POLYPHARMACY is a “a red flag” for clinicians on the lookout for medication-related harms in their older patients, say experts.

Almost 1 million older Australians regularly take five or more prescription medicines, according to research, published in the MJA, that highlights the need to implement a proposed National Strategic Action Plan to address polypharmacy.

Professor Sarah Hilmer, Conjoint Professor of Geriatric Pharmacology at the University of Sydney, said the findings underlined the importance of continued action on inappropriate medication use.

“We look at polypharmacy as a red flag because it tells us that there is a higher chance of medication-related harm. There is a higher chance of cumulative side effects of drug–drug and drug–disease interactions, and the more drugs a person is on, the more likely they are to be on a drug that is unnecessary,” Professor Hilmer told InSight+.

“But it doesn’t necessarily mean that every single person who takes five or more drugs is getting inappropriate therapy.”

The researchers reported that, in 2017, more than one-third of older Australians (935 240 people) were affected by continuous polypharmacy, defined as having five or more unique medicines dispensed during both April–June and October–December.

After analysing a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for people aged 70 and older, the researchers found that continuous polypharmacy increased from 33.2% in 2006 to 36.2% in 2017 (up by 9%). And, despite a small reduction since 2014, the number of older people affected by polypharmacy jumped by 52% in the 11-year period, reflecting Australia’s ageing population.

The researchers said PBS policy changes – such as the delisting of low cost medicines such as paracetamol and aspirin – were more likely to be responsible for the slight decline in dispensing than changes in actual medicine use.

Rates of polypharmacy were highest among those aged 80–84 years (44%) or 85–89 years (46%), the researchers reported.

“Polypharmacy can be appropriate, but there is substantial evidence for its potential harm and the importance of rationalising unnecessary medicines, particularly in older people,” they wrote.

Lead author Dr Amy Page, Adjunct Senior Lecturer at the University of Western Australia’s Centre for Optimisation of Medication and an Adjunct Research Fellow at Monash University’s Centre for Medicine Use and Safety, said the estimated prevalence of polypharmacy was conservative because the study captured only PBS-listed prescriptions. Private prescriptions, over-the-counter medications and complementary medicines were not included in the findings.

“We chose a conservative measure of polypharmacy to ascertain a lower estimate,” Dr Page told InSight+. “We also looked at polypharmacy in two different quarters to make sure that it was continuous, and it wasn’t just a once-off medicine, like an antibiotic, that we were capturing.”

Dr Page, who is also Lead Pharmacist at Alfred Health, said, to date, estimates of the extent of polypharmacy had focused on high risk populations, such as those who were hospitalised or in residential aged care.

“We haven’t had that snapshot of how many people over 70 are affected by polypharmacy,” Dr Page said. “And we needed that estimate to be able to evaluate if any of these programs and strategies to increase the awareness of deprescribing were making an impact. This gives us a baseline that will allow us to evaluate future public health initiatives.”

Professor Hilmer led the development of recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy, which was released in December 2018.

The Plan – which aims to reduce harmful or unnecessary medicines use by older Australians by 50% over 5 years – comprises seven action items.

“These range from policy interventions – like explicitly [addressing] polypharmacy and multimorbidity in the National Medicines Policy, including subheadings on how to stop medicines in [product] information and consumer medicines information – through to trying to integrate the fairly fragmented system that we have for pharmaceutical care, so different sectors of the health care system know what medicines people are taking and why,” Professor Hilmer said.

She said the plan also recommended providing incentives to health professionals for optimising quality use of medicine.

“For example, Medicare item numbers to give GPs time to review people’s medicines as part of their routine consultations,” Professor Hilmer said, adding that plan was being disseminated to key stakeholders and groups responsible for quality use of medicines and guidelines.

“We are working on each of the items [in the Action Plan],” she said. “We need a multipronged approach to be able to make inroads into what is a really wicked problem.”

Professor Hilmer said clinicians often cited patient resistance as a barrier to deprescribing, but this was often not the case. She said Dr Emily Reeve, while at the University of Sydney (now at the University of South Australia), had developed a revised  Patients’ Attitudes Towards Deprescribing questionnaire, which had shown that nine in ten patients would be willing to stop one or more of their medicines if their doctor told them it was safe to do so.

“People do not like to rattle when they walk,” Professor Hilmer said. “It’s really just a matter of explaining to the patient what you are doing, why you are doing it, and that it’s a supported process, that you will be monitoring their progress and seeing if they feel better.”

For clinicians, time was often a barrier to addressing polypharmacy.

“There is wide and increasing recognition about the harms of polypharmacy and a lot of the clinician barriers seem to be around having time to prioritise a medication review within a routine consultation – because it does take a long time,” she said.

Professor Hilmer said that, as part of the National Strategic Action Plan, work was underway to develop tools to better support clinicians in deprescribing for older patients.

