May 31, 2017
Ahmed Hassanin, MD, an instructor at the University of Colorado Anschutz Medical Center, recently published a case study that he hopes highlights the dangers of polypharmacy in the elderly.
The study described the care of an 83-year-old woman with atrial fibrillation (AF) and congestive heart failure who was hospitalized with lightheadedness and heart palpitations. It was the third time in 6 months that the patient was admitted for uncontrolled heart rate related to AF. Pharmacy records indicated the patient had not refilled either of her prescribed nodal blocking agents for several months, according to the report, which noted the patient was restarted on her reported home dose of metoprolol succinate at 50 mg daily and diltiazem 180 mg daily. Her heart rate quickly normalized and she was discharged the following day. Two days later, however, she was back in the emergency department for treatment of a presyncopal episode caused by bradycardia and hypotension due to a metoprolol overdose.
The patient’s condition eventually improved, but she expressed frustration that her home medication regimen was confusing, burdensome, and costly. At discharge, the regimen was simplified to include only medications that would preserve the patient’s function and keep her out of the hospital. Dr. Hassanin recently said the case study wasn’t an outlier and demonstrates that patients can be at risk of adverse events, even when multiple medications are prescribed according to current guidelines.
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What are the inherent challenges of managing medication regimens in elderly patients?
There are two things to keep in mind: As patients age their medication needs change and the pharmacokinetics of medications and how different agents interact also change within patients’ bodies. Those are factors providers must be very cognizant of as they care for the elderly. If older patients no longer suffer from conditions for which they were prescribed medications, than obviously the treatment approach needs to change and some of those medications might need to be discontinued.
What lessons should providers take away from the case study?
One of the main points we’re trying to make is that patient preferences might preclude providers from following clinical care guidelines. At the end of the day, patients control what goes into their body and their decisions about medication use often depend on how much therapies cost and what they expect in terms of quality of life.
Preference misdiagnosis—when physicians fail to account for patients’ opinions when prescribing medications—is one of the forms of medical overuse that has been associated in the literature with worse prognoses. Providers need to talk to patients in order to determine their treatment goals, which medications they might prefer, which therapies work for them, and which don’t. A one-size-fits-all approach to prescribing doesn’t work when treating geriatric patients.
Who’s ultimately responsible for ensuring patients take needed medications as prescribed?
It’s quite a challenge to manage regimens when patients are cared for by more than one provider. Primary care physicians oversee the treatment of their patients, but every member of the care team must take some responsibility in ensuring medications are used properly. There should be coordinated among team members, but, generally speaking, communication between providers is often inadequate, perhaps because they hesitate to alert each other when questions arise about a patient’s therapy. The patient care culture needs to change from more is better to less is more. It’s a point we emphasize to our patients time and again: Taking more medications doesn’t necessarily make you feel better or let you live longer.
What role do pharmacists play in that movement?
They oversee medication interactions and help decide which therapies are appropriate, and which are not. That’s critically important, especially when prescribing physicians are distracted by the details of patient care. It’s always encouraging when pharmacists inform physicians of potential medication interactions and suggest the use of alternative therapies or entirely different medication classes. I always welcome calls from pharmacists about concerns they might have about a patient’s medication regimen, and I think other physicians feel the same way. We’re very happy to receive pharmacists’ recommendations and put them into action.
Do you think enough providers are focused on the dangers of polypharmacy?
Over 20% of the geriatric population is on 10 or more medications and that’s simply not sustainable. Awareness of polypharmacy is increasing—more providers are realizing that prescribing medications for every complaint or every diagnosis isn’t necessarily the best approach. The recognition that there are many forms of overprescription is starting to set in as we see more polypharmacy-related adverse events. I don’t know of new regimens intended to optimize medication regimens, but it’s definitely a conversation we’re having within the internal medicine community. Instead of doing more to the patient, we need to do more for the patient.
Providers or pharmacists must meet with patients every six months, or at least annually, to review medication lists in order to determine if patients are on the most appropriate therapies and ensure those therapies are working as they should.