World Health Organization has evaluated that in every nine people there is one elderly people, i.e. of age 60 years or older. This value is to be expected to increase to one in five people by 2050 accounting for about half of the total growth of the world population. Ageing population is not just a concern for high-income countries. The majority of older people already live in low- and middle-income countries, and this is where some of the fastest rates of ageing are occurring. This demographic transition in the elderly population constitutes a significant challenge for health authorities worldwide as with advancing age multiple chronic diseases such as hypertension, diabetes mellitus, arthritis, chronic heart disease, renal diseases, etc. are associated. As a result of which elderly people tend to take multiple medications in a day that can be referred to as poly pharmacy. There is no as such standard definition of poly pharmacy. It can be explained as the use of multiple medications generally referred to five or more prescribed drugs per day and/or the administration of more medications than are clinically indicated, representing unnecessary/unwanted drug use.1 Various studies globally have shown that on an average 2-9 medications per day are taken by the elderly people.1 The prevalence of inappropriate medication used by the elderly people was found to be from 11.5-62.5%.2

Poly pharmacy is an area of concern for elderly because of several reasons. Elderly people are at a greater risk for adverse drug reactions (ADRs) because of the metabolic changes and reduced drug clearance associated with ageing; this risk is furthermore exacerbated by increasing the number of drugs used. Potential of drug-drug interactions is further increased by use of multiple drugs. In a case–control study carried out among old age people, poly pharmacy was found to be an independent risk factor for hip fractures.3 Poly pharmacy may sometimes lead to “prescribing cascades.”4 Prescribing cascade is said when signs and symptoms (multiple and nonspecific) of an ADR is misinterpreted as a disease and a new treatment/drug therapy is further added to the earlier prescribed treatment to treat the condition. This inherits the potential to develop further more side-effects and thus making a prescribing cascade.

The symptoms caused by poly pharmacy is unfortunately usually demented with the normal aging signs and symptoms, which can be: Tiredness, sleepiness, or decreased alertness, constipation, diarrhea, or incontinence, loss of appetite, confusion, falls, depression or lack of interest in your usual activities, weakness, tremors, visual or auditory hallucinations, anxiety or excitability, and/or dizziness.

Poly pharmacy can lead to ADRs, mostly due to over-the-counter medications. The most consistent risk factor for ADRs is the number of drugs being taken, i.e. as the number of drugs taken increases, the risk of ADR increases exponentially. Poly pharmacy may also lead to decreased medication compliance, poor quality of life, and unnecessary drug expenses.5Poly pharmacy and Policy Case Study Paper

In respect to oral health, the most common adverse effect of poly pharmacy, reported is dry mouth syndrome or xerostomia. Drugs/medications that can cause a dry mouth includes cardiovascular medications (diuretics, calcium channel blockers), anti-depressants and anti psychotics, sedatives, central analgesics, anti-Parkinson’s medications, anti-allergy medications, and antacids.6

Evaluation of poly pharmacy is of important concern in an elderly patient so as to avoid all the possible adverse effects. Comprehensive medication review and risk assessment should be carried out by interdisciplinary team to identify the poly pharmacy and its adverse effects. It can be carried out using various tools like Assess Review Minimize Optimize Reassess, Screening Tool to Alert Doctors to the Right Treatment, Screening Tool to Older Person’s Potentially Inappropriate Prescriptions. ADR probability scale and the Trigger tool for measuring Adverse Drug Events in the Nursing home helps in evaluating the cause and effect of medication errors resulting in ADRs. Studies have shown that Comprehensive Geriatric Assessment has proved to be effective in reducing the number of prescriptions and daily drug doses for patients by facilitating discontinuation of unnecessary or inappropriate medications.7

To reduce the incidence and adverse effects of poly pharmacy medication regimes of elderly patients should be evaluated monthly. A single agent/drug should be prescribed instead of multiple drugs for the treatment of a single condition, if possible. Medications should be started with the lower drug dosage where clinically indicated and if required incremental increase can be done. Drugs that can be given once or twice a day should be preferred over the drugs given three times a day. Drugs that are suspected to cause a problem should be discontinued. If the drug taken has no therapeutic beneficial effect or clinical indication it should be eliminated. Unessential drugs should be identified and eliminated prescribed by different health care providers for the same condition/disease. Safer drugs should be substituted with the higher risk medications.

