Medical Essay on Polypharmacy

In contemporary nursing practice, polypharmacy has to be associated with multiple prescribers, selected filling pharmacies, numerous forms of medication, giving prescriptions that are lacking clinical basis and necessary medication to treat comorbidity maladies often resulting in what is commonly referred to as pill burden (Haque, 2009). Equally important is the fact that a polymedicine may be defined as the utilization of multiple medications for various illnesses while polypharmacy is inferred to high dosage medication, duplicative medication, and medications that have been prescribed for a prolonged period. This distinction is drawn from an array of definitions, which seemingly confuse even for medical professionals causing polypharmacy to problematic, prevalent and in most cases unnecessary (Haque, 2009). One of the grandest challenges faced by health providers is the barriers towards the empirical identification of patients who are seemingly consuming too much medication.

The Problem of Polypharmacy

There various identification propositions have been developed based on the principle of which individuals are at a higher risk of experiencing problems with their medication. In addition to these facets, the rationality behind augmented incidences of polypharmacy amongst individuals aged 65 years and older is based on the kinetic alterations that are occurring in the body as one age. According to Skinner (2015), this leads to the likelihood of drug reactions in senior citizens as pharmacodynamics also come into play. Research indicates that the gastric pH levels tend to rise while the bowel surface area diminishes which creates a slight alteration in the onset of digestive processes. Besides, the lipid and water distribution naturally increases with medications, which are either lipophilic or hydrophilic, tend to shift to such areas where they remain seated for an extended period. In the long run, this manifestation causes hepatic metabolism to slow down. According to Bushardt & Jones (2005), the marked decrease in renal function, the state of hydration of the patient including analysis for the presence of intrinsic renal disease is also considered. Such a phenomenon may be evidenced by the application of equations such as Modification of Diet in Renal Disease and Cockcroft-Gault in most medication packages when presenting suggestions on renal dosing. Nonetheless, Pequignot et al. (2009) concluded that the Cockcroft-Gault was the widely accepted method for assessing renal fuction in the elderly due to a higher degree of accuracy in the findings obtained.

Factors Contributing to Polypharmacy

The comprehension of mechanisms of preventing polypharmacy demands the knowledge of its genesis. A common etiological approach is paying attention to pharmacies and the roles played by multiple prescribers. Typically, different specialists treat patients by their disease progression, and this trend is based on factors such as access to health facilities, convenience, and other implied costs (Hajja, Cafiero & Hanlon, 2007). Such tendencies always culminate in incomplete medical histories and unknowingly, physicians end up prescribing more medication than is necessary to further compounding the problem of polypharmacy (Best et al., 2013). On the other hand, patients hold the perception that they only need to report the type of medication they are taking based on their current acute condition or the specialist they are consulting. Moreover, over-the-counter (OTC) drugs such as ibuprofen and aspirin and herbal supplements are often omitted in patients reports. As a result, professionals may not be aware of the possible interactions that may occur due to maintenance medications (Fialova, & Onder, 2009). Additionally, the pharmacist may be unaware of other types of medication, which may impede the new prescriptions from working. Drug interactions may be minimized through standardization of patients interactions with pharmacies and providers. According to Banerjee et al. (2011), another contributing factor that propagates to the prevalence of polypharmacy is the tendency to demand prescription drugs by patients when they pay consultation visits. The standard expectation of most patients is that they are entitled to order drugs with every visit because they justify certain ailments. Inadequacies in treated disease state management have also emerged as a contributor to polypharmacy including other issues such as sub-therapeutic dosages, non-treatment, nonadherence, and misdiagnoses. For instance, a sub-therapeutic dosage of donepezil, which is used to treat dementia and requires risperidone as an additional dosage, presents inadequate initial treatment.

Moreover, there is also the problem of giving concurrent medications from the same class has also proven to be problematic. Nonetheless, this phenomenon is not to be confused with the multiple uses of appropriate medication to treat various drugs. For instance, a patient may be treated with lisinopril for hypertension and metoprolol together with amlodipine for blood pressure regulation presents a right combination of medication that addresses a clinical problem (Serge Brazeau, 2001). In contemporary science, prescribers attempt to avoid treating a disease pharmacologically, but the non-treatment of a disease may culminate in adverse outcomes. For instance, avoiding treatment of pain may lead to alterations in behavioral problems, and in most cases, it leads to depression. Use of alternative methodologies of treatment of results in therapeutic functions leading to increased costs, aggravation in side effects and prolonged nursing time. Non-adherence is mostly associated with the lack of compliance by the patient in regards following instructions as described by the physician. According to Hubbard, OMahony & Woodhouse (2013), refusing medication may be as a result of dementia, costs, adverse side effects and the lack of knowledge on the potential benefits of using the prescribed medication. Another example of nonadherence is the crushing of drugs which some possess extended-release properties that reduce the shelf-life the drugs. This phenomenon has been determined as a being problematic before the administration of the next dosage and this it is recommended that medication is switched to more palatable forms such as crushable formulations or liquid medicine which also enhances its kinetic properties. On the other hand, prescribers argue that lack of adherence may be attributed to complicated protocols, limitations in autonomy and decreased independence in prescription procedures (Prybys & Gee, 2002). This problem is further compounded by a misdiagnosis where following medication proves futile due to the treatment based on an inaccurate diagnosis.

