What is polypharmacy?
We know that medicines have an enormous, positive impact on the lives of millions of people. But as more of us live longer, with multiple long-term conditions, we take more and more medicines. Taking many different medicines at once can become either a practical challenge or increase the likelihood of harm, or both.
Problems with polypharmacy happen when:
• Medicines are prescribed that are no longer clinically indicated, appropriate or optimised for that person
• The harm of a particular medicine outweighs the benefit
• The combination of medicines being taken has the potential to, or is actually causing harm to the person
• Where the practicalities of using the medicines have become unmanageable or are causing harm or distress.
Who is at risk?
Polypharmacy is a significant, complex and growing issue affecting many people. Polypharmacy is often linked to the taking of multiple medicines in older people, but there are other aspects of polypharmacy that shouldn’t be overlooked such as deprivation, learning difficulties as well as long term conditions in younger people and those with mental health problems.
Polypharmacy occurs in a wide range of health and social care settings such as hospitals, hospices, care homes, prisons as well as in people’s own homes and in the homeless. It is a serious and significant public health challenge affecting populations where people are living longer and coping with multiple conditions.
What can we do about it?
New guidance from the RPS Polypharmacy: Getting our medicines right sets out a number of recommendations for a range of healthcare professionals, health care organisation and for patients and the public.
1. Shared decision making
If true shared decision-making formed part of every consultation where medicines are prescribed, then it is hard to see how we would prescribe upwards of 20 medicines to people living alone with cognitive impairment (for example). And yet we do. The evidence base for shared decision making is emerging but we have long way to go to. A number of tools exist to help this. See Me and My medicines and NICE guidance on shared decision making.
2. Think about the patient
This might seem obvious, but how many times are medicines prescribed and dispensed without thinking about how the patient might actually comply with a medicine regimen? Patients asked to take tablets before and after breakfast may simply not be able to organise their morning around such specific timings. We need to move away from a paternalistic prescribing model towards a much more pragmatic solution. We need to ask the patient about what is important to them and what makes up their home environment in order to establish if what is being asked of them is even possible. As pharmacists, we our role to identify clinical challenges around taking medicines such as interactions but how many of us stop to think about the practical challenges?
3. Good use of data to identify people at greatest risk from harm
We won’t resolve the problems caused by polypharmacy overnight. But by using good data sources such as the NHS Scotland SPARRA tool, or the NHS BSA polypharmacy prescribing comparators in England, or the National Prescribing Indicators in Wales, we can identify those people who appear to be at the greatest risk from harm. Evidence is emerging that demonstrates that PCOs and GP Practices that have fully engaged with such tools have made significant impact on their polypharmacy.
4. Work together across systems and professional boundaries
Healthcare professionals have a collective responsibility to address the many areas of polypharmacy. Everyone, including healthcare organisations, policy makers, prescribers, pharmacists and their teams, nurses, the people taking medicines, carers and the public at large, has a role in ensuring that they all play their part in the collective response to this issue.
Whilst a collaborative approach is required, pharmacists, as the experts in medicines, are well-placed and well-equipped to lead this change and have some important responsibilities to work with the various stakeholders including prescribers.
5. Change the medicines pathway
In a recent series of Action Learning Sets conducted with GPs and pharmacists in Wessex AHSN, a GP asked “how can you do a holistic, person centred medication review in a 7 minute consultation?” Well the simple answer is that you can’t, not comprehensively. Talking to a patient about what is important to them and how their medicines might support their priorities will require some significant changes to local infrastructure. Some suggestions include:
1. GP practices having access to Pharmacists to conduct medication reviews with patients at risk
2. Dedicated appointment slots established with longer appointment times for multi morbidity medication review
3. Closer working between GPs, Pharmacists and Community Geriatricians to share learning and experience of stopping medicines safely
4. IT solutions to enable those that have received a recent medication review to be flagged to secondary care to ensure medicines that have been stopped safely are not restarted inadvertently
5. IT solutions to enable secondary care to highlight where admissions may be thought to be due to multiple medicines taking and if necessary refer such patients to the practice for a person-centred medication review.
6. A widespread culture shift
There needs to be a shift away from a paternalistic approach to prescribing towards a truly person-centred approach, where patients are able to raise their priorities and any changes they want to their medicines.
Over time, we should aim for a situation where patients understand what all their medicines are for and expect regular, holistic medication reviews. These conversations will highlight medicines that are no longer needed or ones that are no longer practicable to take. The prescriber and patient can then make a plan for stopping those medicines safely.