Identifying and avoiding the poly pharmacy can lead to better outcomes in the elderly patients and also helps in improving the quality of life. Medication review is an essential part in the elderly patient to avoid adverse effects that can be caused due to poly pharmacy.Poly pharmacy and Policy Case Study Paper

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We've all heard or read about poly pharmacy, the practice of one patient using multiple medications, over-the-counter (OTC) drugs, and supplements to treat several diagnoses and comorbidity. Prescribed drugs may be duplicative, counteracting, and implicated in a cascade leading to additional drugs ordered to treat side effects. Even when used with caution and according to directions, prescribed drugs all have the potential for interactions, adverse drug events, and more severe consequences.

An older adult's medical profile may include diagnoses from one or more of the more prevalent medical conditions from more than one than physician, including congestive heart failure, adult onset diabetes mellitus, hypertension, chronic obstructive pulmonary disease, glaucoma, osteoarthritis, depression, and anti coagulation for deep vein thrombosis prophylaxis. These patients could potentially be taking a combination of prescription drugs, OTC drugs, and supplements in excess of 20 different products. Research on the leading causes of hospital admissions in the United States identifies adverse drug events and medication errors as two of the most frequently preventable reasons for admissions.1

The Institute of Medicine, chartered under the National Academy of Sciences, provided the clarion call in 2000 with the ground-breaking report, "To Err Is Human: Building a Safer Health System."2 According to the Institute's Agency for Healthcare Research and Quality and the National Institutes of Health, adverse drug events result in approximately 1 million emergency department visits per year, with a dollar value approaching $3.5 billion in the US health care system.3 Avoidance and prevention of adverse drug events and medication errors would greatly reduce spending on remediation and help redirect resources to the provision of care.

What Contributes to Poly pharmacy?

Disease States
The elderly are diagnosed with chronic medical conditions, for which prescribe rs order maintenance medications. One review of what constitutes poly pharmacy has identified different numbers of drugs for different settings. Ambulatory or community-dwelling older adults may be identified with poly pharmacy when more than five medications are ordered; in hospitalized patients and long-term nursing home residents, poly pharmacy occurs when the total reaches nine or more.4 In one study, poly pharmacy was associated with duplicate therapy and contraindicated drug combinations.5 In addition, clinical practice guidelines provide a step like approach to the management of many of the frequently diagnosed chronic illnesses. The standards recommended in guidelines include multiple medications; for example, a patient diagnosed with more advanced congestive heart failure may receive medications from four different pharmacological classes. Add a COPD diagnosis, which may include three different inhaled drugs as well as oral steroids, and we have already achieved poly pharmacy.Poly pharmacy and Policy Case Study Paper

Multiple Providers
The ability to function at the highest practicable level is a goal not easily achieved for individuals with chronic illness. As patient's providers, physicians, nurse practitioners, specialists, and hospitalizes are all responsible for completing a thorough assessment of the whole patient. However, in practice, prescribe rs may overlook the complete picture and may be prescribing with only one specific disease state in mind.

Inappropriate Use of Prescribing Software
The advent of the electronic health record has made the task of prescribing safer from the risks associated with poor handwriting. Prescriptions are clearly provided with drug names and strengths, directions for use, and many times include the exact indication. The multitude of proprietary prescribing software products includes a suite of drug-related warnings and precautions. Therapeutic duplication alerts will frequently be triggered regardless of the severity or clinical indication for use. "Alert overload" is a phenomenon to which many providers fall susceptible, with so many warnings and "soft stops" to review that many times a prescribe r will simply disregard a legitimate precaution on the potential additive adverse effects of two or more drugs.

Pharmacist Interventions at Pharmacies
Patients become susceptible to increased incidence of non adherence due to complicated regimens and missed doses. The use of multiple pharmacies including community and mail order services complicate matters because a complete singular record of dispensing is not readily available.6 Pharmacy dispensing software contains informatics standards designed to help prevent duplication's, providing multiple tiers of warnings for the dispensing pharmacist to process. Alert fatigue also plays a role when a pharmacist may approve a combination of medications that can increase the risk of adverse drug events secondary to cumulative side effects of multiple medications.Poly pharmacy and Policy Case Study Paper

Pharmacology
Therapeutic duplication from the same pharmacological class can lead to cumulative effects. Drugs from different pharmacological classes may have similar side effect profiles, increasing the risks of adverse side effects. The use of herbal supplements used to self-treat common conditions should be avoided together with certain categories of drugs. For example, St. John's Wort for depression should be avoided if a patient is using warfarin because of the risk of reducing the effects of warfarin.

