Polypharmacy and the Importance of Medication Review in

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Nursing Capstones Department of Nursing

4-30-2016

Polypharmacy and the Importance of MedicationReview in the Elderly PopulationRose Betak Agbor

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Running head: POLYPHARMACY AND MEDICATION REVIEW IN ELDERLY 1

POLYPHARMACY AND THE IMPORTANCE OF MEDICATION REVIEW IN THE

ELDERLY POPULATION

By

Rose Betak Agbor

The University of North Dakota

POLYPHARMACY AND MEDICATION REVIEW IN THE ELDERLY 2

PERMISSION

Title Polypharmacy and the importance of medication review in the elderly population

Department Nursing

Degree Master of Science

In presenting this independent study in partial fulfillment of the requirements for a graduate

degree from the University of North Dakota, I agree that the College of Nursing of this

University shall make it freely available for inspection. I further agree that permission for

extensive copying or electronic access for scholarly purposes may be granted by the professor

who supervised my independent study work or, in her absence, by the chairperson of the

department or the dean of the Graduate School. It is understood that any copying or publication

or other use of this independent study or part thereof for financial gain shall not be allowed

without my written permission. It is also understood that due recognition shall be given to me

and to the University of North Dakota in any scholarly use which may be made of any material

in my independent study.

Signature ____________________________

Date _____________________________


Abstract

As people get older, they are at increased risks of increased co-morbidities. As such elderly

patients maybe prescribed many medications to manage these multiple medical conditions. An

attempt to treat one medical condition may result in complications or drug interactions. With

hospitalization, clinicians tend to prescribe more medications to the elderly. This becomes

complex, and sometimes lead to non-compliance, improper administration and negative effects

on the body. Clinicians do not usually focus on medication review. Elderly may continue to take

these medications indefinitely if they are not reviewed for effectiveness or appropriateness. The

case study presented a patient with multiple medications with possible adverse drug reactions.

This case report aims to examine polypharmacy, consequences of polypharmacy and the

importance of medication review in reducing negative consequences of polypharmacy.

Medication review in elderly patients is important in preventing drug adverse effects, improves

of prescription quality and patient outcomes. A literature review was conducted to review

polypharmacy, the process, benefits and tools used in medication review in older population

according to National Health Service (NHS) and National Institute for Health and Care

Excellence (NICE) guidelines.


Background

Polypharmacy is defined as prescribing at least four to five medications (Avery, 2011).

Polypharmacy can also be classified as “taking medications with no appropriate indication, use

of therapeutic equivalents to treat same illness, use of interactive medications, use of

inappropriate dosage and use of other medications to treat adverse drug reactions” (Farrell,

Shamji, Monahan, & Merkley, 2013). This includes prescription and over-the-counter

medications. In the United States, the incidence of polypharmacy is increasing in the geriatric

population. According to Pretorius and colleagues, older adults who are 65 years and older

consume about 30% of all prescription medications with a total cost of about $3 billion dollars in

annual prescription (Pretorius, Gataric, Swedlund &Miller, 2013). As people get older, the

prevalence of chronic diseases increases. Drug therapy is necessary in the management of these

diseases and the use of multiple medications makes drug regimen complex and increases risk for

complications such as polypharmacy.

With increasing age, many physiological changes occur which affect pharmacokinetics

of drugs in the elderly (Cope, 2013). This includes changes in absorption, distribution,

metabolism and excretion of drugs. Absorption of medication decreases with age due to decrease

in the intestinal epithelial surfaces (Pretorius et al, 2013). This increases drug concentration in

the body. Distribution of drugs depends on the water, protein and fat content of the body. Body

fat increases with age and muscle mass decreases. Drugs tend to remain longer in the body with

these changes; adding the potential of drug overdose (Pretorius et al, 2013). Drug metabolism

occurs in the liver. Supply of blood decreases with age with the potential increase drug

concentration. Decrease renal function also poses risk for increased drug toxicities.


There is also high risk of drug-drug interaction and adverse drug events with

polypharmacy, including falls, gastrointestinal bleeds, cognitive changes, constipation

(Kaufman, 2015; Pretorius et al, 2013). More and more people are being re-admitted due to

hospital as a result adverse drug reactions. According National Health Service, Scotland (NHS,

2012), there is little guidance to assist providers with balancing evidence based practice

recommendations when managing multiple co-morbidities to obtain better patient outcomes.

Medication review is an important process used in the management of polypharmacy.