“We have been working on guidelines to help clinicians with some of the more common drugs where the harm often outweighs the benefit in old age, and are developing complementary consumer information,” she said.

7 thoughts on “Polypharmacy a “red flag” for older Australians

  1. Ludomyr Mykyta says:

    For many, many, years Drug Treatment in the Elderly has been a popular topic with all kinds of audiences. I always mentioned Additive (or serial) Prescribing as a problem. In the 1970s my clinical mentor the late great Dr Peter Last tried to introduce a patient-held Medication record for use at the OPD at the RGH (Daw Park) with the intention that any prescription changes would be documented without success. Many specialist consultations result in new prescriptions without due consideration of what the patient is already taking. I rarely prescribe, because I believe that the GP is the patient’s Case Manager and conductor of the multidisciplinary orchestra that constitutes modern Primary Care. As a consultant, I make recommendations and give detailed advice to the practitioner who can see the whole picture.

  2. Jennifer Thompson says:

    So much evidence that policymakers need to pay attention and take up Prof Hilmer and her fellow medication management researchers and specialist’s recommendation for the National Strategic Action Plan.

    Multiple research projects have shown that the number of drugs someone takes is the highest independent factor for serious adverse reactions (Saedder et al, 2015 and Gnjidic, Hilmer et al, 2012); the most frequent complaints to the Australian Aged Care Complaints Commissioner in 2017-18 were about management and administration of medication (https://www.agedcarequality.gov.au/about-us/corporate-publications/aged-care-complaints-commissioner); and there are an estimated 90,000 medication related hospital admissions per annum in Australia, costing the health system around $1.2 billion (AIHW, Australia’s Welfare 2017: in brief).

    The evidence is indeed piled high…

  3. Anonymous says:

    I am a retired pharmacist now but when I was practising pharmacy for many years I was very concerned at the practice of adding a new drug to counter the side effect being caused by a drug that had been prescribed earlier.
    I used to contact the doctors and suggest changing the product causing the adverse event rather than adding a new drug to deal with the problem.
    I often met with annoyance and resistance from the prescriber but at other times I was thanked for my advice.
    I produced drug interaction charts in the late 1960’s and kept updating them in the 1970’s
    When I was working as a hospital pharmacist (before the computer era) I introduced a card system and encouraged surgeons particularly to use it as I found at the time that their knowledge of pharmacology was rather poor. This was in 1958 in South Africa and it was quite a success.
    I strongly support your efforts.
    I am also concerned at the anticholinergic effect in the elderly that can occur as a consequence of giving too many drugs even if each as low anticholinergic effect, the total adds up.
    There are concerns at their increasing the risk of dementia in the elderly.

  4. Anonymous says:

    In a client case, a widow of approx 12 years who is now 81 years of age told me that she and her husband went to the Doctors for their flu shot. After a general check up the Doctor advised the husband that he was in tip top shape and whatever he was doing, keep doing it. She said to him, while you are here why not have your pneumonia vaccine as well to save you coming back. He agreed to have that. The reaction of the two vaccines on the one day caused a reaction, and within 2 weeks he was dead.

    He was on no other medication. His fitness was due to the type of job he had most of his life as well as now he was retired, tending a large garden with trees that needed pruning as well as a substantial vegetable garden that gave them the best food that money can’t buy these days unless you go to an organic farmer who sells his produce in a small shop or at the markets.

    I just hope that the Doctor in question passed on this happening to avoid such a future happening.

  5. Anonymous says:

    Many of my patients have both diabetes and heart disease ( coronary disease and or heart failure) They often have hypertension and dyslipidaemia so are very likely to be on five or more medications which impact on their symptoms and outcomes so their polypharmacy may well be justified. These same patients may well have other conditions such as GORD, gout or other forms of musculoskeletal disease.

    Patients need to be considered on an individual basis . The degree of mobility, cognitive function and projected life expectancy ie “Biological age” rather than “chronological age” are key considerations in prioritising their type and number of medications.

    For those with very limited life expectancy deprescribing is very appropriate. Some older but very well preserved patients may well benefit from taking multiple indicated medications.

    Having said that Disease specific guidelines written by mono-specialty teams often fail to recognise the broader picture for older/multimorbid patients who are generally excluded from most RCTs.

  6. Anonymous says:

    I had an elderly patient recently who developed inoperable lung cancer. I did a medication review and decided to stop her statin. Some time later she was reviewed by her cardiologist who instructed her to restart her statin. The patient could not be convinced by me, her GP that the statin was likely to do more harm than good because her specialist had told her to continue it. As anticipated the patient died of her lung cancer within about 12 months.

  7. John Barr says:

    Why consider only the elderly?
    Polypharmacy in the general population is common, and I am sure that a significant proportion of the medications are unnecessary. The profession in general could save many millions if more note was taken of excessive prescribing

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