Polypharmacy,Unintended Consequences,and Impact of Lifestyle Medicine

Abstract

The coexistence of more than one chronic condition is called multimorbidity. Polypharmacy is defined as the use of multiple medicines with the typical definition stating 5 or more medications. There are several risk factors associated with polypharmacy and it may occur due to many reasons. Polypharmacy has been associated with multiple negative outcomes including nonadherence to treatment, side effects, drug-drug or disease interactions, falls, fractures, impairments—physical and cognitive, and medical errors. Strategies to assess and address polypharmacy are necessary, and lifestyle medicine is shown to play a role in improving health outcomes even when polypharmacy exists.

Multimorbidity and Polypharmacy

The coexistence of more than one chronic condition is called multimorbidity. Polypharmacy is defined as the use of multiple medicines with the typical definition stating 5 or more medications. While these definitions are generally accepted, there are various considerations when describing polypharmacy, such as does the definition only incorporate the number of medications, certain health care settings, duration of therapy or whether there is a qualifier such as appropriate, minor, or major before the polypharmacy. ¹

A systematic review was conducted to summarize the definition of polypharmacy in literature from Jan 2000 to May 2016. This study found that 80.4% (111) of all definitions were numerical only, 10.9% (15) incorporated numerical, duration of therapy or health care settings. Five or more medications daily was the numerical definition of polypharmacy in 46.4% (n = 51) of articles with the range of 2 or more medications to 11 or more medications in the other definitions. Appropriate and inappropriate polypharmacy was discussed in 6.4% of the articles. ¹ While the exact definition has varied, there are many studies evaluating the relationship between polypharmacy, risk factors, health outcomes, and considerations for best practices.

Risk factors associated with polypharmacy include: older age, cognitive impairment, developmental disability, frailty, lack of primary care physician and/or seeing many specialists, mental health and/or multiple chronic conditions, residing in long term care facilities. ² In addition to patient risk factors, the health care system also contributes to polypharmacy. ³

Polypharmacy may occur due to many reasons—and some of it may be considered to be appropriate medications for the patient. For instance, clinical practice guidelines (CPG) are the standard for providing evidence based recommendations. While this information is invaluable to ensure patients are receiving optimal care based on the most current data, this could lead to the prescribing of many medications. For example, in a study that reviewed CPG for how to manage a 79 year old person with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, the authors found that 12 medications would be initiated. ⁴ This could potentially lead to many unintended consequences.

Unintended Consequences of Polypharmacy

Polypharmacy has been associated with multiple negative outcomes including nonadherence to treatment, side effects, drug-drug or disease interactions, falls, fractures, impairments—physical and cognitive, and medical errors. ⁵ Prescribing cascades, described as prescribing a new medication to counteract an adverse effect of a current medication may occur. This happens because a side effect of a current medication may be considered a new symptoms or condition, leading to prescribing a new medication to treat this new symptom or condition. ⁶ In addition to these findings, polypharmacy has also been negatively associated with the physical domain of the health-related quality of life (HRQOL) scale. ⁷ As regimens are more complex, studies have shown there is a correlation between this complexity and increased rates of nonadherence and hospitalization. ⁸ (Wimmer) On the other hand, there is also an association with community dwelling older adults and polypharmacy, showing a decline in cognitive ability.^9,10

Additionally, polypharmacy may be a cause of medication errors, especially for older patients—this can be for many reasons including lack of knowledge by the prescriber of aging physiology and geriatric pharmacotherapy, overprescribing, inappropriate prescribing, and inappropriate drug omission. Recommendations to reduce medication errors due to polypharmacy include education of health care team, medication reconciliation, including pharmacists on the health care team, improving the work environment, role of information and communication technology. ¹¹

Polypharmacy: Clinical Recommendations and Strategies for Best Practices

A Cochrane review evaluating the effectiveness of interventions to improve the appropriate use of polypharmacy and reduce medication-related problems in older people found that it was unclear which interventions resulted in clinically significant improvement. ¹² While there is no one validated tool, there are different types of assessment tools healthcare providers can use for polypharmacy including: Beers Criteria, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to right treatment, and Medication Appropriateness Index. ² Another tool to consider is ARMOR (Assess, Review, Minimize, Optimize, and Reassess). ¹³

