Population Care

Senior doctor wants to protect older adults from polypharmacy

Timothy M. Smith , Contributing News Writer

It’s safe to say Americans take a lot of prescription medications. And herbal supplements. And over-the-counter (OTC) drugs. And while few studies have looked at the effects of polypharmacy—taking five or more medications concurrently—on health-related quality of life and psychological distress in patients with chronic disease and multimorbidity, we do know that, as recently as 2019, more than one-fifth of U.S. adults 40–79 had taken five or more medications in the previous 30 days.

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For one physician, the evidence of polypharmacy has been around for years.

“In my clinical practice, I have been amazed by the number of medications—and OTC meds and herbs—that some of my patients have in their possession, and I suspect that is true for the majority of practicing physicians,” said Tom James III, MD, a board-certified internist and pediatrician in Louisville, Kentucky. “I have admitted more patients than I would like who’d had adverse drug events, frequently due to their confusion over all their medicines.”

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One of the problems is physician training, Dr. James noted.

“We physicians have all been taught how to add medications, but we haven’t been taught how to subtract them,” he said.

But polypharmacy hasn’t just been a worry for Dr. James in his role as a practicing physician; it has also been a concern for him in his role as a payer. Besides seeing patients at a community health center on the weekends, he is the chief medical officer for Passport Health Plan, a Medicaid plan operated by Molina Healthcare in Kentucky.

“If people don't have as many side effects, there should be cost savings to that,” he said.

Another impediment is that while some EHRs are set up to automatically screen patient medication lists for incompatibilities, they may not include supplements and over-the-counter medications, and self-reporting is often unreliable, especially when a patient is experiencing cognitive decline.

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Until recently, Dr. James wasn’t sure how to take his work on this issue to the national level. That changed when he was invited to submit ideas for policy resolutions by the AMA Senior Physicians Section (AMA-SPS), one of a dozen AMA member groups.

AMA-SPS members approved of his initial presentation, so he reached out to AMA-SPS Delegate Louise Andrew, MD, in April for help in crafting a resolution that would go before the AMA House of Delegates.

The AMA already had policy on improving the quality of geriatric pharmacotherapy, supporting safe medical products as a priority for public health, geriatric medicine and national health information technology, but had nothing yet that spoke specifically to polypharmacy.

Dr. James’ resolution, with only a few small modifications, was debated at the 2022 AMA Annual Meeting in Chicago. Then it was adopted.

“How gratifying that my thoughts were not only welcomed but supported by colleagues from all over the country and then by the AMA itself, and that I may have helped improve the safety and health of our patients,” he said.

The policy delegates adopted, “Reducing Polypharmacy as a Significant Contributor to Senior Morbidity,” directed the AMA to work with appropriate stakeholders such as pharmacists, EHR vendors, PhRMA and AARP, to:

  • Educate patients about the significant effects of all medications and most supplements.
  • Encourage physicians to teach patients to bring all medications and supplements or accurate, updated lists—including current dosage—to each encounter.
  • Encourage physicians and ancillary staff if available to initiate discussions with patients on improving their medical care through the use of only the minimal number of medications—including prescribed or OTC, including vitamins and supplements—needed to optimize their health.
  • Address the continuing problem of inaccuracies in medication reconciliation and propagation of such inaccuracies in electronic health records, and to include nonprescription medicines in medication-compatibility screens.
  • Include nonprescription medicines and supplements in medication lists and compatibility screens.

Learn more about the AMA Senior Physicians Section, which gives voice to—and advocates for—issues that affect physicians 65 or older, both active and retired.

Table of Contents

  1. Less can be more
  2. Making it real