Polypharmacy

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POLYPHARMACY in Older Adults at Home What It Is and What to Do About It—

Implications for Home Healthcare and Hospice

Polypharmacy—the use of more medications than are clinically indicated—is a problem that affects many older adults. Adults aged 65 years and older make up approximately 13% of the population, but they consume nearly one third of all prescriptions dispensed. Older adults are more prone to adverse drug reactions and drug-drug interactions due to physiological changes and multiple comorbidities. The harm- ful effects that may be caused by the inappro- priate use of medications include but are not limited to: side effects, drug interactions, and high drug costs. Polypharmacy may lead to a decrease in quality of life. With an increase in specialization across medicine, many patients see multiple prescribers and may fill medica- tions at multiple pharmacies. This can contrib- ute to the problem of polypharmacy. Periodic medication reviews and effective and constant communication between healthcare providers and patients can help to identify potentially inappropriate medications, which is essential in aiding to reduce polypharmacy.

Gretchen I. Riker, PharmD, and Stephen M. Setter, PharmD, CDE, CGP

474 Home Healthcare Nurse www.homehealthcarenurseonline.com

vol. 30 • no. 8 • September 2012 Home Healthcare Nurse 475

P olypharmacy may be harmful and is a topic

attracting increased interest among health-

care providers, especially those who work

with older adults. Although adults age 65 and

older comprise only approximately 13% of the

population, they consume nearly one third of all

prescriptions dispensed (Vincent & Velkoff,

2010). Approximately 42 cents of every dollar

spent on pharmaceuticals is serving the older

adult, which accounts for roughly $100 billion a

year. (McCloskey, 2000; Sloan, 2012). Older adults

receiving home healthcare take an average of

eight medications daily and nearly 40% of them

use nine or more drugs (Hayes et al., 2007). Older

adults afflicted by polypharmacy are more prone

to adverse drug reactions (ADRs) and drug-drug

interactions due to physiological changes and

multiple comorbidities. Ziere et al. (2006) found

that the use of four or more drugs significantly

adds to the risk of falls in older patients. Budnitz

et al. (2011) found that 37.5% of emergency room

visits attributed to adverse drug reactions in

adults 65 years or older from 2007 to 2009 re-

sulted in hospitalization. Viktil et al. (2006)

found that there was a linear relationship be-

tween the number of medications a patient takes

and the incidence of drug-related problems. Poly-

pharmacy hurts people. The home healthcare

nurse can play an important role in helping to

recognize and treat this iatrogenic disease.

Nurses can partner with patients and providers

to work toward management of polypharmacy.

Case Study M. L. is a 79-year-old female who was re-

cently discharged from the hospital after

being admitted for fatigue and feeling like

her “heart was going to fly out of my chest.”

M. L. was diagnosed with atrial fibrillation

and congestive heart failure (HF). M. L.

spent 3 days in the hospital before being

discharged. M. L. lives alone in a small one-

bedroom home and does not have any family

nearby. She states she does have friends,

but “they call me the healthy one.” The dis-

charging physician orders home healthcare

to follow up with M. L. until she can see the

cardiologist. M. L. is now taking 13 medica-

tions by mouth (PO): aspirin 81 mg once

daily, metoprolol 50 mg twice daily, warfarin

5 mg once daily (dose adjusted based on

international normalized ratio), amlodipine

10 mg daily, lisinopril 5 mg daily, simvas-

tatin 40 mg once daily, hydrochlorothiazide

25 mg once daily, oxybutynin 10 mg once

daily, citalopram 20 mg once daily, alendro-

nate 70 mg once weekly, calcium 500 mg

twice daily, vitamin D 400 IU twice daily, and

multivitamin once daily. The first four medi-

cations are new for M. L., and she is con-

cerned about how she will pay for her

medications, as well as keeping track of all

of them. The last three over-the-counter

(OTC) medications are recommendations

from her physician.

Do you see patients such as M. L. on a regular

basis? How do you identify if she is experiencing

the harmful signs and symptoms of polyphar-

macy? And most important, what can be done to

“treat” polypharmacy?

Defining Polypharmacy: What Is It? Across the spectrum of healthcare, there are

various definitions of the term polypharmacy.

Bushardt et al. (2008) performed a literature re-

view of the various definitions of polypharmacy.

The purpose of this study was to create a con-

sensus definition. The authors concluded there

was too much ambiguity and chose to use two

common definitions: the use of six or more medi-

cations and the use of at least one potentially

inappropriate medication (based on the Beers

list from 2003). Another common definition was

the medication does not match the diagnosis. As

one can quickly observe, there are a wide range

of definitions used to identify polypharmacy,

further complicating its identification.

For the purposes of this article, the authors

will use Lee’s (1998, p. 142) definition. He states

that polypharmacy is when “more medications

are used or prescribed than are clinically indi-

cated” (Carlson, 1996; Lee, 1998; Montamat &

Cusack, 1992). This means that even if a patient

is on one medication that is not indicated, it

would be polypharmacy. A patient may also be

on a medication regimen of 15 drugs that are all

indicated and not causing adverse effects, mean-

ing this would not be polypharmacy. For a medi-

cation to be indicated, the patient needs to have

476 Home Healthcare Nurse www.homehealthcarenurseonline.com

to the older adult patient. This may lead to grave

amounts of polypharmacy. Boyd et al. (2005) ad-

dress the challenge of using practice guidelines

in older adults with multiple comorbidities and

the impact this has on the quality of healthcare

they receive. There are many other contributing

factors such as polyprescribing, greater utiliza-

tion of specialists, direct-to-consumer advertis-

ing, and longer life expectancies, leading to more

chronic disease states (Rosenthal et al., 2002).