Standard Precautions Prevent Poly pharmacy
Take advantage of opportunities for medication reconciliations. These exist at the hospital upon admission or between hospital and transfer to sub acute care or long term care, or from sub acute care back to the community. It's common to find duplication's when medications used to treat acute conditions are continued post discharge along with medications the patient has been taking at home. There is opportunity to review all drugs and supplements at each care transition and to perform a critical stop-and-think assessment to eliminate unnecessary drugs. Complete medication reconciliation is a crucial task identified in multiple standards of practice guidelines. The Joint Commission provides one such standard for medications in its 2016 National Patient Safety Goals: "Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell patients it is important to bring their up-to-date list of medicines every time they visit a doctor."7Poly pharmacy and Policy Case Study Paper

Complete medication reviews and take action. The Centers for Medicare & Medicaid Services has identified poly pharmacy in the elderly as critically important to the safety of the nation's long term care population. Nursing home residents must have a monthly Medication Regimen Review by a pharmacist who specializes in the care of geriatric patients. It's the role of the consultant pharmacist to ensure that a resident's medication regimen is free from unnecessary drugs, including prescription medications, OTC drugs, or supplements, that have no indication, are prescribed at unsafe doses, or are causing or at risk for producing drug-drug interactions. Whenever a potential for these conditions exists or has in fact occurred, the prescribe r must acknowledge the recommendation of the pharmacist and decide what action should be taken to ameliorate the condition.

Consequences of Poly pharmacy

Hospitalizations
In one study reviewing poly pharmacy, inappropriate medication use in the elderly increased the risks of adverse drug events, hospitalization, and death; the number of prescribed drugs was identified as a creditable indication of the increased risks for most elderly patients.1 Budnitz et al studied the incidence of adverse event data from the National Electronic Injury Surveillance System — Cooperative Adverse Drug Event Surveillance project (2007–2009 data). An estimated 99,628 emergency hospitalizations occurred due to adverse drug events in the United States each year, with nearly 50% occurring in adults aged 80 or older. Unintentional overdoses were the cause of approximately 66% of the hospitalizations.1

Unnecessary Expenditures
Medications that are duplicated and cause side effects but not hospitalizations may result in prescribe-rs ordering drugs to treat symptoms or adverse effects of cumulative drug therapy. Dollars are spent on avoidable medical appointments or for OTC or prescription drugs.

Poly pharmacy's Influence on Patient's Functional/Cognitive Status and Risk of Falls
Consider the additive effects of multiple medications. Psychoactive drugs prescribed for the symptoms of Alzheimer's disease, behavior disorders, or dementia are notorious for their increased risk for adverse effects. Anti psychotics may induce episodes of photostatic hypo tension, thereby increasing the potential for falls. Use of multiple medications in a "cocktail" designed to treat behavioral symptoms frequently results in a reduction in cognition and the ability to function independently. One approach to reduce these risks requires first evaluating a single drug and then attempting to safely tit rate its dose before adding another drug.

Our facility incorporates routine psychotropic rounds team review, consisting of physicians, nurses, dietitians, pharmacists, activity therapists, and social workers. Each resident receiving a psychoactive drug has his or her pharmacy regimen evaluated by team discussion, and ultimately an attempt is made to reduce or discontinue a drug, if not contraindicated. Long term care residents receiving psychotropics from any of the categories including anxiolytics, hypnotics, anti psychotics, and antidepressants all are required to have their medications evaluated for attempts at gradual dose reductions to ensure that medications are at the lowest possible doses to treat symptoms.

