Polypharmacy and its Impact on Drug Concordance

This essay discusses the challenges and impact of polypharmacy on drug concordance in older adults. It examines the pharmacological processes associated with each drug prescribed to a patient and the challenges faced by nurses in drug administration and polypharmacy adherence. The essay also provides insights into nursing management strategies and the nurse's responsibility in safe practice.

Running head: PHARMACOLOGY
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Introduction:
Polypharmacy is a major concern for older adults as they need to use multiple medications due to
increase in age-associated illness. It presents many unique barriers and challenges for older adults in
managing multi-drug regimen because of cognitive impairment, functional limitation and financial
constraints. The most potential issue for older adult is that it has significant impact on medication
adherence (Patton et al. 2017). Multi-morbidity and polypharmacy in older adult is associated with
challenges like increase in treatment burden, poor quality of life, adverse drug event, poor medication
adherence and additional health care expenditure. It increases challenges for the health care
professionals in optimising medication related aspect of care. Dealing with unnecessary adverse outcome
is a common issue for health care staffs. Inability to meet the responsibilities increases workload pressure
in the hospital too (Namara et al. 2017). This essay will use the case study of Connie Cooper to discuss
about polypharmacy and its impact on drug concordance. The case study is about Connie Cooper, an 83
year old patient with multiple morbidities. This essay will critically examine the challenges associated with
Connie’s polypharmacy by discussing about pharmacological processes associated with each drug
prescribed to her and the challenges faced by nurse in drug administration and polypharmacy adherence.
The essay will also provide a critical insight into nursing management strategies related to polypharmacy
and medication adherence issue and discuss nurse’s responsibility in engaging in safe practice while
providing care to Connie.
Pharmacological processes:
Connie Cooper has been recently admitted to hospital after falling in her bathroom. Although she
suffered no injuries, however she experienced symptom of dehydration, dyspepsia and uncontrolled pain
in the spine and pelvic region. After her admission, she has been prescribed multiple drugs like Fentanyl
transdermal patch, aspirin, Naproxen, Tramadol, Furosemide, Ramipril, Zipiclone, Tamoxigen and many
other drugs. The drug has been provided based on her current symptoms and review of past medical
history such as dyspepsia, osteoarthritis, constipation, depression, hyperlipidemia and type 2 diabetes. As
so many drugs are being prescribed to Connie, the chance of drug-drug interaction and adverse effect is
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high. Hence, examining pharmacokinetics and pharmacodynamics of few drugs can give idea regarding
how some of the drugs could create actual or potential issues for Connie.
Fentanyl transdermal patch has been prescribed to Connie to relieve pain. Although Fentanyl is a
pain reliever, the review of medications prescribed to Connie also shows that several other analgesics or
pain reliever has been prescribed to her, which includes paracetamol, aspirin, tramadol and Diclofenac.
Aspirin is an analgesic mostly given orally to relieve pain, fever and elimination. The pharmacokinetics of
the drug suggests how quickly the drug is absorbed, distributed and eliminated from the body. The drug is
absorbed in the gastrointestinal tract and distribute to all tissues of the body. It breaks downs into
salicyclic acid and ultimately excreted by kidneys. The half life of the drug is 15-20 minutes. The
pharmacodynamic or action of the drug is seen by inhibition of prostaglandin synthesis (Russo, Petrucci
and Rocca 2016). Some of the side-effects of aspirin include drowsiness, headache and adverse effect
includes allergic reactions such as breathing difficulty and swelling of face (Cook and White 2016). To
promote safety of Roger, it is necessary to review aspirin’s interaction with others drugs. Aspirin is known
to interact with angiotensin-converting enzymes (ACE) inhibitors, anticoagulants, betablockers and
NSAIDs (Russo, Petrucci and Rocca 2016). This means that Connie should not be provided any of the
above mentioned drugs to prevent complication and promote safety of client. However, Diclofenac is an
NSAID drug that has been found in the medication regimen of Connie. Not considering drug-drug
interaction before prescribing this medication to Connie could lead to risk of gastrointestinal ulcers and
bleeding. Hence, prescribing both the medication together was not appropriate.
