Which interventions can help physicians manage polypharmacy in older patients?
Multidisciplinary interventions that address polypharmacy decrease inappropriate prescribing and medication-related problems in patients 65 years and older, but it is not clear if they reduce hospital admissions or improve quality of life. Most interventions studied were led by pharmacists or health systems rather than physicians. Only one study used computerized decision-making support. (Strength of Recommendation: C, based on consensus, disease-oriented evidence, usual practice, expert opinion, or case series.)
In this review, polypharmacy is defined as current use of four or more medications. Polypharmacy may be appropriate or inappropriate; however, the risk of adverse drug events in patients 65 years and older increases as more medications are prescribed: 13 percent with two medications, 58 percent with five medications, and 82 percent with seven or more. Adverse drug events are responsible for approximately 100,000 hospitalizations among older persons each year.1
Clinicians typically have used the Beers criteria to identify potentially harmful medications; an updated list is available through the American Geriatrics Society (http://www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf). The Medication Appropriateness Index and the McLeod criteria are used more often in research settings.
Ten studies analyzed interventions for managing polypharmacy in older adults, nine of which involved multifaceted pharmaceutical care. Nearly 22,000 patients (mean age = 74 to 75 years) taking an average of eight medications were included. Studies took place in hospital, nursing home, and primary care settings. In a subset of four studies with 424 patients, the mean Medication Appropriateness Index score was nearly 7 percent lower in the intervention group than in the control group (95% confidence interval [CI], –12.34 to –1.22 percent). However, when two studies at high risk of bias were omitted, the difference was closer to 2 percent. Two studies involving 586 patients and using the Beers criteria found that interventions did not lead to statistically significant reductions in the use of these medications, nor did they have a clear impact on hospital admissions or quality of life.
In two studies involving several thousand nursing home patients over a 90-day period, pharmacist interventions were associated with increased alerts for “potential drug therapy problems.” Neither study reported adverse drug events, but one saw a trend toward decreased relative risk of hospitalization of 0.84 (95% CI, 0.71 to 1.00).
Only one study directly involved physicians through computerized decision-making support, a common feature of electronic health records.2 In this study of 12,560 patients, computerized decision-making support modestly reduced the initiation of inappropriate prescriptions by 18 percent as measured by the McLeod criteria, but did not lead to discontinuation of existing inappropriate prescriptions. Another study outside of this review estimated that only one serious adverse drug event is prevented for every 2,700 computer alerts. The authors describe “alert fatigue.”3
In the end, the most common causes of adverse drug events in older patients may be right under our noses. The Centers for Disease Control and Prevention estimated that in 2004, patients 65 years and older made more than 177,000 emergency department visits because of adverse drug events.4 Warfarin (Coumadin), insulin, and digoxin accounted for one in three of these visits, whereas drugs on the Beers list accounted for less than 9 percent. We can reduce the rate of adverse drug events by using validated risk calculators for bleeding in patients taking warfarin (https://www.aafp.org/afp/2010/0315/p780.html), setting less stringent goals for A1C levels in older patients with comorbidities,5 and avoiding high doses of digoxin or use of the drug without proper indications.