These will be discussed in greater detail within

this article.

Polypharmacy may lead to a decreased quality

of life. Polypharmacy can lead to ADRs, falls, and

compliance issues (Sergi et al., 2011). Many stud-

ies have found an increase in ADRs with increased

medication use. Viktil et al. (2006) found an 8.6%

increase in ADRs for each drug increase on a pa-

tient’s medication regimen. This study was done

with patients on admission to an inpatient hospi-

tal facility. ADRs accounted for 30% of unplanned

hospital admission in 219 patients (75 years and

older) in a study conducted by Chan et al. (2001).

The patients admitted for ADRs were taking more

medications than those admitted for other rea-

sons. Gnjidic et al. (2012) looked at functional

outcomes (measured by the Short Performance

Physical Battery [SPPB]) of patients 70 years and

older living in a self-care retirement community.

The authors used Drug Burden Index (DBI), which

looks at anticholinergic and sedating medica-

tions. For each unit increase in the DBI, there was

a 1.7 decrease in the SPPB score, a significant dif-

ference. The use of four or more drugs was found

to significantly increase the risk of falls in older

adults (Ziere et al., 2006).

Budnitz et al. (2011) conducted a study looking

at emergency room visits due to ADRs in adults

ages 65 and older. An estimated 37.5% of emer-

gency room visits due to ADRs resulted in hospital-

ization. Almost 50% of the hospitalizations were

among patients 80 years or older. The authors

identified four medications that accounted for 67%

of these hospitalizations: warfarin, insulin, oral

antiplatelet medications, and oral hypoglycemic

agents. Within this study, they also report the

number of medications that patients are taking

concomitantly. 40.6% of patients who were hospi-

talized were between five and nine medications,

one of which was implicated in causing an adverse

drug effect. This illustrates the glaring harm poly-

pharmacy can cause.

the disease, symptom, or a risk factor for which

the medication is targeted to treat and the

medication must be appropriate for that

individual patient. Appropriateness can be as-

sessed by ensuring the medication is not causing

adverse effects to the patient and that the bene-

fits outweigh the risks.

Why Address Polypharmacy? Polypharmacy needs to be addressed because it

causes harm. It hurts people. The people most

afflicted by polypharmacy are often fragile and

vulnerable—older adults. One study (Bootman et

al., 1997) reported that for every $1 spent on

medications, $1.33 was spent on treating drug-

related problems. As a pharmacist and someone

who handles medications, this plagues me. Poly-

pharmacy is iatrogenic—a disease that is a result

of medical treatment—therefore something we

are causing as healthcare providers, something

we need to work toward avoiding.

Spending for direct-to-consumer advertising

nearly doubled from 1996 to 2000 according to

Rosenthal et al. (2002). The United States is one

of two countries, along with New Zealand, that

allow this form of advertising. Although stronger

regulations have been put in place to monitor the

type of advertising allowed, this strong form of

promotion of medications is still concerning. Pa-

tients can now learn from advertising what they

should “speak with their doctor about” in order

to treat many ailments they have. This has the

potential to increase the overuse of medications

and polypharmacy.

Along with a push to use evidence-based guide-

lines in medicine, there is a focus of using quality

indicators to measure the quantitative quality of

healthcare. Lee and Walter (2011) identify that by

2030, adults 65 years and older will represent 20%

of the U.S. population and 50% of healthcare costs

(Vincent & Velkoff, 2010). Based on this prediction,

the older adult will represent the “average” patient.

The emphasis on providing evidence-based

medicine provides a significant challenge when

caring for older adults. When caring for older

adults, healthcare providers must navigate what

may be known as an “evidence-free zone.” As

people age, they are more likely to have multiple

comorbidities, which in turn leads to less guid-

ance when choosing treatment measures. In the

absence of specific guidance from evidence, data

are extracted, often inappropriately, and applied

vol. 30 • no. 8 • September 2012 Home Healthcare Nurse 477

As will be discussed further, many older adults

do not present with the common adverse effects

associated with medications, but more of an in-

creased “off” feeling or contributions to many of

the common geriatric syndromes such as an

increase in confusion, urinary incontinence, in-

creased weakness, and changes in sleeping pat-

terns, just to name a few (Sloan, 2012). These can

often be passed over as not being a side effect of

a medication; however, they can significantly im-

pact a patient’s quality of life.

Rossi et al. (2007) bring up another point that is

not as widely discussed in the literature or medical

community, the health beliefs of the older outpa-

tient. In this study, they identified patients’ health

beliefs and the relationship this has on polyphar-

macy. Patients who believe that their health was

not determined by a “powerful other” (such as a

prescriber or other healthcare provider) were

more likely to experience polypharmacy. Patients

who did believe their health was determined by

their physicians were more likely to request writ-

ten material about their medications and ask ques-

tions. The authors conclude that there is a need

for better communication between prescribers

and patients to enhance this relationship and work

toward shared decision making.

