VOL: 99, ISSUE: 17, PAGE NO: 54
Anne Bretherton, MSc, MRPharmS, BSc, is pharmacy and prescribing adviser, Dartford Gravesham and Swanley Primary Care Trust;
Liz Day, MA(Gerontology), PGCEA, BA, RGN, HV, DN(Cert), is elderly care nurse adviser, Dartford Gravesham and Swanley Primary Care Trust andGillian Lewis, BSc, RGN, RM, DN(Cert) is nurse practitioner/practice nurse adviser, Gravesend Medical Centre, Dartford Gravesham and Swanley Primary Care Trust
Polypharmacy is defined as the practice of prescribing four or more medications to the same person (Department of Health, 2001). This often occurs with older people who have concurrent disease processes, each needing a specific treatment regime (Box 1). Older people receive more prescriptions per head than any other group. The National Service Framework for Older People (DoH, 2001) shows that 5-17 per cent of hospital admissions are caused by adverse reactions to medicines. It also indicates that 6-17 per cent of older patients in hospital experience adverse drug reactions.
Managing multiple health problems
Some older people have multiple health problems. The prevalence of hypertension in those over 60 years is 50 per cent (Ramsey et al, 1999) and it is suggested that the number of people with diabetes will double by 2010 (DoH, 2002). Hypertension, diabetes, obesity and smoking are all risk factors for cardiovascular disease, ischaemic heart disease and stroke.
Managing multiple health problems creates a tension for prescribers between the need to treat common conditions while avoiding the risks associated with polypharmacy. These tensions are evident in the National Institute for Clinical Excellence guidance on the medical management of conditions such as hypertension, hyperlipidaemia, diabetes and cardiovascular disease. Although NICE emphasises the need for health promotion and lifestyle change for patients with these health problems, recommendations for prescribed medicines for any one patient could include: up to three different anti-hypertensives; drugs for glycaemic control; aspirin; and statins for lipid control. It is important to consider that the number of medicines could be further increased if patients have other diseases.
Problems associated with polypharmacy
The hazards of prescribing include causing secondary morbidity from unnecessary or inappropriate medicines and drug incompatibility. Problems can also occur when patients have a poor understanding of the purpose of their medicine regime and how to take their medicines.
The effects of polypharmacy
There are age-related physiological changes that alter the ways in which drugs are handled by the body. Pharmacokinetics describes what happens to a drug in the body from the point of administration, absorption, distribution, metabolism and excretion. Pharmacodynamics describes what the drug does to the body (Heath and Schofield, 1999). Pharmacokinetics and pharmacodynamics may both be altered by the ageing process.
Age-related changes that are relevant to pharmacokinetics include:
- Reduced renal function;
- Reduced liver function;
- Reduced ratio of body fat to water;
- Delayed stomach emptying.
Age-related factors that are relevant to pharmacodynamics include:
- Toxicity of the drugs and interactions between different drugs;
- Site of action;
- Response of the body to the drugs.
The effect of altered biophysiology may result in the older person being unable to tolerate the medications prescribed to them in the recommended doses. They may experience side-effects and the combinations of medicines taken together may cause iatrogenesis. For example, some drugs can cause confusion, increase the risk of falls or reduce salivary secretions. In addition, polypharmacy may severely affect quality of life and well-being (Box 2). It is, therefore, important that the nurse is aware of the possible side-effects of prescribed medicines and can act on this knowledge.
Why polypharmacy happens
Reasons for polypharmacy are complex and may include one or all of the factors listed below:
- Multiple pathology;
- The use of repeat prescriptions, which may result in a lack of direct patient contact between prescriber or pharmacist;
- Computerised records not being updated after home visits where prescriptions are issued;
- Poor communication between health care providers;
- Lack of knowledge about ageing;
- Use of NICE and NSF guidelines without considering the individual’s needs.
When a prescribing guideline is used it is important to weigh up the potential risks to the individual patient. It is essential that every effort be made to keep the number of medicines prescribed to manage chronic health problems to a minimum and that clear and simple regimes are created and are reviewed regularly. (Medicines Partnership, 2002; DoH, 2001).
Undertaking a medicines review
The NSF for older people recommends that medicines reviews are undertaken every six months when patients aged 75 years and over are prescribed more than four medicines, and annually for patients prescribed fewer than four medicines, to evaluate effectiveness and changing needs (DoH, 2001).
Reviews should include a face-to-face interview between the health professional and patient to review every medication they are taking. Room for Review (Medicines Partnership, 2002) provides helpful information on how to undertake reviews and should be essential reading for all those involved in the prescribing and administration of medicines.
The Department of Health has also recommended that by 2004 every primary care trust will have schemes in place that will enable people to obtain more help from pharmacists in using their medicines (DoH, 2000).
The role of nurses and pharmacists
There are many ways in which nurses and pharmacists can contribute to the reduction in the number of prescribed drugs including taking a lead role in the management of chronic health problems.
Practical measures include:
- Supported self-administration of medications for people in hospital;
- Evaluating how the patient manages to take prescribed medicines;
- Being alert to unexpected interactions, and effects of medicines (Mallett and Dougherty, 2000);
- Providing written materials for patients, that complement pharmaceutical leaflets with larger print and good colour contrast between paper and print for people with poor vision;
- Verifying that the patient understands and agrees to the regime;
- Advising on lifestyle changes that may reduce the need for medication and combat the side-effects of necessary medicines;
- At times of illness, older people may experience temporary cognitive problems, and nurses must be acutely aware of the need to provide prompts and aids so the patient can revise, rehearse and remind themselves about their medicines. Alternatively, carers may take responsibility and will need information and advice.
There is potential for polypharmacy to occur when a patient is discharged from hospital due to poor communication between primary and secondary care. When a patient is discharged from hospital, information sent to the GP, care home and community staff must clarify whether the new medicine regime replaces or is taken with any previously prescribed medications.
Nurses and pharmacists can play an important part in prevention, health promotion and the management of common physical problems such as constipation, insomnia and pain relief, which can avoid the use of prescribed medicines.
Older people can benefit from many of today’s medicines, but adverse reactions and side-effects can jeopardise their health. Prescribers, pharmacists, therapists and nurses can contribute to the reduction of the need to prescribe medicines, and polypharmacy can be managed by regular medication reviews.