Polypharmacy

noun Derived from the Greek words for “many” (poly) and “drug” (pharmacon)

  • While there is no absolute definition for polypharmacy, most clinicians agree that it signifies the patient taking five or more medications.

The term also describes the use of more medications than are medically necessary. Medications that are not indicated, are not effective or constitute a therapeutic duplication are considered polypharmacy.1

Potentially inappropriate medication is a patient safety issue for our older adult population, especially for those who have multiple chronic conditions and take multiple medications.

Nearly 50% of older adults take one or more medications that are not medically necessary. Research has clearly established a strong relationship between polypharmacy and negative clinical consequences.1 Some of those consequences are:

  • Increased healthcare costs: Polypharmacy contributes to a rise in costs for both the patient and the healthcare system. The elevated risk of outpatient visits and hospitalization stemming from taking a potentially inappropriate medication can increase medical costs by approximately 30%.2
  • Higher risk of adverse drug events (ADE): Patients taking five or more medications had an 88% greater risk of experiencing an ADE compared with those taking fewer medications.3
  • Drug-to-drug interactions: The likelihood of a drug-to-drug interaction increases 50% if a patient is taking five to nine medications. That risk jumps to 100% when a patient’s regimen includes 20 or more medications.4
  • Nonadherence to medications: Patients taking four or more medications are 35% more likely to not adhere to their regimen.5
  • Mental and physical risks: Polypharmacy is associated with functional decline and cognitive impairment in older adults. Falls that result from polypharmacy may lead to increased morbidity and mortality.6

The American Geriatrics Society (AGS) Beers Criteria focuses on opportunities to decrease ADEs and complications for patients. AGS recommends:

  • Avoiding concurrent use of three or more central nervous system (CNS) medications, as such use increases a patient’s risk of falling
  • Avoiding concurrent use of anticholinergic (ACH) medications, due to an increased risk of cognitive decline

In 2013, the Centers for Disease Control and Prevention (CDC) reported that opioids were associated with the most pharmaceutical-related overdose deaths in 2010 (75.2%), followed by benzodiazepines (29.4%). Concurrent use of benzodiazepines was associated with 30.1% of opioid overdose deaths, and concurrent opioid use was associated with 77.2% of benzodiazepine overdose deaths.7

For information about prescribing opioids, consult the following guides.

Based on extant evidence, the Pharmacy Quality Alliance (PQA) developed and endorsed two polypharmacy measures for older adults and a performance measure to reduce the combined use of opioids and benzodiazepines:

  • Polypharmacy: Use of Anticholinergic Medications in Older Adults (POLY-ACH)
  • Polypharmacy: Use of Multiple Central Nervous System Medications in Older Adults (POLY-CNS)
  • Concurrent use of Opioids and Benzodiazepines

The Centers for Medicare & Medicaid Services adapted these three performance measures for display in 2021 (using 2019 data) and 2022 (using 2020 data).

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Sources:

  1. Maher, R.L.; Hanlon, J.T.; Hajjar, E.R.; Clinical consequences of polypharmacy in elderly. Expert opinion on drug safety. 2014; 13(1): 10.1517/14740338.2013.827660.
  2. Akazawa, M.; Imai, H.; Igarashi, A.; Tsutani, K;. Potentially inappropriate medication use in elderly Japanese patients. The American Journal of Geriatric Pharmacotherapy. 2010; 8:146–160.
  3. Bourgeois, F.T.; Shannon, M.W.; Valim, C.; et al;. Adverse drug events in the outpatient setting: an 11-year national analysis. Pharmacoepidemiology and Drug Safety. 2010; 19:901–10.
  4. Doan, J.; Zakrewski-Jakubiak, H.; Roy, J.; et al.; Prevalence and risk of potential cytochrome p450-mediated drug-drug interactions in older hospitalized patients with polypharmacy. Annals of Pharmacotherapy. 2013; 47:324–32.
  5. Rollason, V.; Vogt, N.; Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs & Aging. 2003; 20:817–32.
  6. “Clinical consequences of polypharmacy in elderly. Expert opinion on drug safety.”
  7. Jones, C.M.; Mack, K.M.; Paulozzi, L.J.; Pharmaceutical overdose deaths, United States, 2010. JAMA 2013; 309(7):657-659. doi:10.1001/jama.2013.272. CDC guideline for prescribing opioids for chronic pain.
    http://www.cdc.gov/drugoverdose/prescribing/guideline.html, opens new window.