Polypharmacy

ANATOMY OR SYSTEM AFFECTED: All

DEFINITION: The concurrent use of several drugs, sometimes more than prescribed to and/or clinically needed by the individual. Individual adults, especially elders, who receive too many medications for an extended time or in high doses may experience adverse drug reactions.

Causes and Symptoms

Polypharmacy has many causes and symptoms. Common causes include the need to treat multiple conditions, misunderstanding of or misinformation about drug actions, and miscommunication between patients and providers. Symptoms may be due to drug interactions, inadvertent overdoses, or multiple toxicities, and they may imitate those of other diseases or may be so slight as to be everyday occurrences. Although polypharmacy could reflect the inappropriate prescription and use of drugs, it is not in itself an accurate measure of the appropriateness of a given drug therapy.

Older adults are most affected by polypharmacy, not only by alterations in pharmacokinetics and pharmacodynamics, but also by accompanying illnesses requiring drug administration. Taking many drugs can result in increased adverse reactions, often because of slower drug excretion from the and slower absorption in the of older adults, both of which cause drugs to remain in the body for longer periods of time.

Another factor that could contribute to polypharmacy is a substance-use disorder, such as those characterized by abuse and dependence. Abuse and dependence can occur with alcohol and prescription drugs, as well as street and over-the-counter drugs. Individuals attempt to self-medicate with these agents if they believe that their regular medicines are not effective.

Other causes of polypharmacy include incompetence in self-administering medication, inconsistent use of caregivers who know the patient, and overprescription or underprescription of medications for older adults. Individuals may also wrongly use outdated or borrowed drugs to treat illnesses or diseases. Finally, there may be chronic illnesses that are misunderstood by the individual’s family and undertreated by healthcare providers.

Polypharmacy is sometimes overlooked because the symptoms that it causes can be confused with those of normal aging or another disease. As a result, still more drugs may be prescribed or purchased over the counter and used to treat these new symptoms. Symptoms or signs that are caused by interactions between drugs or side effects of drugs are varied. They may include symptoms as mild as tiredness or sleepiness, decreased alertness, constipation, diarrhea, loss of appetite, weakness, mild anxiety, loss of interest in usual activities, or skin rashes. More pronounced symptoms may include incontinence, confusion (all the time or only sometimes), falls, clinical depression, tremor, hallucinations, severe or excitability, dizziness, and increased or decreased sexual behavior. Sometimes, side effects occur shortly after starting a new drug, but in other cases they take time to appear.

Treatment and Therapy

Although there is no defined treatment for polypharmacy, certain precautions can be taken. Individuals need to have good relationships with their healthcare providers so that they feel comfortable disclosing pertinent information to them. Patients need to inform their providers of all drugs that they are using, including prescriptions, alcohol, nicotine, street drugs, over-the-counter medications, vitamins, and alternatives such as herbal supplements. They also should disclose if they are following any especially odd or restrictive diet that may affect their metabolism. Patients should ensure that every medical professional involved in their care has a complete list of their medications. It is helpful to have a primary care provider coordinating medications when there are multiple providers involved. Regular medication reviews should be conducted, especially if an individual is being treated by more than one provider. Finally, patients need to self-monitor their drug intake and be informed and aware of drug side effects. It is also helpful for family members to be educated about the effects and important side effects of patients' medications.

Medical personnel need to be concise and clear when prescribing drugs. The dosage schedule should be simple, and the number of doses taken should be as low as possible. Healthcare providers need to educate patients and their families about side effects, adverse reactions, and the proper way to take medications. When possible, nonpharmacological treatment methods should be considered to minimize the number of substances that the patient is using at any one time. For example, rather than prescribing a drug to relieve a patient’s stress, a physician may suggest that they learn and practice relaxation exercises.

In addition, patients should ask their pharmacists for advice before taking any new drugs, vitamins, or alternative remedies, whether prescribed or over the counter. They should limit themselves to using only one pharmacy so that the pharmacy can monitor and identify potential effects of multiple prescription drug use. Finally, every attempt should be made to ascertain whether the patient is competent to self-administer medication and avoid missed doses, combining doses, or noncompliance with instructions. If patients are not responsible for their own care, then medical professionals should give consistent drug information to their caregivers.

Perspective and Prospects

Polypharmacy with adverse drug reactions can occur in healthy younger adults, but it is more likely to happen as a result of a combination of age-related changes, disease-related conditions, and drug interactions. Thus, the risk of adverse effects is two to three times higher in older adults. Although research has not been able to distinguish among the unique influences of age-related, disease-related, and drug-related factors, studies have identified certain for adverse drug effects, such as processes, the number and duration of drugs consumed, and a history of adverse reactions.

Potential consequences of polypharmacy include more visits to healthcare providers, increased accidents, decreased feelings of wellness, admission to or a prolonged stay in a hospital, and death. Polypharmacy is a common and dangerous healthcare problem for all adults, and drugs must always be suspected as the cause of a new symptom, especially if the symptom shortly follows the administration of a new drug.

With patients able to buy medications through websites and other channels that do not monitor the quality or quantity of drugs carefully, problems related to polypharmacy may increase. This situation is compounded by the greater access that some teenagers have to in the home for use in experimentation. Adding the ubiquitousness of new beverages marketed as healthy drinks that contain high doses of and other substances identified as health supplements creates a recipe for further problems. A lack of awareness of the dangers of mixing such substances can be problematic for persons of almost any age, but especially children and older adults. As such, it is important for public health campaigns to address these problems in order to stave off additional risks posed by increased drug availability to such vulnerable populations.

While polypharmacy is most often unintentional and prone to adverse effects, it may have therapeutic applications as well. One developing area of interest is the use of polypharmacy in psychiatry to treat certain disorders, such as schizophrenia and bipolar disorder, that respond poorly or inconsistently to single medications. Research is ongoing as to the safety and efficacy of such an approach.

Bibliography

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Kane, Robert L., et al. Essentials of Clinical Geriatrics. 8th ed. McGraw, 2018.

Neel, Armon B., Jr., and Bill Hogan. Are Your Prescriptions Killing You? How to Prevent Dangerous Interactions, Avoid Deadly Side Effects, and Be Healthier with Fewer Drugs. Atria, 2013.

Reuben, David, et al., eds. Geriatrics at Your Fingertips. 26th ed. Amer. Geriatrics Soc., 20234.

Ritsner, Michael S., ed. Polypharmacy in Psychiatry Practice. 2 vols. Springer, 2013.

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