Polypharmacy Common in Elderly Psychiatric Inpatients
By Jill Stein
Medscape Medical News
March 2, 2010 (Munich, Germany) — Older psychiatric inpatients may be a “vulnerable target” for polypharmacy and are, in fact, frequently discharged with multiple medications that have potentially hazardous interactions, according to data from a small study reported at the European Psychiatric Association 18th European Congress of Psychiatry.
"Older psychiatric inpatients are susceptible to polypharmacy," Ashwani Kumar, MRCPsych, who is a consultant psychiatrist at Woodhouse Hospital in Cheadle, United Kingdom, explained to Medscape Psychiatry. "They are likely to be excluded from any clinical decision-making given that they may be cognitively impaired because of both their psychiatric illness and age."
Dr. Kumar presented the results of a study that assessed the extent of polypharmacy and potential drug interactions in 25 elderly psychiatric inpatients at the time they were discharged from the hospital to their home, a nursing home, or residential care.
"There is increasing concern about the use of multiple medications in elderly populations in general practice and in psychiatric services, and the ‘statistics’ illustrate the potential scope of the problem. Eighty percent of individuals over age 75 years take at least 1 prescription medication, with 36% taking 4 or 5 medications," said Dr. Kumar.
Polypharmacy has both clinical and financial implications, he added. "It has been widely documented to increase the risk of confusion, falls, and consequent functional decline in this vulnerable population, and the cost of treating all the outcomes of polypharmacy is exorbitant for a publicly financed health care system that is already burdened by high costs," he said.
Multiple Medications at Discharge
For their study, the researchers identified potential interactions by entering information on the patient’s medication prescriptions as documented in their medical records on a UK Website known as www.BNF.org. The organization aims to provide UK health professionals with authoritative and practical information on the selection and clinical use of medicines in a clear, concise, and accessible manner.
Overall, 8 patients (32%) had prescriptions for 4 or fewer medications at discharge, 10 (40%) had 5 to 8 prescriptions, and 7 (28%) had 9 or more prescriptions at discharge.
The median number of prescriptions at discharge was 6.5.The median number of hazardous interactions was 3.1.
A prescription for 6 or more medications was more likely to cause drug-drug interactions and hazardous drug-drug interactions.
"I would urge psychiatrists and nonpsychiatrist physicians to think twice before adding additional medications in older psychiatric inpatients as the new ‘symptom’ the doctor may think he is treating may actually be a side effect of a drug already on board," Dr. Kumar said. "A new prescription may actually potentiate new problems."
Part of the reason psychiatrists may rush to prescribe without conscientiously seeking the causes for a patient’s symptoms may lie in the "nature" of contemporary medicine.
"It may be that we are so fixated today on specialization and subspecialization and superspecialization that we sometimes forget the basics," he added. "But what is clear is that we need a more holistic approach where we focus more on the patient as a whole rather than exclusively on his psychiatric symptoms."
Preventing Polypharmacy
To improve patient outcomes, Dr. Kumar echoed prior published recommendations:
Know your patient well before starting treatment;
Order a treatment package, not just a prescription;
Educate the patient;
Choose the right medicine;
Ensure that the patient takes the medication;
Use as few drugs as possible;
Tailor the treatment to the patient’s needs;
Familiarize yourself with the drug;
Have a high index of suspicion; and
Consider the patient’s viewpoint.
Obviously, the psychiatrist may need to work with nurses and social workers to ensure that these recommendations are implemented given that older patients may have difficulty in communicating.
He also said that a dedicated in-house pharmacist may be pivotal in reducing the risk of polypharmacy in elderly psychiatric inpatients.
"A pharmacist can add some evidence-based thinking to treatment planning," he said. "Sometimes in an emotionally charged situation, a psychiatrist is pressured to prescribe in order to provide a quick fix for a patient in a disturbed ward. A pharmacist can work with the psychiatrist and nurse to safeguard against this practice."
P. Murali Doraiswamy, MD, head of the Biological Psychiatry Division at Duke University Medical Center in Durham, North Carolina, said that polypharmacy is also a significant problem in the United States.
"A recent study suggests that 2 million older adults in the US may be at risk for drug interactions, and more than half of older adults in the US take 5 or more pills," he said.
"A nurse recently told me about a senior who was taking more than 50 drugs and supplements given by various doctors. Fortunately, forbidden combinations are still rare, which suggests that the system for monitoring those is still working. But there are many combinations we know nothing about, and so the risk is still substantial," he added.
"Bleeding problems are the biggest risk followed by risk for fainting or falls, so people taking critical medicines should be particularly cautious," he added.
Dr. Doraiswamy agrees with Dr. Kumar that "pharmacists are the best at detecting these interactions since most doctors still know very little about drug interactions."
The investigators have disclosed no relevant financial relationships.
European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract 2052. Presented March 2, 2010.
