GERIATRIC POLYPHARMACY 12 - for merge.docx

**GERIATRIC POLYPHARMACY:** **A GROWING EPIDEMIC** +-----------------------+-----------------------+-----------------------+ | **S.NO** | **INDEX** | **PAGE NO.** | +=======================+=======================+=======================+ | **1,** |...

**GERIATRIC POLYPHARMACY:** **A GROWING EPIDEMIC** +-----------------------+-----------------------+-----------------------+ | **S.NO** | **INDEX** | **PAGE NO.** | +=======================+=======================+=======================+ | **1,** | **INTRODUCTION** | **1** | +-----------------------+-----------------------+-----------------------+ | **2,** | **POLYPHARMACY** | **2** | +-----------------------+-----------------------+-----------------------+ | **3,** | **EPIDEMIOLOGY** | **3** | | | | | | | **PHARMACOKINETICS | | | | AND | | | | PHARMACODYNAMICS** | | | | | | | | **RISK FACTORS** | | +-----------------------+-----------------------+-----------------------+ | **4,** | **ADVERSE EFFECTS** | **10** | +-----------------------+-----------------------+-----------------------+ | **5,** | **CONSEQUENCES** | **11** | | | | | | | **ADVERSE DRUG | | | | EVENTS** | | | | | | | | **DRUG INTERACTIONS** | | | | | | | | **GERIATRIC | | | | SYNDROMES** | | | | | | | | **ADHERENCE** | | | | | | | | **REDUCE FUNCTIONAL | | | | ABILITY** | | | | | | | | **INCREASED COSTS** | | +-----------------------+-----------------------+-----------------------+ | **6,** | **ASSESSMENT AND | **15** | | | MANAGEMENT** | | | | | | | | **DEPRESCRIBING** | | | | | | | | **USE OF CLINICAL | | | | TOOLS AND | | | | GUIDELINES** | | | | | | | | **POSSIBLE MITIGATION | | | | MEASURES** | | +-----------------------+-----------------------+-----------------------+ | **7,** | **CONCLUSION** | **24** | +-----------------------+-----------------------+-----------------------+ | **8,** | **REFERENCE** | **26** | +-----------------------+-----------------------+-----------------------+ **CHAPTER 1** **INTRODUCTION** Aging is a status often associated with multiple comorbidities which require pharmacologic intervention and complex medication regimens. Aging population results to the increase of chronic diseases and subsequent comorbidities that require concomitant multiple medications. As population grows older, people aged more than 65 years predominate. It is estimated that by 2030, there will increase to 72 million. Aging population results to the in­crease of chronic diseases and subsequent comorbidities that require concomitant multiple medications. It is re­ported that about 80 % of elderly have at least one chronic condition, and about half of them have at least two (such as heart disease, hypertension, diabetes mellitus (DM), ar­thritis, and cancer). Besides, it is estimated that almost 39 % of the elderly take ≥ 5 medications and about 72 % of this population take at least one nonprescription medication. \[1\] In India, an estimated 50% of elderly people suffer from at least one chronic disease that requires lifelong medications. The term "elderly" or "geriatrics" refers to a population with a chronological age of \>65 years in most of the developed nations, while thus does not adapt very well to the underdeveloped or developing nations. In January 1999, the Government of India adopted the "National Policy on Older Persons" by which "senior citizen" or "elderly" is defined as persons who are of the chronological age of 60 years or above.\[2\] In this context, it is important to understand that the process of biological aging is often accompanied by changes in pharmacokinetics and pharmacodynamics in older people. Consequently, more efforts should have been made towards clinical testing of medications specifically in older adults. Regrettably, the exclusion of older adults from clinical trials for approving medications is often observed, which has led to a lack of evidence regarding the safety and efficacy of many medications in this population. Thus, the appropriateness of many drugs in an increasing number of older multimorbid patients remains undetermined.\[3\] **CHAPTER 2** **POLYPHARMACY** The Greek word \"poly\" means many or much. Polypharmacy refers to the use of several medications by one person at the same time. This is becoming more common as the population ages and people have multiple health conditions. It can be a challenge for doctors. Polypharmacy is typically defined as taking five or more medications per day, or taking more medications than clinically necessary. A high level of polypharmacy is considered to be taking 10 or more medications. Different thresholds, such as 3, 4, 5, or 10 medications, have been used to evaluate polypharmacy.\[2\] Polypharmacy in older adults is often associated with advanced age and has been found to increase the likelihood of emergency department visits, hospitalizations, hospital readmissions, and even mortality. The symptoms caused by polypharmacy can often be mistaken for normal signs of aging in older individuals. These symptoms may include tiredness, decreased alertness, sleepiness, diarrhoea, constipation, bladder incontinence, loss of appetite, confusion, depression, lack of interest in usual activities, weakness, anxiety, tremors, excitability, and dizziness. Polypharmacy can be classified as: Major polypharmacy if \>=5drugs Minor polypharmacy if 2- 4 drugs Hyper polypharmacy if 10 or more drugs are used by the patient per day respectively.\[4\] **Causes of polypharmacy:** - An aging population with comorbidities that require multiple medications, combined with the increased availability of newer medications. - Patients self-medicating with over-the-counter medications and herbal preparations without a clear understanding of potential adverse reactions and drug interactions. - The occurrence of a \"prescribing cascade\" in which patients experience side effects from a medication, which are mistakenly interpreted by healthcare practitioners as symptoms of a new disease and lead to the prescription of additional medications. - When a patient sees multiple physicians and fills prescriptions at different pharmacies, there is often a failure to communicate and keep all parties informed about each other\'s actions. - Ineffective communication and coordination between healthcare practitioners can lead to redundant prescriptions.