The elderly population had an increased risk of illness and used more medications. The 5-year mortality was increased in the elderly population which indulged in polypharmacy (Jyrkkà et al, 2009). The community elderly above 64 took a minimum of 3 medications; those above 80 consumed more (IOM, 1997). They contributed to one-third (33%) of the national consumption of medicines while their population came to just 13% in the US. Surprisingly, the amount spent for them for prescription medicines came to about 38% of the national expenditure at 36 billion in 1991 (IOM, 1997). In 2001, 44.3 billion dollars was the expenditure for elderly medicines (Stagnitti, 2005). In 2002, it grew to 49.9 billion (Stagnitti, 2005). The growth of the expenditure for the elderly medicines simultaneously with the rising elderly population could be noticed from these statistics. The elderly population group was obviously the most vulnerable to drug interactions. Weise reported in the “USA Today” that errors of medication harmed 1.5 million US citizens every year (2006). She indicated that the problem was so serious that one medication error was expected from each hospital per day. These medication-related problems further enhanced the costs of treatment of the elderly, contributing to 3.5 billion of the expenditure per year (Weise, 2006). The Institute of Medicine (IOM) estimated that one-quarter of the number were preventable injuries. The polypharmacy leading to medication-related problems was to be prevented. This paper is aimed at studying the problem of polypharmacy in the elderly and the role of the ARNPs in the prevention of such a problem through a literature review.
Literature review
The Institute of Medicine Report of 1999 indicated that medical errors cost 37.6 billion dollars in which 17 billion dollars were for preventable errors (Graban, 2009). In 2007, the IOM Report indicated that 4 billion dollars were used for treatment of medication errors while the 2008 Report of Milliman Inc, study put the annual cost of harmful medical errors at 17.1billion dollars (Graban, 2009). USA Today reported in 2010 that 44% of the 15000 patients who died every month in hospital care were found to have died of preventable errors. The problem was really huge.
The problem of polypharmacy in the elderly
The elderly had the habit of using more medications than was really necessary; this was termed polypharmacy and it produced significant effects in the health, social and economic sectors (IOM, 1997).
Adverse drug events
Statistics indicated that most of the drug reactions due to polypharmacy occurred
In a hospital or required hospitalization. Dose-related reactions were the cause and they had been avoidable (Routledge, 2004 in Perry, 2011). Medication errors had been the usual causes of adverse drug reactions; they included missed dose (7 percent), wrong technique (6 percent), illegible order (6 percent), duplicate therapy (5 percent), drug-drug interaction (3-5 percent), equipment failure (1 percent), inadequate monitoring (1 percent) and preparation error (1 percent) (Reducing and Preventing, AHRQ, 2001). Antibiotics like amoxicillin, non-steroidal anti-inflammatory drugs like ibuprofen, and hypoglycemic drugs like gliclazide and glucocorticoids like prednisolone were the drugs that caused 60% of the side-effects in the elderly. The side-effects could have occurred through constipation, malabsorption, toxicity to the liver, gastro-intestinal upsets or bleeding issues and diarrhea (Perry, 2011). The elderly who consumed more than 5 medications had adverse problems of pharmacy (Tinetti, 2003 in Perry, 2011).
Multiple reasons had been attributed to polypharmacy. One reason was the anatomical and physiological changes in the human being during the aging process (Hughes, 2008). These alterations affected the metabolism and excretion of the drugs and influenced the distribution in the body.
Communication problems, inadequate information flow, human problems of policies, guidelines, protocols, and processes; patient-related issues of improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education; poor organizational transfer of knowledge; error in staff patterns and work-flow, technical failures and inadequate policies constituted the large range of problems causing medication errors (AHRQ’s Patient Safety Initiative, AHRQ)
Effective State reporting systems for passing on information about medication errors would in the long run hopefully produce a reversal of the current situation and lesser medication errors and adverse drug reactions (AHRQ’s Patient Safety Initiative, AHRQ).
