When was the last time that you made an appointment with your patient solely for the purpose of drug reconciliation, including drug interactions and side effects? Today’s practice of medicine is, unfortunately, limited to a timed visit which is unfair to both patient and practitioner. Patients may be seen prior to the visit by the medical technician for the purpose of recording current medications; but far too many patients do not sit down with a bag of medications that they take daily, for a thorough investigation of what is called polypharmacy. Why is this of importance? Polypharmacy accounts for thirty percent of hospital admissions and is the fifth leading cause of US patient deaths. As a PA of forty-seven years, I perceive that this is important enough for our current discussion.
Polypharmacy is the regular use of five or more prescription or OTC drugs. Fifteen years ago, I was the patient of a famous cardiologist who had written three textbooks and many articles on HCM. He was diligent as he pursued his interrogation of my medications. I happened to mention the four supplements I was taking. He asked me why I did not understand that I needed to divulge, not only prescribed medications, but, in fact, each and everything I used to augment my health! This incomplete reporting of substances is common in seniors, particularly females, and has the potential for other health related issues. The more drugs that a person takes, the greater the risks for adverse effects, over medicating, side effects and over sedation. This is due to metabolic changes and reduced drug clearance with aging. I recently spoke to a person who was taking his seven drugs and at bedtime added THC/CMB gummies and Tylenol PM along with his melatonin patch. Is it a surprise that, on Holter monitor, his HR in early morning, dropped down to a low of 22?
What are some of the common problems related to polypharmacy?
- medication cascades
- drug interactions
- quality of life
- compliance
- expense
Side effects include dizziness, depression, increased falls, cognitive impairment, and other adverse reactions. Death can easily be added to this list, which is why it is so important for a HCP to play the role of a prosecuting attorney and search for information. The American Geriatric Society publishes a comprehensive review of medications, called the Beers Criteria, which includes a list of poorly tolerated drugs.
Johns Hopkins Medicine states that a patient over the age of 60, who may take daily medications for multiple chronic conditions, is at risk for overmedication and other complications of polypharmacy. Their complications listed sedation, increased risk of falls and side effects. It is suggested by many physician societies that a clinician instructs their patient to bring in a bag of every medication that they are currently taking. There exists programs where Health Assessment programs for seniors are free of charge.
What are the chronic conditions that enhance over medication when prescribed by multiple specialties?
- hypertension
- diabetes
- insomnia
- arthritis
- COPD
- CHD
- depression and anxiety
- infections
- cough and colds and OTC meds.
What are some of the presenting symptoms of a person who suffers from polypharmacy? They are usually quite easily appreciated on your consultation if you are an astute provider.
- reduced alertness
- confusion or cognitive problems
- falls and accidents
- weakness and dizziness
- lethargy
- loss of appetite
- GI problems such as diarrhea, constipation, and incontinence
- skin rashes
- depression
- anxiety
- drowsiness from over sedation
- risk of household and motor vehicle accidents which can be caused by opioids, benzodiazepines, antihistamines, and ETOH.
How can you protect your patients and yourself as a clinician? Start a program in your practice for health and medication assessment. Warn your patient about the potential problems inherent in their consumption of medications and chart this information on your patient record. We are all going to have a non-compliant patient who injures themselves, creates a perfect storm for a stroke or cardiac failure and death. We are the vanguard for our patient’s future health. Failure to warn our patients when a chart reflects polypharmacy can easily be construed as medical malpractice and result in litigation. Should this circumstance arise, are you covered by a policy that has the ability to defend your actions and to represent you in a court of law? Practitioners always balk a bit at this last paragraph, but failure to obtain an excellent personal liability insurance can almost guarantee a short career. My responsibility is to be a herald to our professions. Thank you.
Written For CM&F By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor
