Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes

Potential cytochrome P-450 drug-drug interactions in adults with metastatic solid tumors and effect on eligibility for Phase I clinical trials

PURPOSE

Potential cytochrome P-450 (CYP) drug-drug interactions in adults with metastatic solid tumors and their effect on eligibility for Phase I clinical trials were characterized.

METHODS

This study included adult patients with metastatic solid tumors seen by a medical oncologist from January 2008 through July 2011. The medications used by these patients were identified. Each medication's potential for interacting with CYP isozymes was also characterized. Medication changes required to meet Phase I trial eligibility criteria were also reviewed.

RESULTS

Data from 1773 patients were analyzed: 1489 were not enrolled in a Phase I trial and 284 were enrolled in a Phase I trial. Polypharmacy was significantly more prevalent in the group enrolled in a Phase I trial compared with those not enrolled (95% versus 80%, p < 0.001). The majority of patients not enrolled in a Phase I trial were taking at least one CYP isozyme inhibitor (87%) and at least one CYP isozyme inducer (45%). In a separate analysis, four Phase I trials were evaluated. Of 295 screened patients, 3.2% could not enroll due to concurrent medications. Charts from 74 enrolled patients revealed 655 concurrent medications—93 medications required further review for eligibility involving 51 (69%) of patients. Of the 93 medications, 38 (41%) were stopped and 41 (44%) were changed for the study.

CONCLUSION

Polypharmacy and the use of medications that interact with CYP isoyzmes were common in adult patients with metastatic solid tumors. Patients enrolling in Phase I studies often require medication changes to meet eligibility requirements.

Medication Use Among Ethnically Diverse Older Adults in the United States

As primary consumers of health care and prescription medication, older adults are more susceptible to potential drug-related adverse effects and medication interactions. With growing diversity among the older adult population, understanding ethnic differences in medication use becomes increasingly important. The current study describes polypharmacy and the occurrence of underprescribing among community-dwelling, low-income individuals 55 and older from four ethnic groups: (a) African American, (b) Afro-Caribbean, (c) European American, and (d) Hispanic American. Results revealed that number of illnesses, income level, and age were three major predictors associated with polypharmacy. No underprescription was identified. Overall, prevalence of polypharmacy was 47.5%. European American individuals had the highest prevalence followed by Hispanic American, African American, and Afro-Caribbean individuals. When caring for older adults from various ethnic groups, nurses should focus their efforts on those who have multiple illnesses and sufficient income to purchase medications to reduce the risk of polypharmacy.

Prevalence of concomitant medications in older HIV+ patients and comparison with general population

OBJECTIVE

The increasing population of human immunodeficiency virus (HIV)-infected elderly patients results in a higher number of comorbidities and greater incidence of polypharmacy in addition to antiretroviral therapy (ART). The aim of this study is to describe the use of concomitant medication in older HIV-infected patients and to compare it with older general population.

METHODS

The study included HIV-positive outpatients (>49 years) who received ART in 2011. Co-medication dispensed by pharmacies in that year was collected. Defined daily dose (DDD) for each drug was calculated by patient. A comparison was made between the use of co-medication among men between 50 and 64 years old in general population against the HIV-infected population.

RESULTS

The study was based on 118 patients (77% men), of which 82% took at least one co-medication and 58% at least five. The commonest co-medications used by HIV-positive patients were antibiotics (44%); analgesics (44%); anti-inflammatories (39%); antacids (38%); and psycholeptics (38%). The medicines used for the greatest number of days per HIV-positive patient were those related to the renin-angiotensin system; anti-diabetics; lipid modifying agents; antithrombotics; and calcium channel blockers. In comparison with the general male population, a higher proportion of HIV-infected patients used antibiotics (42 vs 30%, P = 0.018), antiepileptics (16 vs 5%, P = 0.000), psycholeptics (35 vs 17%, P = 0.000) and COPD medications (14 vs 7%, P = 0.008). The duration of antibiotics and psycholeptic use in HIV-infected patients was longer compared to the general population (P < 0.05).

CONCLUSIONS

Older HIV-positive patients frequently take a higher number of co-medication, which increases the risk of adverse events, interactions with other medication, and may lead to poorer treatment adherence.

