Polypharmacy-the use of more medications than are clinically indicated-is a problem that affects many older adults. Adults aged 65 years and older make up approximately 13% of the population, but they consume nearly one third of all prescriptions dispensed. Older adults are more prone to adverse drug reactions and drug-drug interactions because of physiological changes and multiple comorbidities. It can be difficult to address the problem because there are many contributing factors, including multiple prescribers and specialists, the use of multiple pharmacies, and gaps in communication. The initial step is to avoid the problem. However, when this does not work, it must be identified and then treated by carefully changing medication regimens to improve the quality of care to patients. The home healthcare nurse has an essential role in this process, which will be reviewed in this article. Some of the barriers that may be encountered and examples of communication with providers are included.

Patient Example: ML

ML is a 79-year-old female who was recently discharged from the hospital after being diagnosed with atrial fibrillation (A. fib) and heart failure (HF). The discharging physician orders home healthcare to follow up with ML until she can see a cardiologist. ML is now taking 13 medications by mouth (PO): aspirin 81 mg once daily, metoprolol 50 mg twice daily, warfarin 5 mg once daily (dose adjusted based on International Normalized Ration [INR]), amlodipine 10 mg daily, lisinopril 5 mg daily, simvastatin 40 mg once daily, hydrochlorothiazide 25 mg once daily, oxybutynin 10 mg once daily, citalopram 20 mg once daily, alendronate 70 mg once weekly, calcium 500 mg twice daily, vitamin D 400 IU twice daily, and a multivitamin once daily. The first four medications are new medications, started when ML was in the hospital and the last three are over-the-counter (OTC), but recommended by the primary care prescriber. You, the home healthcare nurse, are out to visit ML and start her care with your home health agency (HHA). As you ask to see her discharge paperwork and medications, ML gets teary eyed and says she doesn't know how she will keep track of all of her medications.

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The Problem

Part 1 of this two-part article explored the causes of polypharmacy, who is at risk for polypharmacy, the importance of addressing this iatrogenic disease, and some of the tools currently available that have been used to try to identify and reduce polypharmacy. Part 2 will further expand on ways a clinician can identify polypharmacy and help to reduce the problem. For the purposes of this article, the word prescriber will be used as an all-encompassing term for all clinicians who are legally authorized to prescribe, including but not limited to physicians, nurse practitioners, and physicians assistants. Any clinician with legal prescribing authority within their state may be used interchangeably when physician is used.

Tackling the Problem

There are several questions that need to be considered when tackling the problem of polypharmacy. First, how can the problem be avoided to begin with? If it does occur, how can the problem be identified? Once identified, how do clinicians advocate for discontinuation of problem medications by the prescribing provider?

Avoiding the Problem

The situation: A 76-year-old gentleman visits his primary care physician with his daughter and the daughter reports increased confusion and forgetfulness. After brief questioning, the physician writes a prescription for donepezil, a medication used to slow the progression of symptoms of Alzheimer's disease. Several months later, the gentleman returns to his doctor. He reports a new problem of urinary incontinence. The physician writes a prescription for oxybutynin and sends the gentleman on his way, assuring him this will help.

It is important to note that prescribers alone cannot eliminate polypharmacy. They are working directly with their patients (and patients' caregivers) and patients play a very important role in decreasing polypharmacy. Patients need to be sure to share their complete, up-to-date, and accurate medication lists with all prescribers they see. When possible, they need to be advocates for themselves (a role a home care nurse or pharmacist can fulfill in some situations), when they are noticing changes in how they feel that may be side effects of the medications they are taking. It is less important for patients to focus on if a symptom or change they notice is a "side effect" of a medication, but rather that they have noticed a change. Prescribers can only work with as much information as they are given or request. Although it can be difficult-and at times impossible-to get the complete picture from a patient, it is important that the prescribers, nurses, and pharmacists partner together to get this "complete picture" as their common goal.

