4/29/2019 Topic: Week 2: Polypharmacy Discussion
This is a graded discussion: 50 points possible due Mar 17
7 45
Week 2: Polypharmacy Discussion
Students will not receive credit for any discussions posted after Sunday 11:59pm MT.
Polypharmacy is a common concern, especially in the elderly.
List the definitions of polypharmacy you encounter in your assigned reading. Include an additional reference from an evidence
based practice journal article or national guideline.
Discuss three risk factors that can lead to polypharmacy. Explain the rationale for why each listed item is a risk factor. Risk
factors are different than adverse drug reactions. ADRs can be a result of polypharmacy, and is important, but ADRs are not a
risk factor.
Discuss three action steps that a provider can take to prevent polypharmacy.
Provide an example of how your clinical preceptors have addressed polypharmacy.
This topic was locked Mar 17 at 11:59pm.
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(https:// Pessy Kramer
(h ps://chamberlain.instructure.com/courses/40085/users/15112)
Mar 10, 2019
Week 2 Discussion 1: Polypharmacy
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,4/29/2019 Topic: Week 2: Polypharmacy Discussion
Hi Dr. Mompoint and Class,
Polypharmacy is a frequent concern, especially in the elderly. According to Kennedy-Malone, Plank, & Duffy (2019),
Polypharmacy has many definitions, including prescribing numerous drugs such as five or more drugs, prescribing potentially
inappropriate medications (PIMs), including underprescribing, overprescribing, and misprescribing, leading to adverse drug
reactions (ADR). This is particularly important with the older adult since pertinent changes occur with aging that alter the
dynamic processes the drugs undergo to produce therapeutic effects (Kennedy-Malone, Plank, & Duffy, 2019, p. 470).
Specifically, these changes involve the processes of pharmacokinetics, what the body does to the drug, and pharmacodynamics,
what the drug does to the body (Kennedy-Malone, Plank, & Duffy, 2019, p. 470). As future FNP’s it is of utmost importance to
study and research this topic as we will be proscribing frequently to the elderly and simple mistakes can be quite significant. It is
important to keep in mind with the elderly, that in general, the therapeutic window narrows with age, so the potential for
benefiting the patient measured against the risk of doing harm becomes more significant for the prescribing professional
(Kennedy-Malone, Plank, & Duffy, 2019, p. 470).
Three main risk factors that can lead to polypharmacy is; Distribution, Metabolism, and Elimination (Kennedy-Malone, Plank, &
Duffy, 2019, p. 471) The rationale for each listed item, and why it is a risk factor is as follows; Firstly, drug distribution is different
in the elderly due to the aging process, particularly in individuals of smaller body size, those who have decreased body water,
and those with higher body fat (Kennedy-Malone, Plank, & Duffy, 2019, p. 471). To explain further, Drugs that are distributed in
water have a higher concentration in elderly persons, thereby exerting a more profound drug effect, however if the drugs
distributed in fat have a wider distribution and a less intense effect, but a more prolonged action, particularly in those individuals
with more adipose tissue (Kennedy-Malone, Plank, & Duffy, 2019, p. 471). This is something the provider must keep in mind
when determine the drug dose for the specific patient. Regarding metabolism, advancing age and the ability of the liver to
metabolize drugs does not decline similarly for all pharmacological agents (Kennedy-Malone, Plank, & Duffy, 2019, p. 471).
Although liver size and blood flow do decline with age, routine liver function test results are typically normal when no disease
exists, however, the decreased liver size and blood flow that results from aging can lead to a decreased first-pass metabolism;
drug activity for some medications is prolonged, because drugs are metabolized and eliminated more slowly (Kennedy-Malone,
Plank, & Duffy, 2019, p. 471). Therefore, being familiar with the age-related pharmacokinetics of drugs is of the utmost
importance when determining the initial and maintenance dosages (Kennedy-Malone, Plank, & Duffy, 2019, p. 471). Lastly, the
most profound reason for polypharmacy, is a reduced elimination of drugs. Most drugs are excreted in the urine via the renal
system, although some are excreted in the feces via the biliary system. Deviations in kidney function begin in the fourth decade
of life and continue to deteriorate with each successive decade, therefore, by age 70 years an individual might reasonably have
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,4/29/2019 Topic: Week 2: Polypharmacy Discussion
a 40% to 50% decrease in renal function, even in the absence of disease (Kennedy-Malone, Plank, & Duffy, 2019, p. 471).