Outcome of gastric emptying and gastrointestinal symptoms after liver transplantation for hereditary transthyretin amyloidosis

Background

Hereditary transthyretin amyloid (ATTR) amyloidosis is a rare but fatal autosomal dominant condition that is present all over the world. A liver transplantation has been shown to halt the progress of the disease in selected patients and is currently considered to be the standard treatment. Gastrointestinal manifestations are common in hereditary ATTR amyloidosis and are important for the patients’ morbidity and mortality. The aim of this study was to evaluate the long-term outcome of gastric emptying, gastrointestinal symptoms and nutritional status after liver transplantation for the disease.

Methods

Swedish patients with hereditary ATTR amyloidosis transplanted between 1990 and 2012 were included. A standardized method for measuring gastric emptying with a Tc^99m-labelled meal followed by scintigraphy was utilized. Validated questionnaires were used to assess gastrointestinal symptoms and the modified body mass index (mBMI), in which BMI is multiplied by s-albumin, was used to evaluate nutritional status. Non-parametrical statistical tests were used.

Results

Gastric emptying rates and nutritional statuses were evaluated approximately eight months before and two and five years after liver transplantation, whereas gastrointestinal symptoms were assessed in median nine months before and two and nine years after transplantation. No significant change was found in gastric emptying (median half-time 137 vs. 132 vs. 125 min, p = 0.52) or nutritional status (median mBMI 975 vs. 991 vs. 973, p = 0.75) after transplantation. Gastrointestinal symptom scores, however, had increased significantly over time (median score 7 vs. 10 vs. 13, p < 0.01).

Conclusions

Gastric emptying and nutritional status were maintained after liver transplantation for hereditary ATTR amyloidosis, although gastrointestinal symptom scores had increased over time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0284-4) contains supplementary material, which is available to authorized users.

Determinants of frailty: the added value of assessing medication

This study aims to analyze which determinants predict frailty in general and each frailty domain (physical, psychological, and social), considering the integral conceptual model of frailty, and particularly to examine the contribution of medication in this prediction. A cross-sectional study was designed using a non-probabilistic sample of 252 community-dwelling elderly from three Portuguese cities. Frailty and determinants of frailty were assessed with the Tilburg Frailty Indicator. The amount and type of different daily-consumed medication were also examined. Hierarchical regression analysis were conducted. The mean age of the participants was 79.2 years (±7.3), and most of them were women (75.8%), widowed (55.6%) and with a low educational level (0-4 years: 63.9%). In this study, determinants explained 46% of the variance of total frailty, and 39.8, 25.3, and 27.7% of physical, psychological, and social frailty respectively. Age, gender, income, death of a loved one in the past year, lifestyle, satisfaction with living environment and self-reported comorbidity predicted total frailty, while each frailty domain was associated with a different set of determinants. The number of daily-consumed drugs was independently associated with physical frailty, and the consumption of medication for the cardiovascular system and for the blood and blood-forming organs explained part of the variance of total and physical frailty. The adverse effects of polymedication and its direct link with the level of comorbidities could explain the independent contribution of the amount of prescribed drugs to frailty prediction. On the other hand, findings in regard to medication type provide further evidence of the association of frailty with cardiovascular risk. In the present study, a significant part of frailty was predicted, and the different contributions of each determinant to frailty domains highlight the relevance of the integral model of frailty. The added value of a simple assessment of medication was considerable, and it should be taken into account for effective identification of frailty.

Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people

PURPOSE

To assess the prevalence of polypharmacy and frailty, to examine their association, and to establish their independent and combined effects on mortality in a sample of French old people.

METHODS

This is a cross-sectional population study of people aged 70 years and over. A total of 2350 respondents were interviewed at home in 2008-2010. Frailty was defined as impairment in three domains or more among nutrition, energy, physical activity, strength, and mobility, in the absence of difficulties in basic activities of daily living. Mortality data were documented after a mean follow-up period of 2.6 years.

