As experts in dispensing medications, advising customers and ensuring that prescribed medicines are suitable, pharmacists are highly trusted by consumers.
However, when multiple medications are involved, the risks of adverse effects from medication interactions are heightened, meaning potential medicine-related harm can occur. This is why clear communication and medication review are important, especially in the population groups more likely to take multiple medications, such as the elderly.
When patients are given multiple medications, problems arise with adherence, sub-optimal prescribing, and medication interactions. The more medications a person takes, the more difficult it can be to obtain a medical history, and the greater the risk of adverse drug reactions.
When a person is taking five or more medications simultaneously, this is called polypharmacy, which is a significant barrier to medication adherence, due to the complexity of medication regimes and the increased risk of medication errors. 1
The polypharmacy problem
Polypharmacy is common in older people as they often experience multiple chronic illnesses. According to the Australian Commission on Safety and Quality In Healthcare, two-thirds of those aged over 75 take five or more medications. Additionally, the commission provides that 49 per cent of people with polypharmacy had seven or more, and 11 per cent had 11 or more medications dispensed in 2018/19.2 Another issue presents when more medicines are prescribed to treat symptoms that are caused by adverse effects of drugs. This is known as the prescribing cascade.1
The most recent review of Australians aged over 70 taking five or more medications – the University of Western Australia (UWA) study in collaboration with UNSW Sydney in 2019, published in the <itals>Medical Journal of Australia<itals> – found a 53 per cent increase from 2006 to 2019 in the number of people taking five or more medicines.
“The medicines we looked at don’t include medicines purchased without a prescription, such as vitamins, minerals, herbal supplements or medicines not listed on the Pharmaceutical Benefits Scheme, meaning that the estimates in the paper may be conservative,” said lead researcher Dr Amy Page, from UWA’s Centre for Optimisation of Medicines.
“The rates in comparable years are also much higher in Australia than in the US or the UK.
“There have been many awareness-raising activities recently about the risks of taking multiple medicines, and there’s evidence of poor health outcomes in older people. However, the number of older people taking multiple medicines has increased.
“Strategies to increase people’s understanding of the potential risks involved in taking multiple medications are needed to target health professionals and the public.
“Taking multiple medications may be necessary, but it needs to be carefully assessed by a medical professional and balanced against the potential risks.”3
Risks
Certain combinations of medicines present a greater risk than others, including, according to NPS MedicineWise:
- When taking medications that affect the brain and nervous system, people are more prone to confusion, drowsiness, and memory problems. This can lead to falls and accidents.
- Older people are more susceptible to dizziness, light-headedness and confusion. In addition, some medications can cause these effects, such as those for blood pressure, and those for pain relief that contain opioids and drugs for psychotic conditions.
- Some medicines can interact with each other and affect existing medical conditions. For example, NSAIDs taken to relieve pain can worsen high blood pressure and kidney function.4
Managing the effects of polypharmacy
Consumers can take control of their medications by implementing medication organisers and keeping a medicines list. Those taking proactive steps and working with their healthcare providers can more effectively manage their medications and mitigate the risks associated with polypharmacy.
Additionally, a home medicines review can be requested from a patient’s GP if the doctor believes the patient will benefit from such a review and an accredited pharmacist checks the medication the patient is taking at home, including any supplements. The pharmacist will check that the medicines are working correctly.5 If needed, two follow-up services can be offered to resolve medication-related problems.6
Pharmacists help to manage polypharmacy by asking follow-up questions when prescribing, and ensuring clear communication is given regarding medicines, and further, by encouraging the patient to involve a single prescriber and single pharmacist in managing their medication intake. Additionally, raising awareness regarding the harms associated with taking multiple medications means consumers can make informed decisions.2
Another method of managing the effects of polypharmacy is deprescribing, which refers to discontinuing drugs that may be harmful or no longer required. In older people, this has been linked to improved health outcomes. The process should be collaborative between the patient, doctor and pharmacist. Further, it should be carefully monitored, and the dose should be gradually tapered. Pharmacists can assist in the deprescribing process by helping to identify targets for deprescribing and planning the tapering of doses.7
The power of pharmacy-led interventions
Research from the University of South Australia indicates that regular visits to pharmacists for people in aged care can reduce problems with medication and improve health outcomes. The study involved 248 aged-care residents across 39 facilities in South Australia and Tasmania. Pharmacists met with the residents every eight weeks. The results showed that 60 per cent of residents had problems with their medication at each visit, and 309 recommendations were made to change residents’ medication. The study also showed that cognitive scores changed, with those residents monitored by pharmacists less likely to experience negative effects.8
“Medicines are the most prescribed health intervention for older people, yet they’re also the catalyst for concern for many aged-care residents,” lead researcher Professor Libby Roughead said in a 2022 media release.
“People living in aged-care homes rely on the support and care they receive, yet previously, residents have only received a medication review every two years, or earlier if required.”
“Our research highlights the need for personalised and continuing support by pharmacists more frequently.”
“It’s important to realise that the new on-site pharmacists will not only need to monitor and review medications but also be able to recognise the early onset of medicine-induced deterioration, such as changes in a person’s cognition or activity, to prevent harms such as injurious falls or delirium.
“More comprehensive support will not only avoid the many medicine-induced health issues currently experienced by aged-care residents but may also help in preventing frailty and declining cognition.”9
In March last year, before the election of an ALP-led government, the Coalition administration announced funding for on-site pharmacists to improve medication management in government-funded aged-care facilities, to begin in January 2023, after medication management was highlighted as a critical area of concern in the Royal Commission into Aged Care Quality and Safety.10
References
- NPS MedicineWise. ‘The dilemma of polypharmacy’. 2008. org.au/australian-prescriber/articles/the-dilemma-of-polypharmacy#r1
- Australian Commission on Safety and Quality in Healthcare. ‘Polypharmacy, 75 years and over’. 2021 gov.au/our-work/healthcare-variation/fourth-atlas-2021/medicines-use-older-people/61-polypharmacy-75-years-and-over#:~:text=Polypharmacy%20is%20when%20people%20are,Atlas%20of%20Healthcare%20Variation%202021
- University of Western Australia. ‘Older Australians taking multiple medicines may be putting health at risk’. 2019. <uwa.edu.au/archive/2019071511498/research/older-australians-taking-multiple-medicines-may-be-putting-their-health-risk/>
- NPS MedicineWise. ‘Managing your medicines’. 2019. org.au/consumers/managing-your-medicines#risks-of-taking-multiple-medicines
- ‘Home medicines review’. 2022. healthdirect.gov.au/home-medicines-review
- Pharmacy Programs Administrator. ‘Home Medicines Review’. 2022. com.au/programs/medication-management-programs/home-medicines-review
- NPS MedicineWise. ‘Deprescribing in older people’. 2020. org.au/australian-prescriber/articles/deprescribing-in-older-people#tools-to-support-deprescribing-decisions
- Roughead E et al. ‘Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial)’. 2022. ncbi.nlm.nih.gov/35460410/
- University of South Australia. ‘In-house pharmacists essential for aged care’. 2022. edu.au/media-centre/Releases/2022/in-house-pharmacists-essential-for-aged-care/
- Greg Hunt MP. ‘On-site pharmacists to improve medication management in RACFs’. 2022. health.gov.au/ministers/the-hon-greg-hunt-mp/media/on-site-pharmacists-to-improve-medication-management-in-racfs
This feature was originally published in the March issue of Retail Pharmacy magazine.
