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Polypharmacy in the elderly – evaluating the Pill Pruner project.

Student: Monica Johnson
Supervisors: Assoc Prof Dee Mangin, Andrea Copeland, Nikki Ford [Dept Public Health & General Practice and Pegasus Health]
Sponsor: Pegasus Health

'Polypharmacy' can be defined as the use of multiple medications by one patient or as medication use that is excessive or unnecessary. Most New Zealanders over the age of 70 years are prescribed 4 or more medications, and a small number take as many as 20 different medications. Harmful side effects or dangerous interactions increase with the number of medications taken and. these can cause illness and in some cases death. Errors in drug dosage or medication type are also more likely to occur when taking multiple medications. Furthermore, elderly people are more likely to be confused about using medications and this is compounded by any hospital admission during which additions or changes are often made to medications for reasons patients do not understand.

The "Pill Pruner" project was initiated in secondary care (Dept of Medicine Christchurch Hospital) to critically review the medicines of elderly medical inpatients. The project involved 500 patients over the age of 75 years who were taking 5 or more medications when admitted to the Acute Medical Assessment Unit during July 2009.. Medications that could be safely stopped or reduced in dose were targeted, and obviously as part of their care some new medicines were also started. All changes to medication were documented and communicated to the patients' usual primary care team (including community pharmacy) on discharge from hospital.

Approximately 2 months after discharge a follow-up questionnaire was sent to the patients' GP and pharmacist to explore any positive or negative effects of the medication changes.

This study explored what happened to the patients after their pills had been "pruned". It was also used as an opportunity to discuss other issues around polypharmacy in the elderly, especially regarding communication between different providers and sectors of health care.

The follow-up questionnaires from the GPs and pharmacists were analysed. Volunteer GPs and pharmacists then participated in one of two focus group discussions about the Pill Pruner project in particular, and about methods of improving communication around drug changes at hospital admission and polypharmacy in the elderly.

Results

There were 126 replies to the 205 questionnaires sent to GPs. Ten patients had died since their July hospital admission. Of the patients who had medicines stopped in hospital, 20 patients had one or more medicines restarted by their GP. Anticoagulants, antidepressants and acid suppression medications were the most commonly restarted, due to recurrence of symptoms. Of the patients who had new medicines (excluding short course meds, inhalers and nasal sprays) started during their July admission, 16 patients had some medicines subsequently stopped by their GP. Cilazapril (a blood pressure lowering medicine) and drugs for psychological disturbance were the most commonly stopped, due to blood pressure change and sedation respectively.

There were 89 replies to the 140 questionnaires sent to pharmacists. Four patients had died since their hospital admission and another 13 patients had not been dispensed their discharge prescription. One third of pharmacists (29) indicated they had a problem dispensing medication after the patient's discharge from hospital, with the most common reason being that the patient did not present the discharge summary or yellow card, and that the discharge script differed from the previous medication list. Thirty eight pharmacists indicated that the patient was no longer on the same drug regimen due to medication being changed since discharge from hospital.

The GP and pharmacist focus groups were very informative. The Pill Pruner project was generally seen as a positive idea although there were some criticisms. There were issues around some medications being stopped in hospital. Certain medications were often stopped abruptly during hospital admission whereas they really needed to be tapered off. Often medications were stopped by hospital doctors who did not see the patient in full context so did not understand the GP's reasoning for having the patient on that medication. However GPs appreciated when medications such as warfarin (a blood thinning medicine) and statins (cholesterol lowering drugs) were stopped in hospital, as these had often been started by a specialist so the GPs were unsure about stopping them.

Suggestions for improving the Pill Pruner project include: Analysing a patient's medications on admission and adjusting changes during the hospital stay; sending the GP suggestions of which medications to consider stopping; and providing guidelines for when to stop drugs initiated in hospital that GPs are not familiar with.

Other issues that were raised during the focus groups include communication barriers between secondary and primary care; communication issues between pharmacists and GPs; and barriers faced by GPs when trying to decrease medication. There is often significant confusion upon discharge from hospital over what medication an elderly patient should be on and pharmacists frequently receive unclear prescriptions, many of which are still handwritten. Discharge on Friday afternoon and relatives taking a prescription to a pharmacy that is not the patient's usual one were issues that were highlighted. GPs are, on the whole, willing to try and decrease the number of medications their elderly patients are on but they are aware of medicolegal issues and possible misunderstandings from the family of the patient. Suggestions for improving some of these issues include:

  • Improving and encouraging the use of Yellow Cards to record a patient's medication
  • Letting the pharmacist know in advance of a patient's discharge as well as instructing the patient to present their discharge summary to the pharmacist
  • Improving and making use of the funded Medicines Use Review (MUR) service
  • Running more Pegasus small group education sessions for pharmacists and GPs on prescribing in the elderly
  • Annotating all medication changes on prescriptions, so doctor's intentions are clear
  • Providing easily accessible guidelines on when and how to stop medications in the elderly
  • Assessing funded annual reviews for elderly patients on multiple medications
  • Establishing an electronic patient record system that is shared between different health care providers.

The Pill Pruner project was seen as a positive initiative towards reducing the medication of elderly patients in Christchurch and the majority of GPs accepted the changes that were made in hospital. There were some issues with certain drugs being stopped too abruptly and causing relapse of symptoms. For the Pill Pruner project to be continued into routine practice and for polypharmacy to be reduced in the most efficient and safe manner, it should be combined with improved documentation of changes and more effective communication between healthcare sectors as well as encouraging the mindset of pruning pills in both GPs and hospital doctors.