What is Geriatric Cognitive Decline and Polypharmacy?
As we age, health problems tend to increase and our bodies undergo various functional changes, leading to a weakened ability to maintain internal balance. Aging can also change our body composition, meaning that fat-soluble medications can have a greater effect. Further, the ability of our body to remove multiple medications is reduced. These changes can increase the risk of negative reactions to commonly used medications. Polypharmacy, or the use of five or more drugs at the same time, can also occur more often as we age.
Mild cognitive impairment (MCI) is a condition where a person experiences a greater decline in cognitive abilities, such as thinking and memory, than expected for their age and educational level. This doesn’t majorly affect daily activities. However, dementia is more severe and wide-spread, significantly affecting daily functions. Studies have shown that most people with MCI eventually develop dementia or Alzheimer’s disease. People with MCI are three to four times more likely to develop dementia compared to those with normal thinking and memory abilities.
Polypharmacy can sometimes be appropriate, but it can also be inappropriate. Inappropriate polypharmacy can include over-the-counter medications and supplements where evidence supporting their use is lacking, and can interact with other medicines to cause more harm than good. The risks of polypharmacy in older adults can include side effects, depression, disability, falls, frailty, increased use of healthcare services, post-surgery complications, increased death rate, and higher caregiver workload.
Being on multiple medications can lead to interactions between medications and illnesses, which is a problem with polypharmacy in older adults. Overtime, the continued use of multiple medications can lead to new health problems that require even more medications. This can create a harmful cycle making older people weaker and more dependent on others, and can increase the likelihood of disease and death. A study conducted in Italy found that adults with MCI who took more than three medications a day had a higher risk of developing dementia.
Using certain types of medications, including those that block or inhibit the nervous system (anticholinergic drugs), are strongly associated with cognitive impairment. Older adults using these type of drugs had a noticeable decline in memory, motor skills, and cognitive flexibility in comparison to those who did not use these drugs. This effect was strongest in individuals carrying a certain risk gene for dementia.
Research has shown that physical frailty and cognitive impairment are closely linked. A study found that physically frail older adults without dementia and depression have poor scores on cognitive function tests. Current evidence suggests that chronic inflammation, changes in energy metabolism, oxidative stress, and mitochondrial dysfunction (the powerhouse of the cell not working correctly) can contribute to cognitive decline in physically frail individuals. The combined condition of physical frailty and cognitive impairment has been named mental frailty, which is associated with increased death rate. Frailty and cognitive decline are linked with a higher frequency of falls and further physical injuries.
What Causes Geriatric Cognitive Decline and Polypharmacy?
Certain factors can increase the risk of mild memory or thinking problems (also known as mild cognitive impairment) related to taking a high number of different medications (polypharmacy). These include being over 65, having multiple health issues such as high blood pressure, diabetes or obesity, having a specific gene (Apo ε4), a history of strokes, having low income or education levels.
The more medications a person takes, the greater the chances of unexpected interactions between the drugs and side effects. This can lead to reduced mental or physical abilities. As people age, their bodies change, and this combined with the prolonged use of multiple medications makes older people more likely to experience significant mental and physical decline.
Older adults with several health conditions are at a higher risk of negative reactions to drugs and drug interactions due to changes in their bodies as they age. Many older adults see different specialists and might pick up medications at various pharmacies. The complex and fast-paced changes in their healthcare provided by several medical professionals across different locations can lead to polypharmacy and unwanted outcomes.
Certain medications, including benzodiazepines, anticholinergics (drugs that block a certain neurotransmitter in your body), antipsychotics, antidepressants, and opioids, can affect memory and increase the likelihood of frailty in older adults. Therefore, it’s important that healthcare providers regularly communicate with patients and their families. This can help identify any potentially harmful medications and play a major role in reducing polypharmacy and its complications.
Risk Factors and Frequency for Geriatric Cognitive Decline and Polypharmacy
There has been a rise in the proportion of people above 65 years old in the United States taking five or more prescription medications, from 24% to 39%, between 1999 and 2012. On average, nursing home patients have to take up to eight different medications, and unfortunately, medication errors tend to happen in two-thirds of such cases. This use of multiple medications in elderly is known as geriatric polypharmacy. It often leads to more visits to healthcare providers, higher medical costs, and challenges with sticking to medication schedules. It can also lead to a decline in the person’s ability to function.
In future projections, the number of individuals older than 65 in the US is predicted to reach 72.1 million by 2030. This is more than twice the number of such individuals that existed in the year 2000. Although making up only about 15% of the total US population, people of this age group account for 30 to 35% of the usage of prescribed and over-the-counter medications. By the year 2030, it’s predicted that the population of those aged 65 and above will constitute 20% of the US population and will contribute to half of the healthcare costs.
The current figures suggest that out of every 100 seniors above 65 years, anywhere from 8 to 78 of them use multiple medications, indicating a significant public health concern. Consequently, seniors in the US are the largest consumers of medications.
