The growing elderly population has a problem of polypharmacy which can be described as iatrogenic. Having many illnesses requiring different medicines, the elderly has a habit of consuming more than 3 medicines for their various illnesses. These led to medication-related adverse events which increased morbidity and mortality, mostly from preventable medication errors. The harmful effects of medication could be reduced through the efforts of the cohesive multi-disciplinary team of physicians, ARNPs and pharmacists. The prescribing optimization method and intensive medicine reconciliation could work towards the reduction of the problems associated with polypharmacy in the elderly. This paper is investigating the subject through a wide literature review and then taking efforts to reduce the problem in the local hospital, where the researcher works, through an education program maintaining the standards prescribed by the Accreditation Council for Graduate Medical Education (ACGME) into their curricula for all the stakeholders in the prevention of the problem.
The ARNPs were the appropriate and major participants for the IPE. Functioning as part of a cohesive multi-disciplinary team, they already had the experience of being able to change health policies and preventing health problems. The healthy work environment and safety cultures in this hospital were the right background for efficient ARNPs to function. The IPE concept had been endorsed by the World Health Organization and The Center for Advancement of IPE (Olenick et al, 2010). The IPE which involved collaborative medical education was in line with the WHO conceptual framework of multi-professional education for health personnel. The reports by the Institute of Medicine (IOM) which advocated education of health professionals in an interdisciplinary manner and related to collaborative care also had the same message (Olenick et al, 2010). Medical education programs had to integrate six competencies of the Accreditation Council for Graduate Medical Education (ACGME) into their curricula (Olenick, 2010). The competencies included collaborative and effective exchange of information between professionals and patients through interpersonal skills and communication techniques. The students were also required to respond to the health deficits using systems-based methods. The planned IPE could acquire the accreditation for the hospital as it contained these elements in education (Olenick et al, 2010).
Approval would be obtained from the Hospital administration for the education program. The participants would be individually notified about the program. The administration would take special interest in the program conveying the right message to all concerned. Consent would be obtained from the participants about confidentiality.
The IPE was meant for the physicians, house officers, nurses and pharmacists. The shifts were timed so that two educational sessions daily were possible for the education program. The day sessions and evening sessions should be sufficient for all the participants to attend the program and enjoy the benefit of the discussions.
The education program was to include the optimization of the prescription technique and the significance of reconciliation for preventing the problems of polypharmacy. The discussion of prescriptions with feedback of pharmacists contributed to the Prescribing Optimization Method (POM) for physicians as indicated by Drenth-van Mannen (2009). General practitioners had earlier recognized their role in optimizing the prescribing method (Anthierens, 2010). Decisions on 10 different case histories would be discussed. Six possible problems of polypharmacy could be avoided thus (Refer slide 5 in Appendix).
Reconciliation was another technique which could prevent problems of polypharmacy. The prescriptions had to be made according to the Medication Appropriateness Index (Bregnhøj, 2009). The National Patient Safety Goal for 2005 indicated a theme of complete reconciliation of medication at regular intervals (National Patient Safety Goals, JCAHO). The medicines that the patient was using had to be checked at time of admission and when the patient was discharged and then at regular intervals at the nearest medical centers by physicians and nurses (Perry, 2011).
Role-playing and using quiz cards were two other techniques which could be employed in the education sessions. These would be relating to the issues possible in polypharmacy and the solutions. Role playing would have situations already planned earlier and the roles of elderly person, doctor or ARNP, a family member or a junior nurse could be used in a situation. The lapses that could be included are the problem of consultations with different doctors while patient was admitted, any adverse reactions leading to discovery of polypharrmacy and how each situation could be corrected with medicine reconciliation. How the patient should be advised at discharge for preventing polypharmacy and the significance of the list of medicines given must invariably be included in the role-playing situations.
Quiz cards with relevant questions on polypharmacy and its issues could be written in one set of cards. The other set of cards would have answers prepared by the facilitator. The participants could be divided into two where one half would get the questions and the other half would get the answers. Each person in the first half would read out a question and the person with the answer to that would then read it out. Discussion would follow after each question and answer. The facilitator needed to be ready to guide the discussion.
Two evaluations could be done prior to the education program. A pre-intervention evaluation of the statistics of the hospital on the incidence of polypharmacy needs to be made. The participants also could answer a questionnaire on their views on polypharmacy and whether they had made mistakes and answer it again at the end of the program. For them to be honest, the answer sheets were not to be named as it would be the issue that was being evaluated. Following the program, the incidence in the hospital could be evaluated at equal intervals. Polypharmacy mistakes were to be owned up by the professional involved and appropriate action in the form of advice was to be taken by the administration.
