Consultant PharmacistForum

Polypharmacy is defined as the concurrent use of several drugs and the administration of drugs in dosages or frequencies higher than those known to be therapeutically necessary.¹ The consequences of polypharmacy in the geriatric population include an increased risk of adverse drug events (ADEs), decreased compliance, and increased health care costs.²

It may be possible to reduce the use of pharmaceuticals by substituting various foods with similar therapeutic properties. For example, because of increased nutrition research, it is now possible to go beyond the occasional prune juice to treat constipation. Cranberry juice may be useful in the treatment of urinary tract infections in patients with antibiotic allergies or difficulty in swallowing medicaments; the bacteriostatic effect is thought to occur by inhibiting bacterial adherence to mucosal surfaces.³ Grape juice has recently been reported to inhibit platelet aggregation. Red wine contains flavonoids that have antioxidant and antiplatelet properties thought to reduce the incidence of and death from coronary artery disease. This has been referred to as the “French paradox,” citing France’s consumption of high-fat foods but the low incidence of coronary artery disease, possibly due to the high consumption of red wine. Grape juice has many of the same flavonoids as red wine. They are known to inhibit platelet aggregation by blocking the production of thromboxane A2 and by inhibiting phosphodiesterase and, thereby, raising platelet cyclic AMP levels. Thus grape juice flavonoids may be better inhibitors of platelet aggregation than aspirin.

Grape juice flavonoids are also known to inhibit low-density lipoprotein (LDL) cholesterol oxidation. Platelets and oxidized LDL levels are known to contribute to the rate of atherosclerosis development and to cause acute coronary thrombosis and myocardial infarction. Thus consumption of as little as 10 oz. of grape juice daily may protect against the development of and death from coronary artery disease in a manner similiar to red wine.⁴

The addition of oat bran to an individual’s diet may have beneficial effects on blood lipid levels, diabetes control, and blood pressure control. There are two possible hypotheses regarding the mechanism by which dyslipidemia is affected. One hypothesis is that soluble fiber decreases absorption of cholesterol or fatty acids or causes a decrease in the absorption of biliary cholesterol or bile acids.⁵ Another proposal is that soluble fiber reduces cholesterol synthesis by altering the serum concentration of hormones or short-chain fatty acids that affect lipid metabolism.⁶

In one study an inverse relationship between fiber intake and myocardial infarction was found. These results support current national dietary guidelines to increase dietary fiber intake and suggest that fiber, independent of fat intake, is an important dietary component for the prevention of coronary artery disease.⁷ Evidence from experimental studies suggests that fiber (mainly soluble fiber) may reduce the risk of coronary heart disease through (1) cholesterol reduction from increased bile acid excretion and decreased hepatic synthesis of cholesterol, (2) slowed absorption of macronutrients, leading to increased insulin sensitivity, (3) lowered plasminogen activator type I and Factor VII coagulation activity, and (4) increased satiety, leading to overall energy intake. The reduction in serum cholesterol attributable to soluble fiber may range from 0.5%–2% per gram of intake.⁷ For patients in whom fiber intake results in lowered serum cholesterol or lipids, reduction in dosage or elimination of antilipemia medications may be considered.

Glycemic control is an important effect of soluble fiber (oat bran) consumption. The use of insulin, oral hypoglycemics, alpha-glucosidase inhibitors, and biguanide antidiabetic agents can sometimes be modified when soluble fiber is added to the patient’s diet.⁸ Significant improvements in patients’ daily glucose control have been shown. Possible mechanisms for metabolic improvements include delay of glucose absorption, enhanced insulin action at the cellular level, variations in digestion and absorption of carbohydrate and fat, effects on gut hormones that bind bile acids, and intestinal production of short-chain fatty acids.⁹ Recent studies show that increased sugar consumption elevates blood pressure and that consumption of oat bran can ameliorate these elevations.¹⁰

Hyponatremia from depletion of sodium and extracellular fluid volume can be treated with 1 g sodium chloride tablets. But beef and chicken bouillon cubes—which are used to make broth and which contain 1,368 mg and 1,484 mg of sodium, respectively—may be used instead of sodium chloride tablets.¹¹ For example, in geriatric populations, in which large sodium tablets may be unpalatable or hard to swallow, a drinkable broth may be preferable.

In the long-term care setting, polypharmacy is prevalent. With an increasing body of knowledge about the possible health benefits of dietary modifications, it may be possible, with the advent of additional data from clinical trials, to streamline pharmacotherapy regimens in selected patients with the use of dietary modifications. This review represents the “tip of the iceberg” in our expanding knowledge of dietary modifications and their benefits to patients. Individual quality of life and health care costs will be positively affected by the use of these measures when appropriate.

Michael E. Collett, RPh
Staff Pharmacist
Fran Migliozzi, MS, RD
Staff Dietician
Nursing Home Care Unit (NHCU)
Louis Stokes Cleveland VA Medical Center
Cleveland, Ohio

1. Kalchthaler T, Coccaro E, Lichtiger S. Incidence of polypharmacy in a long-term care facility. J Am Geriatr Soc 1977;25:308–13.
2. Bendickson KM, Benitez O, Alexander R. Effect of medication rounds on polypharmacy in a nursing home care unit [Abstract]. Proceedings of the American Society of Health-System Pharmacists Midyear Clinical Meeting, December 1990; abstract 25, p 57E.
3. Avorn J, Monhane M, Gurwitz JH et al. Reduction of bacteruria and pyuria after ingestion of cranberry juice. JAMA 1994;271:751–4.
4. Folts JD. Three glasses of grape but not orange or grapefruit juice inhibit ex vivo platelet aggregation in human volunteers [Abstract 767-3]. J Am Coll Cardiol 1997;226A.
5. Marlett JA, Hosig KB, Vollendorf NW et al. Mechanism of serum cholesterol reduction by oat bran. Hepatology 1994;20:1450–7.
6. Anderson JW, Deakins DA, Bridges SR. Dietary Fiber: Chemistry, Physiology, and Heath Effects. New York: Plenum Press; 1990:339–63.
7. Rimm EB, Ascherio A, Giovanucci E et al. Vegetable, fruit and cereal fiber intake and risk of coronary heart disease among men JAMA 1996;275:447–51.
8. Pick ME, Hawrysh J, Gee M et al. Oat bran concentrate bread products improve long term control of diabetes: a pilot study. J Am Diet Assoc 1996;96:1254–61.
9. Braaten JT, Wood PJ, Scott FW et al. Oat gum lowers glucose and insulin after an oral glucose load. Am J Clin Nutr 1991; 53:1425–30.
10. Zein M, Areas J, Kropka J et al. Oat bran ameliorates sugar induced hypertension. Clin Res 1996;372:554A.
11. Pennington J. Barnes and Church’s Food Values of Portions Commonly Used, 16th ed. Philadelphia: JB Lippincott Co; 1994:271.