Increases in disease awareness, better compliance with preventive medicine and exposure to high technology acute care management have helped to improve life expectancy and have subsequently led to an aging society (1). The elderly constitute more than 12.5 % of the USA population; but account for 33% of all hospital admissions. Most visits to physicians and most personal and insurance resources are spent on healthcare for this age group.^{(1, 2, 3)}.

Polypharmacy among the elderly population, though considered within the norms in terms of the number of medications taken due to the wide prevalence of disease among this age group, leads to higher adverse drug reactions in these relatively fragile patients or those with impaired pharmacokinetics and pharmaco-dynamics⁽⁴⁾.

Higher incidences of inappropriately prescribed medications in the elderly are due to several factors, and lead to higher incidence of hospital admissions, deaths and subsequently higher costs^(5,6). Saudi Aramco Medical Services Organization (JCIA Accredited) provides out-patient and in-patient care for more than 184,000 patients, 3.4% of them above 60 years. Patients are exposed to high technology acute medical care and preventive medical services teams of all disciplines supported by a user-friendly computer-based system for in and out patient services that incorporate detailed patient information, drug information, contra-indications specifications and a high alert list. In 1993, the elderly population above 65 years of age in Saudi Arabia constituted only 2.6% (WHO World Health Report, 2001). Currently, it is postulated that the number has greatly increased due to important and continued governmental and private sector interest in health care over the past two decades. A recent report from Saudi Arabia showed the ratio "of one hospital bed per 476 people and one doctor per 690 people [to be] among the lowest in the world" (Saudi Arabia publication spring 2002 Magazine: Health).

OBJECTIVES

A brief review of literature on the extent and risk factors of polypharmacy in elderly population is intended to increase physicians' and patients' awareness of polypharmacy, as well as list methods used by experts in the field to avoid inappropriate prescribing of medications in an out-patient setting.

DISCUSSION

Elderly patients above 65 years use more than 30% of prescription medications and 50% of over-the-counter medications⁽²⁾. The aging process naturally leads to impaired functional capacity of organs such as lungs, liver, kidneys as well as relative reduction of the immune system. Prevalence of cardiopulmonary diseases, strokes, diabetes, osteoporosis, osteoarthritis, falls and malignancy among elderly population entail multiple clinic visits to primary care physicians and to different other specialists and sub-specialists. This leads to the elderly using more medications than younger age groups. More prescribed medications, over-the-counter medications, and herbal products lead naturally to more drug side-effects ^{(1, 4)}. Garcia recently reported that more than 30% of the elderly population are admitted because of adverse drug effects and more than 50% of these adverse effects can be prevented through appropriate prescribing (5). Fick et. al. in 2000 reported 106,000 medication-related deaths at a cost of $85,000,000 to US Healthcare⁽⁶⁾. Fifty one percent of all deaths occurred in elderly patients over 60 years of age and 35% of ambulatory elderly experience and adverse drug event over a one-year period⁽⁵⁾. Decreased functional capacity of vital organs at old age coupled with higher rate of prescribed drugs leads to more serious drug side effects even at lower doses of medications. Commonly used drugs (beta blockers, calcium channel blockers, ACE inhibitors, H1, H2 blockers, Aspirin, NSAIDs, calcium, biphosphonates, antidepressants and anti-epileptics) can lead to more serious drug results if not appropriately prescribed. Beers' criteria, developed in 1991, updated in 1997 and then in 2003, list a number of medications that are recognized as inappropriate in elderly based on consensus guidelines and experts' opinion^{(6, 7)}. Fluoxetine, non-COX-selective NSAIDs, Benzodiazepines are listed due to risk of excessive CNS stimulation, GI bleeding and sedation respectively. Garcia's⁽⁵⁾ literature review of evidence-supported studies aimed at reducing inappropriate prescribing in the elderly suggested the following four methods:

1. Using pharmacist recommendations can help in reducing polypharmacy through his/her proper screening of patient's drug profile, reviewing potential drug - drug interactions, assessing effect of co-morbid conditions, with recommendations or suggestions to physicians who are part of the multidisciplinary team^(5,8).
   
2. Computerized alerts in an in-patient setting decreased serious medication errors and adverse drug events. Medical practitioners and pharmacists in our health center, have access to a computerized data system that includes all pertinent patient information in both the in-patient and out-patient setting; this has helped to make an adequate decision. A multidisciplinary team consisting of a clinical pharmacist, a physician and a health educator is well established and all aim toward prescribing the proper medications and removing others of no apparent indication or with high side effects.
   
3. Another proven method of reducing inappropriate prescribing in the elderly can be achieved through regular patient education sessions. Patients are encouraged to keep a list of medications taken, including over the counter and herbal medications.
   
4. Physicians' regular review of medications taken by their elderly patients, though time consuming, with the help of the pharmacist consultant and health educators, can reduce significantly serious adverse drug events^(5,8,9).

The Institute of Medicine (IOM) reported 1.5x10⁽⁶⁾ preventable drug adverse reaction each year in USA. Jenkins and Vaida⁽⁹⁾ recommended the following office-based strategies whether physicians are using paper or electronic charts to avoid medication errors:

• Proper patient identification
  
• Document allergies and drug reactions
  
• Highlight significant medical conditions
  
• Keep current update of all medications (prescriptions, OTC, herbal with each clinic visit)
  
• Keep current medication information most commonly used
  
• When writing prescriptions, improve hand writing, avoid abbreviations in names, dosages and frequency of each drug prescribed
  
• Make sure patients and/or caretakers understand specific recommendation of each drug prescribed
  
• Consider using electronic system of prescribing; "Electronic prescribing system can produce computer generated prescriptions or can electronically transmit the prescription directly to the Pharmacy." The Institute of Medicine recommended all prescribers should adopt an electronic system by year 2010⁽⁹⁾

Buschardt and Jones⁽¹⁰⁾ highlighted important inquiries to be followed that might help in assessing and limiting inappropriate prescribing in the elderly:

1. "Is each medication necessary," including OTC and herbal products? Use only drugs that are evidence supported.
   
2. "Is the drug contraindicated in the elderly?" Avoid high risk medications in the elderly e.g. long acting Benzodiazepines associated with sedation and falls, NSAIDs with CNS, GI and renal implications.
   
3. "Are there duplicate medications?"
   
4. "Is the patient taking the lowest effective dosage?" Concept of drug prescribed in elderly to 'start low and go slow' due to natural functional impairment in renal function, liver metabolism and co-morbidity at old age.
   
5. "Is the medication intended to treat side effects of another medication?" Avoid such practice e.g. Anti-tussives used to treat ACE induced cough.
   
6. "Can I simplify a drug regimen?" Try to use the easiest for the patient.
   
7. "Are there potential drug interactions?" Try to avoid them.

CONCLUSION

Polypharmacy in the elderly is a universal problem with serious impacts on patients' health and community resources. Reviewing the literature, we provided the evidence that safe use of medication remains multidisciplinary team-work. Physicians are more challenged for most effective use of office visits/inpatient encounters to apply evidence-based procedures to avoid serious drug events. Pharmacists, health educators' suggestions, and patients' compliance remains a standard rule to increase chances for better prescribing practices.

REFERENCES

Acknowledgment

The authors wish to acknowledge the use of Saudi Aramco Medical Services Organization facilities for the data and the study, which resulted in this paper. The authors are employed by Saudi Aramco during which the study was conducted and the paper written.