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Shaine Cooper, RN student

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mic, video, camera - reason for its selection

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-What? Polypharmacy - the use of multiple drugs or more drugs than may be medically necessary -  is an increasing concern in the elderly community.

-Who is affected? Polypharmacy is a concern for all individuals taking medications, (especially those with comorbidities requiring multiple medications) but the concern is greater for the geriatric community aged 65 and older

-Where? Studies have been performed to evaluate the instances of polypharmacy in the ambulatory care, hospital, and nursing home settings, but these studies suggest that the highest instances of polypharmacy are found in the nursing home setting (Maher, Hanlon & Hajjar, 2014).

-Why? The concern is greater for this population because "the burden of taking multiple medications has been associated with greater health care costs and an increased risk of adverse drug events (ADEs), drug-interactions, medication non-adherence, reduced functional capacity and multiple geriatric syndromes" (Maher, Hanlon & Hajjar, 2014). Declines in health often lead to a number of comorbidities which may require different medications from different specialists. Lack of interdisciplinary care and communication combined with an overall decline in bodily functions and metabolism can lead to adverse reactions and undesirable clinical outcomes for this population.

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The literature reiterates that the "baby boomer" generation is coming to an age where comorbidities are expected, and this area is requiring increased attention for proper care. "Given the rising tide of persons over the age of 65 worldwide, polypharmacy is a becoming more prevalent in older adults" (Maher & Hajjar, 2014). Advancements in medicine and health maintenance are also causing that generation to live longer, which may adversely be contributing the instance of poly pharmacy. One article explains "Because individuals are living longer with chronic diseases, elderly patients also tend to have more complicated chronic conditions, may respond differently to medication therapy or experience more severe adverse reactions due to differences in pharmacokinetic and pharmacodynamic characteristics, compared with younger patients. They may also visit multiple prescribers and use multiple pharmacies that will lead to increased risk of medication-related problems through poorly coordinated or duplicated care" (Golchin, et al., 2015).

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-Nurses have a role in the ambulatory care, hospital, and nursing home settings where they may be the primary care taker or the advance practice nurse overseeing treatment. An article in American Nurse Today discusses how the pivotal roles nurses can play in reducing polypharmacy are focused around three key concepts of intervention - information, instruction, and organization (Woodruff, 2010). Information includes teaching patients about the importance of keeping up to date medication logs both at home and with them during any medical appointment. Instruction focuses on the importance of adequate communication throughout the interdisciplinary team, and also how important communicating clearly to the patient is, and using language that they understand. Organization discusses the need for tools to be provided for the patient that helps them keep their medications organized so adherence and proper dosing are not compromised. Nurses directly involved in patient care in the clinical setting are also contributing to this issue by not using proper clinical judgement when administering medications. Nurses are trained in pharmacology and should know which medication they are giving, why they are giving it, if the dosage is safe, and if this medication is contraindicated. Lack of a questioning attitude in all aspects of patient care increases the development of polypharmacy. Nurses may feel uncomfortable questioning an order for a patient - this issue can be solved by a collaborative interdisciplinary team with open communication and policies in place encouraging a questioning attitude.

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-INTERVENTIONS: Education, comprehensive interdisciplinary team, and a questioning attitude

-Nurses involvement in decreasing the instance of polypharmacy in the elderly is vital. The most important intervention is education. The nurse needs adequate education about the medication, and they need to be able to properly educate their patient as well.
The patient plays a vital role in their own state of health and the interdisciplinary team, which is another intervention - forming a comprehensive interdisciplinary team of providers and patient advocates. A nurse that is a member of a team will also be more comfortable having a questioning attitude, which is the last intervention focused on patient advocacy and team accountability. Having a questioning attitude does not mean that the nurse intends to undermine the decisions of the provider - it simply means that clarification is needed for the nurse to better understand the care that she is providing, allowing her to provide this care to the best of her ability.

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mic, video, camera

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-A Questioning Attitude
Throughout the courses that I have attended in SCOHS, the need for the nurse to have a "questioning attitude" was always taught with great emphasis. Initially, this was an intimidating concept. The thought that I, a novice nurse, should (internally) always be questioning orders or actions of seasoned nurses and providers seemed disrespectful and assuming. I have since realized that it is not about showing who the "alpha" is - its simply how we ensure patient safety and develop understanding. If I am able to always ask myself why we are doing a task a certain way or why I am administering this patient this medication, I will have a better understanding of patient care and patient safety as a whole. Additionally, this will allow me to have the answers for a patient if they do not understand any element of their care. This concept also highlights the fact that regardless of education or experience, we are all humans and are able to make mistakes. Those that begin to get in a routine are more likely to error when they become "comfortable", so new nurses with fresh eyes and a questioning attitude can reinforce this life saving concept.

-Holistic Care
The concept of holistic care was reserved for those that were "naturalists" and "anti modern medicine" in my mind prior to my education at SCOHS. I have since learned that holistic care focuses on caring for the patient physically, spiritually, and mentally. Too often, patients receive treatment that only focuses on their present issue, and not on what may be causing or exacerbating the issue. This can theoretically lead to polypharmacy.Nurses are in the most important position when it comes to implementing holistic care. One article states, "The caring relationship between a nurse and a patient is vital for the total well-being of the patient. Patients require a caring relationship, which enables

enhanced conscious awareness of life and health experiences" (Bamfo & Hagen, 2011). Holistic treatment is just one of many interventions that could address and possibly decrease the issue of polypharmacy in the geriatric community.

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Bamfo, E. A., & Hagin, J. E. (2011). Choosing a holistic care approach for the elderly (Unpublished master's thesis). Novia University of Applied Sciences. Retrieved April 23, 2018, from https://pdfs.semanticscholar.org/b596/2dfe4cd741700715005a290cc1256423f182.pdf

Golchin, N., Frank, S. H., Vince, A., Isham, L., & Meropol, S. B. (2015). Polypharmacy in the elderly. Journal of Research in Pharmacy Practice, 4(2), 85–88. http://doi.org/10.4103/2279-042X.155755

Lavan, A. H., Gallagher, P. F., & O’Mahony, D. (2016). Methods to reduce prescribing errors in elderly patients with multimorbidity. Clinical Interventions in Aging, 11, 857–866. http://doi.org/10.2147/CIA.S80280

Maher, R. L., Hanlon, J. T., & Hajjar, E. R. (2014). Clinical Consequences of Polypharmacy in Elderly. Expert Opinion on Drug Safety, 13(1), 10.1517/14740338.2013.827660. http://doi.org/10.1517/14740338.2013.827660

Woodruff, K. (2010). Preventing polypharmacy in older adults. American Nurse Today, 5(10). Retrieved April 21, 2018, from https://www.americannursetoday.com/preventing-polypharmacy-in-older-adults/