Less is More:

Preventing Polypharmacy in Individuals with Intellectual Disabilities

Individuals with intellectual disabilities, like the general population, will likely experience a variety of illnesses or conditions during their lives, including chronic conditions. Those with multiple conditions often take multiple medications, and as the number of medications increases, they have an increased risk for drug interactions, side effects, and non-adherence to their treatment regimen (Hovstadius & Petersson, 2012). While multiple medications may be necessary, taking too many medications could result in harm.

Polypharmacy and Its Prevention

The term polypharmacy means the use of more medications than is medically necessary. Unnecessary medications may lead to harm without providing additional benefit. Each medication added to a person’s regimen has potential side effects and drug interactions, which may lead to more doctor visits. To lower the risk of polypharmacy, a discussion between the individual with an intellectual disability and their health care providers about the potential risks and benefits of each new medication is important. People with intellectual disabilities have different levels of impairment, and health care providers should deliver individualized patient-centered care. An individual may experience decreased communication, self-care, social skills, use of community services, or selfdirection (DiPiro et al., 2014). Because a complete assessment of an individual is crucial before safely adding medications, using best practices in interviewing patients with intellectual disabilities is very important in obtaining accurate information (see AAIDD’s Guidelines for Interviewing People with Disabilities at https:// aaidd.org/docs/default-source/sis-docs/ sisguidelinesforinterviewing.pdf ).

While some prescribers may not have time for a complete discussion, a pharmacist can help an individual with any concerns about new and multiple medications. Pharmacists usually see people regularly, and may see them more frequently than their physician. This rapport allows pharmacists to ask question about self-care and home life. A pharmacist often has time to ask about side effects in a casual setting when an individual picks up their medication. With access to an individual’s full medication list, the pharmacist checks for drug interactions when a medication is added. The availability of a pharmacist allows people to check-in with their concerns, and as a member of the health care community, a pharmacist can direct people to other needed community resources.

Preventing polypharmacy is better than treating it because stopping a medication can be difficult. Pharmacists have a key role in this prevention. Individuals with intellectual disabilities and caregivers also play an active role by discussing the person’s medication profile with their physician periodically. This allows the doctor and patient to verify all the medications are still needed.

Medications for Mental Illnesses

Individuals with intellectual disabilities experience certain mental illnesses at equal or greater rates than the general population (National Down Syndrome Society, 2012; Center for Autism and Related Disabilities, 2015; Scott & Havercamp, 2014). Common problems include conditions such as anxiety, behavioral issues, and depression. Classes of medications commonly prescribed for mental illnesses include antidepressants, antipsychotics, and benzodiazepines. These medications are effective, but also have side effects (see Table 1). Some side effects disappear with continued use, but others persist or worsen with long-term treatment. Taking multiple medications increases the risk of side effects. Individuals may have even more profound reactions when taking several medications because many have similar side effects. Also, medications may interact, leading to altered drug concentrations in the body. Lower drug concentrations can decrease a medicine’s effectiveness, while higher concentrations may cause adverse reactions or toxic effects.

Medications for Neurological Disorders

Individuals with intellectual disabilities can also develop neurological disorders, such as Alzheimer’s disease, other dementia, epilepsy or other seizure disorders. Several classes of medications are used for various neurological disorders, for example cholinesterase inhibitors for Alzheimer’s disease and anticonvulsant medications for epilepsy. As with medications for mental illnesses, medications for neurological disorders may also cause side effects (see Table 1).

Alzheimer’s disease and dementia treatments can only slow the progression of the disease. While side effects from cholinesterase inhibitors usually resolve after three weeks of treatment (DiPiro et al., 2014), new medications may be needed as the disease worsens. The addition of new medications may increase side effects or result in drug interactions. When new medications are added, individuals should be monitored for adverse effects as well as for changes in medication effectiveness.

Anticonvulsant medications not only have a variety of side effects (see Table 1), but sometimes require additional laboratory testing. The blood concentrations of many anticonvulsant medications are periodically measured to insure that the medication dose is appropriate for the individual. If the anticonvulsant medication’s concentration is too high, it may have toxic effects. If the concentration is too low, the anticonvulsant medication may not work and seizures could occur. Side effects from anticonvulsant medications may occur even if the blood concentration of the medication is in the correct range. If side effects occur, the dose may need to be changed or the medication may need to be switched to another medicine. Some individuals will require more than one anticonvulsant medication or higher doses to control seizures. Each of these cases may increase the person’s risk for side effects or drug interactions.

