Over the past two decades with increasing life expectancy and better access to healthcare, there has been a rise in the population of adults above age 65 years in India. There has also been a significant increase in speciality and super speciality doctors. Many elderly persons suffer from a myriad of health conditions that require consults with many specialists. Also, access to over the counter (OTC) medications and supplements has never been easier with online pharmacies and home delivery of pills. Multiple prescriptions from different practitioners along with self medication by patients themselves has created a problem of polypharmacy or too many drugs taken by patients. In the current COVID 19 scenario, with elderly persons missing their regular appointments this problem has compounded.
There is no strict definition for polypharmacy. Some studies have arbitrarily defined it as four or more medications. But patients with multiple serious conditions may genuinely require them. A better way to define polypharmacy would be the use of more drugs than which are medically necessary. This can be seen in patients of all ages but is commonly encountered in the elderly. There are many consequences of this on the health of older adults. Some of them are:
Adverse drug reactions – With advancing age, there is a decline in the function and reserve of organs like liver and kidneys. These organs are important for the breakdown and elimination of drugs. The gastrointestinal motility may be reduced in old age affecting the absorption of oral drugs. Thus the higher chance of adverse drug reactions in the elderly. In a recent study it was found that nearly 10% of emergency room visits by elderly was attributed to adverse drug events.
Drug Interactions – People may suffer from minor illnesses from time to time. This increases in old age. These may not be related to the area of expertise of the specialist they may be consulting already and thereby they are forced to meet a different doctor. Even though it might be just a minor illness, the drugs prescribed for it can have a serious drug interaction with the patient’s regular medications resulting in dangerous consequences.
One common example of this is with the drug warfarin which is given for prevention of blood clots in patients who have had a heart valve surgery, stroke or venous thrombosis in the past. This drug can interact with many medicines. To quote a few, cotrimoxazole a common antibiotic, fluconazole given for fungal infections or even over the counter pain medications can increase the effect of warfarin putting the patient under high risk of bleeding. Some other common drugs implicated in drug interactions in the elderly are NSAIDs, antibiotics like fluoroquinolones, anti-epileptic drugs, anti-diabetic drugs, sildenafil, anti-arrhythmics and diuretics.
Cognitive impairment – Several studies have found polypharmacy to be associated with cognitive decline in elderly . Anticholinergics are notorious for this. These are used in urinary incontinence, prostate enlargement and Parkinson’s disease which are all diseases of the elderly.
Frequent Falls – Elderly patients have a high risk of falls. A fall can cause significant distress by hip fracture, head injury or blood loss in the already frail individual. Use of 4 or more medications has been found to be a risk factor in older patients for falls.
Apart from these other consequences of polypharmacy are worsening dementia, poor drug adherence and increasing healthcare costs. Elderly patients with many co-morbid health conditions, older adults living alone, the uneducated and those living in old age homes are particularly at high risk for the negative consequences of polypharmacy. We have elderly people running to multiple specialists often in different hospitals and clinics. Patients are in dire need of a medical contact who can filter through and manage their multiple medications on a regular basis. One who is within the community, easily accessible and relatively light on the pocket. The Family Physician or General Practitioner (GP) can fill this need.
About two decades ago the concept of the friendly neighbourhood family doctor was commonplace in India. Every family had their own doctor. He/She would know the medical history including any adverse health events which have happened over the years and have an idea about the medications taken by each family member. They would be consulted regularly and their words were considered trustworthy by the patients. The family doctor was more like a family friend, invited for family events and part of the family’s joys and sorrows.
Today this concept has diminished. Various factors are responsible for this. Firstly, the commercialisation of healthcare with multiple private hospitals, New advances in healthcare, high-end diagnostics and treatment options with growth of many specialists and super-specialist doctors. The failure of government policies and medical education system in strengthening grassroot level healthcare personnel and lack of awareness among the patients themselves about the benefits of having regular follow up with a qualified primary care physician. So, how does a family physician help in avoiding the problems of polypharmacy?
- Intimate knowledge about the patient lifestyle and medical history – Sometimes medications may require adjustment during festivals, family functions or other life events in the older patients. For example, a diabetic patient may require guidance and drug adjustment during festivals like Diwali where his diet will change drastically or during travel. What about a diabetic who chooses to fast during the month of Ramadan? An elderly patient on treatment for dementia, Parkinson’s disease or a cardiac illness may need extra attention and change of drugs in times of bereavement or other stress. A family physician is in a position to do this because he/she has an intimate knowledge about the patient’s lifestyle. It saves the patient visits to multiple doctors and gives him the opportunity to clarify all his doubts and concerns in a single visit.
- Accessible and Inexpensive – A family physician usually has his clinic within the community. He sees patients of all ages. His fees are lesser than that of a specialist and does not need prior appointments.
- Routine Follow up – After the required intervention by a specialist, like an angioplasty by a cardiologist or a prostate removal by a urologist, patients can follow up with a GP at regular intervals. This gives an opportunity for the family doctor to connect with the patient at a personal level and motivate them to follow a healthy lifestyle and other precautions that the specialist may have advised. He can monitor the patient’s health closely, thereby deescalating or stopping certain medications as and when necessary.
- Coordinate with specialists – A common reason for polypharmacy is drug duplication. When consulting different specialists, some drugs could overlap. For example a patient consulting a neurologist for peripheral neuropathy and an endocrinologist for diabetes might be prescribed a vitamin supplement by both having different trade names. This could lead to unnecessary extra drug consumed by the patient. The patient probably visits the specialist once a year or even lesser. So lot of times it is years before such a drug duplication is recognised. This could easily be prevented by a family physician who would be able to coordinate professionally with the various specialists that the patient consults, acting as a single point of care. He can consolidate the prescriptions, do a drug review at every visit and avoid such duplication.
In conclusion, polypharmacy is a fairly recent health problem with a greater incidence in the elderly population. A well qualified, dedicated family physician can have a positive impact in the routine care and follow up of elderly persons. Along with monitoring their health and preventing inappropriate drug consumption, He/she can contribute to a safer, healthier and more comfortable life in old age.
Dr Krithika Ganesh is doctor by profession and currently have her own private clinic in Bangalore.She is passionate about the field of family medicine and believe that dedicated family physicians in every community are the need of the hour in India.