Address the Challenge of Polypharmacy in Older Adults Undergoing Cancer Treatment
By Martha Lassiter, MSN, AOCNS®, BMTCN
Polypharmacy is the use of several medications simultaneously for different medical conditions. Data confirm that polypharmacy is prevalent (https://www.researchgate.net/publication/279862820_Polypharmacy_in_patients_with_advanced_cancer_and_the_role_of_medication_discontinuation) in older adults with cancer, with one study reporting a minimum of four prescriptions to define polypharmacy. Many medications prescribed during cancer care are intended to treat other comorbid conditions that occur prior to a patient’s cancer diagnosis (e.g., heart disease, hypertension, hyperlipidemia, reflux disease). Reportedly, one third of individuals older than 65 years (https://www.mhealthevidence.org/content/safe-and-effective-drug-therapy-older-adults) use more than one pharmacy to fill prescription medications. This can lead to further confusion for patients regarding medication management.
Increased medication burden amplifies the risk (http://ascopubs.org/doi/10.1200/JCO.2014.58.7550) for drug-drug, drug-food, and drug-herbal interactions as well as noncompliance. In addition, patients may see different healthcare providers simultaneously to manage their multiple diagnoses or be followed by different members of the cancer care team if they are receiving multimodal cancer therapy.
Specific criteria have been developed to assist providers in managing polypharmacy in older adults with cancer. The American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (https://geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/CL001) provides a guideline to improve medication safety. It is applicable to many patient scenarios but may be difficult to apply to those at end of life. Some reports show that polypharmacy can increase anticholinergic or serotonergic loads, which may be particularly dangerous (http://journals.sagepub.com/doi/abs/10.1177/0269216309102528) to those nearing death. Many times, long-term medications previously prescribed to manage comorbidities may no longer be necessary and are often overlooked.
A comprehensive medication review (https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf) at every patient encounter is considered a vital part of the geriatric oncology assessment. Discontinuation of unnecessary medications and careful review of the active medication plan can limit the risk for adverse drug reactions and unnecessary side effects. When reviewing a prescribed medication list, nurses and providers should review nonprescription medications carefully as well. Herbal products are not subject to the same regulatory requirements as pharmaceuticals and may pose an added safety risk. Encouraging patients to bring all their medications to their visit allows for a better assessment of their current medication regimen.
A consultation with an oncology pharmacist can further enforce safe medication management and is vital to comprehensive cancer care. Studies show that when pharmacists are involved in care (https://www.pharmacypractice.org/journal/index.php/pp/article/view/578/0) transitions during inpatient discharge, focusing on medication management, the prevalence of medication-related problems, hospital readmission rates, and preventable adverse drug reactions are reduced.
Collaborative descriptive research is a first step in decreasing the burden of polypharmacy. Standardized definitions and measurements will also allow researchers to develop standard practices and research goals. Physicians, pharmacists, advanced practice providers, and nurses need to collaborate to develop tools and interventions to optimize safe medication management for their patients, particularly older adults.