The elderly population is vulnerable to many health complications that come with aging. The geriatrics clinic at Community Health Network works to identify these vulnerable patients by referral from their primary care provider. The clinic provides many services including a comprehensive geriatric assessment. A gap in this service is addressing medication. Polypharmacy is a growing problem among the elderly. There are three main causes of polypharmacy in the elderly. First, the elderly are more likely to have co-morbidities that require multiple medications. Second, the multiple medications they are on are likely to cause adverse drug reactions that are often treated by adding more medications, and third, hospitalization is common in the elderly and it is known to increase the total amount of medications a patient is on. [4] The consequences of polypharmacy from the article ‘Clinical Consequences of Polypharmacy in Elderly,” are explained below. [2]
Compliance: Non-adherence rates in the community setting with elderly adults have been reported to be anywhere between 43-100%. The more complicated the medication regiment, the higher the chance for non-adherence. Medication non-adherence is associated with disease progression, treatment failure, and hospitalization.
Falls/Functional Status: A study was done comparing patients who have fallen and those who have not, and the number of medications the patient was on had a direct correlation with the risk of falling. Increased medication use is also associated with the diminished ability to perform activities of daily living and decreased physical functioning. A prospective cohort of approximately 300 older adults found that patients taking 10 or more medications had diminished functional capacity and trouble performing daily tasks.
Cognitive Impairment: The number of medications a patient is on is a risk factor for delirium. In a prospective cohort study of 294 elderly patients, 22% taking 5 or less medications were found to have impaired cognition, compared to 33% taking 6-9 medications, and 54% taking 10 or more medications.
Adverse Drug Events: In 2005, it was estimated that over 4.3 million health care visits were due to an adverse drug event, and up to 35% of elderly patients in the outpatient setting experience an adverse drug event. To add to this, a population based study showed that outpatients taking 5 or more medications had an 88% increased risk of experiencing an adverse drug event. This can be due to multiple drugs that have the same side effect consequently exacerbating that effect, or drug-interactions that can decrease or increase the efficacy of a drug.
Increased Health Care Costs: With all the consequences explained above, it is no surprise that polypharmacy has a direct impact on health care cost. With each consequence, there is an increased amount of hospitalizations, primary care provider visits, and emergency department visits. In fact, it is approximated to have a 30% increase in medical costs. In addition, patients are spending money on multiple medications that may not be necessary or indicated for their disease states.
The consequences of polypharmacy show that it is not only beneficial, but a vital necessity for a pharmacist to be part of a geriatrics team. The pharmacists can perform an extensive medication review to identify unnecessary medications and potential adverse drug events. In addition, the pharmacists can provide vital education to the patient about their medication regiment and help them come up with a comprehensive plan to be adherent. These tasks can help with cost avoidance, but a pharmacist can also help to provide annual wellness visits, bringing in direct revenue. There are multiple studies and programs that have shown that pharmacy intervention in the elderly is cost effective and beneficial for the patient’s outcomes.
- A quasi-experimental study was done in 6 hospitals in Hawaii to evaluate the association between a medication management service performed by hospital and community pharmacists (Pharm2Pharm) and the rates and costs of medication-related hospitalization, specifically in the older adult population. This study including adult inpatients that were identified as being high risk for medication problems, 62% of which were 65 years or older. The results showed that there was a 36.5% lower hospitalization rate of patients 65 years and older in the hospitals after implementation of the service. Although this study was done in the hospital setting and targeted patients transitioning from inpatient to outpatient. It shows a direct cost avoidance when pharmacists intervene and perform medication reviews in the elderly population. [3]
- A retrospective chart review was done at Alexian Brothers Community Services Program of All-inclusive Care for the Elderly in St Louis, MO to determine whether medication reconciliation (using the Medication Reconciliation Review of Systems Subject, MR ROSS), was an effective method for identifying errors of omission for the outpatient geriatric clinic. Errors of omission were defined as a patient taking a medication that is not recorded during a previous drug history. The review showed that out of the 40 patients looked at, 31 had one or more error of omission identified by the medication reconciliation. Out of these medications 73.2% were nonprescription, and 69.9% were as-needed medications. This review shows that medication reconciliation is vital to get a complete medication history to better prevent polypharmacy and adverse drug events. [5]
- Another review examined various ways of minimizing prescribing errors and polypharmacy in multimorbid older patients. This review found that medication reconciliation and pharmacists were two major players in helping to reduce this issue. It states that pharmacists play both a role in identifying errors through medication reconciliation but can also help to advise physicians on how to correct the error and better treat the patient with an optimum drug therapy regiment. [4]
- A study was done to show the effectiveness and financial benefit of pharmacist-led annual wellness visits with comprehensive medication management for older patients that are identified as being high-risk. Patients were 65 years or older with three or more chronic medical conditions and taking five or more medications long-term. 53 patients participated and a total of 278 medication related problems (MRPs) were identified. Pharmacist’s not only played a beneficial role in completing wellness visits and identifying and addressing MRPS, but the revenue that was brought in exceeded costs by 38.1%. [6]
In conclusion, pharmacists have shown to be key players in the reduction of polypharmacy and medication errors with the elderly population. Through pharmacy intervention there is a cost avoidance from less ED visits, primary care provider visits, and hospitalizations from medication adverse events. In addition to the cost avoidance, adding a pharmacist to the geriatrics clinic team will provide patients with the opportunity to get more face-to-face time with a healthcare provider, medication education, and an opportunity to ask questions. Based on the studies shown and the consequences from polypharmacy, a pharmacist would be a key player in creating better patient care and outcomes in the geriatrics clinic.
Citations
- Lavan AH, Gallagher PF, O’Mahony D. Methods to reduce prescribing errors in elderly patients with multimorbidity. Clin Interv Aging. 2016; 11: 857-866. Doi: 10.2147/CIA.S80280.
- Maher RL, Hanlon JT, Hajjar ER. clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety. 2014; 13(1): 57-65. Doi: 10. 1517/14740338.2013.827660.
- Pellegrin KL, Krenk L, Oakes SJ, et al. Reductions in medication-related hospitalizations in older adults with medication management by hospital and community pharmacists: A quasi-experimental study. JAGS. 2016; 65(1): 212-219. Doi: 10.1111/jgs.14158.
- Sergi G, De Rui M, Sarti, et al. Polypharmacy in the elderly. Drugs and Aging. 2011; 28(7): 509-518. Doi: 10.2165/11592010-000000000-00000.
- Vouri SM, Marcum ZA. Use of a medication reconciliation tool in an outpatient geriatric clinic. JAPhA. 2013; 53(6): 652-658 Doi: 10.1331/JAPhA.2013.13084
- Woodall T, Landis SE, Galvin SL, et al. Provision of annual wellness visits with comprehensive medication management by a clinical pharmacist pratictioner. AJHP. 2017; 74(4): 218-223. Doi: 10/2146/ajhp150938