When older people hospitalized for heart failure are sent home, they are often given a whopping 10 medications to take for a variety of conditions. But is this "polypharmacy" practice necessary, or does it just place a bigger burden on already frail patients?
It's not a question so much of the quantity of the medications, but whether the medications patients are taking are the right ones for them, said senior study author Dr. Parag Goyal, a geriatric cardiologist at NewYork-Presbyterian in New York City.
"It's not just that we're not starting the right medications, there may be situations where we're not stopping the wrong medications as well," Goyal said. "I think we need to look at the medication that older adults with heart failure take in a more holistic fashion."
For the study, Goyal's team examined the medical charts of 558 adults aged 65 and older who were hospitalized in the United States between 2003 and 2014.
When admitted, 84% of the patients were taking five or more medications and 42% were taking 10 or more. When discharged, those numbers had risen to 95% of patients prescribed five or more medications, and 55% taking 10 or more. Most of the prescribed medicines were not for the patients' heart failure or heart conditions, the researchers said
A larger medication burden increases the risk of adverse drug reactions, which could lead to patients ending up in the hospital, Goyal explained. It can also require more work for the patient, which can have an impact on quality of life.
"It's a big challenge," Goyal said. "How exactly do you reconcile the fact that a lot of these medications are meant to prevent events and to help patients feel better with the concept that as the number of medications rise, you might be negatively affecting these parameters?"
The study found that about 90% of older adults with heart failure have at least three other medical conditions. More than 60% have at least five other conditions.
The findings were published online Oct. 13 in the journal Circulation: Heart Failure.
The researchers concluded that there is a need to develop strategies that can alleviate the negative effects of polypharmacy. Among the drugs that may be overused are proton-pump inhibitors, which reduce stomach acid. There are a host of medications patients may have been taking for years that could be reviewed, Goyal noted.
However, the study suggested that the benefits of medication may outweigh the risks of polypharmacy for people with certain conditions, including chronic obstructive pulmonary disease (COPD) and diabetes.
Some medications already are multipurpose, including one that treats diabetes and heart failure, said Dr. Gregg Fonarow, chief of the University of California, Los Angeles, division of cardiology.
"That doesn't mean there are not some medications that are not necessary and could be either reduced or consolidated, but that for patients with heart failure that have a number of other comorbid conditions there are a number of medications that are proven in randomized trials, proven in clinical effectiveness studies -- including in patients above age 65 -- to where the greater the number of medications patients are on, the better the clinical outcomes," Fonarow added.
Among the conditions that are common in heart failure patients are diabetes, COPD, and atrial fibrillation (an irregular heartbeat), said Fonarow, who was not involved with the new study.
"These patients have many other comorbid conditions that if left untreated would leave them at risk for complications," he added.
The American Heart Association defines heart failure as "a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen."
About 6 million Americans have heart failure. It's one of the most common reasons that individuals aged 65 and older are hospitalized, Fonarow said, and it has a high mortality rate.
Goyal noted that a patient's doctors -- from primary care physicians to specialists -- should make time to review the patient's medications to determine if they're all still needed.
Goyal said he will be developing a shared decision-making approach for optimizing medications in older adults with heart failure, a five-year project recently funded by the U.S. National Institutes of Health.
"I think it's important to reconsider and review medications on a regular basis to ensure that a medication that was previously prescribed is still the right medication," Goyal said.