For the purpose of pain management, it has been found that multiple medications have been
prescribed to Connie. Use of fentanyl is justified as Connie is a patient with breast cancer and Fentanyl is
widely used in breast cancer patients. The drug acts by targeting opioid receptor system localized in the
brain and those neuroanatomical structures that are known to control emotions and pain. This further
activates the Mu-receptor leading to analgesia. The release of dopamine elicits relaxation effects to
patient (Sharma et al. 2016). Hence, use of Fentanyl for pain management is considered appropriate for
Ms. Connie. However, the review of the drug-drug interaction and synergism of Fentanyl suggest another
risk for Mrs. Connie. Fentanyl is known to interact with drugs that inhibit CYP3A4. The review of multi-
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modal pain medication of Connie reveals that Tramadol and ramipril is also a CYP3A4 inhibitor
(Kotlinska-Lemieszek, Klepstad and Haugen 2015). Hence, prescribing both this together without
considering synergism of drugs can lead to harmful consequences for Connie. It may lead to risk of
overdose as well as symptom of opioid toxicity such as sedation, dizziness and troubled breathing ( Rickli
& Liechti, 2016). Her symptom of dizziness might be an implication of drug-drug interactions too. Hence,
another case of drug-drug interaction has been identified and it is critical that nurses consider the
medications regimen again before administering the entire drug to Connie. Multiple medications for pain
management might be harmful considering synergistic effect of different drugs prescribed to her. Her
current symptom of uncontrolled pain is also attributed to multiple drug regimen because Fentanyl is
metabolised by CYP3A4 isoenzyme and drug that inhibit CY3A4 can significantly increase the level of
Fentayl leading to adverse symptoms such as sedation. As tramadol is one of the CYP3A4 inhibitor, use
of both medications together raised fentanyl level and toxicity leading to confusion ( Kuip et al. 2017).
Hence, the reason for intermittent confusion by Connie is understood from the pharmacokinetics of pain
medication.
Apart from pain medication, list of other medications that has been prescribed to Connie included
Gaviscon, Furosemide, Fluoxteine, Simvastatin, Tamoxifen, senna, Zopiclone and ramipril. Zopiclone
has been prescribed in response to insomnia as it is a sedative hypnotic used for relief of sleep
disturbances. Connie had been suffering from insomnia one week ago and so this medication has been
prescribed to her. Zopiclone is a hypnotic agent whose action is dependent on the binding of the
benzodiazepine receptor complex and the GABAZ receptor chloride channel. The drug acts at the
benzodiazepine binding site to implement therapeutic effect. The drug is rapidly absorbed following oral
administration and metabolized in liver. The elimination half life of the drug is 5 hours (Hjelmeland et al.
2017). The side effect of the drug includes dizziness and impaired coordination which can increase risk of
fall in elderly people. As Connie is 85 years old and she has been prescribed this medication, the side
effect of zopiclone might be the reason for her fall. Treves et al. (2017) evidence suggests that Zopiclone
is not favoured for long-term treatment of insomnia as it increases risk of fall. The medication is known to
induce drowsiness, impair gait and deteriorate cognitive function. Research studies have shown adverse
effect following treatment with Z-drugs such as falls, traffic accident and increased mortality ( Treves et al.,
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2017). The risk is high for elderly patient because renal clearance of this medication is slow in elderly
patient. Although Connie has been given a lower dose, side-effect of other drug contributed to dizziness
and fall for her.
The review of possible interaction with drugs also suggests that zopiclone should not be
prescribed with antipsychotic drug. Connie was prescribed Fluoxteine and St. John’s wart because of
history of depression and treatment of depression. Both Fluexetine and St John’s are anti-psychotic
medications which are known to have interaction with Zopiclone. Zopiclone is known to interact with
selective serotonin reuptake inhibitors (SSRIs) and flouxetine is a class of anti-depressants which belongs
to SSRIs. Hence, before prescribing zopiclone, it was necessary to assess whether Connie is taking anti-
depressant or not. However, this was not done and this might be the reason behind additional
complication for the client. She was continuing with almost all medication based on her multi-morbidity.
The major limitation in the medication regimen is that Connie has been prescribed too many medicines
without considering possible drug-drug interactions. Some of the drugs should have been discontinued to
minimize adverse effects and health complications for Connie.