\[2\] - Availability of newer medications and curiosity towards it. - Crosspathy: Availability of crosspathy- Ayurvedic, herbal medicines. Often concomitant use of such medication cause polypharmacy \[5\] **CHAPTER 3** **EPIDEMIOLOGY** **Demographic Factors:** Older females (\>65 years) are commonly exposed to polypharmacy. The prevalence of polypharmacy increases with age. Polypharmacy is commonly observed among Caucasians/White Americans. Additionally, older adults with lower socioeconomic status, illiteracy, and those covered by Medicare or public insurance are often recipients of polypharmacy. **Comorbidities:** The presence of prevalent chronic diseases such as cardiovascular diseases, hypertension, and type 2 diabetes mellitus in elderly patients is associated with the use of multiple medications, which has important implications for clinical practice. Multimorbidity, clusters of chronic disease conditions, and a higher Charlson comorbidity score (a method of categorizing comorbidities that predict survival/mortality risk) are associated with geriatric polypharmacy. **Health Condition:** Geriatric syndromes including incontinence, dizziness, limited functional capacity, and declining cognitive status are associated with polypharmacy. Factors related to health, including the severity of health conditions, multiple health problems, poor health perception, lower self-rated health, reduced life satisfaction, and treatment refractoriness, are associated with geriatric polypharmacy. Other comorbid condition associated (heart failure, chronic obstructive pulmonary disease, renal insufficiency) along with pain, depression, gastro intestinal symptoms are significant correlates of poly pharmacy in the geriatric polypharmacy. **Healthcare Setting:** Polypharmacy is commonly observed in nursing home settings. Factors related to healthcare access, such as the number of healthcare visits, multiple providers, interactions with primary care physicians (internists/family physicians), and specialty physicians (neurologists/psychiatrists), are often associated with polypharmacy in the elderly. **Patient determinants:** Patient determinants including attitudes, beliefs, social influences,perception about health care are often associated with polypharmacy. Patient characteristics of polypharmacy include racial, ethnic and individual differences to supplemental drug use, recommendation or suggestion of drugs by a close social contact, traditional health benefits in herbal, complimentary and alternate medication use. Patient request for multiple medication, doctor shopping behaviour, earlyy prescription refill are other determinants of polypharmacy. **Substance Abuse and Addiction:** Substance abuse and addiction problems in the elderly are often associated with polypharmacy. Alcohol use, illicit drug abuse, and prescription drug misuse are prevalent among the elderly. Polypharmacy involving harmful psychoactive substances and benzodiazepine use is often reported in the elderly. The substances abused and/or misused by the elderly include painkillers, anxiolytics, and potentially addictive medications, including prescription opioids.\[6\] **Pharmacokinetics and Pharmacodynamics:** Pharmacokinetics (PK) refers to how the body affects a drug, while Pharmacodynamics (PD) describes how the drug affects the body. The changes associated with aging in PK and PD include reduced end-organ function, changes in receptor sensitivity, patterns of homeostasis, concurrent use of medications, and complexity of disease states. Aging also leads to changes in organ system function, body composition, nutritional state, and a lifetime of metabolic insults, which can vary greatly between older patients. This variability complicates our understanding of how drug activity changes with age. Additionally, older adults are often excluded from clinical trials due to comorbidities, despite their increased use of medications compared to other populations.Pharmacokinetics specifically refers to drug absorption, distribution, metabolism, and elimination.\[7\] **Absorption:** Aging generally does not significantly affect the extent of drug absorption, but it may slow down the absorption rate. This means that the peak serum concentration of a drug may be lower in older patients, and it may take longer for the drug to reach its peak concentration. However, the overall amount of the drug absorbed, known as bioavailability, does not differ based on age. There are exceptions for drugs that undergo extensive first-pass metabolism, as they may have higher serum concentrations or increased bioavailability due to reduced liver size and hepatic blood flow associated with aging, resulting in less drug extraction by the liver. Other factors that can affect drug absorption include the way medications are taken, what other substances the drug is taken with, the presence of comorbidities, and the inhibition or induction of enzymes in the gastrointestinal (GI) tract. **Distribution:** Distribution refers to how a drug spreads and penetrates different parts of the body. It is measured using the volume of distribution (Vd), which is typically expressed in liters or liters per kilogram (L/kg) - Older adults generally have less body water and lean body mass, which leads to a lower volume of distribution for hydrophilic (water-soluble) drugs. Examples of hydrophilic drugs include ethanol and lithium. - On the other hand, aging is also associated with increased fat stores in the body. This leads to an increased volume of distribution for lipophilic (fat-soluble) drugs. Examples of lipophilic drugs include diazepam, trazodone, and flurazepam. - Additionally, albumin, the primary plasma protein that drugs bind to, is usually lower in older adults. As a result, there is a higher proportion of unbound (free) and pharmacologically active drugs in the body. This is usually not a problem in younger patients as they can eliminate additional unbound drugs. However, elimination slows down with aging, leading to the accumulation of unbound drugs in the body. Examples of drugs affected by this include ceftriaxone, phenytoin, valproate, warfarin, diazepam, and lorazepam. **Metabolism**: Drugs can be metabolically converted in various organs such as the liver, intestinal wall, lungs, skin, and kidneys. As individuals age, there is a decrease in hepatic blood flow and liver size, which can result in a reduction of drug clearance by up to 30% in older adults. Drug metabolism occurs through two pathways known as phase I and phase II. - Phase I pathways involve hydroxylation, oxidation, dealkylation, and reduction by cytochrome P450 (CYP) enzymes. Most drugs metabolized through this pathway produce metabolites that have a less severe pharmacological effect compared to the original compound. However, some drugs may be converted to more active compounds through Phase I reactions (e.g., diazepam). - Phase II pathways involve glucuronidation, conjugation, and acetylation. Drugs metabolized through phase II pathways are primarily eliminated through urine or bile. For example, lorazepam undergoes oxidation through phase I reactions and then is further metabolized by glucuronidation. Phase I reactions, which are catalyzed by cytochrome P450, are more likely to be impaired in older individuals compared to phase II reactions. Therefore, medications that are metabolized through phase II pathways are preferred for older adults. **Elimination:** Elimination refers to the final removal of a drug from the body. The terms used to describe a drug\'s elimination are half-life and clearance. For most drugs, elimination occurs through the kidneys in the form of the parent compound or metabolites. - As individuals age, there is a decrease in renal size, blood flow, and glomerular filtration rate. - Additionally, aging leads to reduced creatinine production due to decreased lean muscle mass. However, the reduced glomerular filtration rate compensates for the decreased creatinine production, resulting in normal serum creatinine levels. Thus, serum creatinine may not accurately reflect creatinine clearance in older individuals. To estimate a patient\'s creatinine clearance when prescribing new medications or adjusting doses, the Cockcroft-Gault equation can be employed.