Polypharmacy & Dementia
“The elderly taking at least five medications are at increased risk of mild cognitive impairment and dementia,” conclude Chippa and Roy in their guidance about polypharmacy, Geriatric Cognitive Decline and Polypharmacy. On average, nursing home patients take eight medications daily, they report, often because of increasing numbers of comorbidities associated with aging.
Functional and metabolic changes associated with aging influence the impact of medications on aging patients, making the stakes higher. Thus, attention to polypharmacy is a clinical imperative in nursing home care.
Physical and cognitive impairment “closely related”
Chippa and Roy conclude that physical frailty and cognitive impairment are “closely related”. They explain, “Any increase in the number of medications prescribed to individuals raises the risk of unexpected drug interactions and their side effects, leading to impaired cognitive or physical capability.” For example, in a one-year study among individuals with mild cognitive impairment, researchers found a six times higher likelihood of developing dementia among patients taking more than three medications per day, as compared with those taking fewer than three per day. Drug-drug interactions were the highest determinant of progression to dementia, they note.
Duration of polypharmacy is a factor as well, sometimes creating a vicious cycle: “Over a long time, the continued use of polypharmacy can also create new comorbidities, requiring more medications,” note Chippa and Roy. This makes a patient weaker and can lead to frailty, falls, and injuries, with increases in morbidity, increased caregiver burden, and higher risk of mortality, they say. The GuideStar Eldercare mission promotes safety, functionality, and dignity. We see reducing polypharmacy and antipsychotic stewardship as integral to this mission for these very reasons.
Drug reactions and interactions
The elderly are at heightened risk for adverse drug reactions and drug-drug interactions, Chippa and Roy explain. This is the basis for development of the Beers Criteria®, which identifies medications that are potentially inappropriate for older adults or need to be used with caution/adjustments for the older population.
They advise using tools such as the Beers Criteria and reducing “medication over-prescription” as part of a person-centered approach to geriatric care. Deprescribing, carefully managed, can be part of the individualized solution to polypharmacy. They caution against a “prescribing cascade,” in which a medication is prescribed to counter the side effects of another medication.
Reducing polypharmacy
It is clear that reducing polypharmacy can be important to optimizing cognitive and physical well-being. As a starting point, Chippa and Roy point to the value of comprehensive geriatric assessment, which includes neurology as well as psychological and psychiatric assessment, an in-depth evaluation of comorbidities, and a thorough medications review. GuideStar Eldercare introduced bedside neurology services for nursing homes, recognizing dementias as neurodegenerative brain diseases that benefit from neurology-forward assessment and care.
Assessment is especially important in planning for antipsychotic reduction in dementia care. “A comprehensive assessment considers medications as part of the neurobehavioral picture; this can help practitioners develop accurate diagnoses,” explains the GuideStar blog, Reducing Polypharmacy in Dementia Care. In turn, diagnosis drives treatment.
The GuideStar team offers nursing homes integrated neurobehavioral health services, along with an evidence-based model for antipsychotic stewardship. We can help you implement comprehensive care for your nursing home residents to reduce polypharmacy, reduce use of antipsychotics, and improve clinical outcomes. Get in touch to chat with us about your goals.