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Polypharmacy refers to the concurrent use of multiple medications by a patient, often defined as five or more drugs taken simultaneously. This practice is particularly common in the elderly due to the increased prevalence of chronic diseases such as hypertension, diabetes, heart failure, and dementia.
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While necessary in many cases, polypharmacy can increase the risk of adverse drug reactions, drug-drug interactions, and medication non-compliance, ultimately compromising the safety and quality of life for older adults in nursing homes.
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Common medications used in elderly populations
In nursing homes, elderly residents are frequently prescribed a range of medications to manage multiple chronic conditions. Some of the commonly used drugs include:
Antihypertensives (e.g., amlodipine, losartan) for high blood pressure
Hypoglycemics (e.g., metformin, gliclazide) for type 2 diabetes
Statins (e.g., simvastatin, atorvastatin) for hyperlipidemia
Antiplatelets and anticoagulants (e.g., aspirin, clopidogrel, warfarin) for cardiovascular disease or stroke prevention
Diuretics (e.g., furosemide, hydrochlorothiazide) for heart failure and edema
CNS drugs (e.g., quetiapine, lorazepam, sertraline) for insomnia, depression, and behavioral symptoms of dementia
Proton pump inhibitors (PPIs) (e.g., omeprazole, pantoprazole) for gastroesophageal reflux or gastric protection
Pain relievers (e.g., paracetamol, tramadol, NSAIDs like ibuprofen) for chronic pain or osteoarthritis
Common drug conflicts and their risks
Polypharmacy increases the likelihood of potentially harmful drug-drug interactions. Some common examples include:
ACE inhibitors + Potassium-sparing diuretics (e.g., enalapril + spironolactone)
Risk of hyperkalemia, which can lead to cardiac arrhythmias.Warfarin + NSAIDs (e.g., ibuprofen)
Increased risk of bleeding, especially gastrointestinal.SSRIs (e.g., sertraline) + Tramadol
Risk of serotonin syndrome, which may present as confusion, fever, muscle rigidity.Anticholinergics (e.g., oxybutynin) + Antipsychotics (e.g., quetiapine)
Increased risk of cognitive decline, urinary retention, and falls.Digoxin + Diuretics (e.g., furosemide)
Can result in digoxin toxicity due to electrolyte imbalances (especially low potassium).PPIs + Clopidogrel
Some PPIs (e.g., omeprazole) reduce the effectiveness of clopidogrel, increasing the risk of thrombotic events.
How doctor or pharmacist decides which drugs to continue, reduce, or stop?
Deprescribing and medication optimisation in the elderly should follow a patient-centered and evidence-based approach, talk to your doctor and pharmacist, and they will be able to advise according to your conditions.
Assess goals of care
Is the drug intended for life prolongation, symptom relief, or disease prevention?Evaluate time-to-benefit
Medications like statins may not offer immediate benefit in patients with limited life expectancy.Review current clinical status
Consider kidney and liver function, frailty, and cognitive ability.Apply tools like STOPP/START or Beers Criteria
These guidelines help flag inappropriate medications in the elderly.Engage in multidisciplinary review
Involve the physician, pharmacist, and nurse in shared decision-making.Monitor after deprescribing
Watch for symptom recurrence or withdrawal effects.
Conclusion
Managing polypharmacy in the elderly is a delicate balance between treatment benefits and potential harms. Regular medication reviews (at least every six months or upon any change in clinical condition) are essential to ensure medication regimens remain safe, effective, and aligned with the resident’s current health status and care goals. Deprescribing should not be seen as a failure of care, but as an active, thoughtful process of reducing medication burden, preventing drug conflicts, and enhancing the quality of life for our seniors.
