Hidden polypharmacy: a story waiting to be told?
We often talk about the problems of older people with multiple chronic conditions, especially the issues that arise from using several medications, a situation known as polypharmacy. As I have written before, this has potential to cause problems if the medications interact or cause side effects. There are also more practical problems. Storing multiple medications at different temperatures or humidities is not easy. Remembering what to take and when can also be a challenge. People may struggle to ensure that they don’t run out of any particular medication, and that all their medications are within their use-by date.
Unearthing a hidden problem
However, there is also another problem. When we talk about polypharmacy, we often assume that it only applies to older people. They are, after all, the group most likely to have several conditions, and need multiple medications — aren’t they?
In sheer numbers, the answer is probably yes. However, older people are not the only people who may be affected by polypharmacy. What’s more, when we assume that polypharmacy is an ‘old people’s problem’, we limit how we think about the problem, and the solutions that we develop. Other groups that may be affected by polypharmacy include:
· Psychiatric patients
Psychiatric patients may take multiple medications for two main reasons. First, mental health conditions often have similar symptoms, making it harder to make a single diagnosis. Second, other medications may be needed to fill gaps in the effects of a primary medication, or treat side effects such as nausea. It may also be difficult for this group to manage medication generally: studies have shown that treatment adherence is often a real problem in mental health patients.
· Cancer patients
Cancer gets a lot of press, but the experience of cancer patients paradoxically can sometimes be lost in healthcare. We do not seem to have fully adjusted the narrative from ‘terminal illness’ to ‘long-term condition’ or ‘survival’. Early in their treatment journey, cancer patients are likely to need multiple chemotherapy agents, and possibly other medication to deal with the side-effects of these drugs, such as nausea. Later, they may need medication to manage the long-term effects of either the cancer or its treatment.
· End-of-life patients
End-of-life care for terminal illness is often associated with cancer, so it makes sense that polypharmacy may also be an issue at this stage. Here, ongoing palliative cancer management may crossover with painkilling drugs, and other medication for separate conditions. This is likely to be a particularly difficult stage for families anyway, for obvious reasons. The addition of hospital or hospice care may make storing and managing medications an additional and unwanted challenge.
· Children with complex health conditions
Fortunately, there are not large numbers of children with complex acute or chronic health conditions. However, those children are likely to be on multiple medications, with the added complication of changing drugs and doses as they grow. Keeping track of what is needed is not a challenge for the faint-hearted. This task often falls to their parents, who are also likely to be caring for other children and working. The added complication with children is how to manage medications at school or other education provision, whether in hospital or out.
· Patients who have undergone surgical procedures
The final group of patients who may experience polypharmacy are those who have undergone surgery. They may be on different painkillers, immunosuppressants, especially for certain surgeries, and antibiotics to prevent infection. The timing of when to take each drug may be crucial. It is likely to be especially difficult for surgical patients to manage multiple medications because this is a short-term but very immediate need. They are unlikely to want to spend a lot of money on a physical solution if they only need it for a short period.
Telling different stories
All these groups are very different. The causes of their polypharmacy vary — both within and between groups — and those involved will have different issues. Is it therefore possible to find a single answer to managing polypharmacy? Medicine reviews and deprescribing are certainly part of the answer. Solutions to both physical storage and adherence are also needed. To work best, these need to be relatively broad, but operate flexibly.
This would allow people to opt into the elements they want, building a personalized solution — and that, for me, is key. We need to help people to take back control of their health by tailoring solutions to their situation — not try to provide a one-size solution that fits nobody.