Bergman-Evans (2012) defines medication review as the examination of patient’s

medication with the objective of reaching an agreement with patient regarding treatment and

optimizing positive impact of medications and reducing negative outcomes. When doing

medication review, the individual client should be taken into consideration. Tools that may be

used for medication review include; NO TEARS, BEER criteria, STOPP criteria and START

criteria (All Wales Medicine Strategy Group, 2015, American Geriatric Society, 2015 &

Bergman-Evans, 2012). The purpose of these tools is to improve care of older adults by reducing

potentially inappropriate medication, monitor drug use and to decrease adverse drug reactions.

Case Report

History of present illnesses: EE is an 87 year old Caucasian female who is seen today for

follow up after three days hospitalization for UTI and fatigue. Patient complained of fatigue and

dizziness. Fatigue is worst in the morning upon waking up. Stated she sleeps through the night.

Denies mood changes. Patient feels dizzy when changing position. Denies lightheadedness.

Denies headaches, fever or chills. Denies shortness of breath. Denies dysuria, urinary urgency or

frequency. Patient is on Nitrofurantoin 100mg, has 3 more days of antibiotic therapy. Patient


stated she feels better, has been sleeping well. Patient is alert and oriented with intermittent

forgetfulness.

Medications:

Donepezil 5mg po daily

Fluticasone propionate and Salmeterol 250/50, 1 puff twice daily

Losartan 50mg po daily

Metoprolol 50mg twice daily

Gabapentin 300 mg po three times daily

Paroxetine 20 mg po daily

Quetiapine 200mg po twice daily

Insulin glargine 30 units SQ at bedtime

Nitrofurantoin ER 100mg po twice daily x 7 days (3 days left)

Multivitamin po daily

Iron sulfate 325mg po twice daily

Allergies: NKDA

PMH: Dementia, Diabetes, COPD, Anemia, hypertension, depression and neuropathy.

Family history: Familial history of hypertension and heart disease. Patient unable to state which

family member was affected.


Social History: Lives in an assisted living. Daughter assists with medication set-up. Never

smoked, used alcohol or illicit drugs

ROS:

Constitutional: Denies any fever or chills, reported fatigue

Cardiovascular: Denies chest pain or palpitations

Respiratory: Mild shortness of breath with activity, has history of COPD

GI: Denies decreased in appetite, constipation, nausea, vomiting, diarrhea or abdominal pain

GU: Denies dysuria, urgency or frequency. Currently on antibiotic for urinary tract infection

Musculoskeletal: Denies muscle or joint pain

Neurological: Denies headaches or lightheadedness. Denies numbness or tingling

Skin: Denies rashes or skin lesions

Psychosocial: Denies mood changes. Denies sleep disturbance

Physical Examination:

VS: BP 88/40, HR 50, Temp 98.6, RR 24, FSBS morning 107

General appearance: Alert and oriented, in no acute distress. Well-groomed and engages in

conversation.

HEENT: Head Normocephalic, atraumatic. Wears glasses. Pupils equal and reactive to light.

Neck: Supple, with normal ROM, no thyroidomegaly.

CV: Regular rate and rhythm, S1, S2 no murmurs, gallops, or rubs. No JVD. 2+ bilateral pedal

pulses


Respiratory: Breathing effortless. Lung sounds clear to auscultation in all lung fields no

wheezes, rhonchi, or rales.

GI: Soft and non-distended. Positive bowel sounds in all quadrants. No tenderness with

palpation, no organomegaly.

Skin: warm and dry, no lesions

Extremities: Trace edema to bilateral lower extremities, no tenderness

Differential Diagnosis:

Urinary tract infection, Fatigue, Hypotension, Diabetes, orthostatic hypotension, polypharmacy,

Anemia, hypothyroidism

Labs/Imaging

-CBC, BMP, TSH studies

-EKG

Management and plan

1 Hypotension, likely due to use of hypertensive medications. Currently on Losartan 50 mg and

Metoprolol 50 mg twice daily.

Plan: continue Losartan 50 mg daily; Discontinue Metoprolol, start Metoprolol ER 50 mg daily;

Check orthostatic blood pressure x 3 days. Update provider on any drop in BP from sitting to

standing; avoid changing positions abruptly

2 Fatigue, probably due to anemia vs current UTI. Hemoglobin stable, denies symptoms of UTI


Plan: Continue Iron supplements, return to clinic if symptoms persist

3 Urinary tract infections, on Nitrofurantoin, has three more days of antibiotic

Plan; complete antibiotic regimen

4 Diabetes, stable

Plan, continue Lantus

5 Polypharmacy has multiple co-morbidities and takes 11 different prescription medications

daily. Review medications and discontinue potentially inappropriate medications

Plan; decrease Gabapentin from 300mg to 100 mg three times daily

Literature Review

In this literature review, I will be incorporating a case report of an 87 year old female

with multiple co-morbidities who was having potential adverse drug reaction from

polypharmacy. During her follow-up appointment she had hypotension which increases her risk

for falls. Medication review was done and dose reduction done. The aim of this literature review

is to describe polypharmacy, review evidence-based recommendations on medication review, the

process of medication review and tools used to carry out medication review in the elderly

population.