\[8\]. **PHARMACODYNAMICS:** In contrast to pharmacokinetic effects, pharmacodynamics refers to the actions of drugs on the body or the body\'s response to the drug. It is influenced by receptor binding, post-receptor effects, and chemical interactions. In older adults, the effects of similar drug concentrations at the site of action (sensitivity) may be greater or smaller compared to younger individuals. These differences may be attributed to changes in drug-receptor interaction, post-receptor events, adaptive homeostatic responses, or, in frail patients, pathologic changes in organs. However, distinguishing between pharmacodynamic and pharmacokinetic effects can sometimes be challenging in a clinical setting. Older adults, especially those with cognitive impairment, are especially sensitive to the effects of anticholinergic drugs. Many types of drugs, such as tricyclic antidepressants, sedating antihistamines, muscarinic agents for urinary symptoms, certain antipsychotic drugs, antiparkinsonian drugs with atropine-like activity, as well as over-the-counter hypnotics and cold preparations, have anticholinergic effects. These drugs can lead to adverse effects in the central nervous system (CNS), causing older adults to become more confused and drowsier. Additionally, anticholinergic drugs commonly result in constipation, urinary retention (especially in older men with benign prostatic hyperplasia), blurred vision, orthostatic hypotension, and dry mouth. Furthermore, even at lower doses, these drugs can increase the risk of heatstroke by inhibiting sweating. In general, older adults should try to avoid taking drugs with anticholinergic effects, when possible \[9\]. Selected pharmacodynamics changes with ageing \[10\]. Drug Pharmacodynamics effect Age-related change ----------------- ----------------------------------------------------- -------------------- Adenosine Heart-rate response ↔ Diazepam Sedation, postural sway ↑ Diltiazem Acute and chronic antihypertensive effect ↑ Acute PR interval prolongation ↓ Diphenhydramine Postural sway ↔ Enalapril ACE inhibition ↔ Furosemide Peak diuretic response ↓ Heparin Anticoagulant effect ↔ Isoproterenol Chronotropic effect ↓ Morphine Analgesic effect ↑ Respiratory depression ↔ Phenylephrine α~1~-adrenergic responsiveness ↔ Propranolol Antagonism of chronotropic effects of isoproterenol ↓ Scopolamine Cognitive function ↓ Temazepam Postural sway ↑ Verapamil Acute antihypertensive effect ↑ Warfarin Anticoagulant effect ↑ ↑ = increase; ↓ = decrease; ↔ = no significant change; ACE = angiotensin-converting enzyme. **RISK FACTORS:** The risk factors associated with polypharmacy in the elderly population can be divided into those related to the individual and those related to the General Practitioner. Other studies have classified the risk factors for polypharmacy into three groups: The first is demographic factors such as increased age, white race, and educational status. The second group reflects health status, including risk factors like poor health, depression, hypertension, anaemia, asthma, angina, diverticulosis, osteoarthritis, gout, DM, and the use of more than nine medications. The third and final risk factor group associated with polypharmacy is related to access to the healthcare system (number of consultations, supplemental insurance, and multiple providers). *Multimorbidity* is one of the most common problems in the elderly population, which makes them vulnerable to polypharmacy and subsequent prescription problems. Under this framework, the physician should choose among guidelines for different diseases and select the best medication protocol for each specific individual, keeping in mind possible contraindications and interactions between different drug groups. It is notable that the available guidelines usually refer to a single disease and disregard possible comorbidities within the same patient. Very often, patients consult various specialists due to comorbidity, which might lead to drug duplication and possibly the prescription of a formulation containing the same active substance that the patient is already taking. *The decline of liver and renal function* can alter the pharmacokinetics and pharmacodynamics of the medications taken. Liver metabolism can change due to reduced liver enzyme function, reduced hepatic blood flow, and hepatic mass, so drugs metabolized in the liver (warfarin, theophylline, phenytoin) show altered metabolism and excretion. As renal clearance lowers and the renal glomerular filtration rate and muscle mass decrease, they both result in decreased distribution and excretion of drugs, leading to various adverse drug reactions. Therefore, the prescription of renally-excreted drugs (e.g., digoxin, lithium, and gentamicin) demands caution and dose adjustment. *Self-medication* and the availability of various over-the-counter drugs are potential causes of polypharmacy. *Low literacy and cognitive impairment* are common issues among elderly individuals, leading to miscommunication and misunderstandings of physicians\' orders, particularly when complex regimens are prescribed. The level of education also plays a crucial role in polypharmacy. Patients with higher education levels are generally more knowledgeable about their medications and health status, and are more likely to actively participate in their healthcare. On the other hand, less educated elderly individuals are more susceptible to experiencing polypharmacy. This problem is further compounded when patients visit multiple physicians at different locations, as these healthcare providers may not have access to the patient\'s complete medication history. This can result in the duplication or unnecessary use of medications. Additionally, older individuals often struggle with pill confusion due to similar shapes or colours, or they may unintentionally repeat their prescribed dose due to dementia. Physicians may also contribute to inappropriate or unnecessary polypharmacy by giving in to patients\' demands for prescriptions without proper consideration. The prescription cascade continues with subsequent repeat prescriptions signed by doctors without thorough reviews of the patients\' medical histories or adequate knowledge of the side effects and potential drug interactions associated with long-term medication use. Furthermore, due to time constraints during consultations, general practitioners may unknowingly promote incorrect or prolonged medication use, leading to adverse drug reactions.