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Tools to Manage Polypharmacy

Caregivers have a few tools and guidelines to manage polypharmacy, which is taking five or more medications daily. Polypharmacy affects older patients the most because of their age and a significant burden of decreased physical functioning. Adverse drug events (ADEs) lead to an increased risk of falls, increased delirium, more hospital admissions, and in the most serious ADEs, death.

Comparing Tools

Three of the most common tools used to manage polypharmacy are START, STOPP, and the Beer’s list.

  • START = Screening Tool to Alert doctors to Right Treatment
  • STOPP = Screening Tool of Older Person’s potentially inappropriate Prescriptions

START and STOPP

  • Attempt to capture common and important instances of potentially inappropriate prescribing
  • Organize medications according to physiological systems
  • Give special attention to opiate use and to drugs that adversely affect elderly patients at risk of falls
  • Highlight duplicate drug class prescription (e.g. two ACE inhibitors or two proton pump inhibitors)
  • Address serious errors of prescribing omissions in older people
  • Try to represent the consensus views of a panel of experts in prescribing to the geriatric population

While neither START nor STOPP has been shown to reduce morbidity, mortality, or cost, they are still used by organizations to monitor the quality of prescribing. They should be used as criteria to identify red flags that might require intervention, but not as the final word on medication appropriateness.

Beer’s List

  • Developed by Dr. Mark Beers in 1991, and updated several times since then. Latest edition is from 2015.
  • It was originally a list of medications considered to be inappropriate for long-term care facility residents.
  • The latest version is for use in outpatient and inpatient settings to improve the care of patients age 65 and over.

Common Medications to Avoid

As patients age, the way medications work in the body changes. For example, a pharmacokinetic change in the elderly includes a 40 percent drop in hepatic blood flow, or blood flow to the liver. Nearly half of elderly patients have some form of chronic kidney disease. Add in chronic heart disease, and the impacts are even worse.

For diabetes, the Beers List suggests avoiding medications that can worsen heart failure or put patients at risk of hypoglycemia, for example pioglitazone or glipizide-XL, respectively. Instead use regular release glipizide or basal insulin.

To help patients sleep, avoid benzodiazepines and non-benzo hypnotics. Instead low-dose trazodone is an option, as well as practicing sleep hygiene to develop better habits.

Anticholinergic medications are another area where alternative treatment options can be explored. Tricyclic antidepressants and first-generation antihistamines increase the risks of cognitive impairment and delirium. Instead, for elderly patients, try loratadine for allergies and newer SSRI medications for depression.

To teach medication administration, and educate about how medication looks and proper dosing, see the Demo Dose® family of simulated medications at Pocket Nurse. Solutions include medications suggested in the literature: Demo Dose Glucotrl, Demo Dose Insuln solutions, Demo Dose Sertralin, and more.

For more information about polypharmacy, you can see our article here. For more information about deprescribing, see our blog post here, or visit deprescribing.org.

Resource:
American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication use in Older Adults

Information for this post came from a presentation by Denise Kreckel, R.Ph. “Polypharmacy: Poly-drug, Poly-Problems,” which was presented at Strategies: Educational Excellence for Healthcare Providers and Educators 27th Annual Conference at Penn State University. This is part three of a series of posts based on her presentation. Kreckel is from the Centre Volunteers in Medicine in State College, PA.

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