Assignment: Introduction and Problem Statement: An Effective Plan to Reduce Polypharmacy in a Long-term Care Facility

 Assignment: Introduction and Problem Statement: An Effective Plan to Reduce Polypharmacy in a Long-term Care Facility

 Assignment: Introduction and Problem Statement: An Effective Plan to Reduce Polypharmacy in a Long-term Care Facility

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 Introduction and Problem Statement: An Effective Plan to Reduce Polypharmacy in a Long-term Care Facility

Older adults face multiple health problems exacerbated by the aging process that results in psychosocial and physiological changes. Health concerns, including altered cognitive function, physical frailty, and a high prevalence of chronic conditions, such as cardiovascular diseases (CVDs) and diabetes pose burdensome and significant problems to global healthcare systems. According to Christopher et al. (2022), the projected population of people aged 60 and above will be 22% by 2050. The steady increase in the aging population increases the healthcare burden and contributes to a high demand for patient-centered, evidence-based care. Appropriate medication use is a priority area when caring for older adults grappling with multiple healthcare concerns. In this case, medication processes, including prescribing, ordering, dispensing, administering, and monitoring are central to the achievement of the desired care outcomes (Christopher et al., 2022). Although appropriate medication use may translate to improve care outcomes, older people are susceptible to drug response variations, altered body pharmacokinetics and pharmacodynamics, and an increased likelihood of drug contradictions and adverse effects. Polypharmacy is one of the leading causes of inappropriate medication use and associated adverse effects in older adults with a high prevalence of co-morbidities. This paper elaborates on polypharmacy as a clinical problem and reviews evidence-based elements of an effective plan for reducing polypharmacy in a long-term care facility.

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Problem Statement

Polypharmacy is a profound public health problem, considering its association with adverse medication outcomes and other far-reaching health ramifications. Varghese, Ishida & Haseer Koya (2022) define polypharmacy as “using five or more medications based on a review of current data.” In a long-term care facility, healthcare professionals provide care to older adults at risk of multi-morbidity (coexistence of two or more chronic conditions). For instance, a high prevalence of chronic conditions renders older adults dependent on medical interventions, including medication administration.

In the United States, people aged 65 years and older account for about 14% of the population. However, they are responsible for over one-third of outpatient spending on medication prescriptions in the country (Varghese, Ishida & Haseer Koya, 2022). More essentially, they are likely to require more than ten medications during hospital admissions and more than five medications at discharge; hence, polypharmacy (Dahal & Bista, 2023). Although the current medication prescription guidelines may recommend the use of more than one medication in the prevention and treatment of underlying health conditions, polypharmacy poses significant patient health and safety challenges.

Polypharmacy and Negative Health Outcomes

Exposure to an excessive number of drugs (inappropriate polypharmacy) is the leading cause of negative health outcomes in older adults with multi-morbidity. According to Delara et al. (2022), polypharmacy can result in an increased risk of death, altered drug interactions, non-adherence to the administered medications, and prolonged hospitalization. In the United States, the health burden associated with inappropriate polypharmacy is approximately $50 billion (Delara et al., 2022). Physical and physiological changes associated with aging expose older adults to the multiple adverse effects of the administered medications. Dahal & Bista (2023) identify altered drug metabolism and clearance are primary risk factors for negative outcomes of inappropriate polypharmacy. Further, older adults are an at-risk population for visual impairment and cognitive declines that affect medication adherence and compliance with pharmacologic guidelines.

Besides an increased risk of premature death, altered drug interactions, prolonged hospitalization, and non-maleficence to medications, inappropriate polypharmacy is a risk factor for multiple side effects of drugs. Varghese, Ishida & Haseer Koya (2022) argue that consistent intake of ‘too many’ medications can lead to decreased alertness, constipation, sleeplessness, tiredness, confusion, depression, loss of appetite, and diarrhea. Other overlooked side effects of drugs emanating from polypharmacy include incontinence and a lack of interest in social activities (Varghese, Ishida & Haseer Koya, 2022). In sharp contrast, healthcare professionals may end up administering more medications to manage these side effects, instead of adequately investigating the potential incidences of inappropriate polypharmacy. This concern may exacerbate drug side effects and contribute to more adverse health outcomes.