\[1\] **CHAPTER 4** **ADVERSE EFFECTS** Adverse effects resulting from polypharmacy can significantly impact patients of any age, but older individuals are even more vulnerable. Polypharmacy increases the likelihood of experiencing side effects, drug interactions, adverse drug reactions, and non-adherence, and may contribute to the development of geriatric syndromes. Adverse drug reactions can be further classified into Type A or Type B reactions. Type A reactions are predictable and are related to a medication\'s mechanism of action. For example, bleeding may occur in patients taking warfarin due to drug interactions that raise the medication\'s plasma levels. Type B reactions, on the other hand, are unpredictable and unexpected. Examples include anaphylaxis or Stevens-Johnson syndrome. Examples of medications to be used with caution in the elderly \[11\]. +-----------------------------------+-----------------------------------+ | MEDICATION | **CAUTION** | +===================================+===================================+ | Non-steroidal anti-inflammatories | -Risks: Gastrointestinal | | e.g. naproxen, ibuprofen | bleeding, cardiac failure, | | | nephrotoxic | | | | | | \- Suggested action: Avoid where | | | possible. If essential, offer | | | short courses with proton pump | | | inhibitor cover | +-----------------------------------+-----------------------------------+ | Hypnotics e.g. benzodiazepines | -Risks: Drowsiness, confusion, | | | poor balance and increased risk | | | of falls | | | | | | \- Suggested action: Avoid where | | | possible or offer a short course | | | only | +-----------------------------------+-----------------------------------+ | Diuretics e.g. furosemide | -Risks: Hypotension, increased | | | risk of falls, nephrotoxic. | | | Diuresis can be difficult for | | | patients with poor mobility | | | | | | -Suggested action: Review renal | | | function regularly and ensure | | | good hydration status | +-----------------------------------+-----------------------------------+ | Anti-coagulants | -Risks: Warfarin interacts with | | | many drugs and foods | | | | | | -Suggested action: Careful | | | counseling and consider risk of | | | falls | +-----------------------------------+-----------------------------------+ | Cardiac glycosides e.g. digoxin | \- Risks: Caution in renal | | | impairment as increased risk of | | | toxicity | | | | | | -Suggested action: Start with | | | lower doses in the elderly. | | | Monitor renal function | +-----------------------------------+-----------------------------------+ | Anti-psychotics | -Risks: Cognitive impairment, | | | sedation, cardiac arrhythmias, | | | parkinsonism, increased risk of | | | stroke and heart attack, | | | osteoporosis | | | | | | -Suggested action: If used for a | | | mental health disorder, review | | | regularly. Avoid for behavioral | | | disturbance in Dementia | +-----------------------------------+-----------------------------------+ **CHAPTER 5** **CONSEQUENCES** The most common consequences of polypharmacy, apart from the tremendous increase in drug costs, are adverse drug reactions (ADR), drug interactions, noncompliance and reduced adherence, reduced functional status, geriatric syndromes, and a high risk of hospitalization and possibly death. 1\. Adverse drug events (ADEs): ADEs can result from medication intake errors, overdose, allergic reactions, and ADRs. They are divided into predictable or related to normal pharmacokinetics (such as bleeding on warfarin) and unpredictable or unexpected (such as anaphylaxis and Stevens-Johnson syndrome). The most common drug side effects include sedation, nephrotoxicity, hepatotoxicity, cardiotoxicity, confusion, dizziness, hypotension, and hypoglycaemia. ADRs have increased globally in all age groups and are the primary cause of 10% of emergency room visits. They can affect both outpatients (35%) and hospitalized (44%) elderly individuals. It is estimated that ADRs due to polypharmacy are seven times more common in people over 70 years old than in young individuals. Recent statistics show that ADRs were responsible for 4.3 million healthcare visits reported in 2005, with the most suspicious drug groups being anticholinergic and psychotropic drugs (antipsychotics and benzodiazepines), cardiovascular drugs, diuretics, anticoagulants, nonsteroidal anti-inflammatory drugs, antibiotics, and hypoglycaemic agents. The incidence of ADRs is linearly correlated with polypharmacy, especially the number of medications taken. The risk of ADRs is reported to be about 13% for 2 medications, 58% for 5 drugs, and is estimated to be over 82% if more than 7 drugs are taken. The problem with ADRs is that they are often misreported as new symptoms, leading to further prescriptions and exacerbating the incidence of polypharmacy and prescription cascading. 2\. Drug interactions: Drug interactions are divided into two categories - drug-drug interactions and drug-disease interactions. The former are very common in the elderly due to polypharmacy, comorbidities, decreased nutritional status, dehydration, and diminished liver and renal function. The prevalence of drug-drug interactions is estimated to be between 35% and 60% in the elderly and is directly associated with the number of medications. Additionally, the prevalence of drug-disease interactions in the elderly is reported to be between 15% and 40%. The most common interactions of this kind occur between aspirin and digestive ulcer disease, calcium channel blockers and heart failure, and beta-blockers and diabetes. As drug-drug interactions are a frequent cause of preventable ADEs and medication-related hospitalizations, healthcare providers should keep this in mind when prescribing new medications. 3\. Adherence --- Noncompliance: The prevalence of noncompliance in the elderly ranges from 43% to 95% and is often associated with complex medication regimens, polypharmacy, the mental status of the patient, visual or hearing impairment, and advanced age. Noncompliance is considered a major cause of disease progression, treatment failure, hospitalization, life-threatening adverse drug events, and the need for additional medication. It is estimated that 11% to 30% of drug-related hospital admissions in the elderly result from noncompliance. 4\. Reduced functional ability: Several prospective studies have shown a correlation between excessive medication intake (more than 5 drugs) and functional decline in elderly patients. Diminished functional status includes both physical functioning and a decreased ability to carry out instrumental activities of daily living (IADLs). Therefore, physicians should consider the association between polypharmacy and functional decline when prescribing multiple medications to the elderly. 