Polypharmacy raises risks of side effects, skipped pills

Scenario

An 84-year-old man lives at home with his wife. They are independent and able to complete the full range of activities of daily living. Recently, the man complained about dizziness and worsening constipation and came to your office for advice.

The patient has a medical history of atrial fibrillation, hypertension and coronary artery disease. In addition to warfarin, simvastatin and a low dose of metoprolol, his cardiologist two months ago prescribed amlodipine for elevated blood pressure. When the patient returned for a BP check, the cardiologist's partner prescribed hydrochlorothiazide for mild lower extremity edema and a one-week course of cephalexin to treat an area of cellulitis in his forearm.

Last week, the patient felt dizzy and fell. Since then the patient has been withdrawn and fearful of falling. In addition, he has not taken any Senokot tablets for more than a week. "I'm taking too many pills, and they are too big to swallow," he said.

On exam, his blood pressure was 105/60; his heart rate was 64. He had an irregularly irregular heart rate and rhythm, his abdominal exam was benign but his rectal exam showed stools in the rectum that were trace-blood positive.

The rest of the exam was normal. His positive laboratory findings included borderline low hemoglobin (12.4 g/dL) and elevated INR (4.2).

Discussion

The experience of this patient is common among older people who find themselves juggling a range of medications, often prescribed by different physicians. In fact, statistics indicate that half of people 60 or older take three or more prescription medicines on a regular basis; one in 10 takes seven or more.

For this patient, taking an inventory of his prescription regimen could have a significant impact on his well-being and ability to maintain his independence.

For instance, re-evaluating his current blood-pressure medications, as well as introducing the use of 24-hour BP monitoring to evaluate for postprandial and/or orthostatic hypotension, could address some of his dizziness and minimize his fear of falling.

Also, it's important to avoid treating the side effect of one medication, in this case the lower extremity edema caused by the amlodipine, with another medication, the diuretic. Adjusting the warfarin dose when adding a medication that is metabolized via the same enzymatic pathway is key. This step would help avoid cytochrome p450 interactions.

Lastly, always take patient preferences into account. Here, the patient may be more compliant if his bowel regimen consists of a small drink instead of a large pill.

Conducting this type of medication review is an important task in delivering geriatric care. It's not only a valuable tool for preventive health care but also for helping older patients maximize their quality of life.

Geriatricians recommend incorporating these reviews into patients' regular office visits.

One of the most common methods is the "brown bag" approach. At least twice a year -- and whenever a new medication is added -- patients should be asked to bring a bag containing all of their medications to scheduled appointments. A nurse or other staff member can inventory the bag's contents and reconcile it with the information in the patient's records. This should be viewed as essential as taking a patient's vital signs.

If the office uses paper records, an updated medication list should be maintained and placed in the front of the file. With electronic medical records, the staff can be prompted to review it.

Through this exercise, physicians not only will be sure that information about a patient's medications is complete and accurate but also will determine whether their patients are being compliant with the treatment plans. After all, there are multiple reasons why patients do not follow directions as they should.

Patients also should be asked about over-the-counter medicines. These can, without the patient's knowledge, be causing negative drug interactions or increasing the risks of adverse events.

In addition, patients should be encouraged to keep a copy of the medication list to share with their family members and/or caregivers. Doing so can make them more engaged in the specifics of their own care and can increase their understanding of the importance of complying with treatment plans.