Qualified personnel
ARNPs or advanced registered nurse practitioners are qualified nurses for the management of health care. They cater to the preventive aspect apart from the screening, diagnosis, and treatment of illnesses. In addition, follow-up care is also their responsibility. The ability to conduct Advanced education on Adult Health is an added qualification. Monitoring and management of chronic illnesses form a major aspect of their clinical prowess. Reaching presumptive diagnoses in the patients, they administer medicines. Disseminating information in the form of advice or counseling or classes, they are accepted by the public. Prescribing diets, recommending altered lifestyle habits and making referrals, are good managers of the healthcare of patients. They function as part of the multi-disciplinary team in health care services. Conflict management skills need to be a necessary quality with the stressful nature of work in healthcare organizations (Vivar, 2006). The negotiation skills of ARNPs which form a part of the interpersonal skills could help in managing elderly people and the team members alike (Kriet, 2008). The ARNPs are the best persons who could implement the prevention of polypharmacy in the elderly and spread the message among the other nursing staff and members of the multi-disciplinary team in the organization and the public, provided they are guided through education. In addition they make good reporters of integrity of untoward incidents to the higher authorities.
Nurses have always attempted to improve quality of patient care right from the days of Florence Nightingale who reduced mortality in her institution after studying its statistics. Nursing have contributed to patient safety by the coordination of several aspects of quality within the system and the integration of the better qualified nurses leading to lesser complications and decreased mortality (Hughes, 2008).
Another quality of nurses is that they recognize patient problems before they became adverse events. Adverse events are primarily caused by ineffective leadership and poor communication. Adverse drug reactions account for 16% of hospital admissions and 50% of medication-related deaths (Hughes, 2008). Apart from the reasons already mentioned for adverse drug reactions, inappropriate supervision and poor adherence are culprits. The ARNPs could provide the supervision or trigger others to ensure good drug adherence.
The ARNPs are the best people for producing a change in health care policy
They are good leaders to ensure a cohesive multi-disciplinary team for preventing polypharmacy in hospital or in the homes of patients. They ensure precise goals with outcomes that are measurable (Grumbach and Bodenheimer, 2004). The clinical system and administration are efficiently managed by the ARNPs. Division of labor is appropriately distributed to team members in the hospital and the family members at home. Team members are so trained as to be efficient participants in the administration of health care services. The greater the cohesiveness, the better are the patient outcomes and the higher is the patient satisfaction.
The significance of the duties of the ARNPs in the polypharmacy prevention policy
The ARNPs are used to focusing on various indicators while providing high-quality care. The safety and effectiveness of timely-administered equitable care produced quality where safety was the first and foremost indicator (Hughes, 2008). Safety actually meant that harm was not done by way of adverse events. Delivery of care was not to accommodate errors. The errors could be communication failures between any member of the staff or poor patient management including inappropriate delegation, failure of follow-up, inadequate reference or poor clinical performance at any stage. The ARNPs had to understand that errors occurred when quality was being increased. High-performing organizations were able to increase learning and allow changing leadership. They promoted a relationship between top leaders and managed to project a culture of safety while increasing the quality of care. Medicine reconciliation was needed to do away with omissions, duplications, errors in doses, other errors and drug interactions. The new list made with the right drugs could be handed to the patient. The National Patient Safety Goal for 2005 indicated a theme of complete reconciliation of medication continuously (National Patient Safety Goals, JCAHO).
How polypharmacy could be prevented or decreased
The healthy work environment
The work environment was another reason for decreased patient safety even if nurses were highly qualified (Hughes, 2008). The nurses became an overworked lot due to shortage of their numbers, inadequate medical equipment and inappropriate policies. The American Association for Critical Care Nurses put forward recommendations for a healthy work environment. This environment boasted of skilled communications which were effective, with continuous collaboration, nurse-involved decision-making, sufficient nurse number, all staff being valuable and true leaders (Hughes, 2008).
