Polypharmacy – the concurrent use of multiple medications by one individual – is an increasingly common phenomenon that demands attention at clinical policy and practice level. Driven by the growth of an ageing population and the rising prevalence of multi-morbidity, polypharmacy has previously been considered something to avoid. It is now recognised as having both positive and negative potential, depending on how medicines and care are managed.
This report proposes a pragmatic approach, offering the terms ‘appropriate’ and ‘problematic’ polypharmacy to help define when polypharmacy can be beneficial. Drawing on literature from predominantly Western countries, the report traces the occurrence of polypharmacy in primary and secondary care, and in care homes. It explores systems for managing polypharmacy and considers it in the context of multi-morbidity and older people, offering recommendations for improving care in both cases.
Key findings
For many people, appropriate polypharmacy will extend life expectancy and improve quality of life. Their medicines use will be optimised and prescribed according to best evidence.
In problematic polypharmacy there can be an increased risk of drug interactions and adverse drug reactions, together with impaired adherence to medication and quality of life for patients.
Many clinical trials and practice guidelines do not consider polypharmacy in the context of multi-morbidity. It is important that pragmatic clinical trials are conducted that include patients with multi-morbidity and polypharmacy.
Multi-morbidity and polypharmacy increase clinical workload, so doctors, nurses and pharmacists need to work coherently as a team with a balanced clinical skill-mix.
People often do not take medicines as they are intended. Evidence shows many dispensed medicines remain unused or are wasted.
During medication reviews, prescribers should consider if treatment should be stopped and ‘end-of-life’ care be offered for certain chronic conditions or cancer-related illness.
Patients with multi-morbidity could have all their long-term conditions reviewed in one visit by a clinical team responsible for co-ordinating their care.
Patients may struggle with complex drug regimens; their perspective on medicine-taking must be taken into account when prescribing.
Policy implications
More training is needed in managing complex multi-morbidity, polypharmacy and other aspects of medicines management, involving GPs, older care clinicians, orthogeriatricians, clinical pharmacologists, nurse specialists and clinical pharmacists.
Systems are needed that optimise medicines use where there is polypharmacy so that people gain maximum benefit from their medication with the least harm and waste.
There are numerous evidence-based guidelines for the treatment of single conditions, but there is a need for guidelines on the treatment of multi-morbidity.
I believe that we are missing opportunities to help patients with multiple morbidities when they are admitted to any healthcare setting in taking the time to discuss medicines with the patient and careers and to address the issues before they are discharged back to primary care. My own experience with my family has shown me that there needs to be review of how pharmaceutical care is delivered in secondary care and the expected outcomes. There needs to be greater handover between secondary and primary care on discharge and connecting with the community pharmacists will be key in sustaining any improvements made.
I have a friend who is taking 11 different medications prescribed for him by his doctor. From being a fit healthy marathon runner and rugby player in his youth he has quickly deteriorated living in a sea of nausea. Where can we get advice on the compatibility of the range of drugs he is taking?
Marina Buswell - While I can't comment on the specifics of your case, I find in my daily reviews of patients and their medication that those patients who have been put on a dosette box know little to nothing about their medication. They may very well be taking their medication but not understanding why they take each medicine leads to even poorer compliance. The danger of dosette boxes is that if a patient decides they don't like taking all those tablets they must stop all of them and not just the ones they really need. Better patient education and an agreement between the patient and prescriber regarding which medicines they need to take would probably improve things no end.
That said, it is convenient for carers/relatives etc to just pop the dosette box open and hand the tablets over.
Under practical tips ' Ensure that the directions on each prescription identify the problem it is intended to treat ' no advice is given on how to achieve this . Primary care computer systems can easily add this to the drug use instructions. Visit clinicalindications.com . This is advocated in the latest GMC guidelines on prescribing. We desperately need to move forward on this issue of polypharmacy and proper computerisation of clinical indications approach would help confused clinicians cope with the present avalanche of drug prescribing.
I wonder if I could share Table 1 in page 6 for a talk I'm preparing on the subject- is this copyrighted?
Overall I've found this very useful, although I think the "practical examples" section could be much better- and perhaps it should be developped further into a teaching tool? , Ah, and more needs to be said about the NNT and cardiovascular risk prevention drugs in general.
I've just organised a dosset box for mum-in-law after an impromptu medication review (at my request) at the end of a best interest meeting. I'd attempted to figure out what in the mixed bag of medications was supposed to being been taken and when with a list beside me. It was very confusing.
