What Can We Do to Curtail Harmful Polypharmacy?

I have reached a select milestone: I receive AARP magazine. I guess I can confess that I am no longer a “spring chicken.” Also age-appropriate, I take 4 to 5 medications for chronic conditions (hypertension for one) and, as a result, have become empathetic to patients who are receiving 5 or more pharmaceuticals. Unfortunately, as the number of medicines increases, so do adverse drug events (ADEs). Elderly patients are particularly susceptible to ADEs.¹ How can we mitigate the dangerous epidemic of polypharmacy-induced adverse events?

STOPPING ADVERSE DRUG EVENTS IN THE ELDERLY

Two recent studies looked at this problem. A validated instrument—the Screening Tool of Older Persons’ Potentially inappropriate Prescriptions (STOPP)—lists criteria that emphasize adverse drug-drug interactions and duplicate drug class prescriptions. Six hundred patients 65 years of age and older were prospectively studied.² The cohort experienced admission for an acute illness. There were 329 ADEs, and two-thirds of them were related to the hospital admission. If STOPP medications were prescribed, the odds ratio for an ADE was 1.847. Samples of such STOPP drugs included:

•Benzodiazepines in persons who have had 1 or more falls in the last 3 months.

•Long-term opiate therapy in persons with recurrent falls.

•Long-term NSAID use.

The take-home message is unavoidable: STOPP criteria (which can be flagged on an electronic medical record [EMR]) can prevent avoidable ADEs in elderly persons.

FOR ELDERLY ICU SURVIVORS, LESS IS MORE

Another group at risk for ADEs is composed of elderly critical care survivors. In this second study,³ 85% of these ICU survivors were later discharged from the hospital with 1 or more potentially inappropriate medicines (PIMS). More than half of these patients were discharged with medications that were deemed more harmful than beneficial. Elderly primary care patients discharged from the ICU need their primary physicians’ input for careful medication reconciliation. As the authors repeat: less is more!

TECHNOLOGY HELPFUL BUT NOT ENOUGH

The editorialist added wisdom to these two recent studies.³ His system recommendation is better technology. Electronic tools assist health care providers by detecting patients who have been prescribed PIMS. But technology alone is insufficient. The author suggests that “major changes in the way healthcare is organized and financed” are necessary. (Have we heard that before?)

The problem is not a simple one. The Health Information Technology for Economic and Clinical Health Act will require ambulatory practices to adopt electronic prescribing, and the EMRs will have alerts and selected overrides.

There will be occasions when the benefit of a PIM exceeds the risk. The bottom line, however, is that PIMS will not slip through the system as easily as they do now with written prescriptions. That will be one part of a bigger “process redesign.” The system as it is today is simply untenable and dangerous. These papers go a long way in focusing us on the problem.