Therefore, these kidney function changes may prolong the half-lives of drugs. Understanding this concept and keeping it in mind
when proscribing for the elderly is of utmost importance.
There are over 35 assessment tools currently available assist providers to avoid PIMS and polypharmacy. The three tools I
have chosen to discuss is STOPP/START, the BEERS criteria, and Medication Appropriateness Index (MAI). Firstly, the
STOPP/START is a tool designed to detect prescribing of potentially inappropriate prescriptions, the STOPP, consists of 65
clinically important criteria that relate to PIMs and can contribute to hospitalization for ADRs, including a brief explanation of
each, and the START contains 22 criteria, supported by evidence, to remind prescribers to consider certain drugs that are
appropriate for specific conditions but may be omitted (Kennedy-Malone, Plank, & Duffy, 2019, p. 472). By looking through the
list prior to prescribing medication, one can possibly prevent horrible out comes. Secondly, The Beers criteria consists of a list of
PIMs to be avoided in older adults; they are listed by drug category and also by diagnosis (Kennedy-Malone, Plank, & Duffy,
2019, p. 472). I believe this list to be the most well known as I have witness it used at my clinical site and also in my experience
as an ED nurse. Thirdly, upon researching Polypharmacy, I found a journal article that was interesting and pertinent to our
practice. A systematic review was conducted to identify generic prescribing indicators relevant to polypharmacy appropriateness
(Burt, et al., 2018). The review identified 12 indicators of polypharmacy appropriateness originated from nine different existing
measures, including the influential Medication Appropriateness Index (MAI). The MAI is a list comprised of 10 questions,
completed by a pharmacist or physician in order to assess the appropriateness of a drug and can be used to decrease / avoid
polypharmacy (Burt, et al., 2018). It is important to note that there might be times when drugs on these lists need to be
prescribed; nevertheless, this should be done with full awareness of the above-mentioned factors and the need for monitoring. In
those cases clinical judgment, knowledge of the patient and the disease, clinician and patient shared goals, risk / benefit
considerations, and quality of life all factor into decision making for individual patients (Kennedy-Malone, Plank, & Duffy, 2019, p.
472).
An example of how my clinical preceptors have addressed polypharmacy is by using the BEERS criteria. On 03/07/19 I saw a
74yr old female who was in a minor MVA, complaining of neck pain. My preceptor had recommended 400 – 600 mg of Ibuprofen
TID PRN, however, due to the BEERS criteria education was provided to the patient regarding an increased risk of upper
gastrointestinal ulcers, gross bleeding, or perforation. Statistically, these adverse reactions due to NSAID use has occurred in
approximately 1% of patients treated for 3–6 months and in 2–4% of patients treated for 1 year; these trends continue with
longer duration of use (A Pocket Guide to the AGS 2015 BEERS CRITERIA, 2015). The patient verbalized understanding and
reported she would only use the Ibuprofen if necessary.
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, 4/29/2019 Topic: Week 2: Polypharmacy Discussion
Thank you, Pessy
References:
A Pocket Guide to the AGS 2015 BEERS CRITERIA. (2015). Retrieved from American Geriatrics Society:
http://www.ospdocs.com/resources/uploads/files/Pocket%20Guide%20to%202015%20Beers%20Criteria.pdf
Burt, J., Elmore, N., Campbell, S. M., Rodgers, S., Avery, A. J., & Payne, R. A. (2018). Developing a measure of polypharmacy
appropriateness in primary care: systematic review and expert consensus study. BMC Medicine .
Kennedy-Malone, L., Plank, L. M., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults (2nd ed.).
Philadelphia: F.A.: Davis Company.
(http Marie Mompoint (Instructor)
Mar 10, 2019
Hi Pessy,
Nice overview of this dicussion on Polypharmacy and review of several adverse effects of this phenomenon. I agree that if
a patient is on many medications;ADR’s such as kidney injury, falls, etc could occur.
Medication reconciliation is so important as well as being careful when prescribing. Thanks for the discussion of the
BEERS criteria. Nice overview.
Can you think of any precursors that would lead to an elderly patient being on too many drugs?
Dr. Mompoint
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