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Addressing the Polypharmacy Challenge in Older People

The Polypharmacy Challenge Blog

Polypharmacy and multimorbidity: What’s in the journals Jan-Mar 2017?

Here’s a selection of articles of relevance to the APOLLO-MM project published in early 2017.

A Themed Journal Issue on Deprescribing. European Journal of Hospital Pharmacy, January 2017 Vol 24, issue 1
January’s issue of European Journal of Hospital Pharmacy has a themed issue on deprescribing, with an editorial, a number of articles and opinion pieces, some of which are free to access. The aim of the themed issue is to give an introduction to the deprescribing debate, the challenges that surround depescribing and some of the tools available to help with deprescribing. The guest editors, Nina Barnett (who spoke at the APOLLO-MM launch event ) and Barry Jubraj, have also sought to broaden the remit within which deprescribing is discussed. So, there are articles on the patient view of deprescribing, the legal perspective, collaborative decision-making between patients and healthcare professionals, plus the challenges of deprescribing in special populations: older people with multimorbidity, patients in care homes, paediatrics, and people with learning disabilities.

Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review. European Journal of General Practice

Hannelore Storms, Kristel Marquet, Bert Aertgeerts & Neree Claes

This is a systematic review (a summary of the available evidence) to assess the prevalence of inappropriate medication use in residential long-term care facilities for older people. The review compared studies using different tools (Beers criteria, STOPP, START, PRISCUS list, ACOVE, BEDNURS or MAI) to measure inappropriate medication use, with the Beers criteria and STOPP tools being those most frequently used. The reviewed studies indicated a higher risk of inappropriate medication use due to polypharmacy. The authors suggested that monitoring inappropriate medication use of people living in long-term care facilities may be valuable. However, it wasn’t clear to me what was meant by 'inappropriate medication use' – whether it was polypharmacy per se that was inappropriate or that because of the large numbers of medicines individual items are more likely to be prescribed or consumed in inappropriate ways.

Is Polypharmacy Associated with Frailty in Older People? Results From the ESTHER Cohort Study. Journal of American Geriatrics Society

Kai-Uwe Saum, Ben Schöttker, Andreas D. Meid, Bernd Holleczek, Walter E. Haefeli, Klaus Hauer, Hermann Brenner
This study looked at over 3000 adults aged between 57-84 living in the community (rather than in residential care) and found that polypharmacy is associated with frailty. Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserve. The authors found that participants who were taking 5 or more medicines (polypharmacy) or 10 or more medicines (hyperpolypharmacy) had an increased risk (1.5 times and 2 times higher risk, respectively) for developing frailty within 3 years. This risk remained even when taking into account the number of comorbidities and their severity a person had. Whilst a cohort study like this shows association and does not prove causation, the authors argue that future research should look at the benefit of reducing inappropriate polypharmacy, assessed through well designed clinical trials, and how better pharmacotherapeutic management could prevent medication-associated frailty. Again, the appearance of the word 'inappropriate' raises questions for me about what is meant by 'inappropriate polypaharmcy' and how much clarity is there about what 'appropriate' polypharmacy looks like?

Clinical impact of pharmacogenetic profiling with a clinical decision support tool in polypharmacy home health patients: A prospective pilot randomized controlled trial. PLOS ONE

Lindsay S. Elliott, John C. Henderson, Moni B. Neradilek, Nicolas A. Moyer, Kristine C. Ashcraft, Ranjit K. Thirumaran.
A common problem for ‘polypharmacy patients’ is the experience of adverse reactions to medicines taken at normal, approved doses. These events lead to costly emergency department visits, re-hospitalisations, and decreased quality of life. The authors of this study suggest that pharmacogenetic testing has the potential to predict and reduce unnecessary drug-related adverse reactions. Pharmacogenetic testing can give healthcare professionals knowledge of a patient’s gene-based susceptibility to adverse drug reactions. The authors suggest that by tailoring medication decisions so that they are more specific to each patient might lead to better outcomes, such as decreased pill burden, improvement of disease state, decreased adverse drug reactions, and increased quality of life.
The authors tested this hypothesis in a trial based in one hospital-based home health agency in the USA. 110 patients, 50 years or older, were randomized to receive pharmacogenetic profiling or usual care. 57 received pharmacogenetic profiling and the subsequent drug information was passed onto their doctors. Doctors armed with this information were able to significantly reduce the number of re-hospitalisations and admissions to emergency hospital care in the pharmacogenetic testing group compared to the group that were not tested.

