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Written by

Dr Martin Duerden

Dr Martin Duerden is a GP and Clinical Senior Lecturer at the Centre for Health Economics and Medicines Evaluation, Bangor University, North Wales, UK

Polypharmacy and pain management in older people

Published 31 July 2015

Dr Martin Duerden discusses the related problems of multiple medication intake and pain in the elderly population, along with associated issues such as side-effects and drug-drug interactions

Key learning points

  • Estimates suggest that persistent or chronic pain affects about 50% of people over 65 years old living in a community setting and more than 80% of nursing home residents.
  • Older people are particularly vulnerable to polypharmacy due to pharmacokinetic and pharmacodynamic differences when compared with younger, less-frail people.
  • To mitigate the risks of polypharmacy, non-drug treatments such as physiotherapy and cognitive behavioural therapy should be optimised.
  • Frequent medication reviews to monitor the effects of treatment and to detect potential adverse drug reactions and interactions are essential.

Most countries in Europe are facing large growth in their populations of older people. The European Commission predicts that by 2060 around 30% of Europeans will be 65 or over, with a particularly rapid increase in numbers of people aged over 80 years.1 

As diseases accumulate with age, and people live longer, multi-morbidity (that is, more than one condition) is increasingly challenging for healthcare services. Research from Scotland shows that among older people, patients with multimorbidity are the norm. In a cross-sectional analysis based on medical records of more than 1.75 million people, almost a quarter of all patients, and more than half of those with a chronic disorder, had multimorbidity. By the age of 60 years, fewer than 30% of people had no physical or mental health disorder – many people had two or three disorders.2 

Multimorbidity is associated with increased prescribing of medications and polypharmacy.3 Another study of around 181,000 patients found that 17% received four to nine medications and 5% received 10 or more medications.3 Polypharmacy increased with age and was directly related to the number of morbidities; 42% of patients with six or more co-morbidities received 10 or more medications.3 


Polypharmacy 

Polypharmacy is often described as prescribing more than one medication to an individual to take at the same time. However, there is no clear definition of polypharmacy and the term is often used loosely. In the UK, an attempt was made recently by clinicians, policymakers, academics and patient groups to agree a definition of when polypharmacy is appropriate and when it may be problematic:4 

For an individual with complex or multiple conditions, appropriate polypharmacy is optimised prescribing of medicines according to the best available evidence. The overall intent for the combination of medicines prescribed should be to maintain good quality of life, improve longevity and minimise harm from drugs.

Problematic polypharmacy is where multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not obtained. The reasons why prescribing may be problematic may be that the treatments are not evidence-based, or the risk of harm from treatments is likely to outweigh benefit, or where one or more of the following apply:

  • The drug combination is hazardous because of interactions.
  • The overall demands of medicine-taking, or ‘pill burden’, are unacceptable to the patient.
  • The demands of medicine-taking make it difficult to achieve clinically useful medication adherence (reducing the ‘pill burden’ to the most essential medicines is likely to be more beneficial).
  • Medications are being prescribed to treat the side-effects of other medicines where alternative solutions are available to reduce the number of drugs.

elderly-people-particularly-vulnerable-polypharmacy
Elderly people are particularly vulnerable to polypharmacy
©iStock/Thinkstock

Implications of polypharmacy

Older people are more vulnerable to polypharmacy than younger, less-frail people because of pharmacokinetic and pharmacodynamic differences. Older people are more likely to experience reduced renal or hepatic function, reduced haemostatic reserve and have increased sensitivity of drug receptors. Reduced lean body mass, reduced body water and lower serum albumin may also alter drug distribution.5 If not accounted for, these issues may result in more frequent and more serious adverse effects in an already vulnerable group. 

Older people are also more prone to falls related to medication and are more likely to have an injury after a fall. They are also more likely to experience cognitive decline with the associated potential for mistakes in taking medications. 

In older people it is especially important to consider the potential for drug interactions with over-the-counter (OTC) remedies, including herbal products. It is difficult to gauge the scale of OTC drug use and it is likely to vary between European countries, but in one study in the US more than 40% of people were estimated to buy OTC products.6


Pain in older people

Measuring the prevalence of pain in older people can be challenging, and pain is under-recognised in this population.5 Estimates suggest that persistent or chronic pain affects approximately 50% of people more than 65 years old living in a community setting and up to 80% of nursing home residents.7 

Some older people might be stoical and put up with pain because they believe it is a normal part of ageing.5 Epidemiological studies suggest that musculoskeletal pain may increase with age and the most common sites of pain are the knee and hip joints and the lower back.5 Pain from previous fractures and peripheral neuropathies (often related to diabetes) are also common. Pain is strongly correlated with depression and anxiety, which may themselves require treatment and add to polypharmacy.3,5