Who Is at Risk? Older adults are the group most at risk for expe-

riencing polypharmacy. They use nearly one

third of prescription medications dispensed, and

because of multiple comorbidities many patients

are on numerous medications (Boyd et al., 2005).

This greater use of medications puts them at a

higher risk for having medications that are either

not indicated or clinically appropriate.

Transitions of care are identified as another

high-risk situation. Forster et al. (2003) reported

20% of patients experience adverse health- related

events after being discharged from the hospital to

home. Of this number, it is estimated that two-

thirds of these are medication related. About 20%

of Medicare discharges result in hospital readmis-

sions within 30 days, which costs more than $26

billion per year (Flora et al., 2012; U.S. Department

of Health and Human Services, 2011). Patients are

often discharged with new or changed medica-

tions, which can potentially cause adverse effects

not only due to polypharmacy, but also due to

medication discrepancies related to this transition

(Coleman et al., 2005; Setter et al., 2009). A lack of

communication between providers, especially

during these times of transition, can further lead

to polypharmacy.

Medication Safety Issues ADRs are a well-known problematic consequence

of prescription medications. Unfortunately, they

can often be overlooked as something that the

patient just needs to “deal with” or passed over as

being insignificant by a healthcare provider, when

they may have a profound impact on the patient’s

quality of life. Older adults are especially prone to

adverse reactions to medications due to physio-

logical changes of aging altering the effect a medi-

cation has in the body. Some of these physiologi-

cal changes include decreased muscle mass, renal

function, and organ reserve capacity making it

more difficult for the body to adapt or recovery

from injury. These changes can result in medica-

tions having more pronounced or longer effect in

the older adult. Older adults are, as has been

mentioned, more likely to take multiple medica-

tions and have multiple comorbidities, further in-

creasing their risk for ADRs. ADRs are one of the

leading causes of injury and death in the United

States (Peron & Ruby, 2012).

McLendon and Shelton (2012) suggest that

possible side effects, or symptoms, should be

investigated as drug induced, prompting a medi-

cation review. This concept has been written

about previously by Avorn (2005) and Gurwitz

(2004). This approach can help prevent what is

known as the prescribing cascade, further lead-

ing to polypharmacy. The prescribing cascade is

Many older adults do not present

with the common adverse effects

associated with medications, but

more of an increased “off” feeling or

contributions to many of the common

geriatric syndromes such as an increase

in confusion, urinary incontinence,

increased weakness, and changes in

sleeping patterns, just to name a few.

478 Home Healthcare Nurse www.homehealthcarenurseonline.com

defined as when a medication is added to treat

the side effect of another medication (Rochon &

Gurwitz, 1995). This can happen when it is not

recognized that the initial medication is causing

the side effect; thus, the side effect is viewed as a

new symptom or disease and therefore “treated.”

Sloan (2012) discusses how often times an older

patient will not report a side effect of a medication,

but rather a slight worsening of an already present

symptom or an overall “off” feeling. According to

Sloan, this “off” feeling has been described as

anything from increased confusion, falling more

frequently, more urinary incontinence, a general

malaise, or muscle weakness or fatigue.

At first glance, these patients reported “symp-

toms” may be overlooked by a physician, nurse, or

pharmacist as being a natural progression of the

aging process or a worsening of a geriatric syn-

drome, but it is important that they be viewed as

possible side effects to medications. Examples of

geriatric syndromes include falls, dizziness, delir-

ium, frailty, and urinary incontinence. In home

healthcare, nurses have the perfect opportunity to

observe their patients on a frequent and consis-

tent basis. This allows home health nurses to more

closely monitor the progression of symptoms and

note when significant worsening has occurred. This

can be reported to the appropriate primary care

provider for further investigation as to the cause.

Causes of Polypharmacy Polyprescribing may be the root cause of poly-

pharmacy. The “over” specialization of medicine,

especially among older adult patients, who often

have more comorbidities, has led to the unsafe and

inappropriate use of medications. Prescribers

rarely know every medication a patient is taking

because their patients are seeing multiple pre-

scribers, receive medications from multiple

sources (including OTC medications), and there

may be a lack of communication between each of

these providers.

As people live longer, they develop more dis-

eases, sometimes requiring more therapies. The life

expectancy in the United States has increased by

over 8 years since 1960 (Arias, 2011). There are also

more medications available on the market, offering

a greater variety of options for physicians to

choose from. Diseases that previously did not exist

or even have names now have medications used to

treat them. This has significantly altered healthcare

practice. Diseases that used to progress and even-

tually kill people, such as diabetes, HF, and chronic

obstructive pulmonary disease, all have pharma-

ceutical therapies that can be used to prevent and

slow progression often times delaying death. Al-

though these medications can have great benefit in

some people, it is important to remember they can

also cause harm, which sometimes outweighs their

potential benefit.

One of the biggest challenges when prescribing

medications for older adults, as previously men-

tioned, is that treating older adults needs more age

specific evidence. Many randomized controlled

studies, the gold standard of research, have been

done to show the benefits of medications for pa-

tients under the age of 65. Along with a lack of data

supporting the use of medications in the older

adults, many of the recommended goals used for

monitoring therapy, such as blood pressure, cho-

lesterol levels, and blood glucose levels, have not

been proven in older adults. In fact, the aggressive

treatment of blood pressure, cholesterol, and

blood glucose to the standards recommended in

younger patients has shown little or no benefit,

and in some cases harm, in older adults (Beckett et

al., 2008; Brown et al., 2003; Morley, 2011).