Signs and Symptoms of Geriatric Cognitive Decline and Polypharmacy
When assessing older adults, it’s crucial to gather comprehensive information about their physical and mental health. This should involve multiple sources and include talking about their usual functioning levels, their current symptoms, and their medical history. Some important details to look out for include their ability to walk, any recent weight changes, and feelings of tiredness. Use the Charlson comorbidity index to gauge the severity of their health conditions. Also, make sure to check their nutrition including factors like their self-care, feeding habits, sleep quality, ability to take medicines, and weight maintenance. If possible, also try to get information from the patient’s family members.
For a detailed physical check-up, pay attention to their vitals, the condition of their skin, and their head and neck, including their oral cavity. Examinations should be tailored to their organ systems, including respiratory, cardiovascular, genitourinary, musculoskeletal and neurological checks, along with a mental status examination. Don’t forget to include checks for vision and hearing as these can become problematic as people age.
Cognitive impairment, which includes conditions like Alzheimer’s, is common in older adults. However, it can also be due to other factors like medication side effects, endocrine or metabolic problems, infections causing delirium, and depression. Identifying the cause of cognitive decline is crucial as it helps treat the underlying problems, manage other health conditions, provide the necessary support services, and plan for long-term care. If cognitive decline is spotted early, it can be helpful to involve behavioural health specialists who can provide tools to manage memory loss, and giving caregivers the right information is a key part of this process.
In terms of cognitive screening for older adults aged 65 and over, the United States preventative task force does not have set guidelines. However, it remains crucial for clinicians to be alert to early signs and symptoms of cognitive impairment. There are several dementia screening tools that are useful for initial evaluation in a clinic setting, like the Quick Dementia Rating System (QDRS), Mini-cog, and AD8.
There are also common cognitive performance tests you may encounter, including the mini-mental score evaluation, word-learning task, verbal search speed task, digit span backward test, and the word list recall test. Physical capability can be assessed using tests like the chair rise test, walking speed test, standing balance time and grip strength test.
Finally, understanding the patient’s medications – what they are for and how they should be taken – is a vital part of the assessment. If there’s a change in the patient’s cognition or a decrease from their usual functioning, check if there has been any new or altered medication.
Testing for Geriatric Cognitive Decline and Polypharmacy
An assessment for elderly people involves looking at many areas of an individual’s life. It’s important to evaluate their functional abilities, such as getting dressed and managing their own money, as well as their mental and physical health. This assessment should also consider their social and environmental situations. This type of complete assessment generally happens when changes in memory or thinking abilities are noticed by the person themselves, a caregiver, or their doctor.
While day-to-day functions are important to measure, the doctor should also check for health issues common among the elderly. This would include vision and hearing, depression, and nutritional deficiencies like lacking vitamins A, B12, C, D, and minerals like iron, calcium, and zinc. The doctor should also discuss with the patient and their caregivers about the pros and cons of routine cancer screenings. Another important aspect to check on is whether the person is on many medications, as this can often lead to hospital admissions.
There are various tests available that can identify issues with thinking abilities and exclude other potential causes such as vitamin deficiencies or irregular hormone levels. Some common tests ordered are blood tests for determining overall health and organ function, urine tests to rule out infection or disease, and a CSF test that checks for infections in the cerebrospinal fluid, which surrounds the brain and spinal cord. In certain cases, brain scans might be done to rule out any underlying conditions such as stroke or tumors.
Something to bear in mind is a program initiated by the American Board of Internal Medicine Foundation called ‘Choosing Wisely.’ This is especially applicable to older adults where there is a greater likelihood of having multiple health issues and consequently being on many medications. These are factors that contribute to difficulties in managing medications for older people. It’s crucial to avoid unnecessary medication to control medical expenses and prevent side effects.
A critical part of dealing with being on many medications is to avoid drugs that are unlikely to be beneficial. This concern is individual and situation-specific, so the doctor and patient must decide together. A helpful index to evaluate the appropriateness of a drug takes into consideration its use, effectiveness, drug interactions, and recommended duration of use. Two commonly referenced resources for this are the Beers criteria and the START and STOP criteria.
The Beers criteria identify potentially inappropriate medications for older adults and provide guidance on drug interactions that are best avoided. These criteria, which are regularly updated, outline five points related to checking the suitability of medications, their pairing with certain conditions, potential interactions, and dosing changes based on kidney function. Moreover, the minimal adjustment needed to apply these criteria to suit different patient care set-ups makes it even more useful.
On the other hand, the STOPP and START criteria provide guidelines specifying when to stop and start certain medications for those above 65 years old. They also offer more explicit recommendations across a variety of drug types making the process more clear-cut. Both these criteria can be a significant boost to manage medications effectively for older adults.
