Polypharmacy - ENG - FAR

Polypharmacy

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A PReP-TEAM course Know Your Team - Know Your Treatment

Learning objectives e-learning

Patients are becoming more and more complex and are prescribed and monitored by different healthcare professionals. This may lead to confusion for both the patients and their caregivers. Therefore it's important to know what the risks are of polypharmacy and how to appropriately support the patient in medication management. In this e-learning you will learn about polypharmacy & deprescribing so you can effectively communicate about the topic during the workgroup. You will learn about:

1. The concept of polypharmacy
2. Risks in polypharmacy
3. How to act on these risks

Chapters

What is polypharmacy?

Risks of polypharmacy

Changes in older patients

Meet Mr. Pol E.

START/STOPP criteria

01

What is POLYPHARMACY?

Patient visits

You just started working at the local [pharmacy or nursing home] and your supervisor asks you to check on the medication of a few patients. You receive the following patient cards. Who has polypharmacy?

Furosemide Metoprolol Apixaban Omeprazol Vitamin D supplement

Amlodipine Paracetamol Vitamin D supplement Vaseline cream when necessary

Trazodon Lorazepam Calcium-Vitamin D

Metformin Atorvastatin Aspirin Lisinopril

Salbutamol Tiotropium Lisinopril Paracetamol

What is polypharmacy?

Historically, polypharmacy meant five or more chronic medications in use. Recently, 'problematic polypharmacy' was introduced to differentiate appropriate use from inappropriate use. Appropriate use is when pharmacotherapy has been optimised to ensure quality of life of the patient, achieves its intended goals, and minimises harm. Inappropriate use is when the intended benefit is not realised.

Patient visits

Based on the definition from the previous page, who does the term polypharmacy apply to?

Furosemide Metoprolol Apixaban Omeprazol Vitamin D supplement

Amlodipine Paracetamol Vitamin D supplement Vaseline cream when necessary

Trazodon Lorazepam Calcium-Vitamin D

Metformin Atorvastatin Aspirin Lisinopril

Salbutamol Tiotropium Lisinopril Paracetamol

Contributing factors

Problematic Polypharmacy

Contributing factors

Although not exhaustive, these are frequently observed factors contributing to problematic polypharmacy.

Multiple specialists

Hospitalisation

Patient beliefs

Old age

click on the factors

02

Risks of polypharmacy

Risks of polypharmacy

Using multiple medications knows several risks, such as increased chance of side effects and decreased medication adherence. Especially when patients have a cognitive impairment, they can unintentionally skip medication or take overdoses. In this chapter, we will shortly discuss several important risks in polypharmacy.

Falling and cognitive complications

A major risk of polypharmacy is the increased risk of adverse effects. Older patients are often more prone to becoming frail, physically and mentally. Medications prescribed for psychiatric and neurological conditions target the central nervous system. Side effects that may occur include dizziness and cognitive impairment. Think of medications like antidepressants, opiates, antihistamines, anticonvulsants, and antipsychotics. Benzodiazepines are also often prescribed for older people.

Using antihypertensives, can lead to orthostatic hypotension and consequently falling. Additionally, antidiabetic medication can cause hypoglycemia. This is not the case for all antidiabetic medication. Especially insulins and sulfonylureas can cause hypoglycemia, and consequently dizziness and falling.

Incontinence

Other frequent side effects are incontinence and constipation. These occur more frequently in older patients, and can be worsened by medication. Click on the boxes to see how these medications can cause incontinence.

Increased urine output causes urge incontinence.

antidepressants

benzodiazepines

Detrusor muscle and urinary sphincter relaxation. Sedation causes functional incontinence.

SSRIs cause increase detrusor muscle activity and reduce urethal sphincter tone. TCAs cause urinary retention, with potentially overflow incontinence

DIURETICS

Reduces urethral sphincter tone, causing stress incontinence.

Alpha-blockers

Constipation

Some antidepressants, especially tricyclic antidepressants such as amitriptyline, have (1) anticholinergic properties. Acetylcholine plays a crucial role in (2) activating muscle contractions, including those in the digestive system. Furthermore, opioids reduce the gut motility, but through stimulating (3) µ-receptors. This also slows down the contractions of intestinal muscles. As stool (4) moves more slowly, the intestines have more time to (5) absorb water from it. This can lead to the stool becoming excessively dry and hard, making it difficult to pass.

stimulates

inhibits

click on the bold words!

Delirium

Delirium can be triggered by multiple factors. An imbalance in the physiology, like low sodium or dehydration can cause delirium. Also when a patient experiences discomfort, pain, an infection, or a state of confusion. In some cases, this can be caused by medications.