RESULTS

Mean age of the population was 83.3 +/- 7.5 years, with 59.4% of women. Prevalence of frailty was 17.0%. Polypharmacy (5-9 drugs) was reported in 53.6% of the population, and excessive polypharmacy (10 drugs or more) in 13.8%. After adjustment for socio-demographic and health variables, polypharmacy and excessive polypharmacy were associated with frailty with odds ratio 1.77 [1.20-2.61] and 4.47 [2.37-8.42], respectively. Frailty (hazard ratio [HR] 2.56 [1.63-4.04]) and excessive polypharmacy (HR 1.83 [1.28-2.62]) were independent predictors of mortality. Compared with non-frail people without polypharmacy, frail people with excessive polypharmacy were six times more likely to die during the follow-up period (HR 6.30 [3.09-12.84]).

CONCLUSION

By showing the independent and combined effects of polypharmacy and frailty on mortality risk, this study should reinforce the awareness of clinicians with regard to these factors, rather prevalent in old people.

Predictors of 1-Year Mortality in a Prospective Cohort of Elderly Patients With Cancer

BACKGROUND

Mortality prediction is crucial to select the optimal treatment in elderly cancer patients. Our objective was to identify cancer-related factors and Comprehensive Geriatric Assessment (CGA) findings associated with 1-year mortality in elderly inpatients and outpatients with cancer.

METHODS

We prospectively included patients aged ≥70 years who had solid or hematologic malignancies and in whom the CGA was performed by geriatricians in two French teaching hospitals. We identified independent predictors of 1-year mortality after study inclusion, using multivariate Cox models stratified on inpatient/outpatient status. We built three multivariate Cox models, since strong correlations linked activities of daily living (ADL), Eastern Cooperative Oncology Group Performance Status (ECOG-PS), and timed get-up-and-go test (GUG) results; and since physicians' preferences for these three assessments vary. A sensitivity analysis was performed using multiple imputation.

RESULTS

Of the 993 patients (mean age, 80.2 years; 51.2% men), 58.2% were outpatients and 46% had metastatic disease. Colorectal cancer was the most common malignancy (21.4%). Mortality rates after 6 and 12 months were 30.1% and 41.2%, respectively. In all models, tumor site and metastatic status (p < .001), age >80 years (p < .05), higher number of severe comorbidities (p < .05), and malnutrition (p < .001) were associated with death independently from impaired ECOG-PS (p < .001), ADL (p < .001), and GUG (p < .001). The adverse effect of metastatic status differed significantly across tumor sites, being greatest for breast and prostate cancer (p < .001). Multiple imputation produced similar results.

CONCLUSION

The predictors of 1-year mortality identified in our study may help physicians select the optimal cancer-treatment strategy in elderly patients.

Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs

Objectives

Drug use is a modifiable risk factor for fall-related injuries in older people. Whereas the injurious effect of polypharmacy is established, that of low numbers of medications has not been fully ascertained. Neither do we know whether it is the number per se or the type of medications that actually matters. We assessed this question for fall injuries leading to hospitalization.

Design

National register-based, population-based, matched case-control study.

Setting

Community dwellers aged 65+ years living in Sweden between March 2006 and December 2009.

Methods

Cases (n = 64,399) were identified in the national inpatient register and four controls per case were randomly matched by gender, date of birth and residential area. The association between number of prescribed medications, assessed through linkage with the Swedish prescribed drug register, and the risk of injurious falls was estimated with odds ratios with 95% confidence intervals using conditional logistic regression, adjusted for demographic and health status.

Results

The number of medications was associated with an increased risk of fall injury in a dose-response fashion, even after adjustment for marital status, comorbidity and number of fall-risk-inducing drugs (FRIDs). Using ten or more medications was associated with an almost two-fold higher risk (adjusted OR: 1.76, 95% CI: 1.66 to 1.88). When stratified by use (or not) of at least one FRID, the association weakened slightly among both non-users (adjusted OR: 1.50, 95% CI: 1.34 to 1.67) and users (adjusted OR: 1.67, 95% CI: 1.58 to 1.77).

Conclusion

In older people, not only large but also small numbers of medications may affect the risk for them to sustain injurious falls. Although the mechanisms lying behind this are complex, the finding challenges the prevention strategies targeting either specific types of medications (FRIDs) or high numbers of them.

Derivation of a frailty index from the interRAI acute care instrument

BACKGROUND

A better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care.

METHODS

1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis.

RESULTS

Variables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data. Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0-1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0. In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70-2.48]).