An online search was done using PubMed using keys words “Polypharmacy”, “older

adults”, “Medication review” and “Medication reconciliation” yielded 95 articles. Search was

narrowed to RCT in the last six years, 5 articles were retrieved that were relevant to case study


Another search was done using CINAHL database using key words “Polypharmacy”,

“Older adults”, “Medication review” and “Medication reconciliation”. 4162 articles were

retrieved. Search was narrowed to 2010-2016, peer reviewed, English language, age 65 and

older, and Medline excluded. Fifteen articles were retrieved that were relevant to case study.

Medication Review Process

Medication review is an important factor in determining medication prescription, safety

and compliance. Medication review should be a collaborative approach between the provider,

pharmacist and the patient. According to National Institute for Health Care Excellence (NICE,

2014), medication review should include the following:

Medication history taking into consideration new and existing medications

Is the medication appropriate for the age group?

Complexity of medication regimen, can the regimen be simplified to promote

adherence?

What are the barriers to medication adherence?

Medication pharmacokinetics

Is the patient experiencing adverse drug events including geriatric syndromes?

Medication regimen should be adjusted based on the findings of medication

review.

According to NHS guideline (2012), there are three levels in medication review. Level 1

involves doing a face to face review of medication with the patient. This involves checking

appropriateness, cost, adherence and potential side effects of the medication. Level 2 involves


treatment review which is if medication is yielding good outcomes. Level 3 is clinical

medication review and making recommendations as needed to reduce inappropriate medications.

Benefits of Medication Review

Prescribing a drug regimen using evidence based practice is important in managing

complex medical conditions. However there are many drug-related problems which may result

from this regimen including hospital readmission from adverse drug reactions. These problems

can be prevented by reviewing patients’ medication upon discharge from the hospital.

Medication review will identify clinically inappropriate medications, assist with monitoring of

necessary labs, improve communication between providers and also identifying which

medications may be contributing to adverse reaction (Hellstrom, Bondesson, Hoglund,

Holmdahl, & Rickhag, 2010).

Studies done on medication review and assessment describe a variety of interventions and

outcomes including hospitalization, morbidity, mortality, and quality of life. Mckean, Pillans &

Scott (2015) did a pilot study on medication review and deprescribing in hospitalized patients

receiving multiple medications. The physicians used pharmacist reconciled medication list and

formal sit-down meetings to do the medication review. The authors concluded that a standardized

method of medication may significantly reduce the number of medications. In this study, one in

four medications was deprescribed prior to hospital discharge.

Another study done by Hellstrom et al, 2011, investigated the impact of Lund integrated

medicines management (LIMM) model on medication appropriateness and drug-related hospital

revisits in elderly patients within three months of discharge. The LIMM model is a systematic

approach that optimizes and individualizes drug treatment in hospitalized patients upon


admission, during hospitalization and at discharge. The authors found out that this model is

important in decreasing the amount of inappropriate medications taken by hospitalized elderly

patients.

Lampela, Hartikainen, Sulkava & Huupponen (2010) did a population-based intervention

study to investigate the impact of medication assessment as part of a comprehensive geriatric

assessment (CGA) on drug use over a 1-year period. The participants in this study were home-

dwelling, greater than 75 years and took two to ten medications daily. Interventions included

medication adjustment, evaluation of indication for medication use, clinical evaluation of

patients (cognition, mood, orthostatic reactions) and monitoring of routine labs. At the end of the

review, some medications were adjusted (especially the drugs affecting central nervous systems)

inappropriate medications were discontinued and new medications started for new diagnoses.

Medication Review Tools

A BEERs criterion is a medication review tool implemented by the American Geriatric

Society (2015) to assist clinicians with safe prescription in the elderly population. This tool

enables clinicians to prescribe medications (1) based on the patient’s diagnosis and (2)

independent of the patient’s diagnosis. According to the BEERS criteria the following classes of

medications should be avoided in elderly patients as they have the potential of causing adverse

drug reactions even when normal doses are taken. This includes Benzodiazepines, digoxin, first

generation antihistamines, tricyclic antidepressants, Megestrol, and some hypoglycemic agents.

Screening tool for older person’s potentially inappropriate prescription (STOPP) and

screening tools to alert doctors to right treatment (START) are tools used to avoid medications


that are potentially inappropriate and to identify medications use where risk outweighs benefits.