Inadequate participation in all the sessions could be a limitation. Inadequate response to the questionnaires before the education would be another limitation as the prevention of polypharmacy would be successful only if all the relevant participants were sincere.
Random assignment of case histories in the POM would allow the study to be reliably interpreted. Another strength would be that as 10 case histories are to be used, the bias possible from a single case would be avoided(Drenth-van Mannen, 2009). The next strength would be that the additional value of the POM would be measured as inappropriate decisions are also evaluated along with the appropriate decisions. The limitations would be also accounted for. No contact would be made with patients; all decisions would be made on paper. The expert panel would be familiar with the POM so bias would be a limitation causing overestimation of the method(Drenth-van Mannen, 2009). The time taken for decision would be more for each following case thereby each following case would have better decision-making and would be biased by the earlier one discussed. The next limitation would be that the POM was originally based on Dutch guidelines. Another limitation would be that GPs do not have the chance for references during the study while they could refer during their practice. A selection bias will be avoided as all participants who already know something about polypharmacy are to be included(Drenth-van Mannen, 2009).
Reconciliation was a function that was to be performed by the health care professionals who came across elderly patients (National Patient Safety Goals, JCAHO). The iatrogenic problem of polypharmacy which increased morbidity and mortality of elderly patients could be reduced by reconciliation (Banerjee et al, 2011). Medicine reconciliation was useful for preventing the problems of polypharmacyon a long term basis (National Patient Safety Goals, JCAHO). The role play in the education program would serve to identify the various errors that were being committed in the health care services and the ways in which these could be prevented. The health care professionals participating were to recognize the plans for preventing polypharmacy problems. The significance of medical reconciliation would be impressed upon the participants and the beneficial effects for the patient and the nation would be highlighted.
The quiz cards would be useful for highlighting the significant problems that are associated with polypharmacy and the adverse effects on the patient and nation. Much of the theoretical aspects would be covered in the process. The discussion within the participants and facilitation by the guide would reveal things better than would have been possible through a theory class with only the guide talking. A better grasp of the various issues and their solutions would be possible. The same questionnaire that is given at the beginning of the education program could again be answered at the end. The correct answers would be more in number providing a hint of the usefulness of the education program.
This research paper has provided me the experience of how a research paper could be written. The search for the literature on polypharmacy taught me how to go through the process of reaching the right articles for selection. The guidance by the professor helped me to discard certain statements and add more relevant articles to improve the paper. The significance of the issue of polypharmacy has also struck the right chord in me. Having written this research paper, I have realized that polypharmacy is an issue which has great potential for creating many untoward incidents which raised the morbidity and mortality of the elders. The speedy growth of this population has helped me to understand the gravity of the situation. It also has set me thinking that there are many issues which could be corrected through the cohesive multi-disciplinary team that serves patients in hospital and that polypharmacy is one. As an ARNP, I have understood that my colleagues and I can provide leadership in reversing the problems of polypharmacy in society. Working as one strong unit, we could ensure that the elderly people can have a safe and quality care in their aged days. This same unity and thinking as one mind could in future be the basis for more changes in health policies for lifting the society out of the poor state of health status in many situations. The realization that health authorities have come up with recommendations on polypharmacy and education helped me to understand that the information would be available only if I looked for it. The library is the place to look in for information and research on health problems that arise within my practice. The ARNPs have a great deal to do to improve the health of the society and cannot just perform their jobs without heeding the dynamic health transformations that occur within it. The education program is an eye opener to the possibilities of education in health policy changes. More education programs need to be planned in future based on the issues that rise in hospital. The next time, a different method of education could be used. My instinct tells me that education needs to be provided at intervals so that the cohesiveness of the team could be maintained for future issues.
Anthierens, S., Tansens, A., Petrovic, M. and Chritiaens, T. (2010). Qualitative insights into general practitionersviews on polypharmacy. BMC Family Practice. Web.
Banerjee, A., Mbamalu, D., Ebrahimi, S., Khan, A.A. and Chan, T.F. (2011). The prevalence of polypharmacy in elderly attenders to an emergency department – a problem with a need for an effective solution. International Journal of Emergency Medicine. Web.
Bregnhøj, L., Thirstrup, S., Kristensen, M.B., Bjerrum, L. and Sonne, J. (2009). Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care. Eur J ClinPharmacol, 65, 199–207.