Potential interventions include the use of documentation systems that can help identify behaviors targeted for medication treatment and effectiveness. Common side effects that are appropriate to each category of psychotropic medications ordered are listed within the side effect monitoring system. Long term care facility nursing staff routinely receives continuing education/in services, reviewing common side effects pertaining to each class of drug (eg, anti psychotics, anti anxiety, hypnotics, and antidepressants) prescribed. Class-specific listings can provide better recognition of adverse reactions, especially if drugs from multiple psychotropic drug classes are being administered to an individual. Less common side effects can be added to the monitoring list if they are observed in an individual.Poly pharmacy and Policy Case Study Paper

The use of multiple medications can increase the risk of untoward effects, as side effects of one or more drugs are potentiated. Most common are those drugs that affect the central nervous system, increasing sedation and reducing mental acuity, which leads to an increased risk for cognitive decline as well as an increased risk for falls. Drugs including anticholinergics, anxiolytics, and antihistamines all have risks for common adverse reactions including nervousness, dizziness, drowsiness, ataxia, confusion, and hypo tension. Combining two or more medications with the same side effect profile will increase the likelihood of adverse drug events.

Steps to Address Poly pharmacy
Non pharmacological interventions include behavioral modification strategies, which should be included in any plan for care and documented. Our facility has a robust therapeutic activities program, and the medical staff and therapists incorporate activities centered around the preferences of each patient. Art, music, exercise, pet, and aromatherapy are all creatively offered as vital components of a resident's plan of care; each of these may help reduce the need for or frequency of using psychoactive medications to modify behavioral episodes.Poly pharmacy and Policy Case Study Paper

Identify the indications. All prescribed medications should include the indication or diagnosis for which the drug has been prescribed. This information should be clearly communicated on the prescriptions and in the directions for use, especially if the medication is e Prescribed. Indications for every medication will encourage safe prescribing, as the clinical use for the drugs should be correlated during instances where poly pharmacy exists.

The term "de prescribing" describes the systematic review of medications for reduction and discontinuation. Scott et al have defined a protocol that may be helpful for prescribe-rs to use in their most challenging patients who are at risk for poly pharmacy-related adverse drug events. Medications are evaluated in a systematic personalized review process using a risk vs benefit analysis; the objective is to attempt to simplify drug regimens while maintaining clinical efficacy.8

There are several helpful tools that are both evidenced based and peer reviewed. These guidelines are meant to provide an opportunity to evaluate and discontinue the prescribing of medications that are potentially inappropriate for use in the elderly. Reducing the use of these medications will help reduce poly pharmacy and the potential for adverse drug events. Note the italics on potentially inappropriate, as there are no contraindications for use of the medications in the criteria, but newer medications have fewer side effects. Tools include the following:Poly pharmacy and Policy Case Study Paper

• START (Screening Tool to Alert Doctors to Right Treatment); and

• STOPP (Screening Tool of Older People's Potential Inappropriate Prescriptions).9

The American Geriatrics Society maintains a widely cited reference: The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The document has been recently revised in 2015, and is intended to "improve medication selection, educate clinicians and patients, reduce adverse drug events, and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults."10

It is well known that the potential for drug-drug interactions always is a possible consequence of drug therapy. Moreover, as the geriatric population in the United States continues to rise, so does the incidence of poly pharmacy. Individuals 65 years and older make up > 13% of the population, but they consume ~30% of all prescription medications. Older individuals account for > $3 billion in annual prescription drug sales. Also, 61% of this specific patient population is taking ?? 1 prescription drugs, and most take an average of 3 to 5 medications.¹ Nearly 46% of all elderly individuals admitted to hospitals in the United States may be taking ?? 7 medications.²

Whereas appropriate drug therapy often is necessary in the maintenance and prevention of disease states, excessive use of medications can result in adverse reactions. Use of multiple medications is particularly prevalent among the elderly population, leading to complex drug regimens and the risk of further complications.Poly pharmacy and Policy Case Study Paper

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Poly pharmacy typically is defined as the concurrent use of ?? 5 drugs by the same patient. Poly pharmacy, however, is more complex than just the number of drugs that a patient takes. Clinically, the criteria utilized for identifying poly pharmacy involve the following:

• Taking medications that have no apparent indication
• Using therapeutic equivalents to treat the same illness
• Concurrent usage of interacting medications
• Using an inappropriate dosage
• Utilizing other medications to treat adverse drug reactions3

The problems that may be associated with poly pharmacy can be so extensive that it was designated as the principal medication safety issue in the Department of Health and Human Services report Healthy People 2000.^3-5

Poly pharmacy increases the possibility of drug-drug and drug-disease interactions. The elderly population is at greater risk because of normal physiologic changes that occur with the aging process. These physiologic changes, particularly decreased renal and hepatic function, in turn may contribute to changes in thermodynamics and in the pharmacokinetics process.