Safety cultures
High reliability organizations practiced safety cultures which contributed to favorable working conditions. Organizations needed to understand the weakness of their staff and be prepared to smoothen out matters when errors occurred. Errors could be skill-based, rule-based, work-arounds or individual deficiency-based. The deficiency-based ones included mistakes, violations and incompetence (Hughes, 2008). With the right environment for work, the ARNPs were the right people to help reduce polypharmacy and thereby increase the patient safety and quality of care.
Optimizing the prescription method
Inappropriate prescription had been a cause for polypharmacy in the elderly (Bregnhoj et al, 2009). Overall medication appropriateness could be possible through a message to the clinicians and pharmacists. Educational interventions for General Practitioners could also include feedback from clinical pharmacologists and pharmacists. The prescriptions had to be made according to the Medication Appropriateness Index (Bregnhoj, 2009). Drenth-van Mannen (2009) spoke about the Prescribing Optimization Method for physicians to assist them to optimize polypharmacy. Six problems were to be optimized with this method. The physicians were able to ensure that undertreatment was not present and that more medication needed to be added. They could also ensure that the patient adhered to his schedule (Drenth-van Mannen, 2009). If any drugs were inappropriate, the drugs that could be removed would be understood. Adverse events could be diagnosed if present. The clinical drug interactions which could be expected would be gauged from the Optimization method. The dosages or frequency or form necessary could be adjusted accordingly if necessary (Drenth-van Mannen, 2009). The method improved the prescribing technique of the physicians. The College of Pharmacy in the University of Arizona recommended the use of electronic prescribing systems by 2010 which was sound advice (Weise, 2009).
Prevention of adverse drug reactions
Polypharmacy has to be prevented. Clinicians and ARNPs were to check patent’s medication lists while prescribing drugs (Perry, 2011). Drug regimens were to be kept simple. Medicines could be prepared and delivered inboxes. Combination drugs could be used to reduce the number of drugs used. Advising patients to return for reviews could prevent polypharmacy in addition (Perry, 2011). Safe practice decreased the chances of adverse incidents in health care for all patients. This aspect was useful for the prevention of polypharmacy too.
Tool for regulation of polypharmacy
The ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) was a functional and interactive tool. The patient’s clinical health and functional status were considered. Evidence-based practice and the changed physiological situation of patients were other factors considered. The tool moved in a systematic manner to identify polypharmacy. The restoration and maintenance of functional status formed the outcome goals. Quality of life was a factor for decision making and changing or discontinuing the drugs. How the drugs acted on the bladder, bowel and appetite were further considered.
Education program-IPE
Interprofessional education (IPE) was an accepted method of studying any problem in the health services where multi-disciplinary teams taught each other and learned from each other (Olenick et al, 2010). Doctors and ARNPs could have continuing education on the subject of the prevention of polypharmacy in the elderly. This method of education had been accepted by the World Health Organization which stated that it facilitated effective collaboration for the improvement of health outcomes (Olenick et al, 2010). Quality of care improved simultaneously. Interprofessional education had been defined thus by the Center for Advancement of IPE:
“a teaching and learning process that fosters collaborative work and improves quality of care between two or more professions. IPE occurs when students learn with, from, and about one another”.
The sharing of knowledge and skills between the disciplines also acquired additional values in both groups (Olenick et al, 2010). The process boosted respect and understanding among the professionals. Sharing of practice competencies also was facilitated. Common goals and the understanding of common terminologies made IPE a good method of study (Olenick et al, 2010). The IPE helped the incorporation of education into the practice settings in their institution. The patient-centered outcomes subsequently became optimally effective and collaborative. The message on prevention of polypharmacy could be carried with consensus and consistency and patient safety would be ensured (Olenick et al, 2010). The communication between the health professionals would be productive with better resolution of the complex problem of polypharmacy (Dixon, Larison, and Zabari, 2006).
