Polypharmacy is the ‘treatment of a patient with more than one type of medicine’ 1 and is commonly defined as ‘the use of multiple medications or the use of a medication that is not indicated’ 6. Patients using several types of drugs can be seen as an excess amount of medication 2; taking too many pills can lead to a substantial number of adverse drug reactions and having a lot medication can be hard to keep a track of 4. This is not always the case if the prescribed drugs have an appropriate indication 3. However, as this can be difficult with multiple drug use, it is important to investigate how the Primary Health Care Team can work together to improve both compliance and concordance in relation to medication in patients. Compliance is defined as ‘the extent to which people follow the instructions they are given for prescribed treatments,’ whereas concordance ‘refers to an emerging consultative and consensual partnership between the patient and their doctor’ 5. This essay will discuss how taking multiple medications can be problematic and how compliance and concordance can be improved in patients to reduce these problems.
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The population aged 65 and over is continuously growing 4 and about a fifth of the population in the United Kingdom is aged 60 or older 3. Even though this is only 20% of the population, this demographic group accounts for 59% of dispensed prescriptions and makes up for over 50% of NHS drug costs 3. The same can be seen in the United States, although older people only encompass 13% of America’s population, they use 34% of all prescription drugs. Further more the number of prescriptions prescribed to older people and the complexity of their drug treatment has increased over time 4. The evidence suggests that there is an ageing population, due to factors such as improved healthcare, nevertheless, longer life is accompanied by an increase in the prevalence of chronic conditions and the combinations of chronic conditions 5, meaning more and more patients are requiring several drugs. Over 65% of people older than 65 have two or more chronic conditions 5 and 20% of people over 70 take five or more drugs 3. Therefore we can see polypharmacy is on the increase making it an increasingly important matter that needs to be addressed.
As the number of medications a patient uses increases, so does the risk of adverse drug reactions and drug interactions 3, 4. Taking more medication also means that unnecessary drugs become harder to detect amongst all the medication 3, which could potentially lead to more drug interactions. In Sweden adverse drug reactions are responsible for 3% of all deaths and are the seventh most common cause of death 6 7. It is therefore in the interest of the healthcare profession to reduce this number. The risks of adverse drug reactions and drug interactions are further increased when there is reduced compliance and concordance to the prescribed course of therapy. Factors which can affect patient compliance are: a lack of family support, medication used for illness without symptoms such as hyperlipidaemia and osteoporosis, taking more than four medications, taking more-frequent daily doses, patient confusion linked to poor memory, cultural factors, depression and patient understanding and lack of knowledge 4 6. Concordance is affected when there are poor relationships between patients and healthcare professionals and inadequate social support to help patients with their regimen 6. Compliance and concordance is very important for patients in order that they take their medication properly and can reduce or stop adverse drug reactions and drug interactions from happening. Seeing that there are many factors which can affect compliance and concordance it is of importance to the Primary Health Care Team to improve compliance rates.
Polypharmacy leads to a complex treatment regimen which in turn makes compliance harder for patients. Increasing the amount of medication, decreases compliance rates and in patients with a regimen of four or more drugs, only half are following their regimens properly 8. The main reason for this is because as the number of drugs a patient has to take increases, the harder it is to remember and keep a track of what needs to be taken and when. The National Council on Patient Information and Education estimated that full compliance is only carried out by 1/3 of patients with chronic conditions such as diabetes and heart failure due to the vast amount of drugs which are prescribed to manage these conditions. Compliance is very important for polypharmacy in treating infectious disease. If there is a lack of compliance then this leads to drug resistance which will affect the patient and other patients in the population 9.
From my community based medicine placement I saw a patient on multiple medications first hand and observed problems with polypharmacy and how they were managed. The patient suffered from numerous chronic conditions such as: cerebrovascular disease, hypertension, fibromyalgia, type II diabetes mellitus, ischaemic heart disease and depression. These chronic conditions meant that the patient was housebound and was on over 18 different types of drugs which were taken daily. The reason for being on so many types of medication is because chronic conditions are more effectively treated with two or more drugs i.e. drugs show more efficacy when working together 9. For example, to treat the patient’s type II diabetes, as well as having insulin injections, metformin and sulphonyurea were taken together. According to the United Kingdom Prospective Diabetes Study, using metformin and sulphonyurea achieves better glycemic control in patients using them together rather than just using sulphonyurea or metformin on its own 9. Moreover to help treat diabetes the patient was on statins to protect against cardio problems and angiotensin-converting enzyme inhibitors for renal protection which added up to the long list of medication that had to be taken.
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To manage the medication the patient had a monitored dosage system (MDS). An MDS is a medication storage device designed to simplify the administration of pills orally 10, medicines are placed in separate compartments allowing the patient to be given the correct medicine and dose at the correct time. Using an MDS holds many advantages; it provides medicine storage which is easily accessible to the patient, it minimizes dose, amount and timing errors, and acts as a memory aid 10. These advantages of using an MDS help to improve patient compliance as it overall makes taking several medications much simpler.
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