Types of Poly pharmacy

Poly pharmacy more commonly has a negative connotation, but sometimes it is necessary and can be beneficial in treating certain medical conditions. Poly pharmacy can be categorized into 2 major classes.^{4Poly pharmacy and Policy Case Study Paper}

Therapeutic Poly pharmacy

This type occurs when multiple drug regimens are carefully monitored by clinicians and are necessary for the treatment of conditions and for achieving a therapeutic goal. An example of therapeutic poly pharmacy is the combination therapy of isoniazid, rifampin, ethambutol, pyrazinamide, and pyridoxine in the initial treatment of tuberculosis.⁴ Another example of therapeutic poly pharmacy is the multiple agents used in the management of congestive heart failure, such as digoxin, angioplasty-converting enzyme inhibitors, and a diuretic.

Contra therapeutic Poly pharmacy

This type of poly pharmacy occurs when an individual experiences unanticipated or unintentional adverse effects while he or she is on a drug regimen and is not monitored.⁴ Poly pharmacy is particularly detrimental when an individual takes multiple pharmacologic agents for an extended period of time, particularly at high doses, without being monitored.

Various criteria markers are available for health care professionals to assess which pharmacologic agents may be considered inappropriate for utilization among the elderly population. The criteria are based on the possible risk and benefits of certain pharmacologic agents. The most commonly known criteria are the Beers Criteria. This list was developed by Mark H. Beers, MD, in 1991 and was revised in 1997 to include medications that should be avoided (disease-independent or because of a patient's preexisting medical condition).^{6Poly pharmacy and Policy Case Study Paper}

Poly pharmacy and Adverse Drug Reactions

The major concern for all cases of poly pharmacy is the prospect of adverse drug reactions and serious drug-drug interactions. In some instances, it is therapeutically necessary to use multiple agents to treat certain conditions. It is the responsibility of pharmacists to assess patients with multiple medication regimens and to make recommendations when necessary.

Researchers have shown that more than 75% of adverse drug reactions that result in hospitalization are related to known pharmacologic agents and are partly due to inadequate monitoring, inappropriate prescribing, and lack of patient education and compliance.⁷ Research also suggests that the potential for an adverse drug reaction to occur is 6% when an individual takes 2 medications. It increases to 50% when 5 medications are taken concomitantly, and it rises to 100% when ?? 8 medications are prescribed.³

Screening in cases of poly pharmacy, particularly in the elderly patient population, is crucial because adverse drug events can often imitate other geriatric syndromes or precipitate confusion, falls, incontinence, urinary retention, and malaise. These side effects in turn may cause a physician to prescribe another agent to treat them.¹

The Role of the Pharmacist in Poly pharmacy Management

Jay L. Schwab, RPh, BCNSP, a clinical pharmacist practicing in Louisiana and specializing in adult medicine, surgery, nutrition, and critical care, has stated that pharmacists can aid in the reduction or avoidance of poly pharmacy in the following ways:Poly pharmacy and Policy Case Study Paper

• Screening patient drug profiles
• Assessing the effects of comorbid conditions
• Reviewing potential drug-drug interactions

Some of the most common pharmacologic agents that are associated with adverse effects are non steroidal anti-inflammatory drugs, psychotropics, anti hypertensives, and antibiotics. One important step is to review and assess the specific indications for certain medications.

As stated above, it is very common, particularly in the elderly, to see medications prescribed to treat side effects of other medications. Pharmacists can make recommendations to discontinue those medications and prescribe alternative therapeutic choices. As clinicians, pharmacists can play a fundamental role in identifying those agents that may not be necessary in a patient's drug regimen. They also may be able to suggest non pharmacologic therapies to meet a patient's particular needs.

