Why Older Adults In India Are Popping More Pills?

India’s older population is popping pills in a hurry while overlooking the harm the drugs can cause when taken unchecked. The polypharmacy, hyperpolypharmacy and PIM (Potentially Inappropriate Medications) use rates in India in the age group of over 60 are staggering, a study published in the US journal PubMed in 2021 noted that rates to be 49 per cent, 31 per cent and 28 per cent respectively. 

Polypharmacy is defined as taking five or more medicines at one time which is more common among older adults due to them having multiple ailments, similarly, hyperpolypharmacy is defined as popping ten or more pills at one go.  

Whereas PIM use as the name suggests are those drugs which can cause adverse health outcomes resulting in morbidity and mortality when taken together. Oftentimes polypharmacy and hyperpolypharmacy are the proxy indicators of PIM use, hence they are all closely knitted. 

The research looked at data from 27 studies conducted between 2002 to 2020 involving around 11,649 participants. The study noted that the trend of hyperpolypharmacy in India is significantly higher than in the most developed part of the world for instance the rate in the USA is 1 per cent, in New Zealand at 2.1 per cent and in Australia at 8 per cent. 

The study found out that in India overuse and misuse of medications in older adults is a major cause for concern and the rising culture of unnecessary prescribing of medications may enhance the risk of adverse outcomes. 

Among the reasons listed in the study, poor prescribing practices, inappropriate medication selection and misuse of drugs to earn profits were the major factors behind a large number of older adults popping pills as a norm. 

BW Healthcare World got in touch with top clinicians of the country to know the present scenario and learned about a plethora of reasons as to why this must be the case in India. 

India’s Prescription Delusion

Clinicians say that there various factors which are causing this rise which include an ageing population, increased prevalence of chronic disorders, a fragmented healthcare ecosystem and comorbidities. 

“The elderly population is at an increased risk of polypharmacy, due to the fact that they have multiple comorbid conditions and partly due to availability of newer medications. The younger generation is also at risk due to the easily available over the counter medications and a majority of the population have the habit of self-medicating. Often the patients consult with many physicians and get the prescriptions from different pharmacies and there is a failure to keep all the involved parties informed about each other’s action,” stated Dr Ganesh K M, Consultant, Critical Care, Fortis Hospital, Bannerghatta Road, Bangalore. 

The medical experts also revealed that there might also be a case of psychology and vested interests behind how India is getting its medicines prescriptions, Dr Rajeev Jayadevan, Member, Public Health Advisory Panel, Kerala State IMA said the reasons for polypharmacy in India are three fold which involve patients, doctors, and the industry. While the reason for patients and doctors using more medications than needed are somewhat interlinked, for the industry, the profit only comes from maximising sales. 

Dr Jayadevan said, “Patients in India generally go to the doctor with an expectation of getting a prescription. Consequently if they don’t get a set of new medicines, many of them do not feel satisfied. The doctors learned advice alone might not suffice. Occasionally they might even blame such doctors for ‘not being knowledgeable enough’ to write a prescription, and complain that they have ‘wasted the consultation fee’.”

Explaining further Dr Jayadevan said that some patients who do not medically need a new drug, might still feel better even if they are given something by their doctor, for example, even a multivitamin tablet. “This is called the placebo effect. Rather than give nothing, doctors often write supplements in such instances, so it keeps the patient happy. Although it is done in good faith, it is not strictly science, but rather pseudoscience which doctors end up practising just to make sure their patient stays happy,” he added. 

Experts also said that some times the physcians mis-interpret side effects as new symptoms and prescribe new medications for them. Apart from this people seeking herbal and other alternative forms of medications assuming that they are free of side effects might also lead to polypharmacy.

“There may also be cases where doctors write more medications due to financial incentive involved with a pharmacy or a particular pharmaceutical company,” Dr Jayadevan added. 

The Adverse Outcomes - Tools To Analyse

Medical experts believe that polypharmacy is closely related with PIM use and can lead to adverse health problems  such as mental and functional decline, adverse drug events, drug interactions, unplanned hospitalisation, morbidity, and mortality.

“Inappropriate Polypharmacy and hyperpolypharmacy and PIM outweigh the clinical advantages of the drug and are strongly linked to a broad range of negative health outcomes, such as mental and functional decline, adverse drug events, drug interactions, unplanned hospitalization, cost, morbidity and mortality,” explained Dr. Rishi Kumar, Consultant, Critical Care Medicine & Physician, P.D. Hinduja Hospital & MRC, Mahim.

The PubMed research noted that 37 per cent of hyperpolypharmacy cases occur in patient settings although the clinicans maintainted that the Indian doctors by and large are quite aware about the down side of prescribing multiple medicines. 

“We (clinicians) are aware of the issues pertaining to hyper polypharmacy and we do seek clinical pharmacist`s advice in avoiding hyperpolypharmacy,” Dr Ganesh pointed out. 

Higher-income countries have developed tools to screen and prevent PIM use in older patients that include the lists of drugs or class of drugs that can cause adverse health events. Commonly referred tools are Beers criteria, the Screening Tool of Older Persons’ Prescription (STOPP) and the Screening Tool to Alert to Right Treatment (START).

Dr Dipu TS, Associate Professor, Division of Infectious Diseases, Amrita Hospital, Kochi said that India has the Pharmacovigilance Program of India (PvPI) under the Central Drugs Standard Control Organization (CDSCO) for monitoring and addressing adverse drug reactions. The programme aims at promoting a culture of reporting adverse drug events. 

While Dr Ganesh revealed that only a few centres in the country have digitalised systems to keep a check on the prescriptions and alert the clinician about potential interactions with other medications.

“The responsibility of government here maybe is to centralise the digital systems, prevent dispatching of over-the-counter medications, and raise awareness about polypharmacy in social media,” Dr Ganesh added.

Way Forward

Polypharmacy can cause several issues for the patients as well as the healthcare system of India, hence the experts believe that detecting polypharmacy and optimising the medication regimens accordingly is a crucial element in the care for elder patients. 

Dr Kumar said that developing guidelines, screening tools, safety checklists, regular physician education programs, follow-up with patients and public awareness programs might prove as effective ways to tackle polypharmacy. 

Dr Dipu TS further stated that clinicians can adopt strategies such as comprehensive geriatric assessment, rational medication use, interdisciplinary collaboration, geriatric training and advocating for supportive public policies.