5\. Geriatric syndromes: - Cognitive impairment: There is a direct association between polypharmacy and cognitive impairment in the elderly. Polypharmacy and excessive polypharmacy were reported in 33% and 54% of patients with dementia, respectively. Increased use of specific drug groups can also cause or worsen delirium in the elderly, such as opioids, benzodiazepines, and anticholinergic drugs. In a prospective cohort study, 22% of elderly patients taking 5 or fewer medications were diagnosed with impaired cognition, compared to 33% of patients taking 6 to 9 medications and 54% of patients taking 10 or more medications. Polypharmacy itself has been implicated in 12% to 39% of delirium cases in the elderly population. - Falls: The risk of falls, including recurrent falls, in the elderly is directly associated with the number of medications taken, even as few as 4 to 5 medications. This finding applies to both community-dwelling individuals and those in hospital or nursing home settings. The risk is usually associated with the use of antihypertensive medications, diuretics, laxatives, anticholinergic drugs, hypnotics, and benzodiazepines. According to a large cohort study, the prevalence of polypharmacy in elderly individuals increased from 48% before the incidence of a fall to 88% after the fall. Not only did the incidence of polypharmacy increase, but also the total number of drugs per person and the number of psychotropic medications (more than three). It is important to exercise caution when prescribing certain drugs, such as benzodiazepines, which affect the central nervous system, even at the minimum dose, to minimize the risk of falls and other related adverse reactions. - Urinary incontinence is a common problem in the elderly, and it can be made worse by taking multiple medications (polypharmacy). - Polypharmacy also affects the nutritional status of older individuals. Studies have shown that there is a correlation between the number of medications someone takes and a decrease in their intake of soluble and insoluble fiber, fat-soluble vitamins, B vitamins, and minerals. On the other hand, there is an increase in the intake of cholesterol, glucose, and sodium. The prevalence of malnourishment (50%) is higher in those who take multiple medications compared to those who take fewer medications (10%).\[1\] Emerging approaches to polypharmacy among older adults \| Nature Aging 6\. *Increased healthcare costs:* Polypharmacy has been shown to lead to higher healthcare costs for both patients and the healthcare system. One retrospective cohort study revealed that polypharmacy was linked to a greater likelihood of taking potentially inappropriate medications, as well as an increased risk of outpatient visits and hospitalizations, resulting in approximately a 30% rise in medical expenses. Similarly, a study conducted in Sweden indicated that individuals taking five or more medications experienced a 6.2% increase in prescription drug spending, while those taking ten or more medications saw a 7.3% increase.\[12\] 7.Hospitalisation: Polypharmacy has been linked to hospital admission in studies involving older adults, nursing home residents, and individuals diagnosed with dementia. These studies have found that polypharmacy is associated with unplanned hospital admissions and re-hospitalization in hospital-based samples. The study also found an independent association between exposure to polypharmacy and subsequent all-cause and fall-related hospitalization. This association remained significant even after adjusting for the use of potentially inappropriate medications and anticholinergic burden. Additionally, Payne et al. found that the risk of unplanned hospital admissions increased with the number of medications used. However, this effect was less apparent for individuals with a high number of chronic conditions.\[13\] **CHAPTER 6** **ASSESSMENT AND MANAGEMENT** **DEPRESCRIBING**: Deprescribing is the intentional act of stopping or reducing one or more medications that a patient is taking. The goal is to identify medications that are no longer providing reasonable benefits to the patient, prevent any negative effects caused by the combination of high-risk medications, and reduce both cost and complexity while ensuring the patient continues to receive necessary medications. Purposeful deprescribing, which aims to reduce the number of medications a patient is taking, has been proven to reduce emergencies and hospitalizations associated with medications. When deprescribing medications for older adults, it is important to take into account the patient\'s level of functioning, support needs in their living situation, and decisions regarding their ongoing care. The overall objective should be more than just eliminating the unnecessary use of proton pump inhibitors or supplements; it should be tailored to the specific health and living status of each individual patient.  REDUCE THE USE OF HIGH-RISK MEDICATIONS IN OLDER ADULTS Studies have shown that over one-third of older adults living independently and half of those residing in long-term care facilities are taking medications that have been deemed \"unnecessary\" by CMS (Centres for Medicare and Medicaid Services). These medications fall under Beer\'s Criteria of Potentially Inappropriate Medications, which are drugs that should be avoided in older adults due to their high risk of adverse drug events. Both the Beers Criteria and the STOPP/START criteria have supporting data that demonstrate the benefit of reducing medications that pose unnecessary risks to older adults. DEPRESCRIBE STRONGLY ANTICHOLINERGIC MEDICATIONS Older antihistamines like diphenhydramine, muscle relaxants such as cyclobenzaprine, and overactive bladder agents like oxybutynin have strong anticholinergic effects. These medications are often poorly tolerated by older patients. Their broad blocking of muscarinic receptors can have negative effects on vision, urination, constipation, and cognition. Acetylcholine physiology naturally declines with age, and anticholinergic medications further block its effects. Taking multiple anticholinergic drugs, known as \"anticholinergic burden,\" can significantly impact cognition and functioning. DEPRESCRIBE NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Deprescribing nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended to avoid worsening kidney function and medication accumulations. In older adults, NSAIDs have the potential to negatively affect blood pressure, kidney function, and can cause heart failure and gastrointestinal bleeding, which often outweighs their benefits.