**3. Polypharmacy and inappropriate medication in older patients**

Pharmacotherapy can improve the quality of life, cure, prevent and relieve the symptoms of many pathologies. However, there is a growing concern that many older people are taking an inappropriately high number of medications [18]. Polypharmacy consists of the use of several drugs by the same patient and appears as a response to the increase in health-related problems, particularly in older adults. There is no consensual definition for polypharmacy; however, most studies consider the consumption of five or more drugs per day per person [19]. In older patients, polypharmacy has been associated with a wide range of negative health outcomes, including falls, ADR effects, changes in physical and cognitive ability, hospital readmission and mortality. It has also been associated with increasing costs in health [4, 18].

Besides, older adults often self-medicate themselves to improve their quality of life. This is a concern because the use of home medicines and herbal products, as well as the diet, can interfere with their health, due to the many drug interactions that can occur [20].

The inappropriate use of medicines by older patients who suffer from multiple diseases is a public health problem due to its impact on morbidity, quality of life and the improper use of health resources. There is an increase in hospital readmissions

and the occurrence of ADR, leading the older patients to have difficulties in carrying out their daily activities, progressively losing their autonomy and, consequently, with loneliness and social isolation [4, 21]. Polypharmacy and multiple comorbidities are also associated with a lack of therapeutic compliance by older patients. The non-adherence may represent a risk because adverse health outcomes could occur like hospitalization and mortality [22].

Polypharmacy represents a challenge for health professionals, and it is essential to improve patients' knowledge about their medication because beliefs about drugs are a strong predictor of adherence. If the patient knows what medicines he is using, the reason for pharmacotherapy and believe about its benefit, the adherence problem will be improved. In practice, the main goal is to achieve an ideal pharmacotherapy by reducing the number of drug-related problems (DRP).

The probability of a drug interaction occurring also increases with ageing due to the higher number of drugs used by older patients. These interactions have negative effects on health, and therefore, health professionals must be alert to possible interactions and must prevent them from occurring [23].

Most of the medications are considered appropriate for older patients, as long as they are used in the correct dosage and for the period strictly necessary. However, since older adults are more susceptible to the adverse effects of drugs, as a result of changes on pharmacokinetics and pharmacodynamics, special care by health professionals is needed when treating older patients.

Having more than one prescriber increases the risk of inappropriate medications use. Thus, it is crucial to implement medication review procedures and that the most frailty older adults have a clinician with knowledge of all their pharmacotherapy and improve communication with caregivers [23].

Some studies have shown that some measures can be implemented to decrease polypharmacy and its adverse effects, improving the quality of the prescription, such as educational programmes for patients and professionals and the creation of multidisciplinary teams of health professionals [24].

#### **4. Improve pharmacotherapy in older patients**

To improve the pharmacotherapy in older patients, the available tools must be friendly to improve the use by the health professionals.

According to Wooten [25–27], 10 rules must be followed by the physician's when prescribing, especially in older patients: (1) know the patient and use the patient's most current medical record; (2) follow the tenets of evidence-based medicine, but understand the limitations of the evidence; (3) understand the potential pharmacokinetic and pharmacodynamic changes that can occur in older adults, and use this specific patient information to make prudent prescribing decisions; (4) recognize and investigate patient factors that may contribute to medication problems; (5) avoid the prescribing cascade, if possible; (6) prescribe and recommend only those medications/drug classes for which have a thorough understanding of the pharmacology; (7) identify, anticipate and monitor potential drug interactions before they become a problem; (8) establish a monitoring plan for each medication prescribed for both efficacy and toxicity; (9) properly counsel patients/caregivers on all of the patient's medications, and ensure that the patient understands the pharmacotherapy plan; and (10) assess and address compliance issues.

Clinical decision support includes a variety of tools and interventions that can be computerized or noncomputerized. Clinical decision support systems (CDSS) are characterized as tools for information management and include several clinical guidelines.

#### *Elderly and Polypharmacy: Physiological and Cognitive Changes DOI: http://dx.doi.org/10.5772/intechopen.92122*

In the last decades, the focus has been on tools to provide specific recommendations to patients, called advanced CDSS. These may include, for example, checking interactions between drug-disease, drug-drug, individualized dosing support and advice on laboratory tests during drug treatment [28]. The creation and implementation of this type of tools are responsible for increasing the quality of care and improving health outcomes, reducing the likelihood of errors and adverse effects. Thus, it is possible to reduce uncertainty and increase the reproducibility of decisions, increasing efficiency, cost-effectiveness and the satisfaction of the patients and caregiver [29].

