Polypharmacy is a major public health problem in the United States and abroad. Although there is no standard definition of polypharmacy, I see and recognize it every day in the outpatient and inpatient environment. A typical example that I saw yesterday was an 84-year-old man admitted to our internal medicine service for worsening heart failure. He had a list of 14 different medicines that he claimed to be ingesting each day. This list even included 2 different β-blockers! In addition, he was taking significant quantities of an over-the-counter nonsteroidal anti-inflammatory agent, which had caused deterioration of his renal function and was a major factor in his worsening heart failure. I see patients like this literally every day, and I believe that the readers of this editorial will concur: polypharmacy is as common as dirt (!!), and it leads to a multitude of potentially dangerous adverse reactions, many of which result in hospitalization. Polypharmacy is not just a problem in the United States; it rears its ugly head in all resource-rich countries where patients, particularly elderly individuals, have ready access to prescription and over-the-counter drugs.
The extent and implications of polypharmacy were extensively reviewed in 2007 by Hajjar et al.1 They reviewed the MEDLINE database (1986-June 2007) and the International Pharmaceutical Abstracts (1986-June 2007) and found 21 articles dealing with polypharmacy in elderly patients. These studies consistently documented the multiplicity of negatives associated with geriatric polypharmacy: large numbers of adverse events, potentially dangerous drug–drug interactions, increased morbidity and mortality directly related to excessive consumption of multiple pharmaceutical products, increased cognitive dysfunction and urinary incontinence, and augmented balance problems with associated increased risk for falls. This is truly a frightening collection of negative consequences.
Today almost all physicians in the United States and abroad recognize polypharmacy as a major health problem, and so one would expect that following the review of Hajjar et al and others1, 2, 3, 4, 5 there would have been serious attempts to decrease the use of too many drugs in elderly patients. Unfortunately, the situation has not improved. In this issue of The American Journal of Medicine, Morin et al6 report on the burden of polypharmacy in Sweden, a country with an outstanding, universal, national health service. All drugs prescribed in the country are followed in the Swedish Prescribed Drug Register. Consequently it is possible to track how many drugs any 1 Swedish citizen is taking or supposed to be taking. Morin et al6 identified more than 500,000 older adults (>65 years) who died in Sweden between 2007 and 2013. They reviewed their drug prescription history for the last 12 months of their lives. Over that short period the percentage of patients taking 10 or more drugs rose from 30.3% to 47.2%. In other words, during the last year of their life nearly half of the citizens of Sweden who died were taking 10 or more drugs, truly a frightening statistic when one considers the possible negative consequences of polypharmacy in elderly individuals.
A second important observation in the study of Morin et al6 was that many of the drugs prescribed were given for long-term preventive therapy, for example, statins or antihypertensive medications. Given that many of these patients were chronically and severely ill and not expected to live for many more years, the value of preventive medicine at that stage of life is clearly questionable. For example, it is likely that moderate hypertension will not harm an elderly patient with end-stage disease. Therefore, an aggressive antihypertensive medication program in such a patient is not needed.
Recognition of the problems associated with polypharmacy is widespread. Solutions to this problem are much less commonly recognized. In the review of Hajjar et al,1 a number of interventions were observed to be of modest benefit in reducing the number of prescription drugs in elderly patients who were identified as victims of polypharmacy. One study cited by them involved supplying a medicine grid to residents who were discharging patients.2 The grid showed the full number of medications and the times of administration of these drugs. Once the residents saw the complexity of their patients’ medical protocols, significant reductions occurred in the number of medications and the frequency of administration. Several other studies used letters to patients requesting that they review their medication list with their primary care doctor or consult with their pharmacist about the number and nature of their prescribed medications.3, 4, 5 Each of these studies documented a reduction in the number and complexity of the medications prescribed.
Perhaps the most effective approach is for each of us who see patients on a daily basis to review patient medications carefully and eliminate as many unnecessary and duplicative agents as possible. In my own practice I review all of the patient’s medications with them at each visit, and I see this as one of the most important components of that individual’s visit with me.
As always, I welcome comments to this editorial on our blog at amjmed.org.
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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
This article originally appeared in the August 2017 issue of The American Journal of Medicine.