Dyspepsia or impaired indigestion was also one of the symptoms for Mrs. Connie. Medications
like mucogel and Gaviscon were provided to Connie mainly because of dyspepsia. Both are antacids
used to treat stomach upset and indigestion. Gaviscon provides fast acting relief from indigestion. It is a
combination of two antacid and alginate. After ingestion of gaviscon, the drug reacts with gastric acid to
form a protective barrier of alginic acid gel. This has a neural pH and the gastroephageal reflux continues
upto 4 hours. As the mode of action of the drug is physical, the quick action of the drug is seen because
of the lack of dependence on absorption process. However, since gasviscon is a fast acting medicine, the
use of mucogel should have been considered further. Apart from antacid, senna has also been prescribed
to Connie for constipation. However, therapeutic efficacy of the drug is reduced due to interaction with
several drugs like Furosemide and the risk of adverse effect increased. Hence, considering multiple drug
use to cure constipation and indigestion problem was necessary. Dependence on polypharmacy has
contributed to more risk than health benefit for patient.
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Medicine management:
Based on the review of Connie’s medication and the pharmacological process associated with the
drugs, it has been found that Connie’s current symptom of confusion, dizziness and incidence of fall has
occurred because of polypharmacy and drug-drug interaction effect. Polypharmacy can also impede
Connie from adhering to the medication regimen. Hence, in this scenario, nurse’s role in safe
administration of medication and management of polypharmacy is important. The first responsibility of a
nurse will be to follow the six rights of medication administration to ensure that right client, right route,
right, right dose, right time and right documentation is maintained. This would involve first asking the
name of patient and then match it with the patient’s chart. The second step will be rigorous as Mr. Connie
has been prescribed long list of medications. As polypharmacy is a major risk for elderly patient,
medication review before drug administration will be important to understand side-effects of each drug
and avoid medications which could deteriorate condition of patient.
Based on nursing assessment related to polypharmacy, many professional issues have been
identified for Mrs. Connie. Firstly, the review of pharmacokinetics, side-effects and drug-drug interaction
of medications prescribed to Connie revealed that drug-drug interaction was the reason behind fall and
mild confusion in client. For example, multiple medications were prescribed for pain management and
drug-drug interaction for these drugs revealed that providing these drugs at the same time was not
important. For example, not considering drug-drug interaction and effect of pharmacokinetics of the drug
on elderly patient was the major limitation in pharmacological regimen. For example, aspirin was found to
interact with Diclofenac and Fentanyl was found to interact with Tramadol. As continuing with this drug
would lead to opioid toxicity and symptom overdose, it will be critical for nurse to remove those pain
medications which lead to complications for Mrs. Connie. Aspirin and Tramadol should be removed to
minimize adverse reaction. Continuing with Fentanyl will be important as Mrs. Connie is a breast cancer
patient and Diclofenac is also important as part of pain management medication as osteoarthritis is also
an issue for the client. Evidence shows that Diclofenac is the most effective NSAID drug to reduce
osteoarthritic pain (Taylor 2018). Hence, continuing with Diclofenac as a pain management medication
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will be important. This form of nursing assessment is beneficial in identifying inappropriate polypharmacy
for client and takes adequate step towards risk reduction.
Another vital responsibility for nurse before prescribing the medications to Mrs. Connie is to make
Connie aware about side-effects and possible precautions needed while taking each medications. This is
necessary to avoid future risk of fall and adverse event for patient. For example, opioid toxicity and drug-
drug interaction was identified as a reason behind fall as this leads to symptom of sedation and dizziness
in patient. These side-effects were not considered before prescribing the medications to Connie.
Diclofenac is a medication that will be continued for Mrs. Connie and the main side effect of this drug
includes dizziness, rashes, constipation and pain. Hence, nurses have the responsibility to make patient
aware about possible side effects and educate them to immediately report about such symptoms to
patient. As zopiclone also increase risk of fall for elderly, considering the dose of drug and the need for
continuing with the drug will be important too (Treves et al. 2017). After the administration of medication,
the vital responsibility of the nurse will be to analyse changes in vital parameters of patient and prevent
any major complications for patient. To avoid risk of fall, environmental modifications such as using bed
railing and providing walking support is also necessary.