Why is there a lack of evidence in this popula-

tion if they consume such a large percentage of

prescription medications? In fact, some clinical

trials often exclude older adults (Boyd et al.,

2005). Drug trials are designed to eliminate out-

side factors such as comorbidities and multiple

medication use, which could potentially tangle

the findings. For this reason, older adults, espe-

cially frail older adults, are often excluded from

drug trials. However, this is still the population

that consumes one-third of medications used, so

how are decisions made to put these patients on

medications when there is such a paucity of evi-

dence? Data may be often extrapolated by pre-

scribers from studies and then applied to older

populations. Although this may be the only evi-

dence or information available in how to use the

medication in older adults, is this a safe practice?

Many would argue that the data are “stretched

too far” when a medication is studied in a younger

presumably healthier patient population and then

extrapolated and applied in an older and/or

frailer population (Boyd et al., 2005). Not only

does this raise the question of if a medication is

EFFECTIVE if used in this older population, but

if that medication is SAFE for use in this older

population?

vol. 30 • no. 8 • September 2012 Home Healthcare Nurse 479

A. Cardiovascular system 1. Digoxin at a long-term dose > 125 µg/day with impaired renal

function* (increased risk of toxicity) [Cusack et al. 1979, Gooselink et al. 1997, Haas and Young 1999].

2. Loop diuretic for dependent ankle edema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate) [Alguire and Mathes 1997, Kolbach et al. 2004].

3. Loop diuretic as first-line monotherapy for hypertension (safer, more effective alternatives available) [Williams et al. 2004].

4. Thiazide diuretic with a history of gout (may exacerbate gout) [Gurwtiz et al. 1997].

5. Non-cardioselective β-blocker with Chronic Obstructive Pulmonary Disease (COPD) (risk of increased bronchospasm) [van der Woude et al. 2005, Salpeter et al. 2005].

6. β-blocker in combination with verapamil (risk of symptomatic heart block) [BNF 2006].

7. Use of diltiazem or verapamil with NYHA class III or IV heart failure (may worsen heart failure) [BNF 2006].

8. Calcium channel blockers with chronic constipation (may exacerbate constipation) [Dougall and McLay 1996].

9. Use of aspirin and warfarin in combination without histamine H2-receptor antagonist (except cimetidine because of interaction with warfarin) or proton pump inhibitor (high risk of gastrointestinal bleeding) [Garcia Rodriguez et al. 2001, Holbrook et al. 2005].

10. Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy) [De Schryver et al. 2006].

11. Aspirin with a past history of peptic ulcer disease without histamine H2-receptor antagonist or proton pump inhibitor (risk of bleeding) [Garcia Rodriguez et al. 2001].

12. Aspirin at dose > 150 mg/day (increased bleeding risk, no evidence for increased efficacy) [Fisher and Knappertz 2006].

13. Aspirin with no history of coronary, cerebral or peripheral vascular symptoms or occlusive event (not indicated).

14. Aspirin to treat dizziness not clearly attributable to cerebro- vascular disease (not indicated).

15. Warfarin for first, uncomplicated deep venous thrombosis for longer than 6 months duration (no proven added benefit) [Pinede et al. 2001].

16. Warfarin for first uncomplicated pulmonary embolus for longer than 12 months duration (no proven benefit) [Pinede et al. 2001].

17. Aspirin, clopidogrel, dipyridamole or warfarin with concurrent bleeding disorder (high risk of bleeding) [BNF 2006].

B. Central nervous system and psychotropic drugs

1. Tricyclic antidepressants (TCAs) with dementia (risk of worsening cognitive impairment) [Smith 1998, Sommer et al. 2003].

2. TCAs with glaucoma (likely to exacerbate glaucoma) [Smith 1998, Sommer et al. 2003].

3. TCAs with cardiac conductive abnormalities (pro-arrhythmic effects) [Smith 1998, Sommer et al. 2003].

4. TCAs with constipation (likely to worsen constipation) [Smith 1998, Sommer et al. 2003].

5. TCAs with an opiate or calcium channel blocker (risk of severe constipation) [Smith 1998, Sommer et al. 2003].

6. TCA’s with prostatism or prior history of urinary retention (risk of urinary retention) [Smith 1998, Sommer et al. 2003].

7. Long-term (i.e. > 1 month), long-acting benzodiazepines, e.g. chlordiazepoxide, fluazepam, nitrazepam, chlorazepate and benzodiazepines with long-acting metabolites, e.g. diazepam (risk of prolonged sedation, confusion, impaired balance, falls) [Gray et al. 2006, Hanlon et al. 1998, Tamblyn et al. 2005].

8. Long-term (i.e. > 1 month) neuroleptics as long-term hypnotics (risk of confusion, hypotension, extrapyramidal side effects, falls) [Alexopoulos et al. 2004, Maixner et al. 1999].

9. Long-term neuroleptics (> 1 month) in those with parkinsonism (likely to worsen extrapyramidal symptoms) [Smith 1998, van de Vijver et al. 2002].