Treatment Options for Geriatric Cognitive Decline and Polypharmacy
If other causes of memory loss or confusion have been excluded, the focus may shift towards determining whether an older person’s decline in cognitive function could be set off due to consuming multiple medications, a condition known as polypharmacy. After discussing the situation with the patient and their family, health care providers should consider adjusting the medication regimen to manage symptoms of memory loss or confusion brought on by polypharmacy.
Having a good understanding of polypharmacy and how it could be tied to cognitive decline, helps health care providers in managing this multifaceted condition seen among older individuals. There isn’t any specific treatment for memory issues linked to polypharmacy. A good starting point is to gather detailed information on the patient including their medical history, hospital records, pharmacy data, and narcotic prescription refills. The ‘brown bag assessment’ is a widely recognized method for checking medications. It involves the patient bringing all their medications, including items from hospital visits, to their appointment in a brown bag for the provider to review.
Deprescribing – the reduction or discontinuation of medication – should be considered, as taking a large quantity of medications can be a major predictor of unnecessary or inappropriate medication use. The deprescribing process focuses on reducing one medication at a time. Firstly, it checks for those medications that have no valid reason for being prescribed, evaluates their risk against their benefit, and prioritzes the removal of the ones with high risk but low benefits. It also prevents prescribing cascade which is using medications to treat side effects of other medications, and new-to-market medications. For any supplements or herbal products the patient is self-medicating with, the provider would also evaluate their effectiveness and safety. It is advised to have a review of all prescribed medications, over-the-counter drugs, herbal products, and supplements using an interaction checker such as an app or online tool.
Research has shown that deprescribing can be successfully carried out in clinical practices when it incorporates the patient’s preference, promotes shared decision-making, and involves the cooperation of a multi-disciplinary team. Algorithms specific to medication can aid in the deprescribing process in the clinic.
Having a systematic approach to handle polypharmacy in older adults, like doing a thorough medication check during every visit, reducing the usage of potentially inappropriate medications, and making sure to properly monitor their usage, can help improve long-term outcomes, preventing medication-related side effects and cognitive decline. Polypharmacy can place a huge medical and economic burden on patients and their families; that’s why it’s critical for providers to focus on patient-centered approaches. Rather than relying on medication to manage simple symptoms, try to find non-medication alternatives as a priority. The end goal of managing polypharmacy is to enhance and optimize the patient’s overall functioning and quality of life.
What else can Geriatric Cognitive Decline and Polypharmacy be?
Figuring out the link between taking multiple medications (polypharmacy) and experiencing mild cognitive impairment can be a tricky job. Doctors need to thoroughly examine the patient to ensure that the symptoms are not due to other health issues. These include:
- Depression
- Underactive thyroid (hypothyroidism)
- Vitamin B12 deficiency
- Chronic alcoholism
- Parkinson’s disease
Only after these potential causes have been ruled out can doctors conclude that polypharmacy is the reason for the patient’s mild cognitive impairment.
What to expect with Geriatric Cognitive Decline and Polypharmacy
Mild cognitive impairment, when related to taking multiple medications, usually has a positive outlook. It’s important to identify the specific drug causing the issue and manage any underlying health conditions with alternative medicines, if possible. When there are no other risk factors, removing the problematic medication could lead to a good recovery from mild cognitive impairment.
However, remember that conditions like natural aging, diabetes, high blood pressure, and diseases related to the brain’s blood vessels can also lead to a decline in cognitive abilities over time.
Possible Complications When Diagnosed with Geriatric Cognitive Decline and Polypharmacy
Using multiple medications, getting older, and being physically weak can make treating complications extra challenging. Taking too many medications can lead to a number of problems, such as negative drug reactions, falls leading to head injuries, slight mental confusion with or without changes in behavior, and dementia.
Medication overload can cause negative reactions due to interactions between different drugs, herbal supplements, and medications you can buy without a prescription. The main thing that increases the risk for these reactions is the total number of medicines a person takes. In other words, the more medications, the higher the risk of negative reactions. There can also be other problems from medication overload. These include:
- Reduction in a patient’s ability to consistently take their medicine which can cause their health problems to get worse,
- A lower quality of life,
- An increased number of visits to the doctor,
- Unnecessary costs for medication,
- Rise in the overall health care costs,
- An increase in hospital stays, and even
- Death.
Preventing Geriatric Cognitive Decline and Polypharmacy
Treating a condition that involves taking multiple medications, alongside a mild decline in mental abilities, needs a team effort. This team should consist of the patient, their family, a home-care nurse, a primary care doctor, a doctor who specializes in elderly health (geriatrician), and a pharmacist. The goal is to handle this complicated health situation effectively.
Each medicine needs to be reviewed for its purpose, and how it interacts with the other medications the patient is taking. Thorough discussions about any possible side effects of the drugs in the short-term and long-term must occur before ultimately deciding the suitable treatments.
Moreover, it’s important to frequently check on the patient’s daily life and mental health status. Any changes or updates should be shared with the team, ensuring the patient’s care is tailored to their evolving needs.