Nursing Care, Safe practice and the nurse role:
As Mrs. Connie’s current symptom has emerged because of issues related to polypharmacy, the
nursing care strategy that is important for nurse is to continue only with those medications that are
important currently for patient and support patient to reduce barrier to medication adherence. Medication
adherence will be one major challenge for Mr. Connie because she has been prescribed long list of
medication due to multimorbidity and developing appropriate care plan for medication adherence would
promote health of patient. Pain management medications were not appropriate for Connie as many
medications with drug-drug to interaction was prescribed and multiple medications could further lead to
medication non-adherence. Zelko, Klemenc-Ketis and Tusek-Bunc ( 2016) also states that polypharmacy
correlates with increased risk of adverse drug reactions aand drug-drug disease interactions. It could also
lead to suboptimal thepeutic effectiveness and poor clinical response. Hence, identifying and mitigating
barriers to medication adherence should be nursing care priority.
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Hence, the first nursing care priority is to cut down the list of pain medications based on
pharmacokinetics and drug-drug interaction analysis of each drug. This is because polypharmacy
resulted in symptom of dizziness and risk of fall for client. The second weakness was that no precaution
or extra education was given to patient to avoid adverse event. Hence, the second nursing care priority
will be to make appropriate plan to ensure that Mrs. Connie continue with the prescribed medication at the
scheduled time. To promote adherence, it will be important to teach patient about each medication, the
adverse effects and drug-related problems that would require emergency care. Mrs. Connie can also be
provided a written factsheets and verbal advice regarding the importance of adhering to medication
schedules. A separate bag can be developed with timing so that Mrs. Connie can take all the drugs
needed at specific time of the day. Electronic devices can be used to take note about the schedule of
each drug and accordingly remind Mrs. Connie regarding taking her medications on time ( Verloo et al.
2017).
Dyspepsia was another immediate health issue for Mrs. Connie. Two medications were
prescribed to the client for management of Dyspepsia. This included mucogel and Gaviscon. As elderly
patient requires multiple medications, considering drugs that could aggravate situation of elderly is
important. Drugs like aspirin and NSAID drugs can aggravate situation of patients. Hence, NSAIDS and
aspirin should be removed from medication regimen. This action is part of safe practice too as this form of
evaluation helps to mitigate any risk to Connie because of multiple medications. The NMC code ofpractice
also mentions that nurses should maintain the knowledge and skills needed for safe and effective practice
and make sure that everyone is adequately supported to provide safe care (Nursing and Midwifery
Council (NMC) 2015). As a responsibility to provide safe practice, the nurse can take the step to provide
only a single antacid instead of two or three medicines together so that issues related to polypharmacy is
reduced. However, Gaviscon is considered beneficial for Connie as it eliminates the toxic side-effects
occurring in patient after taking antacids. This form of critical thinking and decision making skills can
promote safety of Mrs, Connie and lead to therapeutic effectiveness too.
As part of accountable and safe practice, it is also critical for nurses to follow the six rights of
medication administration and take consent from patient regarding the administration of medication.
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Medication management is effective in ensuring that medication order is for the right patient and the
medication match the order. In addition, considering dosage and frequency of each medication is
important for Connie due to different rate of clearance of drug in elderly. In addition considering
appropriate route of each drug for Connie would ensure that the patient does not face any issue during
drug administration and no risk of medication administration related errors take place. For nurses,
collaboration between multi-professional teams like physician, pharmacist and dieticians will also be
important to understand the possible diet needed for elderly patient and reducing issues occurring due to
polypharmacy such as loss of appetite, gastrointestinal problem and weight changes. Ramgoolie and
Nichols (2016) suggest that nutritional evaluation is necessary for elderly patient as the probability of
nutritional problem as a result of multiple drug is highest in elderly people. Hence, collaboration with
dietician would help to ensure that right diet is provided to Connie for her health and safety.
Conclusion:
To conclude, it can be said that polypharmacy was a reason for immediate symptom of dizziness
and risk of fall in Mrs. Connie. The review of pharmacological processes associated with the use of each
drug revealed that pain management medications provided to Connie was not appropriate as the drugs
were prescribed without considering drug-drug interaction and pharmacokinetics of each drug. For
example, Fentanyl was found to interact with tramadol, aspirin had interaction with NSAID drug like
Diclofenac and these interactions were the reason for toxicity and adverse side-effects of each drug. The
report suggested using six rights of medication administration and conducting nursing assessment of pre
drug administration to ensure that side-effects are managed and possible risk is reduced. Accountability
and collaboration between multi-professional team has also been suggested to eliminate risk for patient.
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Zopiclone concentrations in oral fluid and blood after, administration of therapeutic doses of
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