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Table 1: Commonly Used Medications and Their Side Effects

Medications Causing Sedation (DiPiro et al., 2014)

• Tricyclic Antidepressants: All medications in this class
• Other Antidepressants: Trazodone, Remeron (mirtazapine)
• Antipsychotics: Thorazine (chlorpromazine), Mellaril (thioridazine), Clozaril (clozapine), Zyprexa (olanzapine), Seroquel (quetiapine), Risperdal (risperidone), Geodon (ziprasidone)
• Anticonvulsants: Tegretol (carbamazepine), Ethosuximide, Keppra (levetiracetam), Trileptal (oxcarbazepine), Phenobarbital, Dilantin (phenytoin), Depakene (valproic acid)
• Benzodiazepines: All medications in this class

Medications Causing Insomnia (DiPiro et al., 2014)

• Antidepressants: Wellbutrin (bupropion), Zoloft (sertraline), Prozac (floxetine), Paxil (paroxetine), Effexor (venlafaxine)
• Alzheimer’s/dementia medications: Cholinesterase inhibitors (all medications in this class)

Medications Causing Nausea (DiPiro et al., 2014)

• Anticonvulsants: Tegretol (carbamazepine), Ethosuximide, Vimpat (lacosamide), Trileptal (oxcarbazepine)
• Alzheimer’s/dementia medications: Cholinesterase inhibitors (all medications in this class)

Medications Causing Constipation (DiPiro et al., 2014)

• Antipsychotics: Clozaril (clozapine), Zyprexa (olanzapine), Mellaril (thioridazine), Thorazine (chlorpromazine)
• Alzheimer’s/dementia medications: Namenda (memantine)

Medications Causing Diarrhea (DiPiro et al., 2014)

• SSRI Antidepressants: Zoloft (sertraline), Paxil (paroxetine)
• Alzheimer’s/dementia medications: Cholinesterase inhibitors (all medications in this class)

Medications Causing Weight Gain (Bray & Ryan, 2012)

• Tricyclic Antidepressants: Nortriptyline, Amitriptyline, Doxepin
• SSRI Antidepressants: Paxil (paroxetine), Lexapro (escitalopram)
• Other Antidepressants: Remeron (mirtazapine)
• Antipsychotics orMood Stabilizers: Lithium, Zyprexa (olanzapine), Clozaril (clozapine), Risperdal (risperidone)
• Anticonvulsants: Tegretol (carbamazepine), Depakene (valprioc acid), Depakote (divalproex)

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Minimizing Side Effects

If a medication is the likely cause of a side effect, the health care provider and their patient should discuss other options for treatment. Sometimes side effects can be minimized. For example, some medications cause sedation; these can be taken before bedtime as a way to minimize problems from that side effect. Other medications cause insomnia and these should be taken early in the person’s day. If a person feels nauseous after taking a medication, they may be able to take future doses with food. Constipation and diarrhea are problems that may warrant switching medications if they limit a person’s day-to-day activities. Individuals with constipation may need to increase fiber intake, try a laxative, or switch medications. Some medications cause profound weight gain. Individuals should monitor their weight often when starting these medications, so they can know if weight gain occurs. They may need to adjust diet and activity level, but to prevent excessive weight gain a medication change may be necessary.

While these basic solutions may decrease side effects, individuals should visit their health care provider if the side effects persist. The physician may switch medications, change medication doses, or provide education on non-pharmacological methods to lower side effects.

Conclusion

Polypharmacy can occur in all populations, not just in individuals with intellectual disabilities. However, people with multiple medical conditions often take multiple medications, which increases the risk of side effects and drug interactions. Communication between health care providers, caregivers, and the individual will help identify problems early and prevent polypharmacy.

Reprinted with permission from Impact: Feature Issue on Supporting Wellness for Adults with Intellectual and Developmental Disabilities (Winter 2016), published by the Institute on Community Integration, University of Minnesota. Retrieved from https://ici.umn.edu/products/view/739.

References

Bray, G.A .& Ryan, D.H. (2012). Medical therapy for the patient with obesity. Circulation,125(13), 695-1703. Center for Autism and Related Disabilities (2015). Autism and mental health issues. Retrieved from http://card-usf.fmhi.usf.edu/docs/resources/ CARD_ASDMH_Brochure092109.pdf. DiPiro, J.T., Talbert, R.L., Yee, G.C., Matzke, G.R., Wells, B.G. & Posey, L.M., (Eds) (2014). Pharmacotherapy. A pathophysiologic approach. 9th ed (pp 1019-1045). New York NY: McGraw Hill. Hovstadius, B. & Petersson, G. (2012). Factors leading to excessive poly- pharmacy. Clinical Geriatric Medicine, 28(2), 159-172. National Down Syndrome Society (2012). Mental health issues and Down syndrome. Retrieved from http://www.ndss.org/Resources/Health-Care/ Associated-Conditions/Mental-Health-Issues-Down-Syndrome/. Scott, H.M., & Havercamp, S. M. (2014). Mental health for people with intellectual disability: The impact of stress and social support. American Journal on Intellectual and Developmental Disabilities, 119(6), 522-564. DOI: 10.1352/1944-7558-119.6.552. Christopher Selph is a PharmD Candidate in the Skaggs School of Pharmacy, University of Montana, Missoula. He may be reached at christopher.selph@umontana.edu. Briana Cosca is a PharmD Candidate at the Skaggs School of Pharmacy, and she may be reached at briana.cosca@umontana.edu.