Role-playing and using quiz cards were two techniques that could be employed in the education sessions. These would be relating to the issues possible in polypharmacy. Role-playing would have situations already planned earlier and the roles of an elderly person, doctor or ARNP, a family member, or a junior nurse could be used in a situation. The lapses that could be included are the failure of discovery of polypharmacy at admission, how polypharmacy became worse after many consultations with different doctors while the patient was admitted, any adverse reactions leading to discovery of polypharmacy and how each situation could be corrected with medication reconciliation. How the patient should be advised at discharge for preventing polpypharmacy and the significance of the list of medicines given must invariably be included in the role-playing situations.
Quiz cards with relevant questions on polypharmacy and its issues could be written in one set of cards. The other set of cards would have answers prepared by the facilitator. The participants could be divided into two and one half would get the questions and the other half would get the answers. Each person in the first half would read out a question and the person with the answer to that would then read it out. Discussion would follow after each question and answer. The facilitator needed to be ready to guide the discussion. Plenty of relevant facts would be evolved during the discussion. The participants would learn new facts during the teaching program and the collaborative communication would be more evident. This would help them put into practice what they had understood. The relationship among these participants would be enhanced and would bode well for patients and the institution. Olenick had stated that IPE if effective would involve the following: “cognitive processes, reflective processes, problem-solving, critical thinking, the development of trust relationships, and the fostering of curiosity” (2010).
Two evaluations could be done prior to the education program. A pre-intervention evaluation of the statistics of the hospital on the incidence of polypharmacy needed to be made. The participants also could answer a questionnaire on their views on polypharmacy and whether they had made mistakes. For them to be honest, the answer sheets were not to be named as it would be the issue that was being evaluated. Following the program, the incidence in the hospital could be evaluated at equal intervals. Polypharmacy mistakes were needed to be owned up by the professional involved and appropriate action in the form of advice was needed to be taken.
Discussion
Polypharmacy was a grave issue among the elderly and growing with the growth of this population. The health professionals had not been able to contain this issue which was costly to the Nation. The mental make-up of the elderly had been one of the reasons for the issue. The others were the lapses on the part of the health professionals. The result was that the elders suffered by having adverse reactions and the nation lost by way of increased expenditure and loss of lives. Altered absorption of drugs, changed bodily functions, poor mobility, poor adherence, poor access to nursing care and cognitive deficits were the causes of polypharmacy in the elder. They could die of the issue due to multiple organ failure and adverse drug reactions. Communication problems, inadequate information flow, human problems of policies, guidelines, protocols, and processes; patient-related issues of improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education, poor organizational transfer of knowledge; error in staff patterns and work-flow, technical failures and inadequate policies constituted the large range of problems causing medication errors in the health care system. The time had arrived for the prevention of this costly issue and for ensuring patient safety with high quality of care. All health professionals needed to be aware of the problem and learn to manage it. Exhaustive education programs involving all the health care professionals were to be implemented globally. The ARNPs in the right work environment are efficient staff to spread the message and manage the problem. Research is to help reduce the issue of polypharmacy. Effective state reporting of medication errors and adverse drug reactions could curb the issue at the national level.
Conclusion
The current information on how aging affected pharmacokinetics, pharmacodynamics, and drug interactions was limited (IOM, 1997). The scope of research needed to widen and focus on this vulnerable and growing population. Age-related differences in the metabolism of drugs, drug interactions, the influence of age-related hormonal changes and altered nutritional responses were other recommendations for research. A limitation to expanding research on geriatric care was the limited number of professionals opting for research in geriatrics. Quality care in geriatrics is needed to be accorded through multi-disciplinary teams of doctors, nurses, physical therapists, and occupational therapists. The problem of polypharmacy in the elderly is needed to be controlled through further research and standardization of guidelines with the ARNPs playing a big role for the achievement.
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