Polypharmacy is the use of multiple medications by a patient, particularly when too many forms of medication are used by a patient, when more medications are prescribed than are clinically warranted, or when all of an individual’s medications are not clinically necessary. While there is no set number of medications that defines polypharmacy, the term is often used when a person uses five or more medications concurrently. However, polypharmacy can be present for someone on three medications, depending on the circumstances. Polypharmacy is particularly common in older adults due to the prevalence of multiple chronic conditions in this population. It is important for healthcare providers to regularly review all of a patient’s medications to ensure they are all necessary and beneficial. [AC_PRO id=913]

Problems arising

1. Increased risk of adverse drug reactions: The more medications a person takes, the higher the likelihood of potential drug interactions, which can lead to adverse effects.
2. Drug-Drug interactions: Some medications can interact with each other in harmful ways, altering the effectiveness of one or both drugs, or causing unexpected side effects.
3. Drug-Disease interactions: Certain medications can exacerbate existing health conditions. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen hypertension and kidney disease.
4. Medication non-adherence: Managing multiple medications can be complex, leading to mistakes in medication administration, such as taking the wrong dose or forgetting to take a medication.
5. Increased healthcare costs: Polypharmacy can lead to higher healthcare costs due to the need for additional medical attention and hospital admissions related to adverse drug reactions.
6. Reduced quality of life: The side effects and drug interactions from multiple medications can negatively impact a person’s quality of life.
7. Increased risk of falls: Some medications, particularly those affecting the central nervous system (like sedatives or antipsychotics), can increase the risk of falls, especially in older adults.
8. Cognitive impairment: Some medications can contribute to cognitive impairment or confusion, particularly in older adults. This can lead to issues with medication management, further increasing the risk of adverse drug reactions or interactions.
9. Nutrient depletion: Certain medications can affect the absorption or utilisation of nutrients in the body, potentially leading to deficiencies over time.
10. Inappropriate medication use: In some cases, polypharmacy can result from inappropriate prescribing, such as when a new medication is prescribed to manage the side effects of a current medication rather than addressing the root cause of the symptom. Unlicensed medications may have been prescribed without due care.
11. Iatrogenic dependence: Refers to a state of dependence on a substance (usually a medication) that is caused by medical treatment or advice. This can occur when a patient is prescribed a medication for a legitimate medical reason, but over time develops a physical or psychological dependence on the medication. In the context of polypharmacy, iatrogenic substance dependence can become a significant issue. This is particularly true when the medications involved have addictive potential, such as opioids for pain management, benzodiazepines for anxiety, or certain stimulants used for attention deficit disorders. Here is how this can happen:

1. 1. Tolerance: Over time, the body can become accustomed to certain medications, requiring higher doses to achieve the same effect. This can lead to increased use and potential dependence.
   2. Withdrawal: Some medications can cause withdrawal symptoms when stopped abruptly, which can make it difficult for patients to discontinue their use even if they are no longer medically necessary.
   3. Overprescribing: In some cases, medications may be prescribed for longer than necessary, or in higher doses than needed, which can contribute to dependence.
   4. Inadequate Monitoring: Without regular review of all a patient’s medications, it can be easy to miss signs of dependence.

To prevent iatrogenic substance dependence, healthcare providers should be cautious when prescribing potentially addictive medications, use the lowest effective dose, regularly review the patient’s medication regimen, and monitor for signs of dependence. It is also important to educate patients about the risks and signs of dependence. Notably during the pandemic period standards of prescribing appeared not to be given due attention.

Managing polypharmacy

Recognition of a problem is the first important step. Reversing or managing polypharmacy involves a systematic approach that includes regular review and monitoring of all medications a patient is taking.  Here are some strategies that can be employed:

1. Systemic issues: Addressing systemic issues that led to polypharmacy need to be recognised and addressed if any of the following are to have traction.
2. Medication review: This is the first and most important step. A healthcare provider should regularly review all of a patient’s medications (including prescription drugs, over-the-counter medications, and supplements) to determine if they are all necessary and if they are at the lowest effective doses.
3. Deprescribing: This is the process of tapering, stopping, discontinuing, or switching off unnecessary medications under a healthcare provider’s supervision. The goal is to reduce the medication burden and potential for adverse drug reactions while maintaining or improving quality of life.
4. Patient education: Patients should be educated about their medications, including what each one is for, how to take it, potential side effects, and what to do if a dose is missed. They should also be encouraged to ask questions and report any side effects or concerns.
5. Health workers’ education: All staff should be educated or re-educated about the problems created by polypharmacy. They should be provided with clear guidelines on what to do, if or when they come across it.
6. Close monitoring: After changes are made to a patient’s medication regimen, close monitoring is necessary to watch for withdrawal symptoms, return of symptoms the medication was managing, or other adverse effects.
7. Collaboration among healthcare providers: If a patient sees multiple healthcare providers, it is important for them to communicate and coordinate the patient’s care to avoid unnecessary or conflicting medications.
8. Application of clinical guidelines: Healthcare providers should follow clinical guidelines for prescribing medications, particularly for older adults and those with multiple health conditions.
9. Pharmacist involvement: Pharmacists can play a key role in managing polypharmacy by providing medication reviews, patient education, and recommendations for deprescribing.
10. Advocacy: In the UK advocates have traditionally had minor involvement in medication reviews. Changing the cultural pattern means that advocates should be educated about polypharmacy so that they can ask relevant questions on behalf of those they represent.
11. Technology: Electronic health records and other technology can help track medications and flag potential interactions or other issues.

Changes to medication should always be done under the supervision of a healthcare provider. It is important for patients to never attempt to stop or reduce their medications without professional guidance.

Takeaway points

1. Polypharmacy refers to the use of multiple medications by a patient, particularly when more drugs are prescribed than are clinically warranted. It is often used when a person uses several medications concurrently.
2. Health risks of polypharmacy include adverse drug reactions, drug-drug interactions, drug-disease interactions, increased risk of falls, cognitive impairment, nutrient depletion, decreased functional status and quality of life, increased healthcare utilisation and costs, and medication non-adherence.
3. Iatrogenic substance dependence can occur due to polypharmacy, particularly when the medications involved have addictive potential. This can lead to physical and mental health risks, withdrawal symptoms, increased sensitivity to pain, falls and fractures, poor quality of life, and increased healthcare utilisation and costs.
4. Reversing polypharmacy involves a systematic approach that includes regular review and monitoring of all medications a patient is taking. Strategies include medication review, deprescribing, patient education, close monitoring, collaboration among healthcare providers, use of clinical guidelines, pharmacist involvement, re-education, advocacy involvement and the use of technology.
5. Regular review: It is important for healthcare providers to regularly review all of a patient’s medications to ensure they are all necessary and beneficial. Patients should never attempt to stop or reduce their medications without professional guidance.