Polypharmacy management

Polypharmacy affects about one million (36.1%) older people, aged over 70 years, in Australia and as the population ages and the number of people living with multiple health conditions rises, the number is expected to increase.

In Australia, the prevalence of polypharmacy increased by 9% between 2006 and 2017, according to Dr Amy Page, research fellow and NHMRC Early Career Fellow and Teaching Associate at Monash University and Adjunct Associate Professor and Research Assistant at The University of Western Australia. She is also a Research Pharmacist at Alfred Health and a Practice Pharmacist at Emerald Medical Centre.

Gender and age

“Rates of polypharmacy were higher among women than men (36.6% v 35.4%) and were highest among those aged 80–84 years (43.9%) or 85–89 years (46.0%). The prevalence of polypharmacy among PBS concessional beneficiaries aged 70 or more increased by 9% during 2006–2017 (from 33.2% to 36.2%), but the number of people affected increased by 52% (from 543,950 to 828,950),” according to a research report, by Dr Page and fellow researchers, published in the Medical Journal of Australia (MJA)¹.

“Overseas countries like the United States and the United Kingdom had much greater increases over these time periods, though our rates remain slightly higher. This finding indicates that the rate in Australia has been relatively high over a sustained period of time,” said Dr Page, lead author of the study.

“Conventionally polypharmacy has been perceived as an overuse of medicines, whereas it may be more useful to perceive in terms of appropriateness, as there are many cases where the concurrent use of multiple medicines may be deemed necessary and beneficial,” noted the World Health Organization in its Medication Safety in Polypharmacy report².

“Countries should therefore prioritise raising awareness of the problems associated with inappropriate polypharmacy and the need to address this issue.”

Risks

Polypharmacy can increase the risk of experiencing falls, fractures and increased frailty, Dr Page said. “People who use polypharmacy additionally experience an increased rate of other medication-related harm including an increased risk of side effects and drug interactions.

“Sometimes side effects are identified as new conditions that are then treated with other medicines causing a further escalation in polypharmacy. Additionally, polypharmacy is associated with an increased risk of under-prescribing, which means that it becomes more likely that one or more indicated medicines will not be used as the number of medicines a person takes increases.”

It is currently unknown if the prevalence of polypharmacy has changed over the last few years with COVID-19, Dr Page said. “There have been substantial changes to healthcare delivery with COVID-19 with electronic scripts and telehealth. It is unknown if this has affected polypharmacy.”

Medication reviews

A recent project³ — SPPiRE (Supporting prescribing in older people with multimorbidity and significant polypharmacy in primary care) — by researchers from the RCSI University of Medicine and Health Sciences led to an overall reduction in the number of medicines prescribed for older people.

The SPPiRE study consisted of a randomised controlled trial involving 51 GP practices and 404 patients throughout the Republic of Ireland. Older patients with multimorbidity taking at least 15 regular medicines were invited to attend a medication review with their GP.

“The review included screening their prescription for potentially inappropriate combinations of medicines, considering opportunities for stopping medicines and assessing the patient’s priorities for treatment. It then assessed whether this once-off GP-delivered medication review reduced the number of medicines and improved the quality of prescribing,” according to the university.

There was a significant reduction in the number of medicines in the intervention group compared to the control group, with over 800 medicines being stopped in 208 intervention patients. Of the 800+ medicines ceased, 15 possible adverse events were reported, almost all of which were mild reactions that stopped once the medicine was reintroduced, indicating that stopping certain medicines in older people is generally safe.

Dr Page also emphasised the importance of regular review of all medicines both individually and as a whole medication regimen. These reviews give the opportunity to review if the medicines continue to be appropriate and if they continue to be aligned to the individual’s health care goals, she said.

Prescription management

Dr Caroline McCarthy, GP and Clinical Lecturer and Research Fellow in the Department of General Practice at RCSI, said, “It can be daunting for GPs with limited time and resources to actively manage these prescriptions and patients can also be wary about change, particularly if they have been on a medicine a long time.”

It’s possible that the identification of this at-risk group who are prescribed at least 15 medicines may have led to improvements in prescribing, Dr McCarthy said.

Professor Susan Smith, Associate Director of the HRB Primary Care Clinical Trials Network, said, “The intervention approach to managing this challenging problem is promising and demonstrates that, even in this very complex group, stopping medicines that may no longer be needed or appropriate is both possible and generally safe.”

^{1 Polypharmacy among older Australians, 2006–2017: a population‐based study; Med J Aust 2019. https://doi.org/10.5694/mja2.50244}

^{2 Medication safety in polypharmacy: technical report; World Health Organization. (‎2019)‎. https://apps.who.int/iris/handle/10665/325454}

^{3 GP-delivered medication review of polypharmacy, deprescribing, and patient priorities in older people with multimorbidity in Irish primary care (SPPiRE Study): A cluster randomised controlled trial. https://doi.org/10.1371/journal.pmed.1003862}

Image credit: ©stock.adobe.com/au/OlegDoroshin