\ DEPRESCRIBE HYPOGLYCEMIC MEDICATIONS Episodic hypoglycaemia remains a leading cause of emergency department admissions in older patients. Sulfonylureas and short-acting insulin are among the highest-risk medications in causing hypoglycaemia. Guidelines suggest relaxing glycaemic and haemoglobin A1c goals. DEPRESCRIBE ANTIHYPERTENSIVES Achievement of goal-directed blood pressure control has repeatedly proven to reduce neurovascular and cardiovascular complications of hypertension in large clinical trials, even in advanced-age patients. However, careful monitoring is necessary for patients with limitations such as orthostasis, which increases the risk of falls. Scott et al. 26 propose that modifying antihypertensive treatment within a decision framework for older patients, taking frailty and specific considerations into account, is likely to be beneficial. This framework includes considerations for labile blood pressure, determination of blood pressure targets, comorbidities, and cognitive status. Patients who experience intermittent low pressures, syncope, or falls should have their blood pressure regimen adjusted and monitored. DEPRESCRIBING STATINS Lipid-lowering drugs, specifically statins, are often considered for discontinuation in aging adults. These drugs are typically not high-risk, and in patients older than 80 years of age, they continue to confer cardiovascular benefits compared to those who do not take or continue statin therapy. In a recent trial involving 17,204 adults older than 75 years of age with no previous cardiovascular disease, statins were discontinued, and it was found that there was an increased risk of 1.33 (95% CI, 1.18 to 1.50) for any cardiovascular event. Several studies have shown that ongoing use of statins after a coronary event significantly reduces recurrences, and discontinuation of statin therapy leads to an increased risk of recurrence. Therefore, it may be necessary to reconsider the continuation of statin therapy in the primary prevention of coronary disease for patients facing end-of-life issues.\[14\] CHALLENGES TO DEPRESCRIBING: The benefits of deprescribing and having shorter medication lists are recognized by patients, physicians, and the healthcare system. However, there are barriers that hinder the acceptance of deprescribing as a routine medical practice. These barriers include limited time, patient resistance, and lack of systematic support. Patients may be hesitant to discontinue medications, even when presented with evidence that the medications are not beneficial and may cause harm and financial burden. Patients who take chronic medications may have concerns about their conditions worsening and may resist stopping medications, even if new guidelines discourage their use in certain combinations (such as opioids and benzodiazepines). Furthermore, patients who are taking medications prescribed by previous physicians may worry about contradicting the original care plan by discontinuing those medications. Automated refills of discontinued medications can also confuse patients and delay the deprescribing process due to unclear communication. Primary care physicians may feel pressured to address multiple issues during each visit and may not have enough time to counsel patients on polypharmacy or engage in shared decision-making for deprescribing. Additionally, physicians may feel pressure from patients who request medications with unclear benefits, leading them to prescribe medications in order to maintain workflow efficiency in the clinic. Patients who see multiple prescribers may be hesitant to have one physician stop medications that were prescribed by another. In cases where deprescribing is necessary, it is important to have clear communication among healthcare providers in order to develop a comprehensive patient care plan.\[15\] **USE OF CLINICAL TOOLS AND GUIDELINES** There are several clinical tools and guidelines predicting and preventing ADEs and unnecessary polypharmacy: these include Electronic medical records, the Beers Criteria, and the STOPP/START Criteria. 1\. **Electronic medical records**: can help prevent prescription errors and subsequent ADEs. It is important for the General Practitioner (GP) to be familiar with drug interactions, changes in drug metabolism due to aging, and the impact of drugs on Cytochrome P450 enzymes. Electronic medical records facilitate a clinical medication review, assessment of compliance, and the evaluation of side effects during consultations. \[1\] The main functions of EMR systems are to electronically document patient care and provide this information at the point of care. Additionally, most EMR systems offer other functions, such as computer-based order entry, decision support, and analytics. Advanced medication management functions are also available, allowing for the recommendation of specific drugs based on clinical indications and known interactions. These systems can also dispatch reminders and alerts to inform the care team of any changes in clinical parameters or evidence-based changes. EMR systems allow for the search of patients on specific drugs or monitoring of potential drug interactions. Healthcare providers can retrieve prescriptions, dispense and administer drugs using EMR systems. They can also receive automated recommendations for drug choices and perform important tasks like medicine review and reconciliation. These functionalities and actionable information support healthcare providers in making critical decisions and adhering to organizational procedures and processes, ultimately improving prescription quality.\[16\] 2\. **Appointments for Drug Regimen Review**: can reduce polypharmacy. Multiple randomized controlled studies have shown benefits in both inpatient and ambulatory settings. These studies involved physicians, pharmacists, and/or managed care organizations. Scheduling dedicated appointments with a named GP for medication review can prevent unnecessary prescriptions, identify potential drug reactions, address prolonged use of medications, improve awareness of hospital discharge summaries and changes in regular medications, reduce drug wastage costs, and enhance the patient-GP relationship. Several studies demonstrated statistically significant improvements in medication appropriateness, reduction of ineffective medication use, and reduction in serious ADEs. It is ideal to minimize the number of prescribed medications and ensure they are taken under the appropriate indication, while regularly checking patient adherence. GPs should also inquire about over-the-counter medications that patients may forget to mention. Non-pharmacologic therapies, such as diet modification or exercise, should be considered when appropriate. When medication is necessary, GPs should carefully adjust the dose based on the patient\'s individual characteristics to prevent toxicity or interactions with other drugs or diseases. 3.