Strategies of Avoiding Polypharmacy

The paramount procedure of averting polypharmacy is the scrutiny of a patients complete medication list and making an effort at identifying the diagnosis for each drug. A nurse may watch out for factors such as duplication in drug therapy, from the same class, disease-drug interactions and the possibilities of non-drug interventions. According to Stawicki & Gerlach (2009), unnecessary medication has been found to occur commonly in at the point of determination for efficacy, duplication, and level of indication. In essence, the Assess, Review, Minimise, Optimize, Reassess (ARMOR) instrument was developed to evaluate the instances of polypharmacy in the elderly correctly. The ARMOR framework presents a systematic and structured approach for the thorough scrutiny of medication while accounting for most of the prescriptions aspects (Haque, 2009). Some of these components include adjusting dosages, minimizing non-essential medicines, reviewing for possible interaction and reassess for cognitive, functional and clinical status including medication adherence. Additionally, the considerations of a patients functional ability and clinical status ensure that efforts are made in balancing the best prescription practices while the physical profile and quality of life are improved continuously. Moreover, the Beers criteria provide a selected drug medication, which should be avoided in treating the elderly (Le Couteur et al., 2004).

According to Patterson et al. (2012), long-term care settings are also afflicted by the unique problem of the drug prescribing cascade. Such a phenomenon occurs when the side effect of one drug is treated by prescribing another medication. For instance, a patient may report having experience constipation due to the use of calcium supplements. Rather than recommending the use of laxative in such a case naively, the prescriber should investigate on the type of calcium product that is being utilized by the patient and make a decision on whether the benefits outweigh the risks. Equally important is the fact that it is paramount that a nurse be on the lookout for anticholinergic properties (Woodruff, 2010). Studies indicate that the prescription of two or more sets of drugs with anticholinergic characteristics results in effects such as blurred vision, increased heart rate, CNS complications, and cognitive impairment.

The issue of nonadherence may be resolved through a proper organization as it has emerged that complicated medication regimen may take a toll even in the most dedicated of patients. Consequently, caregivers are advised to caution their patients to confine themselves to taking medication that has only been prescribed by a physician, as this will limit chances of drug-drug interactions (Nawaz et al., 2015). Patients also need to be equipped with knowledge on the proper storage methodologies for the prescribed medicine. Adherence to medication may be augmented using color-coded charts, use of automatic dispensers for individuals with cognitive impairments and linking the dosage schedules to daily activities such as eating breakfast or brushing ones teeth.

Conclusion

In sum, the assessment of benefit-to-risk ratio in prescription medicine is a fundamental step in minimizing polypharmacy. Prescribers need to understand that at time the use of less medication is better hence the need to seek for non-pharmacological interventions whenever possible. Moreover, the examination of the chemical properties of drugs as defined by their classes is also important as it safeguards against instances of duplicated dosages, which is prevalent in nursing practice. Physicians should also endeavor to critically analyze the medical histories of patients before administering any form of medication.

Reference

Banerjee, A., Mbamalu, D., Ebrahimi, S., Khan, A. A., & Chan, T. F. (2011). The prevalence of polypharmacy in elderly attenders to an emergency department-a problem with a need for an effective solution. International Journal of Emergency Medicine, 4(1), 22.

Best, O., Gnjidic, D., Hilmer, S. N., Naganathan, V., & McLachlan, A. J. (2013). Investigating polypharmacy and drug burden index in hosp0italised older people. Internal Medicine Journal, 43(8), 912-918.

Bushardt, R. L., & Jones, W. (2005). Nine key questions to address polypharmacy in the elderly. Journal of the American Academy of Physician Assistants, 18(5), 32-37.

Fialova, D., & Onder, G. (2009). Medication errors in elderly people: contributing factors and future perspectives. British Journal of Clinical Pharmacology, 67(6), 641-645.

Hajjar, E. R., Cafiero, A. C., & Hanlon, J. T. (2007). Polypharmacy in elderly patients. The American Journal of Geriatric Pharmacotherapy, 5(4), 345-351

Haque, R. (2009). ARMOR: a tool to evaluate polypharmacy in elderly persons. Annals of Long-Term Care, 17(6), 26-30..

Hubbard, R. E., OMahony, M. S., & Woodhouse, K. W. (2013). Medication prescribing in frail older people. European Journal...