People are living longer and with more chronic health conditions – including heart disease, diabetes, arthritis and dementia – than ever before. As societies continue to grow older, one pressing concern is the use of multiple medications, a phenomenon known as polypharmacy.
Authors
Emily Reeve
Senior Research Fellow in the Centre for Medicine Use and Safety , Monash University
Jacinta L Johnson
Senior Lecturer in Pharmacy Practice, University of South Australia
Janet Sluggett
Enterprise Fellow, University of South Australia
Kate O’Hara
PhD student, Clinical Pharmacology and Toxicology, University of Newcastle
About 1 million older Australians experience polypharmacy and this group is increasing. They may wake up in the morning and pop a pill for their heart, then another one or two to control blood pressure, a couple more if they have diabetes, a vitamin pill and maybe one for joint pain.
Polypharmacy is usually defined as taking five or more different medications daily. In aged care homes, 90% of residents take at least five regular medications every single day. That can put their health at risk with increased costs for them and the health system.
Adding up over time
As people age, the effects of medications can change. Some medications, which were once beneficial, might start to do more harm than good or might not be needed anymore. About half of older Australians are taking a medication where the likely harms outweigh the potential benefits.
While polypharmacy is sometimes necessary and helpful in managing multiple health conditions, it can lead to unintended consequences.
Prescription costs can quickly add up. Taking multiple medications can be difficult to manage particularly when there are specific instructions to crush them or take them with food, or when extra monitoring is needed. There is also a risk of drug interactions.
Medications bought “over the counter” without a prescription, such as vitamins, herbal medications or pain relievers, can also cause problems. Some people might take an over-the-counter medication each day due to previous advice, but they might not need it anymore. Just like prescription medications, over-the-counter medications add to the overall burden and cost of polypharmacy as well as drug interactions and side effects.
Unfortunately, the more medications you take, the more likely you are to have problems with your medications, a reduced quality of life and increased risk of falls, hospitalisation and death. Each year, 250,000 Australians are admitted to hospital due to medication-related harms, many of which are preventable. For example, use of multiple medications like sleeping pills, strong pain relievers and some blood pressure medications can cause drowsiness and dizziness, potentially resulting in a fall and broken bones.
Prescribing and deprescribing are both important
Ensuring safe and effective use of medications involves both prescribing, and deprescribing them.
Deprescribing is a process of stopping (or reducing the dose of) medications that are no longer required, or for which the risk of harm outweighs the benefits for the person taking them.
The process involves reviewing all the medications a person takes with a health-care professional to identify medications that should be stopped.
Think of deprescribing as spring cleaning your medicine cabinet. Just like how you tidy up your house and get rid of objects that are causing clutter without being useful, deprescribing tidies up your medication list to keep only the ones truly required.
But care is needed
The process of deprescribing requires close monitoring and, for many medications, slow reductions in dose (tapering).
This helps the body adjust gradually and can prevent sudden, unpleasant changes. Deprescribing is often done on a trial basis and medication can be restarted if symptoms come back. Alternatively, a safer medication, or non-drug treatment may be started in its place.
Studies show deprescribing is a safe process when managed by a health-care professional, both for people living at home and those in residential aged care. You should always talk with your care team before stopping any medications.
Deprescribing needs to be a team effort involving the person, their health-care team and possibly family or other carers. Shared decision-making throughout the process empowers the person taking medications to have a say in their health care. The team can work together to clarify treatment goals and decide which medications are still serving the person well and which can be safely discontinued.
If you or a loved one take multiple medications you might be eligible for a free visit from a pharmacist (a Home Medicines Review) to help you get the best out of your medications.
What’s next?
Health care has traditionally focused on prescribing medications, with little focus on when to stop them. Deprescribing is not happening as often as it should. Researchers are working hard to develop tools, resources and service models to support deprescribing in the community.
Health-care professionals may think older adults are not open to deprescribing, but about eight out of ten people are willing to stop one or more of their medications. That said, of course some people may have concerns. If you have been taking a medication for a long time, you might wonder why you should stop or whether your health could get worse if you do. These are important questions to ask a doctor or pharmacist.
We need more public awareness about polypharmacy and deprescribing to turn the tide of increasing medication use and related harms.
In the past five years, Emily Reeve has received funding from the National Health and Medical Research Council (NHMRC), Australian Association of Gerontology, Nova Scotia Health Research Foundation, Canadian Frailty Network, United States NIH, Australian Commission On Safety And Quality In Health Care, and US Agency for Healthcare Research and Quality. She has also received honorarium for writing and presentations from the US Deprescribing Research Network, Encyclopedia of Pharmacy Practice and Clinical Pharmacy (Elsevier), UpToDate (Wolters Kluwer), and Society of Hospital Pharmacists of Australia. She is Chair of the Australian Deprescribing Network (ADeN).
Jacinta Lee Johnson is senior pharmacist for research within SA Pharmacy and Board Director for the Society of Hospital Pharmacists of Australia. In the last five years, she has received research funding or consultancy funds (for development and delivery of educational materials) from SA Health, the Medical Research Future Fund, the Hospital Research Foundation – Parkinson’s, the Pharmaceutical Society of Australia, the Pharmacy Guild of Australia, the Society of Hospital Pharmacists of Australia, Mundipharma Pty Ltd, Aspen Pharmacare Australia Pty Ltd and Viatris Pty Ltd.
In the last five years, Janet Sluggett has received research funding, prizes or consultancy funds from the National Health and Medical Research Council, Medical Research Future Fund, Australian Association of Consultant Pharmacy, Dementia Centre for Research Collaboration and various professional societies. In addition to her research appointments, she is a non-executive director of the Australian MedicAlert Foundation and Southern Cross Care SA, NT, Victoria. She is a registered pharmacist who is accredited to perform Home Medicines Reviews.
Kate O’Hara is affiliated with the Society of Hospital Pharmacists of Australia (SHPA).
