Review
Pharmaceutical strategies towards optimising polypharmacy in older people

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Abstract

This paper focuses on the issue of polypharmacy in older people and potential pharmaceutical strategies to optimize the use of multiple medicines. Although polypharmacy has long been viewed negatively, increasing emphasis is being placed on the difference between appropriate and inappropriate polypharmacy. This is largely being driven by the increasing prevalence of multimorbidity and the use of evidence-based guidelines. In this paper, we outline a number of key considerations that are pertinent to optimizing polypharmacy, notably prescribing appropriate polypharmacy, pharmaceutical formulations, the involvement of older people in clinical trials and patient adherence.

Section snippets

Background

The use of medicines in older people (conventionally designated as those over the age of 65 years) has been described as the ‘single most important health care intervention in the industrialized world’ (Avorn, 2010). ‘Polypharmacy’ has often been used to describe the use of multiple medications and has been noted as ‘one of the most pressing prescribing challenges’ (Payne and Avery, 2011). There is no accepted definition as to what number of drugs constitutes polypharmacy, with some authorities

Prescribing appropriate polypharmacy

As noted previously, achieving appropriate polypharmacy is not about ensuring the number of medicines prescribed is within a certain numerical threshold, but rather it is the task of ensuring that the safest, most effective medicines are prescribed to maximise patient benefit and minimise patient harm, while ensuring that all clinical indications are treated (Hughes et al., 2014).

There has been much emphasis in the literature on inappropriate prescribing for older people, i.e. when errors of

Pharmaceutical formulations

As mentioned above, when optimising polypharmacy for older people, it is necessary to consider their ability to take various pharmaceutical formulations as they are prescribed. Specific age-related conditions may preclude the use of particular formulation types for individual patients, thus highlighting the need to tailor pharmacotherapy to the individual patient.

For example, dysphagia, or difficulty in swallowing, is common amongst older people, with the prevalence rates reported ranging from

Older people and clinical trials: include or exclude on the basis of polypharmacy?

Clinical trials are the mainstay by which new therapies are evaluated in target populations. However, trials have often been criticised because participants may not represent the patient population in which drug use is most prevalent. This is particularly the case with older people who have been routinely and systematically excluded from trials, hence treatment recommendations are based on the extrapolation of evidence from trials conducted in healthy, younger populations. A recent publication

Patient adherence

Adherence to polypharmacy is of particular importance because polypharmacy is itself a risk factor for non-adherence, as is the complexity of the prescribed treatment regimen. Non-adherence is a significant problem and has been linked to higher rates of hospitalisations, worsening of clinical conditions and mortality (Gellad et al., 2011). There are also financial implications associated with non-adherence which arise from increased healthcare costs and medication wastage. With estimates of

Conclusion

Optimising polypharmacy for older, multi-morbid patients is challenging, and requires an up-to-date knowledge of clinical guidelines, and an understanding of the unique medication needs of older patients. Screening tools can help to optimise polypharmacy, particularly if used in conjunction with clinical information and with consideration of possible errors of omission as well as errors of commission. When prescribing for older people, due consideration should be given to the types of

Role of the funding

During the writing of this paper, C. A. Cadogan was being supported by a project grant from the Dunhill Medical Trust (Grant No. R298/0513), focusing on the development of an intervention to improve appropriate polypharmacy in older people in primary care.

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