What would be interesting to know from such a study is: how the doctors communicated this complex new genetic knowledge to patients and how they integrated it into their negotiations about possible changes to medication?

Social Science and Medicine

Social Science and Medicine offers five papers (four research articles and a commentary) which, whilst not about polypharmacy specifically, offer up ideas for consideration about the various factors which shape the use of medical treatments: online medicinal product reviews; herbal medicines as identity forming; being a good self-manager; and the problem of 'too much medicine'.
Ioannidis’ commentary and de Barra’s research paper introduce the concept of evidence-based hearsay: the opinion of patients’ experiences of medicines and their reporting of these through online networks and online medicinal product reviews, and through word of mouth to family and social networks. This raises the importance of social networks to taking medicines, something that is often perceived as an individual affair. This is likely to be of special relevance in the context of older people with multi-morbidities and multiple medications and is something we will explore in detail through APOLLO-MM.
Ceutericka and Vandebroek look at herbal medicines usage and identity in Andean populations living in the UK. Through interviews the authors found three identities that frame the use of herbal remedies either as a tradition, a health-conscious consumer choice, or as a coping strategy. An enhanced understanding of how people make sense of their use of traditional, plant-based medicines enables healthcare professionals to better assist patients in making meaningful decisions about their health. Through illustrating how treatment choices are discursively linked with identity, these results ‘debunk the tendency to perceive patients with a migration background as one homogenous group' and thus urge for a patient centred approach to health care. Although not about polypharmacy, this paper made me think about how we define polypharmacy in the APOLLO-MM project and whether we also need to consider other non-prescribed medicines that people may be taking, alongside the ones prescribed by their doctor or nurse. This should make us all think about how we define polypharmacy – and the influence of our definitions on who is included in polypharmacy research and sampling, not only in APOLLO-MM but in polypharmacy research more widely.
Hensher and colleagues look at the phenomenon of ‘too much medicine’ as a form of overconsumption. They define overconsumption of health care as a situation in which individuals consume in a way that undermines their own well-being. This could be in situations where patients are receiving unnecessary investigations and treatments providing them with little or no benefit, but which expose them to risks of harm. The authors question why this phenomenon has received relatively little attention from health economists. They draw on research from health economics, behavioral economics and ecological economics to identify possible explanations for and drivers of overconsumption.
Finally, Ellis and colleagues explore the policy imperative for people with long-term conditions to take responsibility and self-manage their health. Through semi-structured interviews and focus groups with commissioners of healthcare services, healthcare professionals, people with long-term conditions and family care-givers, they looked at what makes a good self-manager. The ‘good’ self-manager is an individual who is ‘remoralised; thus taking responsibility for their health; is knowledgeable and uses this to manage risks; and, is ‘active’ in using information to make informed decisions regarding health and social wellbeing.’ I suspect the concept of self-management will be important in the APOLLO-MM project and understanding how people manage their lives with the many medicines they have been prescribed.

Sociology of Health and Illness

Similarly, SHI has two papers which offer potential insights for our research on polypharmacy. McDowell’s paper ‘Mohit’s Pharmakon: Symptom, Rotational Bodies, and Pharmaceuticals in Rural Rajasthan’ opens with an ethnographic account of a man, feeling unwell, calling on Mohit, an uncertified biomedical practitioner who gives him a cocktail of drugs - antibiotics, painkillers, fever reducers – through an IV drip to ease his symptoms. This account represents the polypharmacy that characterizes private sector biomedicine in India. McDowell reexamines medical anthropological theories of symptom, illness and disease to look at unregulated care in India. Disease as a category is reserved for major illnesses (cancer, TB, leprosy), whereas the treatment of every day, recurring symptoms is left to unregulated doctors like Mohit, who manage discomfort without naming a disease or searching for a diagnosis.
In a similar vein to Ellis et al’s paper, Vassilev and colleagues also explore how neoliberalism, with its focus on individual responsibility, consumer choice and market rationality, shapes the environment within which chronic illness is experienced and managed. People from the UK and Bulgaria discussed their experience of type 2 diabetes in terms of struggling with diet, diabetes as a personal failure, how to manage the illness alongside other activities, and the trustworthiness of the healthcare system. Discussions amongst the UK participants were framed along a narrative of individual responsibility. Amongst the Bulgarian participants a lack of resources dominated discussions. Here, the experience of type 2 diabetes was not connected to individual responsibility and choices but was more to do with structural challenges.

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