A Thorough Medication History and Assessment

Additionally, a thorough history, including gathering a full medication list is vital. Asking patients to bring in all their medications to the visit is the most optimal. This medication list should be complete—including prescription, over the counter, herbals, supplements, complementary, and alternative therapies. Once a list is complete—a comprehensive evaluation of the list should occur—including matching each medication for an appropriate indication, assessing for adverse events or allergies, any type of interaction (drug-food, drug-drug, drug-disease), addressing benefit vs risk, costs, and keeping in mind the patient/provider goals. ²

Other Strategies

While not the purpose of this paper, deprescribing should be considered when appropriate. ² Deprescribing has shown to have positive outcomes including improved quality of life, medication adherence, and lower drug costs. ¹⁴ On the other hand, it is necessary to consider medications that may be recommended for people to optimize health outcomes. Studies also suggest that there is underprescription of drugs—associated factors include multimorbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. ¹⁵

The Relationship Between Lifestyle Medicine and Polypharmacy

Polypharmacy and lifestyle medicine has a compelling relationship. Lifestyles described as unhealthy may contribute to over 60% of all deaths. ¹⁶ The most common chronic conditions that contribute to polypharmacy can be prevented or managed by embracing the pillar of lifestyle medicine. These include type 2 diabetes, cancer, cardiovascular diseases, obesity, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, osteoporosis, Alzheimer’s disease, depression and anxiety, liver disease, and kidney disease. ¹⁷ In addition to positive health outcomes, lifestyle medicine contributes to people taking less medications, having less surgeries, and a reduction in healthcare costs. ¹⁸

Additionally, lifestyle medicine may also be helpful for people who are already taking multiple medications. A study evaluated whether a healthy lifestyle would increase all-cause and cardiovascular mortality associated with polypharmacy. Healthy lifestyle behaviors included: not smoking, eating a healthy diet, being physically active, moderate alcohol consumption, low sitting time, and adequate sleep duration. People in Spain 60 or older taking at least 5 medications were recruited in 2000-2001 and followed through 2014. The study found that mortality risk associated with polypharmacy can be decreased with adherence to a healthy lifestyle. ¹⁹

Another study, reviewing data from 20,417 adults aged ≥45 years from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study found that greater adherence to a healthy lifestyle was associated with lower all-cause mortality, regardless of the number of medications, ranging from people taking none to more than 10 medications. Healthy lifestyle included: healthy diet, physical activity, cigarette smoking abstinence, and sedentary lifestyle avoidance based on time spent watching television. This analysis showed that even though the assumption may be that if a person takes more medications and therefore may be less healthy, and less likely to benefit from healthy lifestyle behaviors—it was demonstrated the benefit existed across the groups, regardless of comorbidity, medication burden, or age. ²⁰

Additionally, studies are evaluating the role of lifestyle and polypharmacy on many medical conditions. For example, several strategies including deprescribing, sex-specific risk assessment, and encouraging healthy lifestyle via shared-decision making to minimize inappropriate and unnecessary use of medications has been recommended for managing polypharmacy in cardiovascular diseases. ²¹

Another example is frailty, which has an increased risk of adverse health outcomes, has been associated with lifestyle factors and polypharmacy, among other factors. Further research needs to occur to determine the most effective interventions to optimizing the associated factors in people with frailty. ²²

Conclusions

Polypharmacy is cited throughout the literature as a potential factor associated with negative health outcomes. While the definitions vary—it is generally accepted that the numeric definition is five or medications. Most often, when discussing polypharmacy, the assessment of appropriateness is not included; therefore, the thorough medication history taking and subsequent assessment is key. There is an abundance of evidence describing the impact of lifestyle medicine on the prevention, mitigation, and reversal of chronic conditions. However, this impact of lifestyle medicine is being seen on polypharmacy as well. The most expected way may be that lifestyle medicine allows for the deprescribing of certain medications, leading to a lesser number of medications a patient may be taking. In addition to this, studies are also showing that healthy lifestyle behaviors are leading to health benefits, despite the influence of polypharmacy may have. Further research is necessary on interventions that are most impactful on polypharmacy and the relationship between polypharmacy and lifestyle medicine on patient outcomes.