To Drug or Not to Drug: The Geriatrician Dilemma of Polypharmacy
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EDITORIAL TO DRUG OR NOT TO DRUG: THE GERIATRICIAN DILEMMA OF POLYPHARMACY I. APRAHAMIAN1,2, J.E. MORLEY3 1. Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics division, Jundiai Medical School, Jundiai, Brazil; 2. University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, The Netherlands; 3Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA. Corresponding author: John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University, SLUCare Academic Pavilion, Section 2500, 1008 S. Spring Ave., 2nd Floor, St. Louis, MO 63110, Email: [email protected], Twitter: @drjohnmorley
Key words: Polypharmacy, drug interactions.
20% of Medicare patients in the USA present 5 or more chronic illnesses while 50% use 5 or more medications (20). The greater the use of prescribed and unprescribed (over-the-counter and herbal drugs), the greater the risk of an adverse drug event. This is particularly relevant for older individuals who intrinsically present pharmacokinetic and pharmacodynamic alterations of aging such as an increased body fat compartment relative to skeletal muscle composition, decreased drug clearance and hepatic metabolization, and increased plasma concentration. Notwithstanding, polypharmacy increases the risk of inappropriate prescribing, iatrogenic “prescribing cascades”, drug-drug and drug-disease interactions, and exacerbation of adverse effects of individual medications such as antidepressants and antipsychotics (21). This later group of drugs deserves special attention due to their anticholinergic activity resulting in many adverse events such as blurred vision, newer or worsening cognitive impairment, confusion, hallucinations, pneumonia, dry mouth, constipation, urinary retention, tachycardia, and increased mortality (22). Most importantly, anticholinergic burden independently increases the risk of dementia and Alzheimer’s disease (23). Three geriatric syndromes are also associated with polypharmacy, namely falls, frailty, and delirium. However, more longitudinal studies are needed. Polypharmacy was associated with increased risk for falls in adults aged 50 years and more with a 2-year follow-up (24). This risk was independent from the individual medication increased falling risks. A possible association between medication harm, polypharmacy and frailty has been suggested (25, 26). Polypharmacy presented high prevalence in most cross-sectional and longitudinal studies, and it was associated with incident frailty (27-31). The association between frailty and polypharmacy is not related to the number of medications involved (27) and presents more negative outcomes among those cognitively impaired or defined as cognitively frail (30, 32). Persons with polypharmacy are at a high risk of developing delirium and reducing drug burden, especially anticholinergic drugs, reduce delirium (33). Overall, several adverse effects and consequent geriatric syndromes derived from poly
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