ASNA Self-Directed Learning

Alabama Nurse, Mar-May 2006 by Varner, Joyce

Polypharmacy and Elders: A Deadly Combination

Authored by: Joyce Varner, MSN, RN, GNP-BC, GCNS, Clinical Assistant Professor, Gerontological Nurse Practitioner Track, University of South Alabama, jvarner@ usouthal.edu.

Objectives: At the conclusion of this activity the learner should be able to:

1. Define the term polypharmacy.

2. Discuss factors that predispose elders to polypharmacy

3. Discuss 2 outcomes associated with polypharmacy

4. Name 4 over the counter drugs that are dangerous for use in elders

5. Discuss 3 ways primary care providers and nurses can help elders avoid the consequences of polypharmacy

Directions: Read the article carefully. Return the evaluation form and answer sheet printed at the end of the article and complete all sections. Mail to the address provided with appropriate fee. A Continuing Education Certificate of Completion will be sent to you upon successful completion of both the post-test and completion of the evaluation form. You must score at least 80% to pass. Should you fail the test you will be notified and offered an opportunity to retake the test. All retakes will require an additional $5.00 fee.

Contact hours and Accreditation: This 1.5 contact hour activity is provided by the Alabama State Nurses Association which is accredited as a provider of continuing education in nursing by the American Nurses Commission on Accreditation (ANCC) and the Alabama Board of Nursing. (The Alabama Board of Nursing does not classify this activity as an Independent Study.) Approval of this program expires 14 February 2008.

Definition of Polypharmacy

Polypharmacy is defined as 1.) taking more medications than are clinically necessary, 2.) concurrent use of more than five medications at the same time, 3.) and/or concurrent use of multiple prescription and over the counter medications.

Polypharmacy may be necessary for multiple chronic health problems. It may occur accidentally if an existing drug regimen is not regularly and thoroughly reviewed prior to adding a new medication. In addition it may occur if there is a lack of patient or family education regarding unsafe drug use. The two major concerns with polypharmacy are the risk of adverse drug reactions and the increased risk for drug interactions, either of which could prove fatal in this population.

Factors that predispose elders to polypharmacy

* The use of medications that have no apparent indication but being taken because the neighbor or friend recommended it.

* The use of duplicate medications such as more than one diuretic because the primary care provider overlooked the fact that the elder was on Lasix and then prescribed Bumex or the neighbor or friend said that if one works then two should really work well.

* Concurrent use of interaction medications such as taking Bumex and then adding Advil every 4 hours.

* The use of contraindicated medications such as the use of some herbal supplements when taking cardiac drugs.

* Inappropriate dosages for this population such as beginning thyroid replacement hormone at the adult rate of 0.5mg daily instead of the recommended starting dose of 0.025mg per day.

* The use of drug therapy to treat the adverse effects of other drugs such as the use of steroids to treat the adverse drug reaction to an antibiotic.

* Inappropriate and false request by the elder for a drug that they intend to use for their spouse or a family member because that person may not be able to afford their own drugs.

* Insufficient monitoring of drug response when elders see one primary care provider and multiple specialists.

* Failure to discontinue ineffective or unnecessary drugs when providers are limited in the monitoring of necessary lab work by insurance company regulations.

* The use of multiple pharmacies due to elders on fixed incomes being forced to shop around for the best price for medications.

* Lack of adequate diagnosis by provider or failure to discontinue medications when on longer necessary.

* Inadequate patient education regarding disease process and therapy due to limited time and staff for education.

* The presence of multiple chronic diseases such as coronary artery disease, hypertension, diabetes, and rheumatoid arthritis.

* Hospitalization or nursing home placement may add new medications to an already overextended drug regimen.

* Advanced age or severe illness predisposing the elder to dementia or inability to manage his or her own medications.

Outcomes of polypharmacy

Although many times elders may do without necessary drugs due to high cost and limited incomes and may be forced to choose between eating and taking their medications they still have an increased hospital admission rate due to polypharmacy. The rate occurs about 23% and is due to 1.) medication errors, 2.) adverse drug reactions, or 3.) interactions alone. In addition it is well documented in the literature that polypharmacy is one of the leading causes of falls and injury. Many episodes of depressive disorders may be traced back to the effects of cardiovascular drugs or sedative use. Drug induced incontinence occurs with the use of methyldopa and beta blockers and in contrast the use of anticholinergics may lead to overflow incontinence. The loss of taste and smell may occur due to antihistamines, Allopurinol, Clindamycin, or leukotriene inhibitors. Malabsorption of vitamins and minerals may occur. Vitamin B6 absorption is decreased with the use of niacin. Vitamins A, K & D absorption is decreased when with mineral oil is used for constipation. Vitamins K&C are not absorbed properly in the presence of salicylates, and Folate and Vitamin D is not absorbed well with anticonvulsants. Calcium and iron are not absorbed well when taken with tetracycline.