In the second of a series from 360info on prescription drug use, Professor Simon Bell looks inside the bathroom cupboard of the elderly
Up to 250,000 hospital admissions each year in Australia are linked to problems with medications.
As we age and our health begins to suffer, the simple solution would seem to be to take medications to address our ailments. But that can quickly lead to a bathroom cabinet full of medications and unintended adverse health consequences.
The reasons for how overprescribing occurs, and why multiple medications can cause problems are complex, but the underlying problem is not going away anytime soon.
Many developed nations have high and increasing rates of people with multiple chronic health conditions requiring ongoing medication.
Data from the United States National Health and Nutrition Examination Survey suggest more than 90 percent of people aged 65 years and older have two or more health conditions. On the other side of the Pacific, the Australian Institute of Health and Welfare estimates half of all Australians aged 65 years and older have two or more chronic health conditions.
Not only does each condition typically result in a medication being prescribed to treat it, clinical practice guidelines used by health professionals increasingly advocate combining different medications for the best therapeutic result.
Unsurprisingly, this has led to people taking multiple medications each day, a phenomenon known as “polypharmacy”, which can be defined as the concurrent use of five or more medications in the community setting, or nine or more medications in the residential aged care setting.
This may be necessary to best manage chronic health conditions but it is not without inherent – and sometimes hidden – risks.
For the most part, prescribing multiple medications has been driven by results of randomised controlled trials demonstrating the benefits of medication treatments.
However, participants in these trials have often been younger and healthier than the average person prescribed these medications in practice. The benefits and risks of medications prescribed to frail older people with multiple chronic health conditions may be different to benefits and risks among the randomised controlled trial participants.
Polypharmacy and complex medication regimens can be baffling to patients and increase the workload for carers, often those least able to manage their medications.
Research by Australia’s NPS MedicineWise, for example, suggests two-thirds of Australians aged 75 years or older use five or more conventional or complementary medications each day.
With multiple daily dosing, different medication formulations – some as tablets, inhalers, or patches – and special instructions for medication administration such as take half a tablet on an empty stomach before meals, it is easy to see why up to one-third of residents of aged care facilities have their medications administered on five or more occasions each day.
Unravelling the problem
While this all might seem to be worth it if it means keeping patients well, the irony is that neither polypharmacy nor complex medication regimens necessarily lead to good health results for patients.
Polypharmacy increases the risk of drug-drug interactions and adverse drug events while complex regimens can increase the risk of medication administration errors, particularly in people with dementia, who are frail, or who may have difficulty self-managing their own medications.
It is difficult to over emphasise the scale of the problem. The Pharmaceutical Society of Australia (PSA) estimates that up to 250,000 hospital admissions each year in Australia are due to problems with medications. Work is underway to address it. The World Health Organisation made “Medication without Harm” the topic of its Third Global Patient Safety Challenge and in 2019, quality use of medicine and medicine safety was declared an Australian National Health Priority Area.
Healthcare professionals around the world are also recognising that not all polypharmacy and medication regimen complexity is necessary.
It may be possible to discontinue or “deprescribe” medications that are no longer consistent with a person’s goal of care. Regular medication reviews performed by pharmacists and general medical practitioners can help identify unnecessary or inappropriate medications for which the benefits no longer outweigh the risks. In Australia, however, government-funded, collaborative medication reviews remain under-utilised both in the community and in residential aged care settings.
Simplifying a person’s medication regimen can also be achieved through strategies, which do not necessarily mean changing the therapeutic intent.
In some cases, for example, it is possible to reduce the number of daily administration times by administering different medications at the same time each day or by prescribing combination products that include two or more active ingredients in the same tablet or capsule.
In other cases, it is possible to use long-acting formulations dosed once per day instead of using multiple short-acting products requiring multiple daily dosing.
There have been a number of recent practice and policy developments to improve medication safety.
Australia’s National Aged Care Mandatory Quality Indicator Program has included a polypharmacy indicator (nine or more regular medications) since July 2021, and public-sector residential aged care services in the Australian state of Victoria now monitor the proportion of residents with more than four daily medication administration times.
If used proactively to provide feedback to clinicians, these data can help inform and evaluate improvements.
Better use of digital health applications, specifying the intended treatment duration on prescriptions, and including information on treatment discontinuation in drug information resources for prescribers could also help.
Advances in the availability of anonymised electronic health record data for research can help address evidence-practice gaps arising from under-representation of older people and those with multiple chronic health conditions in randomised controlled trials of specific medications.
Research using routinely collected hospital and dispensing data is also a promising area for improving safe and effective medication use. This research will form the basis of more nuanced treatment recommendations that will better serve the needs of those most vulnerable to being harmed by medication.
Originally published under Creative Commons by 360info™.
Professor Simon Bell is Director of the Centre for Medicine Use and Safety, Monash University.
The author has received grant funding or consulting funds from the National Health and Medical Research Council (NHMRC), Medical Research Future Fund (MRFF), Victorian Government Department of Health, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged care provider organisations. All grants and consulting funds were paid to the employing institution.