The situation: An 83-year-old woman was recently diagnosed with hypercholesteremia and started on simvastatin. Several weeks later, the patient notices she is feeling increased weakness in her legs and pain with ambulation. She no longer is interested in attending her yoga classes. She also notices she doesn't seem to be thinking as clearly as she used to. She begins to feel saddened as she sees these as signs she is getting old.

Home healthcare nurses have a wonderful and unique opportunity to help identify polypharmacy. Because home healthcare nurses are skilled in patient assessment and interaction, have medication knowledge, and see their patients on a regular basis, they may identify medication-related issues that others do not see or may miss. As is seen with the patient case presented in this article, when a nurse notices that a patient who is typically active and alert is now weak and confused, the question of polypharmacy should be brought up and explored. Sudden changes in a person's status whether mental, physical, or emotional may often be related to a medication problem. Some of the questions they can ask their patients either when doing medication reconciliation or if a concern arises, include

* How long have you been on this medication? Did you notice any changes in how you felt when/after you started this medication? This can include changes in mood, appetite, mobility, thinking, sleep, digestion, dizziness; overall clinical status. [horizontal ellipsis] The list is really endless.

* Why are you taking this medication? Is [insert the reason the patient is taking the medication] still a problem for you?

* What challenges do you have with taking your medications? This may include adverse effects, remembering to take them, mixing up the medications, the schedule, paying for them, the size of the pill, and swallowing them [horizontal ellipsis] just to name a few.

The situation: A 72-year-old male patient is experiencing significant edema in his lower extremities. He is currently taking multiple medications, two of which medications can cause this side effect: gabapentin and diltiazem. As the home healthcare nurse, you are unsure of which of his medications may be causing this side effect, but note that his gabapentin dose was recently increased. You call the prescriber to report your observations.

An example of how this communication may take place is

Dear Presciber,

I have been working with [insert agency] and seeing [insert patient]. Recently I have noticed some changes in how [patient] has been feeling and would like to ensure you are aware of this. I understand that you have been working with this patient for a long time and that I may not have the complete picture. [Patient] has been experiencing a significant increase in lower extremity edema, especially since the increase in his gabapentin dose. Would decreasing his gabapentin back to its previous dose [insert previous dose] be an option to see if this symptom is relieved? If you agree to this change, please contact [patient]'s pharmacy at [insert pharmacy name, phone number, fax]. If you could also please respond to this fax so that we can keep our records up to date. Please do not hesitate to contact me with any questions at (insert number.)

___ Yes, return to patient's previous gabapentin dose.

___ No, continue patient on current gabanetin dose.

___ Other:

Thank you,

[signature]

Once the problem of polypharmacy has been identified, the next step is working to remedy the problem. If a specific medication has been identified as being unnecessary, or possibly unnecessary, a plan for discontinuation should be made. It is important to communicate with all providers, especially the prescribing clinician, when creating this plan. The home healthcare nurse may be communicating the symptoms or concerns she has with the primary or prescribing prescriber, rather than a specific plan for discontinuation. In some cases, more than one unnecessary medication may be identified. When more than one medication will be discontinued, priority must be established to assign an order for which the medications will be discontinued. This order will be specific to each individual.

If a patient is experiencing a symptom that is suspected to be a side effect of the their medications, the most likely medication should be discontinued first, then the next likely medication until the symptom resolves or unnecessary medications have been discontinued. It can be helpful to look at the timing of when medications were changed-this includes new medications added, medications stopped, doses changed, or changes to generics. The timing can help establish the relationship between medications and symptoms and priority of discontinuation. If the patient is not experiencing a specific side effect symptom, and it has been determined that medications can be stopped, the prioritizing may be of less importance. It is very important to discontinue medications cautiously, one at a time, and slowly.

