to older adults; thus, it necessitates careful review of a patient's medication regimen to gauge the appropriateness of medications. However, you provided a poignant point in your letter that there are still some medications that are beneficial to older adults. As such, there is a fine balance between polypharmacy and appropriate polypharmacy. For example, polypharmacy may be appropriate in instances where the medication regimen provides a preventive and protective effect, such as starting a laxative to prevent opioid-induced constipation (O'Mahony et al., 2015). In this scenario, appropriate polypharmacy may help improve a patient's quality of life and help him/her age successfully in place. We can move toward appropriate polypharmacy by tailoring a medication regimen to the patient's goals, weighing the risks and benefits of each medication, empowering the patient/caregiver through education, and constantly re-evaluating the appropriateness of each medication. However, as demonstrated by a recent article that reviewed appropriate and inappropriate polypharmacy, there is still no consensus on defining criteria for appropriate polypharmacy (Fried & Mecca, 2019).

A recent report noted the concept of medication overload in older adults, which is defined as:

the use of multiple medications for which the harm to the patient outweighs the benefit. There is no strict cutoff for when the number of medications becomes harmful, but the greater number of medications a person is taking, the greater their likelihood of experiencing harm, including serious adverse drug events.

The increasing need to improve medication use in older adults is paramount and we are hopeful that these emerging trends and increased efforts in the U.S. health care system will align and improve the delivery of care to improve medication safety in older adults.

Joshua Chou, PharmD
Monica Tong, PharmD
Nicole J. Brandt, PharmD, MBA,
BCGP, BCPP, FASCP
University of Maryland School of Pharmacy
Baltimore, Maryland

References

  • Chou, J., Tong, M. & Brandt, N.J. (2019). Combating polypharmacy through deprescribing potentially inappropriate medications. Journal of Gerontological Nursing, 45(1), 9–15. doi:10.3928/00989134-20190102-01 [CrossRef]
  • Fried, T.R. & Mecca, M.C. (2019). Medication appropriateness in vulnerable older adults: Healthy skepticism of appropriate polypharmacy. Journal of the American Geriatrics Society. Advance online publication. doi:10.1111/jgs.15798 [CrossRef]
  • Lown Institute. (2019). Medication overload: How the drive to prescribe is harming older Americans. Retrieved from https://lowninstitute.org/medication-overload-how-the-drive-to-prescribe-is-harming-older-americans
  • O'Mahony, D., O'Sullivan, D., Byrne, S., O'Connor, M.N., Ryan, C. & Gallagher, P. (2015). STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age and Ageing, 44, 213–218. doi:10.1093/ageing/afu145 [CrossRef]
  • Pelton, L.J., Fulmer, T., Hendrich, A. & Mate, K. (2017). Creating age-friendly health systems. Healthcare Executive, 32(6), 62–63.
Authors

The author has disclosed no potential conflicts of interest, financial or otherwise.

10.3928/00989134-20190509-02

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