Annals of Long Term Care

Background

Polypharmacy is a common problem encountered by clinicians caring for elderly.1 It is encountered in all care settings ranging from outpatient to long-term care (LTC), where it is particularly linked with falls and other associated problems.2 Polypharmacy refers to the use of multiple medications by a patient. The term is used when too many forms of medication are used by a patient, more drugs are prescribed than clinically warranted,3 or even when all prescribed medications are clinically indicated, but there are too many to take (“pill burden”). This has a potential to cause higher adverse drug reactions (ADRs) and drug-drug interactions (DDIs).

The financial impact of polypharmacy-related problems translates into a significant cost to the health system, and it has a financial bearing on patients as well as institutions.4,5 Redundancy and duplication of medications are common. Regulatory issues, particularly in LTC settings, also can influence prescribing patterns.

Lack of proper indications, inappropriate dosage, and subclinical toxicities of medications are common observations. “Prescribing cascade” is a known problem, where a medication results in an adverse drug event (ADE) that is mistaken as a separate diagnosis and treated with more medications, which puts the patient at risk for additional ADEs.6 Polypharmacy takes its own toll on limited physiological and financial reserves. It is common to see nine or more medications prescribed to elderly patients transferred for subacute rehabilitation from hospitals to nursing homes. These medications are prescribed by multiple providers at different times for different reasons. One such common example is medications started for a patient during a hospital stay by consultants and hospitalists that are not re-evaluated for appropriateness after discharge from the hospital by the physician in charge of care of that patient.

Some current strategies available to address this complex issue include “START” (Screening Tool to Alert doctors to the Right Treatment) and “STOPP” (Screening Tool of Older Person’s potentially inappropriate Prescriptions) criteria. START is an effort to help prevent omission of important appropriate medications and is organized by organ system.7 STOPP criteria are a useful guide to identify potentially inappropriate medications (PIMs), particularly in the hospital setting.8

In addition, a multidisciplinary expert panel recently developed a consensus agreement on a list of laboratory findings and medication combinations to help detect potential ADRs in nursing home residents.9 Zhan et al10 published modified Beers Criteria to develop a list of potentially harmful medications in community-dwelling elderly persons. A cross-sectional database study identified older patients receiving medications included in the Health plan Employer Data and Information Set (HEDIS 2006) criteria, using national data from Veterans Affairs.11 The HEDIS 2006 criteria was derived from the medications thought to be the most problematic in the elderly. Results for the HEDIS 2006 measure were similar to those of the 1997 Beers Criteria.12

The ARMOR Tool

The ARMOR tool (Assess, Review, Minimize, Optimize, Reassess) is an attempt to consolidate these recommendations into a functional and interactive tool. It takes into account the patient's clinical profile and functional status, and tries to balance evidence-based practice with altered physiological reserves.13 ARMOR is an effort to approach polypharmacy in a systematic and organized fashion. Functional status, its restoration, and maintenance are the primary outcome goals. This tool also emphasizes quality of life as a key factor for making decisions on changing or discontinuing medications. Use of a certain medication is weighed against its impact on primary biological functions such as bladder, bowel, and appetite.