The Crisis of Polypharmacy in the Elderly 

In a society with more than 20,000 FDA-approved prescription drugs advertised directly to consumers, America’s growing dependency on medication has become a problem that will require combined efforts from the government, healthcare professionals, organizations, and individuals to combat it.

Studies show that in 2020, approximately $348.4 billion was spent on prescription drugs. The most commonly abused prescription drugs, meanwhile, were opioids, tranquilizers, benzodiazepines, and prescription stimulants. 

Further exacerbating the problem are physicians who tend to prescribe prescription drugs on top of existing prescriptions without assessing the impact on the patient’s health. Even if a previous condition has healed, rather than removing the prescribed drugs that are no longer needed, they simply add more prescription drugs to the patient’s records, leading to polypharmacy in the elderly.

Even though prescription drug misuse is common throughout America, it is most prevalent in older adults. Worryingly, statistics from the National Health and Nutrition Examination Survey of 2015-2016 indicate that prescription drug use tends to increase with age, which is when people inevitably develop more chronic health conditions managed with prescription drugs. 

Additionally, older patients are continually prescribed more drugs for a prolonged period, leading to polypharmacy in the elderly and increased polypharmacy risks, such as dangerous drug interactions, severe side effects on their mental and physical health, and drug addiction. 

Polypharmacy in Older Adults: Why Are They Being Overmedicated?

The problem of polypharmacy in the elderly does not boil down to a single issue but rather a combination of issues that must be addressed. Below, we will share the reasons why polypharmacy in older adults is so common and what are the most significant issues and challenges of polypharmacy in the elderly. 

Problem #1: A distinct lack of communication between physicians leads to polypharmacy in the elderly and increased risks in overmedicated seniors. When older adults develop new health conditions, they go to their primary doctor, who refers them to a specialist. The specialist will assess the senior and prescribe medication for the patient. However, the communication between the specialist and the patient’s primary physician is very limited. The patient’s file is typically sent between the primary physician and the specialist. However, the file is rarely reviewed, leading to both physicians being unaware of what medication the patient is taking. 

Additionally, there is the issue of physicians not being willing to override another doctor’s prescribed drugs. Therefore, rather than communicating with other physicians about what medication a patient is taking before prescribing a new medication, physicians simply add more to the list, leading to polypharmacy in the elderly. Communication is so poor between physicians that neither party knows what medication was prescribed to the patient, the dosage, or how long the patient has been taking the prescription drug. 

This leads to a list of inappropriate or unnecessary prescriptions and adverse side effects from taking multiple medications for a prolonged period, including cognitive problems like memory issues, dementia, disorientation, confusion, clouded thinking, and dependency on the prescription drugs.

Problem #2: While some electronic nursing software programs offer customizable processes to improve workflow and enable accurate data collection, other EMR software systems are ineffective, inefficient, and not user-friendly. This hinders physicians from accessing and updating patient records and failing to capture important patient information, which is passed on to other healthcare professionals, increasing the likelihood of medical errors, polypharmacy in the elderly, and poor patient care.  

Additionally, some physicians may not use EHRs or EMRs at all, making it more challenging to review patient records because they are either handwritten or in PDF format. Therefore, if a senior is admitted into a long-term care facility, there may not be a comprehensive record of their medication list. In such cases, it will be the facility’s responsibility to reconcile the records, or, review the records from multiple providers and determine which medication can be discontinued. 

Problem #3: Many senior patients are looking for a quick fix for their ailments. Therefore, it has become common practice to purchase over-the-counter drugs or ask doctors for specific advertised medications, such as Lyrica, Eliquis, or Cialis, which are prescribed upon the patient’s request. However, these are often prescribed without assessing the patient’s records properly, leading to polypharmacy in the elderly, increased overmedication risks, and adverse side effects. 

Prescription drugs also affect senior patients differently from younger patients. Only a trained geriatrician or a clinical pharmacist specializing in geriatric care will be aware of how prescription drugs will impact senior adults, which leads to our next problem.

Problem #4: For the past fifty years, seniors with cognitive issues like dementia or Alzheimer’s, have been wrongly diagnosed with schizophrenia while living in a nursing home. Seniors with dementia typically display symptoms of confusion, forgetfulness, and agitation and have a tendency to wander, which makes them immensely difficult to care for, especially if the facility is understaffed.