Although the solution may not be a simple one, in most cases poly pharmacy can be managed through a multidisciplinary approach. The objectives of appropriate pharmacologic therapy are to treat or manage disease states, to prevent complications associated with comorbidity, and to ease or eradicate pain. The achievement of these goals can be obtained through precise and routine drug monitoring. Therefore, the ultimate challenge for all health care professionals is to ascertain the most suitable drug therapy for each patient that will enhance that patient's quality of life without compromising the patient's ability to function and put him or her at risk for adverse reactions.Poly pharmacy and Policy Case Study Paper

Whereas some degree of adverse effects may be unavoidable, their severity or incidence can be significantly reduced through pharmacist intervention and through educating patients. The elderly population can obtain the benefits of pharmacologic therapy even when a drug regimen is a complex one, if drug regimens are tailored to meet the specific needs of each individual patient. It is important to note that Healthy People 2010, a national initiative to improve the health of all Americans, is planning to ensure regular review of medications used by the elderly population.⁶

The use of drug combinations, termed poly pharmacy, is common to treat patients with complex diseases and co-existing conditions. However, a major consequence of poly pharmacy is a much higher risk of adverse side effects for the patient. Poly pharmacy side effects emerge because of drug-drug interactions, in which activity of one drug may change if taken with another drug. The knowledge of drug interactions is limited because these complex relationships are rare, and are usually not observed in relatively small clinical testing. Discovering poly pharmacy side effects thus remains an important challenge with significant implications for patient mortality.Poly pharmacy and Policy Case Study Paper Here, we present Decagon, an approach for modeling poly pharmacy side effects. The approach constructs a multi modal graph of protein-protein interactions, drug-protein target interactions, and the poly pharmacy side effects, which are represented as drug-drug interactions, where each side effect is an edge of a different type. Decagon is developed specifically to handle such multi modal graphs with a large number of edge types. Our approach develops a new graph convolution al neural network for multi relational link prediction in multi modal networks. Decagon predicts the exact side effect, if any, through which a given drug combination manifests clinically. Decagon accurately predicts poly pharmacy side effects, outperforming baselines by up to 69%. We find that it automatically learns representations of side effects indicative of co-occurrence of poly pharmacy in patients. Furthermore, Decagon models particularly well side effects with a strong molecular basis, while on predominantly non-molecular side effects, it achieves good performance because of effective sharing of model parameters across edge types. Decagon creates opportunities to use large pharmacologic and patient data to flag and prioritize side effects for follow-up analysis.

Multi morbidity, commonly defined as the co-existence of two or more chronic health conditions, is common in the older population [1]. The presence of multiple chronic conditions increases the complexity of therapeutic management for both health professionals and patients, and impacts negatively on health outcomes. Multi morbidity is associated with decreased quality of life, self-rated health, mobility and functional ability as well as increases in hospitalizations, physiological distress, use of health care resources, mortality and costs [2–4]. Globally, the health burden of multi morbidity is expected to rise significantly as a result of the growing number of older people and increasing numbers of people living with multi morbidity [5].

The use of multiple medicines, commonly referred to as poly pharmacy is common in the older population with multi morbidity, as one or more medicines may be used to treat each condition. Poly pharmacy is associated with adverse outcomes including mortality, falls, adverse drug reactions, increased length of stay in hospital and readmission to hospital soon after discharge [6–8]. The risk of adverse effects and harm increases with increasing numbers of medications [9]. Harm can result due to a multitude of factors including drug-drug interactions and drug-disease interactions. Older patients are at even greater risk of adverse effects due to decreased renal and hepatic function, lower lean body mass, reduced hearing, vision, cognition and mobility [10].

While in many instances the use of multiple medicines or poly pharmacy may be clinically appropriate, it is important to identify patients with inappropriate poly pharmacy that may place patients at increased risk of adverse events and poor health outcomes. Studies have suggested a shift towards adopting the term ‘appropriate pharmacology in order to differentiate between the prescribing of ‘many and ‘too many drugs instead of a simple numerical count of medications, which is of limited value in practice [11, 12]. In order to make this distinction between appropriate and inappropriate poly pharmacy, the term poly pharmacy needs to be clearly defined. We therefore conducted a systematic review to explore the definitions of poly pharmacy in existing literature. We additionally aimed to explore whether articles differentiated between appropriate and inappropriate poly pharmacy and how this distinction was made.Poly pharmacy and Policy Case Study Paper

Population demographics are changing worldwide, with life expectancy and the proportions of older persons increasing. Older people are the greatest consumers of medications and healthcare resources in developed countries. It is assumed that as more drugs become available and life expectancy continues to increase, the consumption of prescription drugs by older people will increase further and the incidence of potentially inappropriate prescribing will grow. A survey of non-institutionalized older adults in the United States showed an increased usage of all medications with advancing age, the highest prevalence of drug use being in women 65 years of age and older with 12% taking 10 or more medications and 23% taking at least five prescribed drug therapies 1. In most industrialized nations older people consume three times as many prescription medications as younger people and purchase 70% of non-prescription medications 2. In the United States, 12•5% of the population is over 65 years of age but consume 32% of all prescription medications and account for 25% of drug expenditure and 30% of total national healthcare expenditure 3-5. In Ireland, 11•13% of population is over the age of 65 years but consume 47% of all prescription medications 6. In Europe, people over 65 years of age consume on average 2•3 times the amount of health care than do those <65 years of age 7.

