gms | German Medical Science

Polypharmacy may have different faces in different countries or clinics but there is no doubt that the problem is global. It is defined as “The administration of more drugs than are clinically indicated”; inappropriate medication use (IMU) defined as "medication use that has a greater potential risk for harm than benefit, is less effective than available alternatives, or does not agree with accepted medical standards". However, there is a lack of "accepted medical standards" as age, co-morbidity and the number of drugs increase, resulting in considerable disagreement regarding what exactly is IMU use and how it can be determined.

While comparing risks versus benefits of drug withdrawal in elders, one should remember that the rate of drug interactions is age related, the odds of IMU are higher as the absolute number of medications prescribed increases, and the risk of hospitalization secondary to IMU is much greater in elderly people.

Beers et al. tried repeatedly to establish criteria for defining specific medications that should be regarded as “potentially inappropriate” and should not be given to elders. Many rely on updated Beers criteria with the hope that they may serve as an alarm system to increase physician alertness and avoid specific drugs. However, it is difficult to conclusively defend or refute the use of most drugs listed by Beers, and drugs-to-avoid criteria are insufficiently accurate to use as stand-alone measures of prescribing quality. Furthermore, the Beers approach may be misleading: prescribing 10 to 15 “non–Beers list” medications to patients is still likely to do more harm than good. Several drug interaction tools have been developed in an attempt to inform the physician or patient of drug interactions and their level of risk. However, the sole use of computer or other programs as alarms are of limited benefit because they lack the Doctor's personal touch, time and clinical judgment.

Globally, physicians are increasingly exposed to patients suffering from a complexity of non-curable diseases. For professionals in palliative medicine and in hospices, stopping drugs other than for symptom control is a common practice. These principles which might mitigate against polypharmacy, are less well held in geriatric and general medicine. The name “Good Palliative–Geriatric Practice” was chosen because this tool is based on principles of both fields. In older populations the proposed “reverse extrapolation” perception seems appropriate. Most people would agree that continuing any drug other than palliative medicines is inappropriate in the last hours, days, and even weeks or months before death. However, extrapolating back from this to elders with life expectancy of years is difficult. There is a point beyond which treatment has more harm than benefit, but without an effective way to approach this, treatment is continued as this “brink” point is not recognizable. Several researchers concluded that drug discontinuation should be done selectively, altering one drug at a time. However, this approach is neither practical nor ethical in elders, particularly those with co-morbidity, where life expectancy is short and quality of life increasingly worse. Time is critical and they may suffer further deterioration due to drug-related problems from the remaining medications. It is preferable to withdraw several drugs simultaneously, while carefully monitoring for any adverse effects. The Garfinkel method involves simultaneous discontinuation of as many "Quality of life maintaining drugs" as possible (with patient's consent), thus minimizing drug load using a broader approach that will accommodate changing evidence.

Apart from improved health, the financial benefits of reducing polypharmacy represent a win - win situation for elders and societies. Reducing drug costs relieves an unbearable burden off very many old people. Furthermore, there is also reduction in the cost of unnecessary hospitalizations as a result of IMU. Suppose the Garfinkel method is implemented worldwide, we would be looking at an annual saving of billions of Euros.

"Passing the buck…"? A central question is who should be responsible for what should be named "The war on polypharmacy"? It would be unfair to blame only the family physician for the creation and extent of the problem. Likewise, considering current systems of health in many countries, the time devoted for each patient is always being shortened. As a thorough drug evaluation such as the Garfinkel method is time consuming, it would be unrealistic to expect the family physician to perform it in all his/her old patients. Some researchers believe it would be interesting to extend this method to the hospital setting, suggesting hospital discharge offers a natural break point for the application of this type of tool to reduce rather than expand a patient’s medication list. However, patients are usually discharged on more medication therapy than they were admitted on, and hospital physicians may be reluctant to stop or change medications given by the family physician and vice versa. A possible better solution might be the "Case manager" approach: teams or experienced physicians, who are preferably geriatricians (with/without pharmacists) who would have final responsibility for the patient, particularly for the polypharmacy aspect. The place of clinical judgment should not be understated though in relation to evidence-based medicine.

Obviously, governments and health authorities should devote appropriate resources to promoting such projects referring to it as a new field in adult's healthcare. Eventually, this case manager approach (or any other method which could achieve the same results) would be highly beneficial for both health and economy.