CONCLUSIONS

Quantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs. The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

Appropriate prescribing and important drug interactions in older adults

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review

OBJECTIVES

To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community-dwelling persons.

DESIGN

Systematic review of MEDLINE (OvidSP 1946 to May, Week 3, 2014).

SETTING

Community.

PARTICIPANTS

Observational studies examining health outcomes according to number of prescription medications taken.

MEASUREMENTS

Association between number of medications and health outcomes. Because of the importance of comorbidity as a potential confounder of the relationship between polypharmacy and health outcomes, articles were assessed regarding the quality of their adjustment for confounding.

RESULTS

Of the 50 studies identified, the majority that were rated good in terms of their adjustment for comorbidity demonstrated relationships between polypharmacy and a range of outcomes, including falls, fall outcomes, fall risk factors, adverse drug events, hospitalization, mortality, and measures of function and cognition. However, a number of these studies failed to demonstrate associations, as did a substantial proportion of studies rated fair or poor.

CONCLUSION

Data are mixed regarding the relationship between polypharmacy, considered in terms of number of medications, and adverse outcomes in community-dwelling older persons. Because of the challenge of confounding, randomized controlled trials of medication discontinuation may provide more-definitive evidence regarding this relationship than observational studies can provide.

Prescription rate of medications potentially contributing to lower urinary tract symptoms and detection of adverse reactions by prescription sequence symmetry analysis

Background

The lower urinary tract symptoms (LUTS) increases with age and can have a significant effect on the quality of life of the patients. Elderly patients, who are often characterized by a decline in physiological functional and polypharmacy, are susceptible to adverse drug reactions to pharmacotherapy. LUTS can also be a side effect of medication. The purpose of this study was to investigate the possible association between the initiation of LUTS-causing drug therapy and the onset of LUTS.

Methods

Drug dispensing data at the individual level were retrieved from the CISA (Platform for Clinical Information Statistical Analysis: http://www.cisa.jp) database. A retrospective study was conducted by reviewing patients with LUTS who were dispensed drugs that increased the risk of LUTS between April 2011 and March 2012. Prescription sequence symmetry analysis (PSSA) was employed to investigate the associations between the dispensing of medicines of LUTS and that of LUTS-causing drugs.

Results

LUTS-causing drugs were frequently dispensed to patients with LUTS. The use of medications potentially contributing to LUTS was associated with polypharmacy [number of prescription drugs:12.13 ± 6.78 (user) vs. 5.67 ± 5.24 (nonuser)] but not patient age [ age: (71.38 ± 13.28 (user) vs. 70.45 ± 14.80 (nonuser)]. Significant adverse drug events were observed the use of donepezil, cyclophosphamide, antiparkinson drugs, antidepressant, diazepam, antipsychotic drugs for peptic ulcer, tiotropium bromide, and opioids.

Conclusions

The use of prescription LUTS-causing drugs was correlated with polypharmacy. The adverse drug events associated with LUTS-causing drugs were highly prevalent in elderly patients. To prevent of adverse drug events in patients with LUTS, pharmacists and physicians should regularly review medication lists and reduce the prescribed medicines.

Electronic supplementary material

The online version of this article (doi:10.1186/s40780-014-0004-1) contains supplementary material, which is available to authorized users.

Use of medications and functional dependence among Chinese older adults in a rural community: A population-based study

AIM

To investigate the associations between medication use and functional dependence in Chinese older people living in a rural community.

METHODS

The cross-sectional study included 1538 participants (age ≥60 years, 59.1% women) in the Confucius Hometown Aging Project in Shandong, China. In June 2010 to July 2011, data on demographics, lifestyle factors, health history, basic activities of daily living (ADL), instrumental ADL, and use of medications were collected through interviews and clinical examinations. Functional status was categorized into no dependence, dependence only in instrumental ADL and dependence in basic ADL. Data were analyzed with multinomial logistic models controlling for potential confounders.

RESULTS

Dependence in instrumental or basic ADL was significantly associated with use of antihypertensives and hypolipidemic agents, and basic ADL dependence was also associated with use of sedatives or tranquilizers and cardiac glycosides. An increased number of concurrently used medications was significantly associated with an increased likelihood of dependence in basic ADL (P for trend = 0.016). Compared with non-users of any medication, individuals who concurrently used three or more classes of medications had a multi-adjusted odds ratio of 2.91 (95% confidence interval 1.02-8.28) for dependence in basic ADL.