10. Phenothiazines in patients with epilepsy (may lower seizure threshold) [Alexopoulos et al. 2004, BNF 2006].

11. Anticholinergics to treat extrapyramidal sideeffects of neuroleptic medications (risk of anticholinergic toxicity) [Mintzer and Bums 2000, Tune 2001].

12. Selective serotonin re-uptake inhibitors (SSRIs) with a history of clinically significant hyponatremia (non-iatrogenic hyponatremia < 130 mmol/l within the previous 2 months) [Jacob and Spinler 2006].

13. Prolonged use (> 1 week) of first-generation antihistamines, i.e. diphenhydramine, chlorpheniramine, cyclizine, promethazine (risk of sedation and anti-cholinergic side effects) [Sutter et al. 2003].

C. Gastrointestinal system

1. Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhea of unknown cause (risk of delayed diagnosis, may exacerbate constipation with overflow diarrhea, may precipitate toxic mega-colon in inflammatory bowel disease, may delay recovery in unrecognized gastroenteritis) [Lustman et al. 1987, Thielman and Guerrant 2004].

2. Diphenoxylate, loperamide or codeine phosphate for treatment of severe infective gastroenteritis, i.e. bloody diarrhea, high fever or severe systemic toxicity (risk of exacerbation or protraction of infection) [Thielman and Guerrant 2004].

3. Prochlorperazine (Stemetil) or metoclopramide with parkin- sonism (risk of exacerbating parkinsonism) [Smith 1998].

4. PPI for peptic ulcer disease at full therapeutic dosage for > 8 weeks (dose reduction or earlier discontinuation indicated) [BNF 2006, NICE guideline 2000/022].

5. Anticholinergic antispasmodic drugs with chronic constipa- tion (risk of exacerbation of constipation) [Bosshard et al. 2004].

D. Respiratory system

1. Theophylline as monotherapy for COPD (safer, more effective alternative; risk of adverse effects due to narrow therapeutic index) [Ramsdell 1995].

Table 1. STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions

The following drug prescriptions are potentially inappropriate in persons aged ≥ 65 years of age.

*Serum creatinine > 150 µmol/l, or estimated GFR < 50 ml/min [BNF 2006].

(continues)

480 Home Healthcare Nurse www.homehealthcarenurseonline.com

Table 1. STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions (Continued )

2. Systemic corticosteroids instead of inhaled corticosteroids for maintenance therapy in moderate-to-severe COPD (unnecessary exposure to long-term side effects of systemic steroids) [Buist et al.2006, McEvoy and Niewoehner 1997].

3. Nebulized ipratropium with glaucoma (may exacerbate glaucoma) [BNF 2006].

E. Musculoskeletal system

1. Non-steroidal anti-inflammatory drug (NSAID) with history of peptic ulcer disease or gastrointestinal bleeding, unless with concurrent histamine H2-receptor antagonist, PPI or misoprostol (risk of peptic ulcer relapse) [Hooper et al. 2004].

2. NSAID with moderate-to-severe hypertension (risk of exacerbation of hypertension) [Whelton 2006].

3. NSAID with heart failure (risk of exacerbation of heart failure) [Slørdal and Spigest 2006].

4. Long-term use of NSAID (> 3 months) for symptom relief of mild osteoarthritis (simple analgesics preferable and usually as effective for pain relief) [Altman et al. 2000].

5. Warfarin and NSAID together (risk of gastrointestinal bleeding) [Battistella et al. 2005].

6. NSAID with chronic renal failure* (risk of deterioration in renal function) [Cheng and Harris 2005].

7. Long-term corticosteroids (> 3 months) as monotherapy for rheumatoid arthrtitis or osterarthritis (risk of major systemic corticosteroid side-effects) [Altman et al. 2000, Kwoh et al. 2002, Lee and Weinblatt 2001].

8. Long-term NSAID or colchicine for chronic treatment of gout where there is no contraindication to allopurinol (allopurinol first-choice prophylactic drug in gout) [Schlesinger 2004, Terkeltaub 2004].

F. Urogenital system

1. Bladder antimuscarinic drugs with dementia (risk of increased confusion, agitation) [Kay et al. 2005, Staskin 2005].

2. Antimuscarinic drugs with chronic glaucoma (risk of acute exacerbation of glaucoma) [Staskin 2005].

3. Antimuscarinic drugs with chronic constipation (risk of exacerbation of constipation) [Staskin 2005].

4. Antimuscarinic drugs with chronic prostatism (risk of urinary retention) [Staskin 2005].

5. α-blockers in males with frequent incontinence, i.e. one or more episodes of incontinence daily (risk of urinary frequency and worsening of incontinence) [Sarkar and Ritch 2000].

6. α-blockers with long-term urinary catheter in situ, i.e. more than 2 months (drug not indicated).

G. Endocrine system

1. Glibenclamide or chlorpropamide with type 2 diabetes mellitus (risk of prolonged hypoglycemia) [Cheillah and Burge 2004].

2. β-blockers in those with diabetes mellitus and frequent hypoglycemic episodes i.e. ≥ 1 episode per month (risk of masking hypoglycemic symptoms) [Cheillah and Burge 2004].

