Assessment of Medication & Polypharmacy in Older Adults���Pavithra Nanayakkara�University of Ruhuna��

Objectives

• Explain the significance of Polypharmacy in Older Adults
• Identify common tools used to measure comorbidity in geriatric patients.
• Explain the strategies to assess the Medication & Polypharmacy in Older Adults
• Describe strategies to reduce polypharmacy and promote safe medication use in geriatrics

Introduction

• As people age, they are more likely to develop multiple chronic conditions, leading to the use of multiple medications—a phenomenon known as polypharmacy.
• Assessing medication use in older adults is essential for ensuring safety, preventing adverse events, and promoting optimal health outcomes.

Definitions

Polypharmacy

• Traditionally defined as the use of five or more medications simultaneously.
• May include prescription drugs, over-the-counter (OTC) medications, vitamins, and herbal supplements.

Inappropriate Polypharmacy

• The use of more medications than are clinically necessary or the use of potentially inappropriate medications (PIMs) that pose a greater risk than benefit in older adults.

Significance of Polypharmacy in Older Adults

A. Increased Risk of Adverse Drug Events (ADEs)

• Older adults have reduced renal and hepatic function, altering drug metabolism and clearance.
• Higher risk of falls, confusion, constipation, bleeding, and hospitalization.

B. Drug-Drug and Drug-Disease Interactions

• Some medications may exacerbate existing diseases (e.g., NSAIDs worsening hypertension or kidney disease).

C. Non-Adherence

• Complex medication regimens may lead to intentional or unintentional non-adherence.

D. Functional Decline

• Sedating medications or those affecting cognition may impair mobility, increase fall risk, and reduce independence.

• Comprehensive Medication Review (CMR)

• A structured review of all medications a patient is taking.
• Conducted by physicians, pharmacists, or nurses.
• Includes evaluation of indication, dosage, efficacy, side effects, duplication, and interactions

Assessment Strategies

• History Taking

Collect detailed information on:

• Prescription drugs
• OTC medications
• Herbal supplements
• Administration times and methods
• Patient understanding and adherence

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• Beers Criteria

Assessment Tools and Criteria

Lists potentially inappropriate medications (PIMs) for older adults.

Updated periodically.

Organized into:

• Medications to avoid in all older adults
• Medications to avoid in specific diseases
• Drug-drug interactions
• Dose adjustments based on kidney function

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https://gwep.usc.edu/wp-content/uploads/2023/11/AGS-2023-BEERS-Pocket-PRINTABLE.pdf

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• STOPP/START Criteria
• STOPP: Screening Tool of Older Persons' Prescriptions – identifies potentially inappropriate medications.
• START: Screening Tool to Alert to Right Treatment – identifies potentially omitted beneficial treatments.

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https://nhssomerset.nhs.uk/wp-content/uploads/sites/2/STOPP-START-V3.pdf

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• Medication Appropriateness Index (MAI)

Scores each medication based on:

• Indication, effectiveness, dosage, directions, drug-drug interaction, drug-disease interaction, duplication, and cost.

https://www.hqsc.govt.nz/assets/Our-work/System-safety/Reducing-harm/Medicines/Publications-resources/Use-of-the-Medication-Appropriateness-Index.pdf

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• ARMOR Tool
• Assess, Review, Minimize, Optimize, Reassess
• A clinical framework to evaluate medications in frail older adults, often in nursing homes or hospitals

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Steps of ARMOR Intervention

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• Assess
• Review for possible
• Minimize nonessential medication
• Optimize
• Reassess

Special Considerations in Assessment

• High-Risk Drug Classes
• Benzodiazepines (e.g., diazepam)
• Anticholinergics (e.g., diphenhydramine)
• NSAIDs
• Antipsychotics
• Hypoglycemics (e.g., sulfonylureas)
• Cardiovascular medications (e.g., digoxin)

• Renal and Hepatic Function
• Many medications require dose adjustments based on estimated glomerular filtration rate (eGFR).
• Cognitive and Sensory Impairments
• Visual, hearing, or memory impairments may affect ability to manage medications independently.
• Polypharmacy in Palliative and End-of-Life Care
• Focus shifts to symptom control, and deprescribing becomes essential.

Strategies for Optimizing Medication Use

• Deprescribing
• A systematic process of tapering or stopping drugs that may no longer be beneficial or may be harmful.
• Includes shared decision-making with patient and caregivers.
• Use of Medication Aids
• Pill organizers
• Medication administration charts
• Electronic reminders

• Involving Pharmacists and Interdisciplinary Teams
• Pharmacist-led reviews improve outcomes by identifying medication-related problems and optimizing regimens.
• Patient and Caregiver Education
• Improve awareness of medication purpose, side effects, and correct administration.

Challenges in Medication Assessment

• Polypharmacy normalization: Some patients and providers view multiple medications as unavoidable.
• Time constraints: Limited consultation time in clinics and hospitals.
• Communication gaps: Between specialists and primary care providers.
• Lack of access to complete medication records, especially in transitions of care.

Role of Nurses in Medication Assessment

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• Monitoring for adverse effects and adherence.
• Educating patients and caregivers.
• Supporting medication reconciliation during transitions of care.
• Collaborating with pharmacists and physicians for timely interventions.

References

• Elbeddini, A. (2023). Deprescribing and polypharmacy in an aging population. Springer Nature.�
• Zagaria, M. A. (Ed.). (2018). Polypharmacy: An issue of Clinics in Geriatric Medicine. Elsevier.�
• Jandu, J. S. (2024). Strategies to reduce polypharmacy in older adults. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574550/

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Thank you