POLY PHARMACY:

Poly pharmacy has been defined in many different ways and the appropriate definition may differ according to patient population and study setting 9. Fulton and Allen 10 define poly pharmacy as: 'the use of medications that are not clinically indicated'. In practice, poly pharmacy is defined as using more than a certain number of drugs, irrespective of the appropriateness of drug use 8, 11, 12. Inappropriate prescribing includes the use of medicines that introduce a significant risk of an adverse drug-related event where there is evidence for an equally or more effective but lower-risk alternative therapy available for treating the same condition. Inappropriate prescribing also includes the use of medicines at a higher frequency and for longer than clinically indicated, use of multiple medicines that have recognized drug–drug interactions and drug–disease interactions, and importantly, the under-use of beneficial medicines that are clinically indicated but not prescribed for some reasons. As older patients seek treatment for various ailments from a variety of physicians, they are at increasing risk of accumulating layers of drug therapy. Individuals aged 65 and older use a disproportionate number of prescriptions and over-the-counter medications; 31% use more than one pharmacy and 50% receive prescriptions from more than one prescribe r 13. A higher number of primary care physicians and multiple dispensing pharmacies increase the risk of drug–drug interactions 14. The number of medications prescribed to elderly patients, and the complexity of their drug regimens increase over time 15.
The potential for an increased risk of drug–drug interactions and adverse drug reactions, and factors such as age-related changes in pharmacodynamics (PD) and pharmacokinetics (PK) must be considered. Diabetes and chronic lung disease predict a greater complexity and cost of drugs regimen in elderly patients with heart failure 16. Besides the increase in diseases and worsening of diseases, the literature also mentions other factors as being responsible for the increase in poly pharmacy, i.e. ageing, moving to a residential or nursing home and hospitalization 17, 18. The patient's expectations, the General Practitioner's attitude and consultations with several doctors have been associated with an increase in multiple drug use 19, 20.Poly pharmacy and Policy Case Study Paper

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EFFECTS OF AGING ON DRUG METABOLISM:

Drug absorption, distribution, metabolism and elimination change as a natural consequence of the ageing process. Changes in drug absorption in older patients may result from decreases in splanchnic blood flow and gastric motility, and increases in gastric pH, and other physiological changes that are associated with ageing. Blood flow and gastric motility may be further diminished by cardiovascular and gastrointestinal drugs used to treat co-morbid conditions. Ageing influences drug excretion. Age-related decreases in glomerular filtration rate are well known. These physiological declines coupled with co-morbid conditions and the use of multiple drugs means that medications eliminated by the renal route requires dose adjustment. Drugs that influence renal function and thus elimination/excretion have the potential to pose serious clinical problems if used concomitantly. With ageing, there is a decrease in lean body mass and total body water with a relative increase in total body fat 21. These changes lead to a decreased volume of distribution for hydrophilic drugs such as lithium, and digoxin where adjusted dosing can result in higher plasma concentrations, thus increasing the potential for adverse effects. Conversely, lipid soluble drugs such as long-acting benzodiazepines have an increased volume of distribution, thereby delaying their maximal effects and resulting in accumulation with continued use. There is a reduction in hepatic mass and blood flow with ageing 22.

Drugs such as beta-blockers, nitrates and tricycle anti-depressants that have a first pass effect in the liver may have a higher bio availability in older people and thus be effective at lower doses. Cytochrome P450 oxidation declines with ageing 24 and drug–drug interactions involving these enzymes are important to recognize. Larger drug storage reservoirs and decreased clearance prolong drug half-lives and lead to increased plasma drug concentrations in older people. If serum albumin is decreased there will be an increase in the active unbound drug concentration for highly protein-bound drugs such as phenytoin, theophylline, warfarin and digoxin. Ageing is also associated with changes in the end-organ responsiveness to drugs at receptor or post-receptor level 25. There is decreased sensitivity to beta-receptors along with a possible decreased clinical response to beta-blockers and beta-agonists 26. Increased sensitivity to drugs such as opiates and warfarin is common 27, 28.Poly pharmacy and Policy Case Study Paper