Polypharmacy and an Increased Risk of Falls

Polypharmacy is a risk factor for patient falls and fall-related injuries. Zaninotto et al. (2020) define falls as “an anticipated incident in which a person comes to rest on the ground or a lower level” (p. 2). In long-term care facilities, patient falls are highly prevalent and burdensome, considering their association with life-threatening injuries, fractures, and increased care costs. According to Zaninotto et al. (2020), one-third of people aged 65 and over experience at least one incident of fall annually, while injuries occur in about 20% of these incidences. Although patient falls are multifactorial healthcare concerns, side effects of medications are among the profound risk factors. Co-prescription of medications (inappropriate polypharmacy) of high-risk medications like anticholinergic medications, sedatives (anxiolytics), narcotics, and cardiovascular medications can lead to far-reaching side effects, including confusion, respiratory failure, dependency, memory loss, blurry vision, and hallucinations (Dahal & Bista, 2023). These side effects contribute to an increased risk of patient fall.

Polypharmacy and Medication Errors

Medication errors are often failures in drug therapies that result in adverse effects to patients, including increased mortality rate, lengthy hospitalization, and high care costs. According to Rasool et al. (2020), polypharmacy among older adults is a factor for medication errors since it involves drug duplication, co-prescription, and over-prescription. Further, altered drug-drug, drug-disease interactions, and adverse drug effects can lead to inappropriate prescribing, poor adherence to medications, overdose, and inappropriate drug selection (Ye et al., 2022). In other instances, healthcare professionals overlook drug side effects emanating from polypharmacy and end up prescribing more medications to treat and manage drug side effects. The association between polypharmacy and medication errors represents inappropriate medication use and can significantly lead to poor health outcomes, including poor quality of life and premature mortality.

Based on the adverse outcomes associated with polypharmacy, healthcare professionals should understand the causes of inappropriate polypharmacy, and comprehend changes in drug pharmacokinetics and pharmacodynamics exacerbated by the aging processes. Also, Varghese, Ishida & Haseer Koya (2022) indicate the need for multidisciplinary collaboration among healthcare professionals in preventing medication duplication, determining the thresholds for discontinuing all unnecessary medications, and involving patients, family members, and community pharmacists in medication prescription and monitoring.

An Effective Plan for Reducing Polypharmacy in a Long-term Care Facility

The current scholarly literature provides evidence-based recommendations for preventing polypharmacy and alleviating its associated adverse effects. According to Dahal & Bista (2023), judicious prescribing methods and steps for deprescribing medications that pose significant health threats are the initial approaches for preventing polypharmacy. Secondly, care providers should engage patients, family members, and home-based caregivers in establishing collective goals of care plans, alongside conducting comprehensive risk assessments. Dahal & Bista (2023) recommend various models as profound tools for preventing polypharmacy. These models include NO TEARS, Hyperpharmacotherapy Assessment Tool (HAT), Beers Criteria, Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP), Medication Appropriateness Index (MAI), and Anticholinergic Drug Scale.

The NO TEARS model is a seven-component model that aids and guides efficient medication review to prevent adverse effects and document the physiological decline associated with aging that may affect individual compliance with pharmacologic interventions. According to Dahal & Bista (2023), the seven components of the NO TEARS tool include Need/Indication, Open questions, Tests and monitoring, Evidence-based guidelines, Adverse Events, Risk Reduction, and Simplification. When implementing this model, healthcare professionals review medications’ indications and duration, including intended treatment durations, appropriate dosing, and the review of alternative non-pharmacologic interventions.

Further, healthcare professionals ask patients open-ended questions regarding their understanding of medications, assess the patients’ conditions consistent with clinical findings and labs, review medication appropriateness based on the current evidence-based guidelines, document any adverse drug reaction, and simplify medical treatment with medication reconciliation and proper transition of care planning (Dahal & Bista, 2023). Consequently, this model is effective in reducing the potential side effects of medications, the identification of issues affecting patient compliance with pharmacologic interventions, and the alignment of treatment options with evidence-based guidelines.