3. Estrogens with a history of breast cancer or venous thromboembolism (increased risk of recurrence) [Beral et al. 2002, Collaborative Group on Hormonal Factors in Breast Cancer 1997, Grady and Sawaya 1998].

4. Estrogens without progestogen in patients with intact uterus (risk of endometrial cancer) [Lethaby et al. 2000].

H. Drugs that adversely affect fallers

1. Benzodiazepines (sedative, may cause reduced sensorium, impair balance) [Tinetti 2003].

2. Neuroleptic drugs (may cause gait dyspraxia, parkinsonism) [Tinetti 2003].

3. First-generation antihistamines (sedative, may impair sensorium) [Sutter et al. 2003].

4. Vasodilator drugs with persistent postural hypotension, i.e. recurrent > 20 mmHg drop in systolic blood pressure (risk of syncope, falls) [Leipzig et al. 1999].

5. Long-term opiates in those with recurrent falls (risk of drowsiness, postural hypotension, vertigo) [American Geriatrics Society Panel on Persistent Pain in Older Persons 2002, Leipzig et al. 1999].

I. Analgesic drugs

1. Use of long-term powerful opiates, e.g. morphine or fentanyl as first-line therapy for mild-to-moderate pain (World Health Organization analgesic ladder not observed) [American Geriatrics Society Panel on Persistent Pain in Older Persons 2002].

2. Regular opiates for more than 2 weeks in those with chronic constipation without concurrent use of laxatives (risk of severe constipation) [Walsh 1999].

3. Long-term opiates in those with dementia unless indicated for palliative care or management of moderate/severe chronic pain syndrome (risk of exacerbation of cognitive impairment) [American Geriatrics Society Panel on Persistent Pain in Older Persons 2002].

J. Duplicate drug classes

Any duplicate drug class prescription, e.g. two concurrent opiates, NSAIDs, SSRls. loop diuretics, ACE inhibitors (optimization of monotherapy within a single drug class should be observed prior to considering a new class of drug).

Reprinted with permission from Gallagher P., Ryan, C., Byrne, S., Kennedy, J., & O’Mahony, D. (2008). STOPP (Screening Tool for

Older Persons-Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment: Concensus validation. International

Journal of Clinical Pharmacology and Therapeutics, 46(2), 76-79. Published by Dustri-Verlag.

*Serum creatinine > 150 µmol/l, or estimated GFR 20 – 50 ml/min [BNF 2006].

vol. 30 • no. 8 • September 2012 Home Healthcare Nurse 481

According to Boult and Weiland (2010), the U.S.

healthcare system is not conducive to the care of

the older adult. The authors illustrate this with a

case of an older female struggling to keep up with

her own health. A 77-year-old, she has multiple

chronic conditions, many medications, and gets

around with some difficulty. The authors highlight

the challenges she faces with multiple doctors vis-

its to various specialists and how this leads to

fragmented and incomplete healthcare. An older

patient, such as this one, may spend all their time

going from one medical appointment to another,

then to the pharmacy for medications, making

phone calls to find a specialist who will accept

their insurance—all the while not understanding

the individual aspects of their care and possibly

having some overlooked. This compounded with

an insufficient number of providers trained as geri-

atricians or in geriatrics can lead to poor health-

care, polypharmacy, and poor outcomes.

Guidelines for Medication Use in Older Adults: Three Tools Because older adults often have multiple comor-

bidities, many physicians will treat them based

on guidelines published (again, sometimes

based on studies in younger populations), lead-

ing to inappropriate use of medications, or poly-

pharmacy. Boyd et al. (2005) addresses this with

a hypothetical 79-year-old patient presenting

with five chronic disease states. Following clini-

cal practice guidelines, the patient should be

placed on 12 prescription medications. Boyd

goes on to address the concerns this presents,

primarily from a financial perspective. This

raises a concern that Steinman and Hanlon

(2010) addressed: finding a happy medium when

managing medications in a clinically complex

patient. They focus on the steps to finding this

happy medium, which will be addressed further

in part two of this article. Although Boyd et al.

(2005) were primarily focusing from a payer per-

spective, Steinman and Hanlon (2010) focus on

multiple concerns. They address the cost of

polypharmacy as well as the high risk for drug

side effects, nonadherence, and consequently

increased hospital admissions.

Three tools provide limited guidance when pre-

scribing in the older adult population. Although

there are other tools available, three are discussed

here: (1) the Beers Criteria (American Geriatrics

Society 2012 Beers Criteria Update Expert Panel,

2012), (2) the Screening Tool of Older Persons’

potentially inappropriate Prescriptions (STOPP)

(Gallagher et al., 2008), and (3) the Screening Tool

to Alert doctors to the Right Treatment (START)

(Barry et al., 2007).

The Beers Criteria are a reference that identi-

fies potentially inappropriate medications (PIMs).

It was originally developed in 1991 by a team of

geriatric specialists based on expert consensus

and has been updated by other groups in 1997,

2003, and 2012. The medications included on the

Beers Criteria are divided into three categories:

those to avoid in older adults, those to avoid in

older adults with certain diseases and syndromes

that the drugs listed can exacerbate, and medica-

tions to be used with caution. However, caution

must be used when applying this information.

For example, there are medications listed in the

Beers Criteria that are routinely used, appropri-

ately, in hospice patients or others are end-of-life.

