The dangers of polypharmacy

pile of pills

Dr Caleb Alexander knows how easily older people can fall into polypharmacy. Perhaps a patient, like most seniors, sees several specialists who write or renew prescriptions. “A cardiologist puts someone on good, evidence-based medications for his heart,” said Caleb, co-director of the Johns Hopkins Centre for Drug Safety and Effectiveness, USA.

And let’s say the patient, like many older adults, also uses an over-the-counter reflux drug and takes a daily aspirin or a zinc supplement and fish oil capsules. “Pretty soon, you have an 82-year-old man who’s on 14 medications,” Caleb said.

Geriatricians and researchers have warned for years about the potential hazards of polypharmacy, usually defined as taking 5 or more drugs concurrently. Yet it continues to rise in all age groups, reaching disturbingly high levels among older adults. “It’s as perennial as the grass,” Caleb said. “The average senior is taking more medicines than ever before.” Tracking prescription drug use from 1999 to 2012 through a large national survey, Harvard researchers reported in November that 39% of those older than 65 now use five or more medications — a 70% increase in polypharmacy over 12 years. Lots of factors probably contributed, including the treatment guidelines that (controversially) call for greater use of statins.

Threatening consequences
But older people don’t take just prescription drugs. An article published in JAMA Internal Medicine, using a longitudinal national (USA) survey of people 62 to 85, may have revealed the fuller picture. More than a third were taking at least 5 prescription medications, and almost two-thirds were using dietary supplements. Nearly 40% took over-the-counter drugs. Not all are imperiled by polypharmacy, of course. But some of those products, even those that sound natural and are available at health food stores, interact with others and can cause dangerous side effects.

How often does that happen? The researchers, analysing the drugs and supplements taken, calculated that more than 8% of older adults in 2005 and 2006 were at risk for a major drug interaction. Five years later, the proportion exceeded 15%. “We’re not paying attention to the interactions and safety of multiple medications,” said Dima Qato, lead author of the JAMA Internal Medicine article (Caleb was a co-author) and a pharmacist and epidemiologist at University of Illinois at Chicago.

Though drug interactions can occur in any age group, older people are more vulnerable, said Dr Michael A Steinman, a geriatrician at the University of California, San Francisco, who wrote an accompanying commentary. Most have multiple chronic diseases, so they take more drugs, putting them at higher risk for threatening interactions. The consequences can also be more threatening. Say a drug makes older patients dizzy. “They’re more prone to fall, because they don’t have the same reserves of balance and strength” as the young or middle-aged, Michael said.

To tell or not?
Dima recalled reviewing the medications of a 67-year-old man taking both the cholesterol drug Simvastatin and the blood pressure medication Amlodipine — the most common combination of interacting drugs that emerged in her study. Though her patient wasn’t experiencing problems, he was also taking garlic and omega-3 supplements, which can interact with prescription medications. “Did you tell your doctor you were on them?” Dima recalled asking. “He said, ‘No, why should I? If it was important, why didn’t he ask me?’” A reasonable question. A recent study in JAMA Internal Medicine, however, found that more than 42% of adults didn’t tell their primary care doctors about their most commonly used complementary and alternative medicines.

Usually, that was because the physicians didn’t ask and the patients didn’t think they needed to know; in a few cases, doctors had previously discouraged alternative therapies, or patients thought they would. And they might, especially for older patients with complex regimens. “I’m not a big fan of supplements,”Caleb tells patients taking lots of vitamins, supplements and herbal remedies. “I think the vast majority of evidence raises serious questions about their effectiveness or, in some cases, their safety. They’re less well regulated than prescription medications. I think you’d be better off stopping them.”
Often, patients are confused about what they’re actually taking. Michael recalled asking a patient to bring in every pill he took for a review. He learned that the man had accumulated 4 or 5 bottles of the same drug without realising it, and was ingesting several times the recommended dose. The best way to reduce polypharmacy is to overhaul our fragmented approach to healthcare. “The system is not geared to look at a person as a whole, to see how the patterns fit together,” Michael said.

In the meantime, though, patients can ask their physicians for reviews and discuss whether to continue or change their regimens. Pharmacists, often underused as information sources, can help as well. “We spend an awful lot of money and effort trying to figure out when to start medications,” Caleb said, “and shockingly little on when to stop.”