I work in health service research so know about 'medication reviews', 'concordance' and the availability of dosset boxes but I had to go and ask specifically about them and suggest we go for concordance over compliance.
Perhaps there's something about letting patients and families know what they can ask for and for healthcare professionals to expect to be asked (would they have listened to my mum-in-law if she had been on her own without a 'professional' family member with her who knew the right jargon?)
How do we get what we know into practice for everyone?
I worry health care professionals work in silos & there are very few real concrete drivers to operate differently. A lot of trials exclusively looked at addressing errors at the point of prescribing (PRACtICe )or very intensive pharmacy led interventions (PINCER). While both are extremely laudable & excellent pieces of research & interventions, are they able to be scaled up ?
Is perhaps a more embedded multi-disciplinary approach not the (simpler) answer? Are the existing GP & Community Pharmacy (CP) contractual levers around medicines optimisation really used in a truly multi-disciplinary way ? Have commissioners (both local & national) missed a trick by not dove trailing & integrating the GP & CP contracts better, with patient outcomes as the main driver ? (I specifically only mean in the context of Medicines Optimisation here, I accepted there are lots of other patient outcome focused items in the GP & CP contracts). I appreciated the recent contractual negotiations caused heated discussion in the GP profession, & a similar debate is going to hit the CP profession as that contract is negotiated, but I would propose a truly integrated multi-disciplinary primary care approach is the best lever to address medicines optimisation.
Of course, the rather large elephant in the room is non-compliance, both unintentional and probably more importantly intentional non-compliance. Addressing the latter is the QIPP Holy Grail but very little innovative commissioning seems to be directed at this.
The following line seems a rather understated way to say something we should all be shouting about: Close collaboration of pharmacists and doctors in both prescribing and subsequent medication review seems a sensible approach (Holland et al 2005; Salter et al 2007). (I would have added Practice & Community Nurses, & indeed many others including formal & informal carers to the mix).
There are lots of “call to action” documents being published at the moment, perhaps a “call to action” for us to climb out of our silos is needed ?
Patients with co-morbidities on multiple medications would be first in line in a GP Practice for consultation with an Independent Prescriber, who could optimise the medication spectrum, advise on lifestyle changes, and network with doctors and nurses for patient benefit, and reduce the likelihood of hospitalisation in the future
Comments
That said, it is convenient for carers/relatives etc to just pop the dosette box open and hand the tablets over.
We are happy for you to share the table in a talk, providing The King's Fund is credited.
Kind regards,
Stuart Hill
Overall I've found this very useful, although I think the "practical examples" section could be much better- and perhaps it should be developped further into a teaching tool? , Ah, and more needs to be said about the NNT and cardiovascular risk prevention drugs in general.
I work in health service research so know about 'medication reviews', 'concordance' and the availability of dosset boxes but I had to go and ask specifically about them and suggest we go for concordance over compliance.
Perhaps there's something about letting patients and families know what they can ask for and for healthcare professionals to expect to be asked (would they have listened to my mum-in-law if she had been on her own without a 'professional' family member with her who knew the right jargon?)
How do we get what we know into practice for everyone?
Is perhaps a more embedded multi-disciplinary approach not the (simpler) answer? Are the existing GP & Community Pharmacy (CP) contractual levers around medicines optimisation really used in a truly multi-disciplinary way ? Have commissioners (both local & national) missed a trick by not dove trailing & integrating the GP & CP contracts better, with patient outcomes as the main driver ? (I specifically only mean in the context of Medicines Optimisation here, I accepted there are lots of other patient outcome focused items in the GP & CP contracts). I appreciated the recent contractual negotiations caused heated discussion in the GP profession, & a similar debate is going to hit the CP profession as that contract is negotiated, but I would propose a truly integrated multi-disciplinary primary care approach is the best lever to address medicines optimisation.
Of course, the rather large elephant in the room is non-compliance, both unintentional and probably more importantly intentional non-compliance. Addressing the latter is the QIPP Holy Grail but very little innovative commissioning seems to be directed at this.
The following line seems a rather understated way to say something we should all be shouting about: Close collaboration of pharmacists and doctors in both prescribing and subsequent medication review seems a sensible approach (Holland et al 2005; Salter et al 2007). (I would have added Practice & Community Nurses, & indeed many others including formal & informal carers to the mix).
There are lots of “call to action” documents being published at the moment, perhaps a “call to action” for us to climb out of our silos is needed ?
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