Polypharmacy—often defined as more than four medications, with nine or more considered severe—is common among the geriatric patient population because of a high prevalence of conditions that require multiple medications. A Duke geriatrician encourages clinicians who work with older adults to be vigilant about looking for signs of potential issues with polypharmacy and addressing them before they cause significant health problems.

“We have a lot of evidence for disease-specific management, but we don’t have guidelines on prescribing for people with multiple diseases who require  multiple medications that have a potential for interacting with each other or with a patient’s other conditions,” says geriatric medicine specialist Milta O. Little, DO. “It has become a serious clinical issue that must be addressed and is leading to a whole new field of deprescribing strategies.”

Little notes that while many physicians can recognize geriatric syndromes, they often don’t have the resources or time to comprehensively managing them. “I think if you’re starting to see potential issues in an older adult—if someone is taking 10 or more medications, if they’re starting to have cognitive impairment, if they’re falling more often—it’s important to take a critical look and ask yourself if you need a geriatrician to see the patient.”

Little’s experience with recognizing and managing polypharmacy to avoid its many negative consequences has led her to offer the following strategies for addressing the issues:

1. Work diligently with patients and families to secure an accurate list of medications.

Just getting an accurate list of medications can be extremely challenging, says Little. “I work hard to find out everything a patient takes, and how and when they take it. I also want to know their process and protocol for taking medications. Patients sometimes have creative ways of remembering how much medication to take, such as a patient who marked one ‘X’ on the lids of the bottles for each tablet he needed to take in a day. Knowing all the medications that have been prescribed and filled is important, but so is knowing their system and whether it needs to be altered to improve compliance and safety. Even people without memory problems can forget to take pills or take too many at a time on accident. These are important facts to know,  which takes a lot of sleuthing, and often takes more than one member of the care team to manage properly.”

2. Reorganize the medication list in a patient’s EHR.

When medications are entered into a patient’s EHR they usually appear in alphabetical order, but Little recommends grouping medications by condition or use instead. She reorganizes the list by the condition they’ve been prescribed for; e.g., blood pressure, anticholinergic, pain control, antidepressants. “This grouping allows me to quickly see if I can consolidate and use one medication to treat two conditions, or deprescribe a medication that could be interacting with another and causing problems.”

3. Look for inappropriate and incorrect prescriptions.

According to Little, polypharmacy issues are sometimes caused simply because the wrong medications have been prescribed for a condition, or a patient doesn’t understand that they should have stopped taking one drug when they started taking a new one. “A patient may be on two medications for one indication prescribed by two different physicians,” she says, adding that some patients who subscribe to mail order medications may continue to receive bulk shipments after their physician has changed a prescription, creating confusion. about what they should actually be taking.

4. Use caution when deprescribing medications.

Little believes that although deprescribing has been shown to improve patient outcomes, it’s a complex matter that requires a management process. “We think deprescribing is safe as long as it’s an individualized process done systematically,” she says, “and it requires the efforts of the entire care team to be done correctly. Chronic disease management is not ‘one size fits all.’ Life expectancy, functional status, clinical targets that change with age—all of those are important in determining what treatments are appropriate for each individual.”

5. Watch for signs of potential issues during annual wellness examinations.

The annual wellness examination is a good time for PCPs to look for signs of polypharmacy issues and to consider referring patients to a geriatric medicine specialist if indicated, says Little.