Mr. Azul is admitted to the hospital with a urinary tract infection. After 2 days. he becomes desoriented and agitated. His vitals are stable. He uses the following medications:

• Oxycodon
• Metoprolol
• Lorazepam

• Citalopram
• Levetiracetam
• Furosemide

What could be the cause of his delirium?

Click here!

Click on the icons for more information

Diarrhea

Fill in the blanks!

03

Changes in older patients

Physiological changes

Physiology of older patients may change. This way, medications may get processed differently in older patients. We will shortly discuss the four important changes in ADME.

Absorption

In older patients, the pH of stomach acid may increase. For some medications, like ketoconazole, this means they are degraded and absorbed less effectively. However, for some medications less degradation in the stomach, like ibuprofen, may improve absorption. These changes are often not clinically relevant and do not require interventions.

Distribution

Metabolism and excretion

04

Meet mr. Pol e.

Meet our patient

Mr. Pol E.

His current medication includes:

• Metformin 500 mg twice daily
• Lisinopril 10 mg daily
• Hydrochlorothiazide 25 mg daily
• Tamsulosin 0.4 mg daily
• Acetaminophen 1000 mg twice daily
• Zolpidem 10 mg at bedtime when necessary
• Sertraline 50 mg daily
• Ibuprofen 400 mg when necessary
• Multivitamin daily

Mr. Pol E. is a 67-year-old retired schoolteacher who presents with increasing fatigue, occassional dizziness, and two recent falls at home. He lives alone and uses a walker. His past medical history includes:

• Hypertension
• Osteoarthritis
• Type 2 diabetes
• Insomnia
• Depression
• Benign prostatic hyperplasia (BPH)

Which 2 of Mr. Pol E.'s medication DO NOT contribute to the count for polypharmacy? Hover over the to learn about the indication of the medication.

• Metformin 500 mg twice daily
• Lisinopril 10 mg daily
• Hydrochlorothiazide 25 mg daily
• Tamsulosin 0.4 mg daily
• Acetaminophen 1000 mg twice daily
• Zolpidem 10 mg at bedtime
• Sertraline 50 mg daily
• Ibuprofen 400 mg when necessary
• Multivitamin daily

Mr. Pol E.'s medication

Medication list

• Sertraline
• Ibuprofen
• Multivitamins

• Metformin
• Lisinopril
• Hydrochlorothiazide

• Tamsulosin
• Acetaminophen
• Zolpidem

Neurology: Zolpidem and sertraline both affect the central nervous system, possibly causing drowsiness, dizziness, and cognitive impairment. Renal: NSAIDs like ibuprofen constrict the afferent arteriole, ACE inhibitors dilate the efferent arteriole, and diuretics reduce blood volume — this contributes to acute kidney injury. Blood pressure: Tamsulosin with lisinopril and hydrochlorothiazide have additive hypotensive effects, especially orthostatic hypotension when initiating or increasing doses. This can causes falls in combination with the neurological side effects. Toxicity: Sertraline may affect the metabolism of zolpidem via CYP3A4, potentially increasing zolpidem levels, causing more sedation or toxicity.

05

start/stopP cRITERIA

Inappropriate prescribing

We have discussed how many medications can cause complications in especially older patients. However, sometimes patients can be undertreated as well. To optimize prescribing, we can use the START (Screening Tool to Alert doctors to Right Treatment) and STOP (Screening Tool of Older Persons' Prescriptions) criteria. These criteria hinge on the following points.

1. Undertreatment
2. Ineffective treatment
3. Overtreatment
4. Potential side-effects
5. Clinically relevant contra-indications or interactions
6. Problems with medication intake

We will discuss four considerations for prescribing or deprescribing in this chapter.

Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are frequently continued long after the original indication has resolved, contributing significantly to unnecessary polypharmacy. Although they have clear roles in treating or preventing peptic ulcers disease with anticoagulants or NSAIDs, they’re often prescribed for vague “heartburn” symptoms or continued indefinitely, also after the anticoagulants or NSAIDs have been stopped. Chronic, unmonitored PPI use increases risks of nutrient deficiencies, bone fractures, stomach pain and renal impairment. If there is no indication for PPIs, they should be carefully tapered off instead of abruptly stopped to avoid rebound reflux symptoms.

Gastro-intestinal complications

Mr. Pol E. has been suffering from gastro-intestinal complications for quite some time. He mostly experiences symptoms of constipation and stomach pain. His medication list has been updated. Which 4 of these may contribute to his complaints?