In some cases, after a medication is discontinued, a patient may not respond well. They may have intolerable withdrawal side effects or it may be established that the patient does need the medication to treat a symptom or to control an important clinical parameter, such as blood pressure. For instance, this can be the case when trying to stop a medication that helps to reduce stomach acid known as a proton pump inhibitor. Sometimes patients have what can be known as "rebound acid reflux" after they stop these medications. Depending on the patient, some may be able to "tough it out" until it goes away, whereas others may need to restart the medication. This further illustrates the importance of monitoring and communication; in this case telling the patient that they may have increased "acid" for a time after stopping the medication. A flexible plan will allow the patient, prescriber, and other clinicians involved in the patient's care to change the course of action if an unpleasant reaction occurs.

The situation: An 82-year-old female patient has just received a terminal diagnosis and is admitted to hospice care. She is taking 13 medications, including oral medications to treat her high cholesterol, diabetes, and hypertension. With her recent diagnosis, she has been told she should expect to experience pain and may soon require high doses of pain medication, which may make her drowsy, constipated, and decrease her coordination. She is not looking forward to having to take more medications added to her already burdensome list.

In hospice and palliative care, the goals of therapy often change to have a heavier focus on improving comfort and quality of life rather than preventing future diseases or events. When a patient is admitted to hospice or a palliative care approach is taken, medications that are used for prevention may be discontinued and medications may be added to provide increased treatment of pain or other symptoms. Some of the common symptoms that require assessment and treatment at end of life include pain, constipation, fatigue, nausea and vomiting, delirium, dyspnea, anorexia, and cachexia. Home healthcare nurses and hospice nurses recognize the shift in goals of therapy to a palliative approach where tight control of blood pressure, blood glucose, and cholesterol are no longer the focus of care. And as with any setting, the family and the patient themselves also need to understand and be willing to discontinue these medications. For example, insulin may no longer be needed (or may be needed less frequently) as the goals of diabetes management in these patients will be symptomatic treatment rather than prevention of longer-term effects. It may be comforting for them to understand that stopping certain medications does not mean they are giving up, but that they are changing with their goals of care. Many hospice patients have frequent medication changes as medications are added and stopped for symptom relief and in response to frequent clinical status changes, therefore benefiting from ensuring that only necessary medications are initiated and continued.

Returning to the case presented above, this patient has some concern with having more medications added to her regimen. It is important for her to express these concerns with the clinicians she works with-the nurse, prescriber, or pharmacist. The next vital step is to have a care conference that involves clinicians, prescribers, family, and the patient to discuss goals of therapy and formulate a care plan. With the specific focus of medications, it is important to discuss why each medication is being used. In this patient's case, as is similar with many hospice and palliative care situations, medications that provide long-term preventative benefits are likely to be appropriate candidates for discontinuation. A plan of discontinuing medications can then be formed. This will allow for certain medications to be discontinued, such as the medications to control her cholesterol, as well as perhaps the diabetes and blood pressure medications. As was mentioned earlier, end-of-life care can present a unique set of symptoms that may require new medications to be added and changed frequently. By ensuring that the medication regimen contains only medications that are necessary, in this case, providing symptomatic relief, the patient is likely to experience greater benefit and less burden from polypharmacy.

In palliative and hospice care, a patient-centered approach is essential. As diseases progress and new symptoms arise, medications that are generally considered "forbidden" among older patients may be considered. One example of this is the use of haloperidol in hospice. Typically an antipsychotic that is avoided in older patient due to side effects, haloperidol can be a very beneficial medication for this patient population to relieve delirium. This is one of many examples of how therapy goals will shift during this time of care.

Communicating With Prescribers for Change: Focusing on the Patient's Symptoms

Communication among healthcare providers can be another challenge. Everyone is busy, held to various standards and quality indicators, and can be pulled in multiple directions and by numerous responsibilities and priorities. This makes a conversation regarding discontinuing medications potentially even more daunting. Home healthcare nurses may identify a medication that appears to no longer be providing a benefit to a patient. Examples may be due to an intolerable adverse effect or a lack of efficacy. The nurse may then wonder the best approach to communicate this information to the prescriber. Three strategies may help to make this conversation go more smoothly: (a) identifying that you may not have all the information, (b) addressing the specific concerns with the medication as they pertain to the patient (e.g., reporting the observed symptoms), and (c) proposing a plan.

