Optimizing Medications

March 2020 Blog Post written by Andrea Rochon RN, MScN

Polypharmacy is ubiquitous among our older population. While there is a lack of consensus in terms of the exact number of medications that constitute polypharmacy, it is generally agreed upon that polypharmacy involves the prescribing of at least five or more medications. The Canadian Institute for Health Information (CIHI) reported that in 2016, approximately 25% of older persons were prescribed 10 or more classes of medications and 66% were prescribed 5 or more classes. As a result of the ‘normal’ physiologic changes associated with aging and other clinical factors, older persons are particularly sensitive to the side effects of medications and the potential for adverse medication-related safety events such as falls, fractures, and cognitive issues.

There is an interesting quagmire in healthcare in which we prescribe additional medications in order to treat the side effects or adverse events experienced from one medication, which we may incorrectly assumed to be the new onset of a medical condition. There should be consideration for the potential issues and negative outcomes associated with this so-called ‘prescribing cascade’, including interactions between medications; and additional assessment and investigation should be conducted before immediately assuming that the appropriate treatment is additional medication.

Appropriate prescribing must include safe, judicious prescribing and deprescribing according to the changing needs, condition, and health status of an individual. Potentially inappropriate prescribing (PIP) refers to the practice of prescribing medications that have a high potential risk for side effects or adverse events (potentially inappropriate medications (PIMs)), or not prescribing medications that may provide benefits that outweigh risks.

Optimizing medications is the responsibility of all members of the healthcare team and is crucial in order to enhance or maintain quality of life and quality of care for every individual. While physicians and nurse practitioners are the providers who typically prescribe medications, all members of the team can provide valuable information that can contribute to evidence-informed, assessment-driven, clinical decision-making around medication management as part of a comprehensive, person-centered care plan. For example, the nurse may report a subtle change they have recognized as part of their assessment or the pharmacist may flag a potential drug interaction as part of a medication review. Effective collaboration and communication amongst the team is vital to safe medication practices.

Finally, and perhaps most importantly, we need to include older persons, their families, and their caregivers in conversations about incorporating medications as part of the plan of care, including providing them with information about benefits and risks, asking about side effects and any impacts on quality of life, and supporting them in making informed decisions.