Polypharmacy: A Modern Day Silent Epidemic - Signs & Symptoms
By: Demetra E. Antimisiaris PharmD, CGP, FASCP
The definition of polypharmacy most cited in literature is the taking of five or more medications simultaneously. But a more appropriate definition might be the taking of any medication that is not clinically warranted. More than just a term that describes the taking of many medications, polypharmacy is a risk factor for morbidity and mortality.
Adverse medication outcomes have been estimated as the fourth or fifth leading cause of mortality in hospitals (1). In 2000, medication related problems cost $85 billion dollars and 106,000 lives (2); by comparison, in 2002 diabetes cost $91.8 billion dollars, and 224,092 lives (3).
If polypharmacy were a disease, there would be numerous initiatives and organizations to fight its threat to public health. The problem of polypharmacy touches everyone's life either with their own medical experience, or through family members or friends who struggle to deal with managing medication regimens in every way from costs, follow-up appointments, lab tests, to ability to take several medications at the right time every day.
The enormity of this problem is coming to public attention more and more as people face caring for chronically ill loved ones, something that demands understanding Medicare D, insurance access issues and the myriad of information needed to correctly use complex drug therapy.
The days of one doctor (who can spend ample time to address all aspects of care), one pharmacy (with a pharmacist who can spend the time it takes to go over the use of every medication in detail), and the use of just a handful of medications are all but non existent today.
Polypharmacy is not a diagnosis given to a person by a doctor, but it is a phenomenon that carries as much risk as many other diagnosable disease states. It is important to understand the risk that polypharmacy poses, its causes, and what each person or care giver can do to minimize medication related problems.
It is not enough to “blindly” take medications prescribed by several separate prescribers, or take recommended over-the-counter products based on advertising and marketing, and not question the total drug picture as it applies to your unique mix of health conditions.
Increasing awareness amongst everyone, care givers, family and friends about the causes of and how to avoid medication related problems can help the whole community, both within and outside the healthcare community improve medication use outcomes.
Ways to avoid unnecessary medication-related problems:
Know purpose for the drug.
One principle that helps fight polypharmacy is to avoid taking medications for which there is no true condition or diagnosis. An example: taking the antihistamine called diphenhydramine (some brand names: Benadryl®, Tylenol PM®) every night to sleep when the cause of insomnia is the 8 p.m. cup of coffee, or decongestant use.
Diphenhydramine causes a whole list of “anticholinergic” side effects which can lead to other problems, like constipation, urinary retention, changes in heart beat, dry mouth, and confusion, and then more medications to treat these problems.Why be exposed to another drug when the problem could be solved by addressing the cause of the insomnia?
Recognize potential side effects.
If a person is unaware of the side effects a drug may cause, they may think it is just “old age” and end up with another drug to treat a condition that is actually drug induced. Example: a patient who is taking a class of antidepressants called serotonin reuptake inhibitors (SSRI), such as Zoloft®, or Prozac® in addition to a analgesic called Ultram®.
Both of these medications can, at high doses, cause tremor. The tremor may be misdiagnosed as Parkinson’s disease rather than a side effect of medication, and another drug may be added to control the tremor when removing the offending medications would be the appropriate solution.
Understand potential interactions
Drug-Drug, Drug-Disease and Drug-Food interactions can all be significant when it comes to avoiding medication-related problems. A common example is consuming too many green leafy vegetables (a source of Vitamin K, which reverses the blood thinning effects of the blood thinner Coumadin given to prevent strokes and excessive blood clotting).
Keep medication records or a journal
This is a very valuable tool for combating medication related problems. Often physicians are unaware within the confines of a 20-minute office visit what medication the patient is actually taking, what has been changed due to hospitalization, and other details of medication adherence for a presumed drug regimen.
The health care team often has only the drug list in the chart as a reference without benefit of knowing how many doses were missed, why and when. In addition, patients often forget to report or do not recognize side effects. Keeping a daily journal of what medications were taken, when and documentation of symptoms or health status on a daily basis is good practice.
Always carry a current medication list including prescribing doctor’s name.
Again, the clinic chart usually reflects whatever the medication regimen was at the last visit. The list can change with visits to specialists, hospitalization or while seeing out-of-town doctors.
Annual Brown Bag
Place all medications, including over-the-counter medications, herbals and supplements in a brown bag and bring it in to your doctor’s visit at least annually. Include old medications (so the staff can confirm you are not to take them), cough syrup, decongestants...everything!
Inform physician about over-the-counter drug use, herbals and supplement use.
With the endless amount of vitamins, herbal supplements and over-the-counter drugs on the market, patients are often taking something the physician is unaware of that may be causing symptoms like elevated blood pressure or stomach upset.
These symptoms may be treated with a new prescription, hence, more polypharmacy risk! Some herbal supplements have serious physiological effects. For example, Ginko Biloba is known to significantly thin the blood. It is used to help increase memory, but can be dangerous in that it can cause a stroke or other kinds of serious bleed.
Be aware of what lab tests should be done annually
Often times drug therapy requires lab tests to monitor for safe use. If the drug was started in the hospital or by a doctor you do not see regularly, be certain that the appropriate monitoring gets done. You can ask your primary care doctor, the prescribing doctor or pharmacist for help with this information.
Self-medicating includes adjusting doses without informing your doctor, using an “old” discontinued medication for a flare-up of a condition or trying out something that worked for a friend. The risk here is that the drug taken may not be appropriate for your current set of conditions, and may result in serious consequences, for which the cause would be unknown to the health care team because it’s not on the record. (For example if you are in the office with a symptom or at the ER unconscious).
Ultimately, as patients and health care givers, improving communication and knowledge is the key.
Demetra E. Antimisiaris, PharmD, is a Certified Geriatrics Pharmacist, a Fellow of the American Society of Consultant Pharmacist and is a graduate of UCLA’s geriatrics pharmacist residency program. Dr. Antimisiaris is a faculty member of the University of Louisville Department of Family and Geriatric Medicine. She was recruited to the University of Louisville thanks to a generous donation by Mrs. Jean Frazier whose support resulted in an initiative aimed at fighting the problem of polypharmacy.
1. Zagaria MA, Pharmaceutical care of the older patient. US. Pharmacist 2000, 25(2):94-95.
2. http://diabetes.org/diabetes-statistics/costs-of-diabetes-in-us.jsp. Last accessed 17October 2007.
3. Ernst FR, Grizzie AJ: Drug-related morbidity and mortality: Updating the cost of illness model.
Am Pharm Assoc 2001; 41:192