Drenth-van Mannen, A.C., van Marum, R.J., Knol, W.,van der Linden, C.M.J. and Jansen, P.A.F. (2009). Prescribing Optimization Method for improving prescribing in elderly patients receiving polypharmacy : Results of application to case histories by general practitioners. Drugs Aging, 26 (8), 687-701.
National Patient Safety Goals. (2011). 2011 National Patient Safety Goals Now Available. Web.
Olenick, M., Allen, L.R. and Smego Jr., R.A. (2010). Interprofessional education: A concept analysis. Advances in Medical Education and Practice, 175–84.
Perry, M. (2011).The problem of polypharmacy in the elderly. Nurse Prescribing, 9(7).
Slides for instruction purposes
Polypharmacy continues in the elderly: aspects and prevention of excessive drug use –in the home, at admission in the hospital and safety prevention: for the Advance Nurse Practitioners (ARNP)
- Elderly population 13% of total US population
- National expenditure $ 36 billion in 1997
- Prescription medicines 38% of national expenditure
The population of the elderly will triple by 2030 so the magnitude of the problem of polypharmacy can be imagined. In 2001, 44.3 billion dollars was the expenditure for the elderly medicines (Stagnitti, 2005). In 2002, it grew to 49.9 billion (Stagnitti, 2005).
Cost of errors
|Year||Cost of medical errors||Report|
|1999||$ 37.6 billion||IOM 1999|
|2007||$ 4 billion||IOM 2007|
|2008||$ 17 billion||Millman Inc.|
Preventable errors in 1999 cost 17 billion dollars. Figures were quoted by Graban, 2009. In 2001, 44.3 billion dollars was the expenditure for the elderly medicines (Stagnitti, 2005). In 2002, it grew to 49.9 billion (Stagnitti, 2005).
|Error||Percentage of total errors|
|Missed dose||7 %|
|Wrong technique||6 %|
|Illegible order||6 %|
|Duplicate therapy||5 %|
|Equipment failure||1 %|
|Inadequate monitoring||1 %|
|Preparation error||1 %|
- Anatomical and physiological changes in the aging
- Communication problems
- Inadequate information flow
- Human problems
- Patient-related issues
- Poor organizational transfer of knowledge
Anatomical and physiological alterations affected the metabolism and excretion of the drugs and influenced the distribution in the body. Human problems included policies, guidelines, protocols, and processes.
Patient-related issues of improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education. Other reasons for polypharmacy were error in staff patterns and work-flow, technical failures and Inadequate policies.
- Prescribing Optimization Method
- Medical reconciliation
- Healthy work environment
- Safety cultures
- Cohesive multi-disciplinary team
- Qualified personnel – ARNPs
Six problems were to be optimized with this method. The physicians were able to ensure that under-treatment was not present and that more medication needed to be added. They could also ensure that the patient adhered to his schedule (Drenth-van Mannen, 2009). If any drugs were inappropriate, the drugs that could be removed would be understood. Adverse events could be diagnosed if present. The clinical drug interactions which could be expected would be gauged from the Optimization method. The dosages or frequency or form necessary could be adjusted accordingly if necessary (Drenth-van Mannen, 2009). The method improved the prescribing technique of the physicians.
Medicine reconciliation was needed to do away with omissions, duplications, errors in doses, other errors and drug interactions. The new list made with the right drugs could be handed to the patient. The National Patient Safety Goal for 2005 indicated a theme of complete reconciliation of medication continuously (National Patient Safety Goals, JCAHO).
- No under-treatment
- Adherence ensured
- Inappropriate drugs removed
- Adverse events diagnosed if present
- Drug interactions understood
- Dosages adjusted if required
The physicians were able to ensure that under-treatment was not present and that more medication needed to be added. 2. They could also ensure that the patient adhered to his schedule.
If any drugs were inappropriate, the drugs that could be removed would be understood 4. Adverse events could be diagnosed if present. 5. The clinical drug interactions which could be expected would be gauged from the Optimization method. 6. The dosages or frequency or form necessary could be adjusted accordingly if necessary.
- Checking of medicine lists of patients (reconciliation)
- Simple drug regimen
- Combination of drugs to reduce number
- Medicines prepared and delivered in boxes
- Continuous medical reconciliation (National Patient Safety Goals, JCAHO).
Medical reconciliation is done for prevention of adverse drug reactions. The methods of prevention are delineated here.