ADVERSE DRUG REACTIONS (ADRs):

The number of elderly is increasing dramatically. In United States, in the next 25 years, as the baby boomer generation begins to turn 65 years old, the number of elderly is expected to double to approximately 70 million. Those older than 85, is now the fastest growing segment of our population. Thus, we can expect the number of adverse drug reactions to increase proportionately. Polypathology, the age-related increase of concurrent diseases, is likely to be the main determinant of drug consumption. However, both over-prescribing and improper prescribing has been reported and seems to contribute to the age-related increase in the prevalence of adverse drug reactions (ADRs) 29, 30. A hospital-based study from Norway showed that the risk of experiencing a drug-related problem increased linearly with the number of drugs on admission 31. A study carried out in the USA found that nursing home patients receiving nine or more drugs were more than twice as likely as patients receiving a lower number of drugs, of experiencing an adverse effect 32. On average, ADRs account for 3%–13% of all the admissions 33-35 and complicate 5%–20% of the stays of patients over 65 years 36-38. More than 40% of persons aged 65 and older use five or more different medications per week, and 12% use 10 or more different medications 39. If an elderly patient takes five or more drugs, he or she has a 35% chance of experiencing an adverse drug event 40.
Drug interactions are significant contributors to morbidity 35. Office visits for an adverse drug event increase from 9% of the population per year at age 25–44 years to as high as 56•8% between age 65 and 74 years 41. Inappropriate drug use is one of the risk factors for adverse drug reactions in the elderly. The risk for an adverse drug event is 13% with the use of two medications, but the risk increases to 58% for five medications 42. If seven or more medications are used, the incidence of adverse drug events increases to 82% 42.Poly pharmacy and Policy Case Study Paper

INTERVENTIONS:

Older people are a heterogenous group, often with multiple concomitant illnesses and multiple prescriptions. There is a thin line between a healthy old person and an ill old person. Prescribing for older people is challenging as any new medication must be considered in the context of altered pharmacokinetics, altered pharmacodynamics and age-related changes in body composition and physiology. Both over prescription and undue prescription seem to characterize the overall pharmacological therapy of the elderly.
Poly pharmacy is the main risk factors for ADRs 43. Thus, attempts should be made to curtail inappropriate drug prescription by utilizing different available tools 44. An interdisciplinary medication review of older individuals in the community helps to reduce the cost and number of medications. Polypathology seems the most obvious explanation of the high number of drugs taken by older people, but additional factors deserve consideration. Changes in patient’s medical status over time can cause medications that have been used chronically to become unsafe or ineffective. Particular care must be taken in determining drug dosages and treatment options when prescribing for older adults. “Pill for an ill” approach should be discouraged as many a time pharmacological treatment may carry more adverse effects then the illness itself.   Use of electronic medical records and other hand held devices to prescribe appropriate medication doses and check drug to drug interactions has been found useful in reducing the medication related errors and hence adopted by various medical groups and hospital practices.
Reviewing medications at every visit   is a simple and very helpful tool too especially if patients are encouraged to bring with them a printed list of their current medications (including over the counter drugs). Printing an updated list of the medication changes in bold and large font after a visit with their physician helps patients to follow the recommendations especially in case of geriatric patients who may not remember all the new changes made at an office visit.Poly pharmacy and Policy Case Study Paper

CONCLUSIONS:

Poly pharmacy is an important issue in the elderly. The problem involves many issues, a number of which have been explored in this article. One of the most important issues involves adverse drug reactions. All pharmaceutical agents have the potential for side effects; therefore, it is obvious that the more drugs one takes the more side effects one will experience. The aging process results in altered metabolism and excretion of medications, and deficits in cognition and senses. Incidence of adverse drug reaction and interactions is increased with poly pharmacy. Since adverse drug reactions are a significant cause of morbidity and mortality, as well as an important cause for hospital admissions, minimizing poly pharmacy is an important consideration. The general principle of “Start Low and Go Slow” holds true in most scenarios but should be modified to “Start Low, Go Slow but Use Enough” to achieve desired therapeutic effect.Poly pharmacy and Policy Case Study Paper