(Pretorius et al, 2013).

Graziano et al (2014) did carry out a project to assess appropriate medication use in

elderly with complex medical conditions who have limited life expectancy, functionally impaired

and have geriatric syndromes. The purpose of the project was to come out with recommendations

that will guide providers do quality prescription in this population of adults. The tool used for

this project criteria to assess appropriate medications use among elderly complex patients

(CRIME). The authors came out with 19 recommendations for medication management in

patients with co-morbidities including diabetes, hypertension, congestive heart failure coronary

artery disease and atrial fibrillation.

Learning Points

Polypharmacy poses a challenge to both providers and patients. There should be

communication between providers, the pharmacist and the patient to prevent potential

adverse drug events.

The provider should be aware of potentially inappropriate drugs in the elderly population.

This can be made possible by making use of medication review tools and evidence-based

practice guidelines.

Medication review should be done with each office visit or hospitalization. Patients

should be encouraged to bring a current list of all their medications, prescription and

over- the- counter medications.

For patients with complex medication regimen, medication review should be done and

those medications that are not therapeutic be discontinued.


Medication review prevents serious complications, easier and safer medication regimen

and may also reduce health care spending by reducing re-hospitalization.

Conclusion

Polypharmacy is significant problem affecting the elderly population. Consequences of

polypharmacy include geriatric syndromes, poor adherence, re-hospitalization, mortality and

increase cost of health care spending. Careful medication assessment and review is important to

prevent some of these complications. There are a variety of tools to assist with medication

review including BEERs, STOPP and START. Medication review has been shown to be effective

reducing the number of inappropriate medications, reduce re-hospitalization and adverse drug

events. While medication review may be time consuming, in order to improve quality of life in

this population, clinicians should make it a routine to review medications with each office visit

or hospitalization.


References

All Wales Medicine Strategy Group (2014). Polypharmacy guidance for prescribing. Retrieved

from: http://www.awmsg.org

American Geriatric Society (2015). American geriatric society 2015 updated BEERs criteria for

potentially inappropriate medication use in older adults. Journal of American Geriatric

Society, 63(11), 2227-2246. doi: 10.1111/jgs.13702

Bergman-Evans, B. (2012). Improving medication management for older adult clients.

Retrieved from: http://www.guideline.gov/content.aspx?id=37826

Cope, D. G. (2013). Polypharmacy in older adults: The role of the advanced practitioner in

oncology. Journal of the Advanced Practitioner in Oncology, 4(2), 107-112.

Farrell, B., Shamji, S., Monahan, A. & Merkley, V. (2013). Reducing polypharmacy in the

elderly. Canadian Pharmacists Journal, 146(5), 243-244.

Graziano, O., Landi, F., Fusco, D., Corsonnello, A., Tosato, M., Battaglia, M.…… Lattanzio, F.

(2014). Recommendations to prescribe in complex older adults: Results of the criteria to

assess appropriate medication use among elderly complex patients (CRIME) project.

Drugs Aging, 31(1), 33-45. Doi.10.1007/s40266.013-0134-4

Hellstrom, L., Bondesson, A., Hoglund, P., Holmdahl, L. & Rickhag, E. (2011). Impact of the

Lund integrated medicines management (LIMM) on medication appropriateness and drug

related hospital revisits. European Journal of Clinical Pharmacology, 67, 741-752. doi:

10.1007/s00228-010-0982-3


Kaufman, G., (2015). Multiple medicines: The issues surrounding polypharmacy. Journal of

Nursing and Residential Care, 17(4), 198-203

Lampela, P., Hartikainen, P., Sulkava, R. & Huupponen, R. (2010). Effects of medication

assessment as part of a comprehensive geriatric assessment on drug use over a 1-year

period. Drugs Aging, 27(6), 507-521. doi: 1170-229x/10/0006-0507

McKean, M., Pillans, P. & Scott, I. (2015). A medication review and deprescribing method for

hospitalized older patients receiving multiple medications. Internal Medicine Journal,

46(1), 35-42.

National Health Services, Scotland (2013). Polypharmacy guidance. Retrieved from:

http://www.central.knowledge.scot.nhs.uk

National Institute for Health Care Excellence (2014). Managing medicines in care homes:

Guidance and guidelines. National Institute for Health Care Excellence. Retrieved from;

http://www.nice.uk>guidance

Pretorius, R., Gataric, G., Swedlund, S. & Miller J. (2013). Reducing risk of adverse drug events

in older adults. American Family Physicians, 87(5), 331-336

http://www.central.knowledge.scot.nhs.uk/


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