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POLYPHARMACY
The more medical conditions an individual is diagnosed with, the more medications that individual is likely prescribed, and the greater the risk of drug interactions and side effects due to polypharmacy. The elderly and, in particular, individuals with intellectual and developmental disabilities are more susceptible to medication misadventures that the general population. One thing to keep in mind is that when a drug is approved by the FDA, it has been tested on only a relatively small number of people. It is not until later (post marketing surveillance) that many of the side effects and drug interactions are discovered.
The practice of polypharmacy (having been prescribed multiple drugs from one or more classes of medications for one or more diagnoses, often resulting in duplication of therapy and unintended side effects) has been increasing in prevalence in the treatment of individuals with dual diagnosis (IDD and Mental Health Disorder).
Individuals with intellectual disabilities have complex pharmaceutical care needs due a high prevalence of multimorbidity. Patients may be seeing primary care providers as well as specialists in psychiatry, neurology and others. It is likely that each practitioner is prescribing multiple medications for each individual. Polypharmacy results in a high prevalence of adverse drug reactions for those at risk.
In addition to healthy lifestyle and proper diet, medications are essential for managing the health-disease process. Prevention is key to not getting sick, while drug therapy is the main therapeutic resource to cure and control diseases. Safe medication use involves maintaining a balance of risks versus benefits and often leads to adverse drug events. Currently, the use of multiple medications is a problem, especially with the continuous introduction of new medications into the marketplace.
The worldwide epidemiological profile has been changing over the years. We are no longer succumbing to acute pandemics. Instead, we are living longer, resulting in the population’s aging and consequently in the predominance of non-communicable chronic health conditions and related complications arising from the aging process, which in turn increase the need for multiple treatments. Complexity of the medication regimen is an independent risk factor for missed doses, errors in drug administration, side effects and drug interactions (Erickson, 2017).
The use and overuse of antipsychotic medications in individuals with IDD is another parameter that needs to be monitored. Medication regimen reviews for IDD clients in the community should be conducted on a monthly basis (although there is not a law or regulation that requires this at the community level) as they are (by federal mandate) in the long-term care setting. It is not uncommon for prescribers or caregivers to utilize sedating medications as chemical restraints. In the long-term care setting, such as nursing homes, consultant pharmacists formally patrol for the use of chemical restraints. In the community at large, however, there are no such protectors.Individuals with IDD live in the community either with their families or more commonly, under community living arrangements (CLA). However, it is common for IDD individuals, especially those with dual or multiple diagnoses, to be under the care of multiple prescribers including, PCP, psychiatrists and neurologists, each with their prescription pads at the ready.
Additionally, frequent emergency rooms visits, and subsequent hospital admissions are the norm. Emergency rooms are revolving doors and it is unlikely that a full medication reconciliation and screening will be conducted by the ER staff who are already running in circles. Family members and caregivers, including DSPs, should be on high alert to recognize any potential medication related side effects such as excessive drowsiness or frequent falls, especially since the individuals may not be able to properly communicate their symptoms.Once hospitalized, it is unlikely that the patients’ PCP will make rounds, but rather the patient will be tended to by various hospitalists on rotating shifts, who will probably never see the patient again after discharge. Upon discharge, yet another set of medications will be prescribed, often with no communication with the client’s PCP and specialists. Meanwhile, drug interactions and side effects are often the underlying reason for the hospital visit in the first place. Hopefully, there will be a proper medication reconciliation, where pre-admission medications are compared to in-house medication regimens and to discharge medications. Medication reconciliation provides the clients, families and outside doctors and pharmacies with some type of guidance regarding which subset of the old medications to discontinue, which meds to continue and which new medications need to be started.
Persons with IDD are typically cared for in the primary care setting (where overprescribing is already the norm) and are on twice as many medications as those without IDD (Erickson, et al.) There are not enough primary care providers out there to spend adequate time on prevention and a typical doctor visit lasts less than 15 minutes. Primary care doctors, like everyone else, are overworked and stressed out by managed care. IDD may not be able to effectively communicate any potential adverse reactions and/or medication side effect to their providers. In many cases, the treatment for one disease state induces another disease state (or symptoms that mimic another disease state) that necessitates even more medications being prescribe. We end up in a vicious cycle of polypharmacy and side effects with still more drugs being prescribed to combat the side effects of the previously prescribed drugs.
Direct support staff must be trained to observe and report any unusual signs and symptoms on behalf of their clients. Practitioners must assess the risk versus the benefit of each medication before choosing what medications to prescribe. Practitioners should also be willing to deprescribe any medications that are producing adverse drug reactions or simply do not have a supporting diagnosis. Compliance packaging, also known as adherence packaging, means that you put all the drugs a patient takes in one package—either blister packs or pouches—to help them be adherent to their drug regimen. You organize the drugs by dose, days of the week and time of day that the patient takes them. That makes it easier for the patient to take the right drugs at the right time.
Direct support staff must be trained to observe and report any unusual signs and symptoms on behalf of their clients. Practitioners must assess the risk versus the benefit of each medication before choosing what medications to prescribe. Practitioners should also be willing to deprescribe any medications that are producing adverse drug reactions or simply do not have a supporting diagnosis. Compliance packaging, also known as adherence packaging, means that you put all the drugs a patient takes in one package—either blister packs or pouches—to help them be adherent to their drug regimen. You organize the drugs by dose, days of the week and time of day that the patient takes them. That makes it easier for the patient to take the right drugs at the right time.
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