Like the NO TEARS tool, the HAT model and other recommended frameworks for preventing polypharmacy emphasize various goals. These goals include monitoring the number of prescribed medications, decreasing inappropriate drug use, optimizing the dosing regimen, avoidance of high-risk medications, comprehensive screening of drug interactions, prevention of duplicate therapies, and effective assessment of drug side effects, including effects on cognition, functional activity, falls, mortality, and hospital readmission (Dahal & Bista, 2023). Other considerations for preventing polypharmacy are patient education, maintenance of accurate medication records, including lists and medical history, linking medication prescriptions with diagnoses, proper communication hand-offs, post-discharge follow-up, and effective medication reconciliation during t   transition of care (Varghese, Ishida & Haseer Koya, 2022). These evidence-based strategies require interdisciplinary collaboration, coordinated practices, and teamwork.

Conclusion

Polypharmacy is a significant public health problem, considering its potential adverse effects. Often, older adults grapple with multi-morbidity, which refers to the coexistence of two or more chronic conditions. These co-morbidities increase the risk of co-prescription and prescription duplication, leading to polypharmacy. Besides multi-morbidity, older adults are susceptible to physical, cognitive, and physiological changes that contribute to poor compliance with pharmacologic interventions, altered drug interactions, and adverse effects of prescribed medications. If left unaddressed, polypharmacy can lead to multiple adverse ramifications, including overlooked side effects like delirium, vomiting, diarrhea, sleeplessness, and tiredness. Also, it can lead to an increased risk of patient falls and medication errors that inflict a massive burden on patients and healthcare systems. An effective plan for addressing polypharmacy should include extensive strategies for assessing drug interactions, identifying drug side effects, discontinuing high-risk medications, and educating patients on appropriate drug interactions and treatment goals. Various evidence-based tools accommodate these approaches and provide frameworks for preventing polypharmacy. Examples of these tools are the Beers Criteria, NO TEARS model, Hyperpharmacotherapy Assessment Tool (HAT), Medication Appropriateness Index (MAI), the Screening Tool for Older Person’s potentially inappropriate Prescriptions (STOPP), and Anticholinergic Drug Scale.

References

Christopher, C., KC, B., Shrestha, S., Blebil, A. Q., Alex, D., Mohamed Ibrahim, M. I., & Ismail, N. (2022). Medication use problems among older adults at a primary care: A narrative of literature review. AGING MEDICINE, 5(2), 126–137. https://doi.org/10.1002/agm2.12203

Dahal, R., & Bista, S. (2023). Strategies to reduce polypharmacy in the elderly. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK574550/

Delara, M., Murray, L., Jafari, B., Bahji, A., Goodarzi, Z., Kirkham, J., Chowdhury, Z., & Seitz, D. P. (2022). Prevalence and factors associated with polypharmacy: A systematic review and meta-analysis. BMC Geriatrics, 22(1), 601. https://doi.org/10.1186/s12877-022-03279-x

Rasool, M. F., Rehman, A. ur, Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Ahmad Hassali, M. A., & Hayat, K. (2020). Risk factors associated with medication errors among patients suffering from chronic disorders. Frontiers in Public Health, 8(1). https://doi.org/10.3389/fpubh.2020.531038

Varghese, D., Ishida, C., & Haseer Koya, H. (2020). Polypharmacy. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532953/

Ye, L., Yang-Huang, J., Franse, C. B., Rukavina, T., Vasiljev, V., Mattace-Raso, F., Verma, A., Borrás, T. A., Rentoumis, T., & Raat, H. (2022). Factors associated with polypharmacy and the high risk of medication-related problems among older community-dwelling adults in European countries: A longitudinal study. BMC Geriatrics, 22(1). https://doi.org/10.1186/s12877-022-03536-z

Zaninotto, P., Huang, Y. T., Di Gessa, G., Abell, J., Lassale, C., & Steptoe, A. (2020). Polypharmacy is a risk factor for hospital admission due to a fall: Evidence from the English longitudinal study of ageing. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-09920-x