**Beers Criteria:** The Beers Criteria were introduced by Dr. Mark Beers in 1991 to describe the possible adverse drug reactions (ADRs) from commonly prescribed medications in the elderly. The criteria classify medications taken by the elderly into three categories: those that should be avoided or dose-adjusted, those that are potentially inappropriate for patients with specific conditions, and those that should be prescribed with caution. A study by Beers et al. found that 21.3% of the elderly were taking at least one inappropriate medication and 2.6% were taking at least one drug that was absolutely forbidden. The recent update of the Beers Criteria includes information on drug interactions, ADEs depending on hepatic and renal status, and medication effectiveness. It is worth noting that the latest review of the Beers Criteria found that antipsychotics were associated with an increased risk of morbidity and mortality, and PPIs were only recommended for a maximum of two months due to a possible increased risk of Clostridium difficile infection, falls, and fractures in patients over 65 years old.\[1\] *Key features of the Beers criteria include:* Identification of PIMs: The Beers criteria provide a list of medications that may pose more risks than benefits for older adults. These medications are categorized into different classes, such as sedative hypnotics, nonbenzodiazepine receptor agonists, antipsychotics, and certain antihistamines. *Consideration of individual patient characteristics:* The Beers criteria consider specific patient characteristics, such as age, kidney function, and existing medical conditions, as these factors can influence the risk-benefit profile of certain medications. *Cautions and Recommendations:* The criteria include information on potential adverse effects and cautions related to the use of specific medications in older adults. They also provide recommendations for safer alternatives when available.\[17\] **4.Canadian criteria:** The Canadian Criteria, also known as the Improved Prescribing in the Elderly Tool (IPET)16, was developed by applying criteria for inappropriate medications from McLeod and colleagues17 to 362 inpatients. This resulted in the identification of 45 different medications in 14 classes of drugs that are considered inappropriate. While the IPET is similar to the Beers criteria, the Beers list identifies even more medications that may be potentially inappropriate18. However, there is currently insufficient convincing evidence regarding the use of IPET in reducing the incidence of adverse drug events, health resource utilization, or mortality.\[18\] **5. STOP/START Criteria** STOPP (Screening Tool of Older Persons\' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria used as a tool for clinicians to review potentially inappropriate medications in older adults and have been endorsed as a best practice by some organizations.\[19\]. 80 STOPP criteria and 34 START criteria. These criteria were developed through a Delphi consensus methodology by a panel of doctors, pharmacists, pharmacologists, and primary care physicians with expertise in geriatric medicine and pharmacotherapy for the elderly population. The panel members were from 13 countries in Europe. The 80 STOPP criteria and 34 START criteria are organized according to different physiological systems, such as the cardiovascular system and central nervous system. Each criterion is accompanied by a brief explanation of the relevant interaction. The STOPP/START criteria have been successfully implemented in various settings. A randomized controlled trial demonstrated that the use of these criteria as an intervention significantly improved medication appropriateness and reduced prescribing errors in older individuals who were hospitalized for acute illness.\[20\] **6.Integrated management and polypharmacy review of vulnerable elders: \[IMPROVE\]** project, based on a pilot study of 28 male veterans aged over 85, aimed to emphasize the importance of educating patients about their medications during physician visits with the help of a clinical pharmacist. The study showed that medical management by both the physician and a pharmacist trained in medication management was successful. It resulted in the discontinuation of at least one medication in 79% of cases and dosage or timing adjustments in 75% of cases. Additionally, the project reduced the use of inappropriate medications by 14% and subsequently lowered medication costs during the 6-month follow-up.\[1\] **7.** **ARMOR Tool:** The ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) is designed to consolidate these recommendations into a functional and interactive tool. It takes into consideration the patient\'s clinical profile and functional status while striving to strike a balance between evidence-based practice and altered physiological reserves. ARMOR aims to address polypharmacy in a systematic and organized manner. The primary goals of this tool are to assess and improve the patient\'s functional status, as well as to maintain it. Additionally, this tool highlights the importance of considering quality of life when making decisions regarding changes or discontinuation of medications. The use of a specific medication is evaluated in terms of its impact on primary biological functions such as bladder, bowel, and appetite. Ultimately, functional status and mobility are regarded as the crucial outcome measures when utilizing ARMOR for any medication changes**.** \[21\]. **The medications appropriateness index** is another tool designed to help doctors, asking the physician to consider 10 criteria in reviewing medication appropriateness. \[22\] +-----------------------------------------------------------------------+ | The 10 criteria of the Medication Appropriateness Index. | | | | 1\. Indication: The sign, symptom, disease or condition for which | | the medication is prescribed. | | | | 2\. Effectiveness: Producing a beneficial result | | | | 3\. Dosage: Total amount of medication taken per 24-hour period | | | | 4\. Directions: Instructions to the patient for the proper use of a | | medication | | | | 5\. Practicality: Capability of being used or being put into | | practice | | | | 6\. Drug--drug interaction: The effect that the administration of | | one medication has on another drug; clinical significance connotes | | a harmful interaction. | | | | 7\. Drug--disease interaction: The effect that the drug has on a | | pre-existing disease or condition; clinical significance connotes a | | harmful | | | | Interaction. | | | | 8\. Unnecessary duplication: Non-beneficial or risky prescribing of | | two or more drugs from the same chemical or pharmacological class | | | | 9\. Duration: Length of therapy. | | | | 10\. Expensiveness: Cost of drug in comparison to other agents of | | equal efficacy and safety. | +-----------------------------------------------------------------------+ **Possible mitigation measures** **Increased awareness among physicians** Healthcare professionals play a crucial role in raising awareness among their colleagues about the importance of medication review in reducing the harm associated with inappropriate polypharmacy practices. Measures