POLYPHARMACY IN GERIATRICS

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About Authors:
T. Vishnuvaravidyadhar*, M. Sushma, R. Mohanraj, M. Babu  
Department of Pharmacy Practice,
Raghavendra Institute of Pharmaceutical Education & Research, RIPER
K R Palli Cross, Near S.K University,
Anantapuramu District, Andhra Pradesh, INDIA

*vishnuvaravidyadhar@gmail.com

Abstract:
Geriatrics is more prone to higher risks of chronic illness and are using multiple medications in order to lead healthy life. Polypharmacy increases the risk of adverse drug events, as a result changes takes place in physiological, social, physical and functional decline in the body. These rapid physiological changes make elderly patients unable to cope with body stresses. Drug toxicity, side effects and adverse drug reactions appear more frequently and are more life-threatening in elderly patients. Tetracyclins, streptomycin, reserpine, and all barbiturates are to be contraindicated in geriatrics in order to prevent further complications. Polypharmacy is the simultaneous taking of many medications, has been well documented and is a topic of much concern for those looking to improve the quality of care for the elderly. Elderly patients often develop complicated conditions and multi-factorial health states that require extensive pharmacotherapy, sometimes surgery leaving the population at risk for exposure to drug-drug interactions, drug-food interactions and other adverse events. Previously literature states that rate of adverse events are directly proportional to number of drugs taken by the patient. To manage all these complications and to avoid polypharmacy Dose regimen should be simple and drugs should be given in combinations to improve patient compliance.

REFERENCE ID: PHARMATUTOR-ART-2158

PharmaTutor (ISSN: 2347 - 7881)

Volume 2, Issue 5

Received On: 04/03/2014; Accepted On: 17/03/2014; Published On: 01/05/2014

How to cite this article: TVV Vidyadhar, M Sushma, R Mohanraj, M Babu; Polypharmacy in Geriatrics; PharmaTutor; 2014; 2(5); 179-184

INTRODUCTION

What is Polypharmacy:
“Polypharmacy is the concurrent use of multiple medications. It can be associated with the prescription and use of too many or unnecessary medicines at dosages or frequencies higher than therapeutically essential. However, multiple medications are often necessary and can constitute best care for patients.” [1][6]

Types of polypharmacy[4]:

Appropriate polypharmacy
Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimized and the medicines are prescribed according to best evidence. The overall intent for the combination of medicines prescribed should be to maintain good quality of life, improve longevity and minimize harm from drugs.

Problematic polypharmacy
Where multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realized. The reasons why prescribing may be problematic may be that the treatments are not evidence-based, or the risk of harm from treatments is likely to outweigh benefit, or where one or more of the following apply:
Ø  The drug combination may be hazardous because of interactions.
Ø  The overall demands of medicine-taking, or ‘pill burden’, are unacceptable to the patient.
Ø  These demands make it difficult to achieve clinically useful medication adherence (reducing the ‘pill burden’ to the most essential medicines is likely to be more beneficial).
Ø  Medicines are being prescribed to treat the side effects of other medicines where alternative solutions are available to reduce the number of medicines prescribed.

Geriatrics: Is the branch of general medicine concerned with the clinical preventive remedial and social aspects of illness in the elderly. The term geriatrics refers to patient’s age 65 years or over.[3] However, the physiological changes that occur with ageing or progressive, occurring gradually over a lifetime rather than abruptly at any given chronological age, so the choice of ‘65 years’ is a relatively arbitrary one, and the definition is sometimes extended to include people aged 60 years and over [3]. The ageing population given below in table (T-1).

(T-1) The ageing population[3][4]

Country


Percentage

U S A

100 years ago

<2% of population over 65 years of age.

1990

13% of population over 65 years of age.

by 2050

Predicted to reach 20%.

India

1951-1995

5.5-7%

Current scenario

65 million people

Age related changes in geriatrics[5][6]:
1. Advance age brings inevitable changes like slow muscular atrophy.
2. There is 20-30% decrease in lean body mass, especially from 30-80 years of age.
3. Fat-free mass diminishes from 60-80%.
4. Fat increases with age especially in men from 18-36%.
5. Cellular mass decreases from 30-65%.
6. Albumin pool is reduced by 20%.
7. After 20 years of age cerebral function starts declining, slowly upto 75 years of age, and slowly deteriorates.
8. Reduction in motor function, often leads to vehicular accidents.
9. Visual and auditory degeneration causes misunderstanding and confusion.
10.  All the above changes together, contribute to interrelated complexes and to what is, known as, ‘old age syndromes’.

REASONS FOR CAUTION WHEN USING MEDICATION IN THE ELDERLY [3][4]

Increased prevalence of disease
The prevalence of many diseases increases with advancing age and as a result elderly people often suffers from multiple co existing medical conditions. Common diseases and health related programs in the elderly are tabulate in table given below (T-2).

(T-2) Common diseases and health problems affecting the elderly[3][4]

1. Cancer
2. Cerebrovascular diseases
3. Cardiovascular diseases
4. Chronic bronchitis, chronic obstructive airway disease
5. Constipation
6. Dementia
7. Depression
8. Infectious diseases (UTI,RTI)
9. Impaired mobility and falls
10.  Osteoporosis
11.  Malnutrition and related problems
12.  Visual and hearing impairment

Polypharmacy[3][4]
As a result of increased disease prevalence, older people tend to use more medications compared to younger people. For example, in Australia people over the age of 65 comprise 12% of the population, yet 40% of all prescriptions dispensed are for this age group. The term polypharmacy has been used to describe the prescription or use of multiple medications. Increasing the number of medications prescribed has been shown to independently increase risk of ADR’s and for this reason unnecessary polypharmacy must be avoided. Other reasons to avoid unnecessary polypharmacy are to minimize cost and enhance compliance.

Altered drug response[3][4]
Older patients tend to be more sensitive to the effects of medication compared to younger patients. This is due to the result of physiological changes that occurs with advancing age resulting in altered pharmacokinetic and dynamic parameters for many drugs. In older patient were mostly observed with more ADR’s and often require lower doses.

Inappropriate prescribing
Inappropriate prescribing for elderly patients is common, with studies throughout the world reporting that 14-16% of elderly patients are prescribed at least one inappropriate medication. For example angiotensin converting enzyme inhibitors decrease morbidity and mortality associated with cardiac failure.[4]

Adverse drug reactions
The incidence of ADR is known to increase with age, although old age itself is one of the important risk factors mentioned above. Adverse drug reactions are most commonly seen in the community settings, and drug related problems contribute 10-24% of hospital admissions among older people.[3]

Patient non-compliance
Poor compliance with prescribed drugs is very common elderly patients. contributing factors include multiple drug prescribing confusion, forgetfulness, visual impairment, illiteracy and poverty.[4]

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