Older adults are at especially high risk for experiencing medication-related problems because of their high rate of medication use, age-related changes in physiology, sensitivity to medications, and polypharmacy.

Proper use of medications is critical to cost-effective disease management. As the number of older adults increases, healthcare professionals must spend more time evaluating medication regimens.

The decline of cognitive health—from mild cognitive decline to dementia—can have profound implications for an individual’s health and well-being. Limitations with the ability to manage medications and existing medical conditions effectively are particular concerns when an individual is experiencing cognitive decline or dementia (Bihari, 2018; Stibich, 2018).

Polypharmacy

The phenomenon of polypharmacy has been recognized for several decades, yet there is no universally agreed-upon definition. While polypharmacy is often used to mean the use of five or more medications by the same person, the specific number varies from definition to definition and some instead use “many” or “too many” in place of a specific number. Often implicit (or stated) in definitions is the idea of “appropriate” or “inappropriate,” regarding the relationship between what is prescribed and the patient’s condition or conditions.

Polypharmacy is often directly linked to comorbidity or multimorbidity—the co-existence of two or more chronic health conditions, a common occurrence in the population of older adults. Some definitions add even more qualifiers such as “for x length of time” or specify the setting in which medications are used (Masnoon et al., 2017).

Literature reviews and research projects currently underway on both polypharmacy and the criteria used to evaluate certain medicines for their use with elders show promise. Sticking with the simplest definition of polypharmacy—the concurrent use of multiple medications—and consistent application of good medication management techniques by both providers and patients with the goal of using the fewest medications necessary suggests itself as a prudent approach.

Effects of Polypharmacy

Patients are constantly admonished to keep their healthcare providers up to date on all medications they are taking, yet many do not understand everything that may include. This is one of several contributing factors in polypharmacy, especially for older adults.

Common concerns of polypharmacy:

• Excessive known side effects as sensitivities to medication increase with age
• Additive side effects when several drugs induce similar physical responses
• Dangerous drug interactions
• Diminished effectiveness of drug due to interaction with another
• Confusion resulting in missed or extra doses or other errors (Stibich, 2018)

Aging changes the way medications are absorbed and utilized in the body, sensitivities increase, and seniors are more likely to experience side effects, drug interactions, and other adverse drug reactions (Bihari, 2018).

Why Polypharmacy Occurs

Older adults often have multiple illnesses or conditions being treated with medications, some of which may require multiple medications to control them. What began as appropriate prescribing can turn into more than necessary. Other issues include:

• Prescribing cascades, which happen when a patient is taking one prescription to deal with the side effects of another
• Disconnected medical care, when a patient is seeing multiple doctors and what one prescribes may not work well with what another prescribes
• Pharmacy changes, when a patient uses multiple pharmacies to fill prescriptions so that no one pharmacy knows all the medications being taken and potential interactions may not be caught (Stibich, 2018)

Typical medications for common chronic medical conditions when taken concurrently have increased potential to cause adverse reactions in older people. The more drugs a person is taking, the higher the likelihood of adverse interactions between the drugs, food, and/or alcohol. The more complicated a dosing schedule becomes, the more likely the patient is to miss doses or take them twice or at the wrong time.

Effective medication depends on the body’s normal process of absorption (usually in the intestine), distribution where needed in the body (usually via bloodstream), its being metabolized or chemically changed (often in liver or kidneys) and finally excreted or removed (mostly through urine). This process is often referred to as ADME and normal aging changes in all four processes can change how drugs are dealt with by the body and can exacerbate side effects.

With age the percentage of body fat increases, body fluid decreases, digestive processes slow down, and liver function decreases. Consequently, fat-soluble drugs may be trapped, water-soluble drugs may become too concentrated, drugs that depend on digestive processes or breakdown in the liver or kidneys can be delayed getting to the body or may remain longer, all increasing the risk of side effects (Bihari, 2018).

Improving Medication Management

What Providers and Patients Can Do

Even if you are not the provider issuing a prescription, you can help your patients develop good drug use habits and help them locate resources.

Discuss with patients that medicines (drugs) are not just those for which they have a prescription but include:

• Prescriptions—only with a doctor’s order
• Over-the-counter (otc)—pills, liquids, creams without prescription
• Vitamins, eye drops, or other dietary supplements

Encourage patients to use a medication-tracking worksheet of some type to record and track all medications. This should help them to know:

• Name of drug
• Why they are taking it
• What medical condition it treats
• When to take it (times per day; time of day)
• How much to take
• With or without food?
• How long it will take to work?
• Possible interactions with other medications they are taking
• Is it safe to drive while taking it?
• What does “as needed” mean?
• What to do if dosage is missed
• Possible side effects and what to do if they occur
• If a refill will be needed

Encourage a patient to fill all prescriptions at the same pharmacy, utilize the pharmacist’s knowledge for questions, and ask if the pharmacy system will flag potential interactions or problems. Always remind them to make sure they have the correct prescription before leaving the store, to keep any allergy information up to date, and to read the printed information that comes with a medication and ask questions if something is not clear.

Discuss possible side effects—unwanted or unexpected symptoms or feelings that occur when taking a medicine—and what the patient should do if they experience a side effect. Side effects can be relatively minor, such as a headache or a dry mouth. They can also be life-threatening, such as severe bleeding or irreversible damage to the liver or kidneys. Medication side effects can also affect driving (NIA, 2017f).

Discuss with a patient any potential interactions between their medication(s) and specific foods and alcohol. Alcohol can exacerbate side effects or interfere with the metabolism of certain medications or lead to dangerous adverse events. Certain medications can also increase the effects of alcohol. Older people can be more adversely affected by medication–alcohol interactions, which can lead to falls and serious injuries (verywellmind.com, 2018).

Remind a patient not to stop taking any medication without the provider’s permission. Multiple drugs for one condition may be appropriate in their case, and while polypharmacy can be harmful, medication adherence is also important (Stibich, 2018).

The internet is ubiquitous in our society and not everyone knows how to evaluate the information they find there. Direct patients to websites that will help them locate reliable information (such as the National Institute on Aging website about Online Health Information or the FDA’s “Quick Tips for Buying Medicines Over the Internet.”

Medication Adherence

Healthcare providers have to rely on patients to follow medication instructions and ask if they have questions or need help. Reviewing the elements of medication adherence may help to ensure this cooperation.

Review with patients the potential problems with:

• Taking old or leftover medications
• Decreasing or increasing dosage without doctor’s approval
• Stopping a medication without doctor’s approval
• Not showing up for IV therapy appointments
• Taking someone else’s medications
• Sharing medications (Moawad, 2018)

Cognitive Impairment

Impairment of cognitive functions presents significant problems for medication management. It is important to prescribe as few medicines as possible and to tailor doses to the person’s personal habits. It is also important to observe the person’s ability to use medication organizers if they are utilized.

Automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. Assistance with medication management should be implemented when safety becomes an issue.

Cost of Medications

Medications are often expensive and patient attempts to save money by cutting pills in half, taking less, or delaying refills can result in an untreated or partially treated condition, a worsened condition, or even disability and death.

If a patient is having trouble getting a prescription filled or it is too costly, a review of their insurance company’s formulary may contain an alternative medication that is more affordable. Be sure patients are taking advantage of their Medicare Part D drug plan benefits and/or any other Medicare drug-related assistance including:

• Medicare Extra Help Program
• State Pharmaceutical Assistance Program (SPAP)
• Pharmaceutical Assistance Programs (PAP)
• Partnership for Prescription Assistance (NIA, 2017g)