CONCLUSIONS

Use of antihypertensives, hypolipidemic drugs, cardiac glycosides and sedatives or tranquilizers, especially use of multiple classes of medications, is correlated with functional dependence among older people in rural China. Geriatr Gerontol Int 2015; 15: 1242-1248.

Design and delivery of a tailored intervention to implement recommendations for multimorbid patients receiving polypharmacy into primary care practices

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.

Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults

BACKGROUND

polypharmacy is an important risk factor for falls, but recent studies suggest only when including medications associated with increasing the risk of falls.

DESIGN

a prospective, population-based cohort study.

SUBJECTS

6,666 adults aged ≥50 years from The Irish Longitudinal study on Ageing.

METHODS

participants reported regular medication use at baseline. Any subsequent falls, any injurious falls and the number of falls were reported 2 years later. The association between polypharmacy (>4 medications) or fall risk-increasing medications and subsequent falls or injurious falls was assessed using modified Poisson regression. The association with the number of falls was assessed using negative binomial regression.

RESULTS

during follow-up, 231 falls per 1,000 person-years were reported. Polypharmacy including antidepressants was associated with a greater risk of any fall (adjusted relative risk (aRR) 1.28, 95% CI 1.06-1.54), of injurious falls (aRR 1.51, 95% CI 1.10-2.07) and a greater number of falls (adjusted incident rate ratio (aIRR) 1.60, 95% CI 1.19-2.15), but antidepressant use without polypharmacy and polypharmacy without antidepressants were not. The use of benzodiazepines was associated with injurious falls when coupled with polypharmacy (aRR 1.40, 95% CI 1.04-1.87), but was associated with a greater number of falls (aIRR 1.32, 95% CI 1.05-1.65), independent of polypharmacy. Other medications assessed, including antihypertensives, diuretics and antipsychotics, were not associated with outcomes.

CONCLUSION

in middle-aged and older adults, polypharmacy, including antidepressant or benzodiazepine use, was associated with injurious falls and a greater number of falls.

Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk

The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug-drug or drug-disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.

Anti-dementia drugs and co-medication among patients with Alzheimer's disease : investigating real-world drug use in clinical practice using the Swedish Dementia Quality Registry (SveDem)

BACKGROUND

There is a substantial risk of drug-interactions, adverse events, and inappropriate drug use (IDU) among frail Alzheimer's disease (AD) patients; however, there are few studies about co-medication and IDU in clinical settings.

OBJECTIVES

To investigate anti-dementia drugs, associated characteristics of cholinesterase inhibitors (ChEIs) and NMDA antagonists, co-medication, and IDU in a large population of outpatients with mild AD.

METHODS

In this cross-sectional analysis of medication characteristics, we analyzed data from the Swedish Dementia Quality Registry (SveDem) on 5,907 newly diagnosed AD patients who were registered in memory clinics. SveDem is a national quality registry in Sweden, which was established in 2007 to evaluate and improve dementia healthcare. Comparisons were performed concerning co-medications, use of ≥3 psychotropic drugs (IDU) and polypharmacy (≥5 drugs) based on anti-dementia treatment (ChEIs or NMDA antagonists). Information on baseline characteristics such as age, sex, living conditions, cognitive evaluation based on the Mini-Mental State Examination (MMSE) score, and diagnostic work-up was also evaluated.

RESULTS

The majority of the AD patients were in the mild stage of the disease. Overall, 4,342 (75.4 %) patients received any ChEI, 438 (7.6 %) used an NMDA antagonist and 74 (1.3 %) patients were treated with both. However, 907 (15.7 %) patients were not treated with any anti-dementia drug. While polypharmacy was seen in 33.5 % of patients, only 2.6 % concurrently used ≥3 psychotropic medications. Patients on ChEIs were significantly younger, had a higher MMSE score and were treated with a smaller number of medications (a proxy for overall co-morbidity). Co-medication with antipsychotics [3.3 vs. 7.6 %; adjusted odds ratio (OR) 0.55 (95 % CI 0.38-0.79)] and anxiolytics [5.8 vs. 10.9 %; adjusted OR 0.62 (95 % CI 0.46-0.84)] was significantly lower in the ChEI+ group than in those with no anti-dementia treatment.