In some unfortunate cases, to prevent these problematic seniors from wandering and help manage their challenging behavior, nursing home physicians have purposely diagnosed seniors with schizophrenia. This allows them to administer powerful anti-psychotic drugs like Haldol or Seroquel to sedate seniors into submission and control their behavior. 

However, these seniors are often so heavily overmedicated that their condition declines because they are asleep for most of the day. In extreme cases, these residents regularly sleep through meals, causing them to lose weight dramatically, while others spend so much time in bed or in a wheelchair that they develop bed sores, leading to the amputation of limbs. 

The reality is that schizophrenia is usually diagnosed in young adulthood, not in senior adults. For nursing homes to diagnose seniors with schizophrenia is a blatant act of mistreatment and abuse of power, an easy for staff to avoid dealing with them. This practice has been widespread for decades, and the result is depriving seniors of their dignity while controlling them against their will or their families. 

Due to the adverse symptoms of sedating seniors, like extreme weight loss, bed sores, amputation, dehydration, and an increased likelihood of falls, government officials and physicians have objected to the “chemical straitjacket” of prescribing anti-psychotic drugs to calm residents down and instead called for a need to address the problems of insufficient staff, ethical issues, and increased health problems. 

Recent changes to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v1.17.1R require healthcare providers to conduct a detailed evaluation with the appropriate diagnostic information to support a mental disorder diagnosis before coding the MDS diagnosis. This aims to reduce misdiagnoses to ensure patients are correctly medicated while decreasing polypharmacy in the elderly. 

Problem #5: Statistics from 2020 show a mass shortage of geriatricians nationwide, with only 7,123 certified geriatricians and 8,220 full-time practicing geriatricians. Meanwhile, there are approximately 52.4 million senior adults in America, so it is easy to see why elderly patients are not getting the care or attention they need. 

Most general practitioner programs do not include any specialized training time for geriatrics. As a result, few physicians understand the complexity of caring for geriatric patients with multiple chronic conditions. 

Furthermore, studies show that medical students have fewer opportunities to gain feedback on specific geriatric skills because they are often unsupervised when assessing older patients. This hinders medical trainees because they lack constructive feedback during their medical training, which is necessary to improve assessment performance, track the progress in geriatric competencies, and decrease polypharmacy in the elderly.

Preventing Polypharmacy Risks in the Elderly

To prevent polypharmacy risks in the elderly, we must look for alternative ways to identify senior patients’ risk from inappropriate polypharmacy while educating patients, families, and healthcare professionals about the dangers of polypharmacy in the elderly. Some practical applications for polyphramacy management in older adults include:

• Working Diligently with Patients and Families: Communicating openly with senior patients and their families is essential to obtain an accurate medication list. In addition, physicians need to know all the previous prescription medications to make amendments to the current medication list and dosage when required. This will improve compliance and safety while ensuring the prescription drugs are taken correctly to reduce polypharmacy in older adults.  
• Explore Alternate Settings with Families: Depending on the resident’s needs, facilities and families can also explore alternative settings and care, such as requesting an elderly sitter from the family. Some residents need more assistance and care, which a facility does not have the resources to provide. In such instances, the family can provide a private elderly sitter who can be employed full-time, part-time, and 24/7. However, private sitters are not funded by the state, meaning the family would bear the full costs, which usually averages around $18 per hour.
• Be Aware of Resident Needs: Every resident has different medical needs, therefore needing different levels of assistance and medication. Healthcare providers and caregivers must consider these factors by performing a comprehensive analysis to determine their needs, allowing them to provide personalized care that caters to their individual needs.   
• Specialized Staff Training: As mentioned earlier, patients with dementia are often overmedicated due to a lack of staff and training. A better way to care for dementia patients is to provide more specialized dementia training for caregivers so they can effectively deal with dementia residents and know how to redirect difficult behaviors. It is also beneficial to assign more skilled staff in dementia care to tend to dementia residents. This will allow the caregiver to develop a stronger bond with the resident while relieving the stress for staff members less skilled in caring for dementia residents.
• Schedule Appropriate Activities: Additionally, healthcare providers and long-term care facilities can schedule appropriate daily activities for dementia patients to provide relief for staff while keeping the resident occupied. This is beneficial because it gives the resident the necessary structure and schedule, which reduce feelings of disorientation, stress, or anxiety. In turn, this improves the behavior of residents, keeping them off the floor while reducing the risk of falls and inappropriate wandering into other residents’ rooms. 
• Developing a Partnership between Providers and Families: Rather than diagnosing and issuing more medication to seniors, it is better to develop a partnership with healthcare providers. This enables physicians to communicate more between the facility and the family while putting the residents’ health first. If a physician wants to prescribe a new medication, there should be a discussion between physicians, specialists, and families about the treatment. Furthermore, this paves the way for a better continuum of care while maximizing other alternative resources for more medication. 
• Adopting an Effective eMAR Software System: Effective eMAR software will have the capabilities to modify how the medication is entered and ordered. For example, ineffective software systems usually organize and display medication alphabetically. However, it is more effective to group medication according to condition, e.g., blood pressure, anticholinergic, pain control, and antidepressants. This allows physicians to consolidate one drug to treat multiple conditions rather than prescribing additional medication and causing adverse problems. 
• Banding Healthcare Professionals Together: Physicians, pharmacists, nurses, and other healthcare workers must work together and be vigilant when reviewing and updating patient records for medication errors or outdated prescriptions. If a medication error is spotted, they must remove the incorrect prescription from the patient’s records to prevent the adverse consequences of polypharmacy, such as further misuse and possibly forming an addiction. 
• Encouraging Dietary Supplements or Natural Remedies: to prevent or treat various health problems, such as depression.  Dietary supplements and natural remedies like vitamins, minerals, ginseng, and echinacea have become increasingly popular. However, some natural treatments may interact poorly with prescribed medication. Therefore, senior patients or their families should speak with physicians before taking additional supplements. 
• Adopt Non-Pharmacological Solutions: Non-pharmacological management is another alternative to explore because it utilizes alternative ways for caregivers and facilities to refocus residents’ attention to better manage behaviors and other symptoms like pain. Some popular non-pharmacological methods to alleviate pain include using hypnosis, providing physical and occupational therapy, counseling, and comfort therapy. Meanwhile, for dementia patients, using fidget or activity blankets is also a popular option as they provide a calming response for seniors who are in distress due to dementia.
• Adhering to the Black Box Warnings: The healthcare industry is highly regulated, so they must take black box warnings very seriously. Unfortunately, in acute settings, these warnings are ignored in some instances, like prescribing anti-psychotic drugs like Seroquel. 

Showing concern that anti-psychotic drugs were being widely prescribed outside of their approved use, in 2005, the Food and Drug Administration issued a black box warning on anti-psychotic drugs, alerting physicians that there was a 16% increased risk of death in older dementia patients for anti-psychotics. Following the advisory, atypical drug mentions fell by 19% among seniors with dementia. 

Furthermore, in 2012, the CMS partnered with federal and state agencies and nursing homes to improve dementia care by reducing anti-psychotic medication use for long-stay residents by 15%. However, despite best efforts, the 15% reduction was not achieved, leading to the CMS extending the goal for another calendar year.

• Increase Transparency: The current loophole does not require nursing homes to disclose who is using what drugs and for what conditions, including schizophrenia. This means that nursing homes can diagnose residents with schizophrenia and never need to report it, leading to them being diagnosed with schizophrenia when it’s not there. Therefore, calling for more transparency between the public, the government, and facilities. Nursing homes should publish reliable statistics, allowing families to see which nursing homes are using anti-psychotic drugs and for what conditions so they can make more informed decisions about the nursing home and whether it is an appropriate residence for their elderly relatives. 

Reducing Polypharmacy in the Elderly

Ultimately, when it comes to reducing polypharmacy in the elderly, physicians and healthcare providers should invest in comprehensive elder care software with medication management capabilities and electronic documents. This will allow them to easily access and share patient data with other physicians and healthcare providers. 

Additionally, physicians and caregivers can also be alerted to any polypharmacy risks by setting up helpful notifications through the senior care software. This will eliminate any immediate medication threats to ensure that all prescribed medications and dosages are accurate, complete, and, most importantly, not duplicated.