Like many other areas of nursing, the nursing care of older adults presents many unique challenges. Specifically, the process of aging in and of itself creates many circumstances that increase the risk and the need for extra precautions for older adult patients. Nurses are in a special and unique place to observe, assess, and intervene to protect and promote the patient's health and well-being. One of the most common issues in care of the older adult in nursing homes, is polypharmacy. Polypharmacy can be described as a patient being currently prescribed, and taking with regular use, four or more medications (Belsky & Hitzmann, 2013). Polypharmacy has many causes and has many potential risks that can significantly worsen a patient's condition or health status.
Age-related changes that can significantly affect how the body processes medication include decreased body water, decreased lean tissue, increased body fat, decreased serum albumin, decreased liver and renal function, and altered receptor sensitivity (Miller, 2015). With these changes in body functions, this means that medications may have a different therapeutic effect, meaning that it could not have the intended effect and could instead cause further issues. With the body systems not functioning as precisely as they do at a younger age, this increases the older adults risk for adverse effects. As aging occurs, it is also more common for the older adult to experience multiple chronic conditions, increasing their need for multiple medications; this is where polypharmacy comes into the situation.
A major change that occurs as our bodies age is the ability to process medications. The term pharmacokinetics refers to the way in which the body reacts to medications. As we age the pharmacokinetics within the body changes and medications that may have been therapeutic and in place for years now metabolize in the body differently. The older adult's ability to metabolize medications is reduced due to decreased functioning commonly in the liver (Perry, 2011). The ability to distribute those medications is slowed down by decreased circulation and functioning of the heart and circulatory system. Excreting the medications from the body is diminished due to inefficient renal systems and increased occurrence of constipation. All of these systematic changes make medications interact with the aging body differently and can increase the likelihood of complications. Decreased metabolism and excretion can lead to drug toxicity and decreased distribution may lead to diminished effect of the medication. These factors must all be taken into account when reviewing and educating medications with an elderly client. They must also be taken into account when providers are prescribing and initiating medications for the elderly population (Perry, 2011). We as nurses hold a responsibility to do the best by our patient, especially those who may not be able to speak for themselves, as is the case with many elderly patients. Nurses must educate themselves on potential interactions, and if possible, assist in the process of deprescribing. "Deprescribing is the process of reducing or stopping unnecessary prescription medications" (Hickner, 2017).
While most medications that the older adults receive are necessary there are many that older adults may be able to forego. There are also circumstances where a different medication with less side effects, has less drug-to-drug interactions, and are essentially less toxic to the older adult that could be used, but they are not always the medications that are prescribed to the patient. It is extremely important that nurses recognize those at risk, screen for, and implement nursing interventions to decrease polypharmacy and its potentially detrimental effects on older adults. "The key to treating older adults is not necessarily to find a set number of medications and try to stay below it, but to find the right medication at the right dosage and for the shortest possible duration on a case-by-case basis" (Planton, 2010). While every patient is different, on different medications, and has different comorbidities, using evidence based practice and research there are some criteria to help determine who is at higher risk of morbidity from polypharmacy. According to Planton (2010), these criteria include: age 85 or older, some level of renal insufficiency, low body weight, six or more chronic disease states, taking more than twelve dosages of medications per day, and previous history of adverse drug reactions.
Polypharmacy will also increase a patients risk for falls, with the prevalence of falls being at least 1 per year for 30% of people over the age of 65 (Siegrist, 2016). Falls are one of the most common causes of hospitalizations (89% of those being dx with a fracture) in the elderly population and the effect that polypharmacy has on falls cannot be understated. The more medications a patient takes the more likely they will experience adverse side effects, and as patients age the ability to cope effectively with those side effects decrease. Managing a patient's medications is not just about minimizing the number of pills they take, it is also about keeping them safe and preventing negative outcomes associated with polypharmacy.
The first step a nurse should take would be to appropriately screen the patient. This screening should include periodically reviewing the resident's medications with a basis of their medical diagnoses, reviewing medications to ensure that the resident is on a minimally necessary dose to achieve the desired therapeutic effect, continuing to monitor for potential drug interactions, and ensuring that optimal dosage and route has been determined for the patient (Schainen, 1994). Once the review of the patient's at-risk area of medication therapy is identified, the nurse should then address this within the interdisciplinary team as necessary. For instance, speaking with the pharmacist to verify the nurse's findings and to perhaps be given ideas for better alternatives. For example, the nurse could ask the pharmacist when the best time to give a patient certain medications for enhanced therapeutic outcome, such as Prilosec (omeprazole). When omeprazole is taken by mouth in capsule form, it must be administered on an empty stomach thirty minutes prior to eating. In doing so this proper administration neutralizes the acidity of the stomach cavity (Davis, 2011). If it is given in a time that is not directed, such as at meal time, this medication is rendered ineffective. If the patient cannot take this medication in its standard capsule form, the nurse should then discuss their findings with the provider, so that they can be appropriately addressed and resolved to ensure a better patient outcome.
There are many different ways nurses can help the elderly understand what polypharmacy means. Making sure that the patient knows what each medication is, what it is for, and why they are taking it is a great place to start. Patients should also have an understanding of potential side effects that their medications may cause, such as ace-inhibitors causing a dry, persistent cough. If a patient is unaware of this potential common side effect, they may start taking unnecessary over the counter medications that could interact with other prescription medications they are already taking. As nurses, we have to make sure we approach this very carefully as this could make the patient not want to adhere to their medication regimen. Educating them that side effects may or may not occur and that the severity and or chance of developing any of the listed side effects are different for every person. It is not uncommon to see elderly patients prescribed ten or more medications at one time. Due to their prescribed load they are at a greater risk for developing adverse effects from the medications not only from drug to drug interactions but also because of absorption rates within the body. Doctors tell patients when to start the medications, but they aren't necessarily explaining to them when to stop (Wallis, 2015). Another factor to consider is the dosage of the medication. Once an appropriate dosage is established for a patient, the dosage might not change in the future and that could interfere with different medical diseases, disorders and/or infections that may occur. Practitioners aren't always looking at these factors as closely as they should, and this practice may cause adverse effects for the aging adult. Another important consideration in polypharmacy is a patient's mental and emotional state. With the elderly population, a change in their mental and emotional status can drastically affect the way the medications are working and if they are still effective for the patient. It can also affect the compliance the patient has with the medication.
In an article titled "Every group has one" discussed how every group has a 'complainer' and a 'troublemaker'. The article touched based on how every nursing home has a resident that is considered a 'polypharmacy patient'. This patient has a very long list of medications and when she was first admitted into the long-term care setting she only had three medications on her chart(Chisholm, 1983). Throughout her years within the facility, she would complain about a headache, stomach hurting and many other various things, it made the nurse question that now that this patient is on so many medications, has it caused her to turn into a 'chronic complainer?' The only way to find out was to gradually discontinue medications that were not needed. At the end, the patient becomes a brand-new person and she was down to only two medications on her chart.
Any nurse who is employed in a long-term care setting needs to display diligence in caring for their patients. These patients are vulnerable, and we are often times their only advocate. One of the most beneficial ways a nurse can positively advocate for their patients is by being proactive in their medication program. Having the confidence and knowledge to understand the aging process in older adults and how multiple prescriptions can adversely affect each patient is essential. There are ways to end polypharmacy and nurses, pharmacists and physicians must try to develop a plan that is most beneficial for each patient and their medical needs.