A complete list of the Beers Criteria can be ac-

cessed online at the American Geriatrics Society

Web site: http://www.americangeriatrics.org/

health_care_professionals/clinical_practice/

clinical_guidelines_recommendations/2012.

STOPP, which was developed in 2008, is a list

of PIMs and is organized by physiological sys-

tems. This tool is based on an evidence-based,

multicenter, multicountry European study con-

ducted in an age-specific population. It ad-

dresses drug-drug interactions, drug-disease in-

teractions, medications that will increase a

patient’s risk of falls, and duplicate drug class

prescriptions. When STOPP was compared to

Beers Criteria (Hamilton et al., 2011), it was

found that STOPP identified significantly more

potentially inappropriate medications and it

identified twice as many medications that have

a relationship to hospital admissions, in the

population studied (Table 1).

START was developed in 2007 and is in-

tended to identify potentially beneficial medi-

cation omissions. It was developed through

evidence-based prescribing criteria and vali-

dated by expert providers. Even in the setting

of polypharmacy, conditions in older adults are

as likely to be undertreated as those without

polypharmacy (Steinman et al., 2006). Similarly

to STOPP, this list is organized by physiologi-

cal system. In a study conducted in a teaching

hospital, 58% of patients were found to have

omissions of medications that could be

providing benefit to these patients (Barry et al.,

2007) (Table 2).

Identifying Polypharmacy Referring back to the definition of polypharmacy

used by the authors of this article, the use of a

medication that is not indicated in a patient or is

inappropriate for that individual, the best tool is a

personal interview with the patient. Yang et al.

(2001) conducted a study comparing medication

lists obtained in a clinic versus those obtained in

follow-up home patient interview and inspection.

The authors concluded that in-home medication

lists are more complete because 48% of the clinic

medication lists had a least one omission of a regu-

lar medication. As was previously discussed, in-

home visits allow clinicians to frequently monitor

patients and identify when new symptoms or

A. Cardiovascular system

1. Warfarin in the presence of chronic atrial fibrillation [Hart et al. 1999, Ross et al. 2005, Mant et al. 2007].

2. Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated, but not aspirin [Hart et al. 1999, Ross et al. 2005].

3. Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm [Smith et al. 2006].

4. Antihypertensive therapy where systolic blood pressure consistently > 160 mmHg [Williams et al. 2004, Papademetriou et al. 2004, Skoog et al. 2004, Trenkwalder et al. 2005].

5. Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, where the patient’s functional status remains independent for activities of daily living and life expectancy is greater than 5 years [Brown and Moussa 2003, Amarenco et al. 2004, Smith et al. 2006].

6. Angiotensin converting enzyme (ACE) inhibitor with chronic heart failure [Hunt et al. 2005].

7. ACE inhibitor following acute myocardial infarction [ACE Inhibitor Myocardial Infarction Collaborative Group 1998, Antman et al. 2004].

8. β-blocker with chronic stable angina [Gibbons et al. 2003].

B. Respiratory system

1. Regular inhaled β2-agonist or anticholinergic agent for mild- to-moderate asthma or COPD [Buist et al. 2006].

2. Regular inhaled corticosteroid for moderate/severe asthma or COPD, where predicted FEV1 < 50% [Buist et al. 2006].

3. Home continuous oxygen with documented chronic type 1 respiratory failure (pO2 < 8.0 kPa, pCO2 < 6.5 kPa) or type 2 respiratory failure (pO2 < 8.0 kPa, pCO2 > 6.5 kPa) [Cranston et al. 2005, Buist et al. 2006].

C. Central nervous system

1. L-DOPA in idiopathic Parkinson’s disease with definite functional impairment and resultant disability [Kurlan 1998, Danisi 2002].

2. Antidepressant drug in the presence of moderate/severe depressive symptoms lasting at least three months [Lebowitz et al. 1997, Wilson et al. 2006].

D. Gastrointestinal system

1. Proton pump inhibitor with severe gastroesophageal acid reflux disease or peptic stricture requiring dilation [Hungin and Raghunath 2004].

2. Fiber supplement for chronic, symptomatic diverticular disease with constipation [Aldoori et al.1994].

E. Musculoskeletal system

1. Disease-modifying antirheumatic drug (DMARD) with active moderat/severe rheumatoid disease lasting > 12 weeks [Kwoh et al. 2002].

2. Bisphosphonates in patients taking maintenance corticosteroid therapy [Buckley et al. 2001].

3. Calcium and vitamin D supplement in patients with known osteoporosis (previous fragility fracture, acquired dorsal kyphosis) [Gass and Dawson Hughes 2006].

F. Endocrine system

1. Metformin with type 2 diabetes ± metabolic syndrome (in the absence of renal impairment*) [Mooradian 1996, Johansen 1999].

2. ACE inhibitor or angiotensin receptor blocker in diabetes with nephropathy, i.e. overt urinalysis proteinuria or microalbuminuria (>30mg/24 hours) ± serum biochemical ranal impairment* [Sigal et al. 2005].

3. Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors (hypertension, hypercholesterolemia, smoking history) [Sigal et al. 2005].

4. Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present [Sigal et al. 2005].

Table 2. START: Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatments.

These medications should be considered for people ≥ 65 years of age with the following conditions, where no contraindication to prescription exists.

