Taking multiple medications is common for many and doing so safely is an issue that’s becoming increasingly important, particularly for the elderly. In this post, IHI Executive Director Frank Federico, RPh, suggests some simple tips for safely managing polypharmacy. At IHI, Frank works in the areas of patient safety and the application of reliability principles in health care. He is faculty for the IHI Patient Safety Executive Development Program and helped to develop the upcoming IHI Expedition on Improving Medication Safety from the Patient's Perspective.
Polypharmacy is a term used to describe treatment for patients who take more than a certain number of medications. I heard one nurse describe polypharmacy as, “More medications than a patient can handle.” To paraphrase a song, another colleague uses the phrase, “It’s raining meds.”
I’m seeing firsthand what this issue means because, over the past few years, I have become increasingly involved in my mother’s care.
Although she still lives independently, my sister and I now manage our mother’s medications. I’m continually struck by how difficult it must be for older people taking many prescription drugs. They must manage what is often a wide array of medications. They have to remember when to take them and when to refill their prescriptions. They must ensure their medication list is up to date. They wonder if the feelings of discomfort they sometimes experience are due to the medications they’re taking.
Those feelings of discomfort may not be unwarranted. Older people are more likely to be harmed by medications because of how their organs function, they often have co-morbidities, and they may have multiple physicians caring for them who each prescribe medications without necessarily consulting one another. The lack of communication between specialists and primary care doctors is one of the challenges in managing polypharmacy. It’s estimated that over 4 billion prescriptions were written in 2011. Unfortunately, that represents many opportunities for error.
How can we help our patients more safely manage the problem of polypharmacy?
Think twice before prescribing: Carefully consider if a medication is really needed and will provide benefit. There are some medications that help younger people. When taken by elderly patients, however, they are likely to cause unintended effects or even harm. Statins are one example.
- Start low and go slow: Initial dosing should be carefully considered and titration should be gradual.
- Keep it simple: Limit your formulary and, whenever possible, use simple regimens with minimal frequency of dosing. Medication reconciliation and adherence to medication therapies are hard enough. Why not try to simplify each by reducing the number of medications and frequency of doses a patient is taking?
When used appropriately, medications can help keep people from needing hospital care for longer periods of time, so I am not advocating that doctors should avoid prescribing a necessary medication. In fact, Dr. E. Robert Feroli, Medication Safety Officer in the Department of Pharmacy at Johns Hopkins Hospital, suggests that we should focus less on polypharmacy (which for some patients may be needed) and put more emphasis on better medication management.
At every visit to the doctor’s office, my mom, her doctor, and I discuss opportunities to discontinue a medication that may not be appropriate or has questionable value for a woman her age. This has become such a ritual that now my mom asks as we prepare for an appointment if there are any other medications we can discontinue.
What are you doing to help your patients manage the issue of polypharmacy?