Polypharmacy Prescription: Better Interventions Needed to Reduce Risks

Interventions to address the risks older people can face taking multiple medications need significant improvement, according to a study by Cedars-Sinai investigators.

The findings are published in JAMA Network Open.

The development and use of medications to treat acute and chronic health conditions has improved longevity and quality of life. But for some older adults, taking multiple medications can do more harm than good. Polypharmacy—the use of five or more medications—is associated with a higher risk for falls, fractures, hospitalizations, along with functional and cognitive decline for some aging patients.

“Polypharmacy, especially harmful or inappropriate polypharmacy, is bad. But the research community hasn’t figured out how to consistently move the needle on hospitalizations, quality of life, mortality and other adverse outcomes associated with being on several medications at once,” said corresponding author Michelle Keller, PhD, a health services scientist in the Department of Medicine at Cedars-Sinai.

Investigators analyzed 14 studies that systematically evaluated various tactics used to address the risks of taking five or more medications. They could not find a clear set of practices that consistently helped polypharmacy patients, but some approaches showed promise.

“Intensive, face-to-face interventions were effective in some studies. In those cases, having a healthcare provider review the patient’s medical record, go over the drugs with them to discuss medication adherence or whether a drug was still appropriate, and providing patient education all appeared to reduce hospitalizations,” said senior author Joshua Pevnick, MD, co-director, Division of Informatics at Cedars-Sinai.

Adults 65 and older tend to take more medications. According to a report by the Centers for Disease Control and Prevention, about a third of adults in the U.S. who are in their 60s and 70s take five or more prescription drugs. Medications to control cholesterol, high blood pressure and diabetes are the most common.

“We must weigh the benefit of prescribing a new medication against the possible risk it may present. Can it interact with other medications the patient is taking or impact the disease course in the older adult? For example, a new medication may effectively treat a specific condition but make the person drowsy, putting them at higher risk for a fall or impair their cognitive abilities. The more tools we develop to help us assess the risk-benefit of medications for our patients, the better care we can give them,” said  Sonja Rosen, MD, chief, Section of Geriatric Medicine at Cedars-Sinai.

While time spent discussing medication use with a healthcare provider, in person, did reduce some negative polypharmacy consequences in a few studies, a simple consult with a pharmacist also proved protective in some cases.

“Older adults often develop a good rapport with their pharmacists, and in some of the studies we reviewed, relatively short consults with them were very helpful to polypharmacy patients—especially those who may be at risk for falls or cognitive decline. I think a lot of health systems are recognizing the important role a pharmacist can play in the overall healthcare of their patients,” Keller said.

Identifying who is at higher risk for adverse polypharmacy outcomes is critical in order to develop effective interventions and is the focus of a pilot program in development at Cedars-Sinai.

“We want to create a risk-prediction model using data from the electronic health records of patients seeing primary care physicians. For the polypharmacy patients we identify as being at high risk for health problems associated with their medication regimen. As a first step, we can flag the record and send a message to their physician recommending a consult with a pharmacist, as a first step,” Keller said.

The Cedars-Sinai pilot program is expected to begin this spring.

Funding: This work was supported by National Institutes of Health grant numbers K01AG076865 and K24AG047899.

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