Common problems – pain medication and polypharmacy

Paracetamol (acetaminophen) is usually first-line treatment in older people with mild-to-moderate pain. It generally does not interact with other treatments. The main concern is the potential for hepatotoxicity if taken at more than the recommended daily dosage. Cases of acute liver failure have even been reported in malnourished patients (<50kg weight) taking the maximum recommended daily dosage of paracetamol, namely 4g daily.5 In people on other medication (polypharmacy) and with cognitive impairment, confusion over medicine taking creates risk of accidental overdose with paracetamol. Recently there have been concerns that long-term use of paracetamol may be less safe than was thought, particularly in terms of cardiovascular safety.8 

Non-steroidal anti-inflammatory drugs (NSAIDs) are relatively effective analgesics in older people and are widely prescribed. But they can cause significant adverse effects from gastrointestinal toxicity, hypertension, cardiovascular events and renal impairment and are best avoided. If essential, they should be used with caution, at the lowest dose, for the shortest duration.9 Risk of gastrointestinal toxicity and bleeding can be reduced by co-prescribing proton pump inhibitors, but these have their own safety issues, and add to polypharmacy. The main drug interactions to monitor with NSAIDs are with angiotensin-modifying drugs (angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers) as their combination can cause renal damage.10 If diuretics are also prescribed this risk is even greater.

Mild-to-moderate opioids such as codeine are often prescribed at low dose in combination products with paracetamol. This can reduce polypharmacy but may not be flexible enough to provide efficient analgesia and can still cause adverse effects. Strong opioids such as morphine should only be prescribed with appropriate anti-emetics and laxatives. Again, this can add to the burden of polypharmacy. Tramadol and fentanyl preparations are hazardous if prescribed to people taking antidepressant drugs because the combination can lead to potentially fatal serotonin syndrome.11


Conclusions 

To reduce problems with pain medication and mitigate the risks of polypharmacy, non-drug treatments such as physiotherapy and cognitive-behavioural therapy should be optimised.12 Older people with pain often think that exercise will aggravate their symptoms, but usually it does not. Frequent medication reviews to monitor the effects of treatment and to detect potential adverse drug reactions and interactions are essential in patients taking several medications. Consider the possibility of non-adherence as a cause of drug treatment failure before changing or adding to treatment. Each new drug should be regarded as a trial rather than long-term therapy. An important component of medication reviews is to consider stopping treatment; drugs are relatively easy to add but often little thought is given to withdrawal.

  • Dr Martin Duerden is a GP and Clinical Senior Lecturer at the Centre for Health Economics and Medicines Evaluation, Bangor University, North Wales, UK

References

  1. European Commission. Demography Report 2010: Older, more numerous and diverse Europeans. Luxembourg: Publications Office of the European Union. Available from: www.ec.europa.eu/social/BlobServlet?docId=6824&langId=en (accessed 27 April 2015).
  2. Barnett K, Mercer SW, et al. The Lancet 2012;380(9836):37–43.
  3. Payne RA, Avery AJ, et al. European Journal of Clinical Pharmacology 2014;70(5):575–581.
  4. Duerden M, Avery A, et al. Polypharmacy and medicines optimisation: making it safe and sound. London, The King’s Fund, 2013. Available from: www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation (accessed 27 April 2015).
  5. Abdulla A, Adams N, et al. Age and Ageing 2013;42 suppl 1:i1–i57
  6. Qato DM, Alexander GC, et al. Journal of the American Medical Association 2008;300(24):2867–2878
  7. Gibson SJ. Older People’s Pain. Pain Clinical Updates 2006;XIV(3):1–4. Available from: www.iasp-pain.org/PublicationsNews/NewsletterIssue.aspx?ItemNumber=2117 (accessed 27 April 2015).
  8. Roberts E, Delgada Nunes V, et al. Annals of the Rheumatic Diseases 2015 Mar 2. pii: annrheumdis-2014-206914. doi: 10.1136/annrheumdis-2014-206914. [Epub ahead of print].
  9. American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2009;57(8):1331–1346.
  10. Day RO, Graham GG. British Medical Journal 2013;346:f3195.
  11. Buckley NA, Dawson AH, et al. British Medical Journal 2014;348:g1626.
  12. Makris UE, Abrams RC, et al. Journal of the American Medical Association 2014;312(8):825–836.

Date of preparation: July 2015; MINT/PAEU-15001u