such as implementing mandatory training on safe medication management practices and incorporating knowledge of human factors influencing polypharmacy into medical curricula can be highly beneficial. These measures can improve patient communications and facilitate shared decision-making. One of the main causes of polypharmacy is inappropriate prescribing, which includes overprescribing, mis prescribing, and under prescribing. Several tools have been proposed for identifying inappropriate polypharmacy, such as the Screening Tool of Older Person\'s Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START). **Improved medication management and adherence** In polypharmacy, it is essential to find strategies to improve medication adherence and ensure that medications are taken correctly. Various medication compliance devices, also known as pill dispensers, have been introduced to the market and have proven to be highly beneficial for elderly individuals. These devices are user-friendly and can greatly assist in medication management. Patient-centred measures, such as mobile applications, labels with pictograms, and reminders, are also being explored as potential strategies\[5\]. **Efforts to reduce self-medication** Self-medication refers to the unsupervised use of medications, including nonprescription drugs, traditional products, herbal remedies, and food supplements. Studies have shown that self-medication is prevalent among the elderly population. The reasons for self-medication in this group are multifactorial. Factors such as high treatment costs, inadequate insurance coverage, and financial constraints may lead many elderly individuals to opt for self-medication when they cannot afford to see a physician. Other reasons include avoiding work-time loss, long waiting times for consultations, prior disease experience, underestimating the severity of the condition, prior experience with a particular drug, and a belief in its safety. Increasing awareness about the risks of self-medication through proper educational interventions can empower patients and minimize the dangers associated with self-medication. \[5\] Pharmacists play a valuable role in identifying, solving and preventing drug-related problems for the purpose of achieving optimal patient outcomes and quality of life. Ambulatory based pharmacists have the opportunity and responsibility to foster safe, appropriate, effective and economical use of all medications, especially those therapies patients are self-selecting. Pharmacists should guide their customers to consult the physician before taking any medication by self.\[23\] **Efforts to reduce crosspathy** India has a diverse medical culture, encompassing various traditional systems of medicine such as Ayurveda, Yoga, Unani, and Siddha, which predate the modern healthcare system. This pluralistic medical culture in India increases the likelihood of drug interactions when self-medication is practiced incorrectly. Crosspathy refers to the practice of prescribing homeopathic, ayurvedic, siddha, or Unani drugs along with allopathic medications. Modern medicine physicians should be aware of any medications from other systems that a patient may be concurrently taking. Therefore, it is essential to gather a comprehensive history of self-medication in the elderly population to ensure safer prescribing practices. Appropriate measures to address polypharmacy should be implemented at all points of care transition, from therapy initiation to medication review and care transitions.\[5\] A \"brown bag\" evaluation is a crucial procedure for primary care clinicians, where patients bring all prescription and over-the-counter drugs to the appointment. Pharmacy calls, home visits by family health nurses, and prescription evaluations are common ways to corroborate drug usage. Clinic appointments should include periodic \"brown bag\" assessments of each medicine to determine efficacy, tolerability, and suitability. According to statistics, 63% of potentially preventable adverse medication events were caused by doctors not reacting to drug-related symptoms, while 37% were caused by patients not reporting symptoms. By encouraging patient discussion about each medicine, \"brown bag\" evaluations may help prevent adverse medication occurrences.\[24\] **CHAPTER 7** **CONCLUSION** Polytherapy is often mandatory in the management of most of the common ailments affecting geriatric patients. Drug prescription in the elderly is a serious challenge as there is an increased possibility of drug interaction resulting in toxicity, treatment failure, or loss of drug effect. Duplicative prescribing within the same drug class often occurs, and unrecognized drug side effects are treated with more drugs. To minimize polytherapy, periodic evaluation of patients' drug regimen is necessary. Prescribers need to know what other prescriptions patient is taking including herbs and teas. The small number of drugs in low doses with a simple regimen is good for drug therapy in the elderly. A significant proportion of hospitalized geriatric patients are exposed to substantial polypharmacy. Further researches are required to identify the risk of adverse drug effects following multiple drug administration and specific potential drug--drug interaction. It would be pertinent to develop country‑specific list of medications inappropriate for the elderly and include this list in national drug formularies so as to reduce their prescription and use in this age group. In future, a multidisciplinary approach which will be involving doctors, nurses, and pharmacists shall be implemented for bringing out rational drug use to minimize polypharmacy especially in geriatric population. Polypharmacy is preventable and can be rectified by prescribing appropriate medications, rational use of drugs, and periodic evaluation of patient's drug regimen. **REFERENCE:** 1. Kotsalou E. polypharmacy in elderly people. *international journal of endocrinology*, 2021, 17; 56-62. 2. Priya Sharma, NG. Prevalence of polypharmacy. *Indian journal of community and family medicine*, 2019; 4-9. 3. 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Johanna Connor O, Babak Adabavazeh, Shahnal Shah, Hyun choi *et al,*Use of the STOPP ans START criteria to address polypharmacy for elderly patients, *Hong Kong Journal of emergency medicine,*2021;28(2);79-84 21. Raza Haque, Armor: A tool to evaluate polypharmacy in elderly patients, *HMP global learning network*;2009. 22. Hanlon JT, Schmader KE, Samsa GP et al, A method for assessing drug appropriateness, *Journal of clinical epidemiology*;1992; 45(10); 1045-1051. 23. Darshana Bennadi, Self-medication: A current challenge, *Journal of Basic and Clinical pharmacy;*2014;5(1);19-23. 24. Ana Maria Dascalu, Maarina Ionela Ilie, Dragos Serban,*et al*, Polypharmacy in geriatric patients undergoing surgery- strategies to reduce the risk of iatrogenic events, *Farmacia Journal;*2023;71(3);463-470.