By initially identifying that you are only one of the many clinicians this patient interacts with and therefore may not have all the information is a good way to partner with the prescriber. Addressing specific symptoms (low heart rate at 60, nausea, muscle weakness, fatigue, etc.) that the patient is exhibiting helps establish a strong focus on the patient and help provide information about what may be beneficial for the patient. If it is lack of efficacy of a medication or impracticality of using a preventative medication in an older adult because of shortened life expectancy, these points can also be shared. By proposing a plan, which should include a schedule for how the medication can be discontinued or tapered and what will be specifically monitored and by whom, such a discussion and plan will help complete the conversation.

In some cases, a nurse may not be able to have this much information to provide to a prescriber. It may be a vaguer situation in which the patient appears to be having a symptom that could be a side effect or an overall decline in function or quality of life. In this case, the message to the prescriber may take on more of a "reporting" of the situation in the home to allow the prescriber to have more information and a greater understanding of the patient. It may be appropriate to identify if the patient is struggling with their medication regimen and could benefit from a less complex regimen.

Pharmacists can also help with this process by taking a deeper look at the symptoms the patient is experiencing and possibly linking this to a medication. Home healthcare nurses might provide the list of medications to the pharmacist along with the observations of the patient's individual situation. The pharmacists can then review the regimen and aid in further questions the home healthcare nurse may be able to ask the patient leading to identification of potential problems with the medications such as side effects, interactions, or decreased benefit.

The Beers Criteria: Identifying Potentially Inappropriate Medications in Older Adults

When the home healthcare nurse sits down with ML, she begins by asking how she is feeling. ML says she is feeling very weak and confused. Her muscles just don't seem to work like they did before she went to the hospital. As she gets up to go into the kitchen to get her medications, she sways and clutches her head saying she feels very dizzy. ML is taking small steps and groans some with each step. The nurse asks if she is in pain, noting a grimace on ML's face. ML says that her feet hurt with every step because her shoes don't fit right anymore. After examining ML's feet, the home healthcare nurse notes there is significant swelling around her ankles and feet. The home healthcare nurse wonders if one of these newer medications may be contributing to ML's complaints. She calls the pharmacist working with the HHA and reports her findings.

The pharmacist obtains the comprehensive list of what ML takes, including OTC and herbal remedies. The pharmacist next identifies that three medications may be contributing to the feelings that ML is experiencing. They are amlodipine, metoprolol, and simvastatin. The pharmacist bases this on the timing of the medications partly (the new amlodipine starting to lead to edema, recent metoprolol prescription starting to contribute to dizziness) and classic medication adverse effect relationship of simvastatin leading to muscle weakness and pain. The pharmacist next offers to contact the primary care prescriber. The pharmacist writes a fax to be sent to the primary care prescriber. First, the pharmacist states the symptoms the patient has reported and then goes on to identify the three medications as potentially contributing to the symptoms. It can be helpful for the pharmacist to also acknowledge that the HHA may not have the whole picture, but based on the information they have provided to the pharmacist, a trial to stop these medications may be beneficial to the patient. The pharmacist proposes stopping the amlodipine, then the simvastatin, and finally the metoprolol. The medications should be stopped one at a time, with the dose first being reduced by half for 1 week, then off completely for 1 week. The symptoms the patient is experiencing should be monitored frequently and the patient should be encouraged to contact a healthcare provider if he or she experiences any new symptoms. Continued communication should occur between the HHA and the primary care prescriber as well as appropriate prescribers.

Summary

Creating and maintaining open lines of communication between all clinicians and the patient are essential in treating and addressing the problems of polypharmacy. Creating and maintaining a single medication list that contains all the prescription and nonprescription medications, including OTC products such as vitamins, herbals, and dietary supplements the patient is taking, is necessary for all aspects of care. This list should be updated and periodically reviewed by the primary care prescriber, the pharmacist, and the home healthcare nurse. Polypharmacy causes harm to patients and it should be a goal of clinicians to work together to help reduce polypharmacy whenever possible.

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