GPs ‘central’ to reducing polypharmacy

The most recent figures, taken from a joint University of Western Australia and University of New South Wales study, found the number of older people taking five or more medicines increased by 52% between 2006 and 2017, despite evidence that it places patients at risk of harm and is associated with poor clinical outcomes.
 
Dr Mark Morgan, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told newsGP while polypharmacy is sometimes seen as an ‘inevitable’ part of ageing, GPs should be able to engage in targeted de-prescribing.
 
‘Many GPs have observed how patients gather medicines as they gather specialists,’ he said.
 
‘It is hard for our specialist colleagues to reduce or stop medicines that were recommended by a different speciality. How confident will a cardiologist be at changing gynaecologist medications?
 
‘The GP role in reducing inappropriate polypharmacy is central. GPs are uniquely placed to be able to determine patient values, to understand social circumstances and to be able to identify medicines for de-prescribing.’
 
Dr Morgan said while many GPs will reduce and cease medications as part of palliative care, de-prescribing should be considered in any patient with polypharmacy. As an example, he pointed to a pilot study he helped conduct that assessed systems of care used to achieve de-prescribing and increase patient safety.
 
‘We identified over 75-year-olds at high risk of hospital admission, then used the senior health assessment to establish patient priorities for care. Patients entered a multimorbidity care plan and quarterly review cycle that allowed the GP time to taper medications,’ he explained.
 
‘Simple steps to improve safety included reconciling the medication list, checking patient renal function and standing blood pressure.
 
‘The project identified many patients who were at risk from over-treatment of diabetes and blood pressure. Other patients were taking medicines that were part of a prescribing cascade where side effects from one treatment led to prescriptions for the next and so on.’
 
The latest research, based on a 10% random sample of people eligible for medicines listed on the Pharmaceutical Benefits Scheme between 1 January 2006 and 31 December 2017, found people in their 80s are most likely to take five medicines or more a day.
 
Lead researcher Dr Amy Page believes while the increase could be attributable to a growing ageing population, more needs to be done to ensure medication management balances the potential for benefits against the potential for harm.
 
‘The medicines we looked at do not include medicines purchased without a prescription such as vitamins, minerals, herbal supplements or medicines not listed on the Pharmaceutical Benefits Scheme, meaning that the estimates in the paper may be conservative,’ Dr Page said.
 
‘The rates in comparable years are also much higher in Australia than in the US or the UK.’
 
While the study focused exclusively on Australia, reducing polypharmacy has also been highlighted by the World Health Organization as an area for improvement in its effort to halve the global burden of iatrogenic medication-related harm.
 
‘There have been many awareness-raising activities in recent times about the risks of taking multiple medicines and there is evidence of poor health outcomes in older people.  However the number of older people taking multiple medicines has increased,’ Dr Page said.
 
‘Strategies to increase people’s understanding of the potential risks involved in taking multiple medications are needed that target both health professionals and the public.
 
‘Taking multiple medications may be necessary, but it needs to be carefully assessed by a medical professional and balanced against the potential risks.’
 
Information on de-prescribing will be available in the new edition of the Medical care of older persons in residential aged care facilities (Silver Book), to be launched later in 2019. Other sources include Primary Health Tasmania, NHS Scotland, and MedStopper.

Aged care Elderly Polypharmacy Research