Reducing Polypharmacy in Community-Dwelling Elderly Patients
Compared with younger patients, elderly patients are most likely to have more comorbid conditions and thus are at risk for inappropriate medication use and adverse drug reactions. Issues associated with polypharmacy and inappropriate use of medications correlate with age, comorbidity, disability, and the number of medications, as well as with an increase in the likelihood of nursing home placement, impaired mobility, morbidity, hospitalization, and death. Medications are often prescribed to elderly patients based on studies of younger patients, whose life expectancy is several decades longer, increasing the likelihood of inappropriate use in the older population; in addition, there is a higher risk-to-benefit ratio associated with increased age, comorbidity, disability, and number of medications prescribed.
The Good Palliative-Geriatric Practice algorithm for discontinuation of medications has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home residents. Researchers recently conducted a study to assess the feasibility of applying the same algorithm to community-residing elderly patients. They reported study results in Archives of Internal Medicine [2010;170(18):1648-1654]. The Good Palliative-Geriatric Practice algorithm was applied to a cohort of 70 older patients residing in the community to recommend possible drug discontinuations. Mean age of the patients was 82.8 years, 61% (n=43) were female, 26% (n=18) were defined by a geriatrician as independent and ambulatory, 57% (n=40) were defined as frail and ambulatory, and 17% (n=12) were defined as disabled (required assistance with activities of daily living).
The Mini-Mental State Examination was performed in all 70 participants; scores ranged from 0 to 30 (mean, 18.2). Of the 70 participants, 62% (n=43) had >3 diseases, 44% (n=31) had ≥4 diseases, 26% (n=18) had ≥5 diseases; 71% (n=50) had ≥3 geriatric syndromes. When these data were combined for an overall assessment of health problems (diseases + syndromes), 94% (n=66) had ≥3, 79% (n=55) had ≥4, and 51% (n=36) had ≥6. No patients were lost to follow-up following the initial medication recommendations, and the response rate to patient/family questionnaires was 100%. Mean follow-up was 19.2 months (range, 4-45 months). Initially, the 70 participants took a mean of 7.7 medications (including a mean of 0.8 vitamins or minerals per patient). Six of the patients had no basis for drug discontinuation following application of the algorithm. In the remaining 64 patients at least 1 drug was discontinued (a total of 311 medications were recommended for discontinuation); the mean number of drugs recommended for discontinuation per patient was 4.4.
Following a consultation with the patients, family, and family physicians, 82% (256 of 311) of the medications were discontinued. Six of the 256 were later readministered by the family physician. Successful discontinuation was achieved in 81% of the suggested medications. The study found that 84% of antihypertension medications could be safely discontinued. Successful discontinuation of ≥75% was achieved for other frequently used drugs including nitrates, furosemide, histamine type 2 blockers, and omeprazole. Nearly 100% successful discontinuation was achieved for benzodiazepines. There were no significant adverse events associated with discontinuation of medications, and 88% of patients reported global improvements in health. In conclusion, the researchers stated that “it is feasible to decrease medication burden in community-dwelling elderly patients. This tool would be suitable for larger randomized controlled trials in different clinical settings.”
