Building Block#1: Understanding the problem

Causes and Effects of Problematic Polypharmacy

Polypharmacy is commonly defined as the long-term use of 5 or more medications. This is increasingly common among older adults as the number of people living with more than one chronic condition (also called multimorbidity) grows. Evidence shows that polypharmacy can have a significant, negative impact on people’s lives. Polypharmacy is linked to a number of negative consequences for individuals, including:

Increased risk of falls
Increased risk of hospitalizations, and leading to unnecessary hospitalizations
Cognitive and motor impairment
Adverse drug events and reactions
Increased risk of drug-drug interactions and drug-disease interactions
Increased rates of morbidity and mortality

Polypharmacy may also impact a patient’s life in other ways. For example, many patients with complicated medication regimens consider them burdensome and confusing. Patients may find it difficult to adhere to their medications, and financial and social constraints may make accessing their medications difficult or stressful.

Who Experiences Polypharmacy?

Patients with Multimorbidity

Multimorbidity, or having more than one concurrent chronic condition or risk factor, is associated with polypharmacy. Patients with multimorbidity have distinct challenges and their healthcare needs are often complex. A 2017 qualitative study from our team explored the perceptions of patients living with multimorbidity in their own words. Many reported challenges with activities of daily life and difficulties with navigating the healthcare system. Importantly, patients in this study disclosed numerous difficulties in managing their medications—issues such as remembering to take their medications, experiencing side effects, and financial challenges.

For patients with more than one condition, having prescribers adhere strictly to clinical guidelines for prescribing (rather than considering the patient and their multimorbidities as a whole, as well as and their priorities and preferences for treatment) can result in complicated and confusing medication regimens, decreased adherence to medications, and increased risk of polypharmacy. Clinical guidelines are often written using a single disease model, which tend to focus more on treating one condition in isolation, rather than considering the potential effects of polypharmacy where multimorbidity is present.

Frailer Patients

Multimorbidity is also associated with patient frailty. The more chronic conditions a patient has, the more likely they are to become frail. Frailty, in turn, is associated with lower socioeconomic status, complex care management needs, higher risks for hospitalizations, and poorer quality of life. In short, frail patients have greater needs than other patients in many areas, including the potential risks of polypharmacy.

Other drivers of polypharmacy include

Inappropriate long-term prescribing of medications that are recommended for shorter-term use. We coined the term legacy prescribing to describe this, and our study showed that this is a very common cause of unnecessary medication use. This offers exciting opportunities for system change to address this.
Prescribing cascades—where prescribing of one medication frequently leads to prescribing of another—for example, a second medication is prescribed to counteract side effects of the first medication (a novel example of this is presented in the legacy prescribing paper, linked above).

The bottom line? Any system that wants to support equity needs to specifically prioritize patients with polypharmacy.