ParacetamolLisinoprilAcetylsalicylic acidOmeprazol

FurosemideFerrofumarateCalciumcarbonate/ColecalciferolDiazepam

Fall risks

Mr. Pol E. uses different types of medication. He isn't very mobile due to his osteoarthritis but he tries to walk around the neighborhood every now and then. However, he always carries a beeper in case he falls so assistance can come right away.

Medications affecting the central nervous system, such as antidepressants, opioids, antipsychotics, and benzodiazepines can alter someone's motor function leading to falls. This risk is especially high if these medications are combined. Antihypertensives can also increase the risk of falling due to orthostatic hypotension. If a patient's status allows for it (i.e. pain not heavy or blood pressure not high), consider lowering the dosage or deprescribing these medications altogether.

Supplementation

Older patients often take dietary supplements to address age-related nutritional gaps, chronic conditions, and changes in absorption. Which statement is true concerning vitamin D supplementation?

You've finished this e-learning!

We've discussed the risks in polypharmacy and what interventions you may take. These topics will be further discussed during the workgroup. For this, do the following: 1) Reflect on these statements and bring you answers to the workgroup.

• How do you represent your health care profession in polypharmacy?What are your responsibilities?
• How do you think other health care professions are involved in this process?
• What skills/competencies do you need to possess to participate in collaborative practice?

2) Download the app Team Up! Find Team Up! in the Google Play Store/App store or scan the QR codes below.

Google Play Store

App Store

Omeprazol can cause different GI-complications, including nausea, diarrhrea, constipation, and stomach pain

Patient beliefs can impact polypharmacy in two ways. First, patients may feel secure with their medication and refuse to stop certain medications, leading to a unnecessary medication use. On the other hand, patients may not see the added value of the many medications and will not be compliant.

It is often older patients with polypharmacy. When we age, the way we process medication changes. We discuss this in chapter 4 of the e-learning.

"Borderline" polypharmacy

The patient uses five medications, but this is often considered borderline polypharmacy and may not qualify in stricter interpretations unless complex regimens, duplicates, or potentially inappropriate medications are involved.

Older patients often have polypharmacy. When we get older, our physiology changes,which affects medication in our body differently.

Benzodiazepines mainly slow down brain activity, causing sedation. In susceptible individuals, this can disrupt the delicate balance of neurotransmitters involved in alertness and cognitive function, contributing to delirium.

Anticonvulsants can trigger a delirium via various routes. Their side effects include drowsiness, confusion, and slowed cognition. Some older anticonvulsants, notable carbamazepine, also have anticholinergic properties.

Acetylsalicylic acid can indeed cause GI-complications, mostly as dyspepsia, stomach pain or nausea

Antidepressants directly affect the neurotransmitter balance, causing delirium. Especially those with anticholinergic properties, like the tricyclic antidepressants, pose a large risk for delirium.

Incorrect answer

The patient uses all medications chronically, but only four different medications.

Pain itself, caused by the urinary tract infection for example, can trigger a delirium. Painkillers, like oxycodon, can also impair cognitive function. This disruption to attention is a important factor in the development of delirium.

Incorrect answer

The patient uses four different medications, of which the vaseline cream does not get used consistently or chronically.

Ferrofumarate can cause constipation. Paradoxically, it can also cause diarrhea, but this occurs less frequently.

An urinary tract infection causes the release of inlammatory chemicals. These can disrupt the neurotransmitter balance in the brain, leading to impaired cognitive function and confusion. Sometimes, urinary retention due to an infection releases stress hormones, which also contribute to a delirium.

Correct answer

This is a textbook example of a patient using multiple medications with a complex regimen.

Vitamin D supplementation is generally safe, but too many vitamin D supplements over a long period of time can cause calcium build up (hypercalcemia). This can cause damage to bones, kidneys, and the hearts. Calcium supplementation is not necessary when calmcium intake through diet is sufficient. It can cause gastro-intestinal complications, which can be addressed by either switching preparations or lowering the dosage. Considering a patient's (dietary) habits is important in deciding the necessity of supplementation.

When a patient has comorbidities, they are treated by multiple specialists. These often manage their own area, but sometimes fail to adequately communicate their reasoning to other healthcare providers. The primary caregiver then loses sight of which medications are prescribed for which indication.

When patients are hospitalised, their medication is often changed. When the patient and primary caregivers are not informed about why new medications are started, patients are prone to improper medication use. Pharmacists are often not properly informed about the hospitalisation in the first place.

Although calciumcarbonate/colecalciferol is mostly safe to use, it can cause dyspepsia and stomach pain. If it is not indicated as a supplement, deprescribing is a reasonable choice for this patient.