For reducing prescription errors in older patients, other measures can be taken, such as implementing an educational system to train prescription, especially in young doctors who have less practice, and also in hospitals, where this type of errors are more frequent [30]. In many hospitals, pharmacists are responsible for identifying errors in the prescription of medications and must report them immediately to the medical team. Sometimes, the environment involving prescribing physicians may influence the prescription process, leading to some errors. So, all the conditions must be met so that the physician can carry out the prescription in the best possible way, making simple changes such as reducing background noise and promoting more effective communication between all health professionals and with patients. Upon admission of the older patients to the hospital, it is advisable to carry out a reconciliation of the medication in which all medicines used should be checked. The importance and suitability of each medicine for the patient should be assessed, as well as the needs of adding a new list with the latest medications, explaining reasons. This list must be updated and given to the next health professional responsible for the patient [30]. There is currently a validated tool used to provide physicians with a method for obtaining their patients' medication history, the structured history taking of medication use (SHiM). The SHiM consists of 16 questions and reveals the potential to avoid discrepancies in patients' medication histories [31].

Another way to improve pharmacotherapy for older patients is to use criteria that were created to identify PIM as tools to support clinical decision support as described above.

#### **4.1 Criteria used as tools to reduce potentially inappropriate medications in the elderly**

To reduce the use of PIM in older patients, strategies and tools have been developed in recent years to assess the appropriateness of medication use in this population. The created criteria can be classified as explicit, implicit or mixed. Explicit criteria are lists of drugs that can be applied with minimal information and clinical judgement. These do not consider individual differences between patients. In contrast, the implicit criteria consider the patient's therapeutic regimen and are based on the judgement of a health professional, being specific to each patient. The mixed criteria, on the other hand, consist of a combination of the previous two, allowing to obtain advantages from both [8].

In 1991, Beers et al. [32] were the first ones to introduce the concept of PIM and to propose a list of PIM for the older adults. These criteria, developed to help healthcare professionals to assess the quality of prescription in older patients, were initially intended for psychiatric patients. In 2011, the American Geriatrics Society (AGS) assumed the responsibility for these criteria and became compromised to update them regularly, and in 2012 [33] the criteria were updated. After that, criteria have been updated, and new, improved versions appeared in 2015 [34] and recently in 2019 [35]. A consensus panel was created with several experts to define what these criteria would be and what individual aspects should be considered.

However, there are drugs not included in these criteria, and that may also be potentially inappropriate for older patients.

Many other attempts have been proposed using implicit or explicit criteria. For example, the Medication Appropriation Index (MAI) measures the appropriation of prescriptions for elderly patients [36]. That is an implicit tool that consists of making a structured assessment of the patient's medications across 10 criteria worded as questions. The 10 items are essential to evaluate the potential of DRP.

Also, according to European standards, the EURO-FORTA List was created in 2018 and is based on the FORTA List that has been validated for Germany and Austria. The EURO-FORTA List is an implicit tool and consists of 264 drugs/drug classes organized in 26 groups according to clinical diagnosis or symptoms [37].

On the other hand, explicit tools, such as the Screening Tool to Alert to Right Treatment (START) and Screening Tool of Older Person's Prescriptions (STOPP) criteria, originally created in 2008 [38], are adapted to European prescription standards. Over time, the START/STOPP criteria have been updated, with the most recent version (version 2) being published in 2015 [39]. These criteria are used as tools to help researchers and professionals to identify 81 PIM and 34 potential prescribing omissions (PPO). Although the STOPP criteria are classified as explicit, according to studies carried out recently in Portugal, for only 29 of the 81 STOPP criteria, a judgement can be made only with the patient's medication profile information. This means that 52 of the STOPP criteria require additional information (i.e., duration of treatment, previous medication, current medical conditions, medical history and laboratory data) [40].

In 2015, the EU (7)-PIM List, an explicit criteria tool, was developed by experts from seven European countries (Germany, Finland, Estonia, Holland, France, Spain and Sweden) that allows the identification and comparison of PIM in these countries [41]. The EU (7)-PIM List development process was based on the participation of several European experts in two Delphi rounds. Some PIM concepts were defined considering the dose, the time of use or the therapeutic scheme, and the final list consists of 282 PIM.

In addition to these criteria, there are many other PIM lists in several countries, such as LaRoche (France) [42, 43], the PRISCUS list (Germany) [44], the Austrian consensus panel list [45], the NORGEP criteria (Norway) [46] and the Canada national consensus panel list [47].

**Figure 1** is a flowchart that represents the steps that must be taken by health professionals when prescribing medications to the elderly, including the moment when they should consult the currently available PIM identification criteria.

#### **Figure 1.**

*Flowchart of the operating procedure of the expected steps during prescription for older patients.*