*Serum creatinine > 150 µmol/l, or estimated GFR < 50 ml/min [BNF 2006].

Reprinted with permission of Oxford University Press from Barry, P. J., Gallagher, P., Ryan, C., & O’Mahony, D. (2007). START

(Screening Tool to Alert doctors to the Right Treatment): An evidence-based screening tool to detect prescribing omissions in

elderly patients. Age and Ageing, 36, 632-638 doi: 10.1093/ageing/afm118

482 Home Healthcare Nurse www.homehealthcarenurseonline.com

clinical changes have occurred. Complete informa-

tion from the prescribers and patient can be used

to assess the use of each medication and medica-

tion regimen as a whole, helping to identify poly-

pharmacy. This will also be developed in depth in

the second part of this article.

Several tools have been developed to aid in

identifying polypharmacy: (1) Comprehensive

Geriatric Assessment (CGA), (2) Medication

Appropriateness Index (MAI), and (3) Assess-

ing Care of Vulnerable Elders (ACOVE). All

three tools provide a conceptual approach that

can be applied in various ways within various

settings.

CGA takes a holistic approach to the patient

assessment evaluating clinical, functional, cog-

nitive, nutritional, and social parameters using

multiple disciplines. This allows for a global

assessment that can provide better long-term

care for patients. It incorporates assessments

from a multidisciplinary team including nurses,

occupational and physical therapists, social

workers, general practitioners, geriatricians,

and pharmacists. Unfortunately, despite the

use of CGA, polypharmacy continues to be a

problem, which needs further attention (Sergi

et al., 2011).

MAI, initially developed in 1992 by Hanlon et

al., is a 10-component assessment tool to evalu-

ate the appropriateness of medications used in

older patients. The components that are included

in these criteria include efficacy (as defined in

clinical practice guidelines), drug dosage, inter-

actions, cost, and duplications (Table 3).

Table 3. Medication Appropriateness Index

To assess the appropriateness of the drug, please answer the following questions and circle the applicable score:

1. Is there an indication for the drug? Comments:

1 2 3 9 DKIndicated Not Indicated

2. Is the medication effective for the condition? Comments:

1 2 3 9 DKEffective Ineffective

3. Is the dosage correct? Comments:

1 2 3 9 DKCorrect Incorrect

4. Are the directions correct? Comments:

1 2 3 9 DKCorrect Incorrect

5. Are the directions practical? Comments:

1 2 3 9 DKPractical Impractical

6. Are there clinically significant drug–drug interactions? Comments:

1 2 3 9 DKInsignificant Significant

7. Are there clinically significant drug–disease/condition interactions? Comments:

1 2 3 9 DKInsignificant Significant

8. Is there unnecessary duplication with other drug(s)? Comments:

1 2 3 9 DKNecessary Unnecessary

9. Is the duration of therapy acceptable? Comments:

1 2 3 9 DKAcceptable Unacceptable

10. Is this drug the least expensive alternative compared to others of equal utility? Comments:

1 2 3 9 DKLeast expensive Most expensive

Note: DK = don’t know. Complete instructions in the use of the scale are available upon request. Reprinted from Journal of Clinical Epidemiology, 45 (10), Hanlon, J. T., Schmader, K. E., Samsa, G. P., Weinberger, M., Uttech, K. M., Lewis, I. K., …, Feussner, J. R., A method for assessing drug therapy appropriateness, 1045-1051, Copyright 1992, with permission from Elsevier.

vol. 30 • no. 8 • September 2012 Home Healthcare Nurse 483

484 Home Healthcare Nurse www.homehealthcarenurseonline.com

The ACOVE project (Wenger et al., 2001) was

designed with several goals in mind, one of which

was to list the medical conditions that affect this

group. Appropriate use of medications is one of

the 22 categories that this group identified as

being a medical condition in this population. A

complete list of the ACOVE quality indicators can

be accessed online at: http://www.annals.org/

content/135/8_Part_2/653.full.pdf+html.

Implications Polypharmacy is a disease plaguing many older

adults. It can have a significant impact on quality

of life by causing ADRs, falls, increased hospital-

izations, and overall feelings of malaise. It is the

responsibility of healthcare providers to identify

and address this problem and work toward iden-

tifying medications that are not being used safely

and causing harm in this vulnerable, sometimes

fragile population. Home healthcare and hospice

clinicians can play an important role in monitor-

ing and advocating for their patients. In the next

part of this article, a clinician’s response when

polypharmacy is suspected as well as some of

the possible solutions, or “treatments,” for poly-

pharmacy will be addressed.

Gretchen I. Riker, PharmD, is an Assistant Clinical

Professor of Pharmacy Practice in Geriatrics, School

of Pharmacy and Health Professions, University of

Maryland Eastern Shore, Princess Anne, Maryland.

Stephen M. Setter, PharmD, CDE, CGP, is a

Geriatric Clinical Pharmacist, Spokane, Washington.

The authors and planners have disclosed that they

have no financial relationships related to this article.

Address for correspondence: Gretchen I. Riker,

PharmD, 1 Backbone Rd., Somerset Hall, Room

107, University of Maryland Eastern Shore, Prin-

cess Anne, MD 21853 ([email protected]).

DOI:10.1097/NHH.0b013e31826502dd

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