On the whole GPs acknowledge that polypharmacy is a problem in their older patient population and a major challenge for general practice. The data show that the respondents identify 4 themes that influence polypharmacy, namely patient related, GP related, evidence based medicine (EBM) and specialist related factors.
Patient related factors influencing polypharmacy according to the GPs
Being the major consumers, older adults are particularly vulnerable to adverse drug reactions.
"With older age, you have to take into account that organs are not working properly anymore." (36) "The chance of side effects of medication in this older age group is also much higher: kidney function is not as good anymore and then you start treating side effects..." (20)
Side effects are not always recognized as such. They can be very pronounced in this population and this can lead to a pharmacological treatment of side effects or even to hospital admission.
GPs acknowledge the difficulty in keeping an overview of the exact intake of medication of their older patients. When older adults have to take a lot of drugs, the danger of self medication exists - patients change their own regimens by discontinuing them, lowering, increasing or skipping doses without consulting their GP.
"...sometimes the older people decide for themselves to reduce some of their medication or to adjust the doses without telling their GP. Therefore as their GP you can have the wrong impression about their medication intake..." (28)
The risk of this is that GPs prescribe additional drugs as it seems the previous doses are not having the expected effect. Therefore GPs place a lot of emphasis on the importance of compliance.
Patients are not always inclined to stop using drugs that they have used for a long time. Some patients can be demanding and difficult when their use of medication is questioned and resist any attempt to change their prescriptions:
"A lot of medication that has once been prescribed is being taken daily. The patient feels fine and does not want to change the medication regime" (38)
Most GPs recognize a very strong attachment in many patients to benzodiazepines or pain medication whilst they also acknowledge that these are some of the drugs that should be avoided or reduced.
GPs perceive self-medication as a real problem. The GP is not the only provider, the older people often receive medication from friends, relatives or from neighbours. They do not perceive this as their prescribed medication and consequently, they do not take into account the possible side effects or interactions:
"They take a blood-diluting drug. Then they take another aspirin with another brand name because their neighbour told them that they should take one daily. They have no idea what they are taking..." (31)
The role of GP related factors and its influence on polypharmacy & suggested solutions
GPs refer to polypharmacy as a slowly growing process and because of that they do not pay sufficient attention to this phenomenon. It is easy to start a new treatment for every new complaint without really evaluating the existing medication schedule. They do find that they are not critical enough. This routine approach might be one of the factors that make polypharmacy so common. Patients keep on taking their prescribed medication (they feel good about it), whilst none is stopped or re-evaluated:
"The number of medications grows slowly. There is a complaint, we give new medication, it continues without really stopping it after a while...and it is our responsibility to try and withdraw it from the patient..."(43)
GPs feel strongly that their role is as a 'gatekeeper' whose responsibility is to control the type and quantity of medication used. They mention that established routines for assessing the total medication schedule of the patient are necessary.
GPs feel they should take the initiative to prescribe only the essential medication and to lower doses. They also realise it is not necessary to treat every single symptom but to look at the overall health status of their patient and the quality of life. GPs suggest that a list of priority medication in order of importance might be very helpful. The respondents mention that it is essential to be alert at every single consultation. For every prescription renewal they should ask themselves whether the medication is still necessary and if not they should stop the prescribed medicine.
The role of evidence based medicine in polypharmacy according to the GPs
GPs feel under pressure from guidelines to prescribe preventive drugs, even though the negative impacts of polypharmacy may outweigh the possible benefits from individual drugs:
"If you want to follow the evidence based guidelines then you need to work preventively. Then quickly you will come to six additional medications..."(36) " If you look at the guidelines on what to prescribe post-infarct...Strictly speaking that is 6 additional drugs...You will have to draw a line between what is scientifically proven and what is realistic in daily practice..." (49).
GPs are aware of the increased risk of interactions. They should be alert to this but they admit it is difficult to keep an overview when there is polypharmacy. GPs report difficulties in differentiating between medical conditions or symptoms due to side effects of medication.
They also experience shortcomings in their pharmacological knowledge. The information available is not always that accurate or up-to-date:
"We do not always have an overview of the interactions, that is a big problem, firstly there is not much information available for us GPs, and secondly when there is information available to us it does not mean that we know it; it is not that simple..." (26)
The role of increased specialization in health care and its influence on polypharmacy
One of the reasons why GPs find polypharmacy a complicated issue is that often more than one prescriber is involved. Inappropriate prescribing can arise from the absence of communication between doctors practising in different settings or even between specialists practising in the same setting. Older adults often have several chronic conditions and need several drugs; they are often admitted to hospital and should have regular reviews of their treatment.
GPs see a role for themselves to protect the patient through regular follow-up.
"The GP has a holistic view of the patient. A specialist often does not have the time to speak with the patient about the entire medication regime. The GP can contact the specialist...The coordination of the medication regime of different disciplines is a tough job..." (12)
When the patient has been admitted to hospital it is important to re-evaluate the medication schedule. GPs find it important to have a coordinating role. They have a holistic view of the patient because of the long standing doctor-patient relationship. This is in contrast to a specialist who only looks at the patient from his or her own discipline. This is perceived as a very tough job for GPs with major implications for their workload:
"As a GP you have a broader view of your patient. You look at him/her from his own life. Specialists narrow the things down a little bit. I think it's very important that there is one coordinator who watches out over the patient and sees that the pneumologist does not prescribe something that can affect the cardiologic state of the patient...." (41)