CONCLUSION

Patients taking ChEIs were treated with less antipsychotics and anxiolytics than those not taking ChEIs. More research is warranted to elucidate whether use of ChEIs in clinical practice can reduce the need for psychotropic drugs in AD patients.

Multi-drug therapy in chronic condition multimorbidity: a systematic review

BACKGROUND

Older populations often suffer from multimorbidity and guidelines for each condition are often associated with recommended drug therapy management. Yet, how different and specific multimorbidity is associated with number and type of multi-drug therapies in general populations is unknown.

AIM

The aim of this systematic review was to synthesize the current evidence on patterns of multi-drug prescribing in family practice.

METHODS

A systematic review on six common chronic conditions: diabetes mellitus, cardiovascular disease, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), osteoarthritis and depression was conducted, with a focus on studies which looked at any potential combination of two or more multimorbidity. Studies were identified from searches of MEDLINE, EMBASE, PsychINFO, the Allied and Complementary Medicine Database (AMED) and the Health Management Information Consortium (HMIC) databases from 1960 to 2013.

RESULTS

A total of eleven articles were selected based on study criteria. Our review identified very few specific studies which had explicitly investigated the association between multimorbidity and multi-drug therapy. Relevant chronic conditions literature showed nine observational studies and two reviews of comorbid depression drug treatment. Most (seven) of the articles had focused on the chronic condition and comorbid depression and whether antidepressant management had been optimal or not, while four studies focused on other multimorbidities mainly heart failure, COPD and diabetes.

CONCLUSIONS

Very few studies have investigated associations between specific multimorbidity and multi-drug therapy, and most currently focus on chronic disease comorbid depression outcomes. Further research needs to identify this area as key priority for older populations who are prescribed high levels of multiple drug therapy.

Does residing in urban or rural areas affect the incidence of polypharmacy among older adults in western China?

The aim of this study is to explore the differences among older adults who are rural or urban residents with respects to their socioeconomic position, chronic health conditions and medication use. This cross-sectional study included 887 community-dwelling older adults (≥60 years) from western China. Trained interviewers collected data from all of the study subjects through face-to-face interviews. Polypharmacy was defined as the concomitant use of five or more medications. A total of 717 participants were included in the study analyses. Compared with their urban counterparts, the older adults in rural China were more likely to have more chronic health conditions, and a lower education level, annual income and insurance coverage rate. In addition, the rural inhabitants were less likely to use medications (58.7% vs. 75.7%, p<0.001). The intensity of medication use (the mean number of drugs) was 1.7 for rural residents and 2.3 for urban residents (p<0.001). The prevalence of polypharmacy was significantly lower in rural residents than urban residents (11.5% vs. 17.5%, p=0.021). Urban residence (odds ratios (OR) 1.89, 95% confidence intervals (CI) 1.03-3.48), number of chronic conditions (OR 1.95, 95% CI 1.16-3.30), diabetes (OR 4.14, 95% CI 2.33-7.37), and cardiovascular disease (CVD) (OR 2.09, 95% CI 1.25-3.51) were positively associated with polypharmacy, whereas good self-rated health (OR 0.32, 95% CI 0.16-0.65) was negatively associated with polypharmacy. In conclusion, urban residence is independently associated with polypharmacy in Chinese elders regardless of chronic health conditions and socioeconomic status.

The quality of outpatient primary care in public and private sectors in Sri Lanka--how well do patient perceptions match reality and what are the implications?

OBJECTIVE

To compare the quality of clinical care and patient satisfaction in public and private outpatient primary care services in Sri Lanka.

METHODS

A prospective, cross-sectional comparison was done by direct observation of patient encounters and exit interviews of outpatients in 10 public hospital general outpatient clinics and 66 private practitioner clinics in three districts of Sri Lanka. A total of 1027 public sector patients and 944 private sector patients were surveyed. Data were collected for 39 quality indicators covering diarrhoea, cough, hypertension, diabetes, asthma, upper respiratory tract infections (URTI) and five other conditions, along with prescribing indicators. The exit interviews collected data for 10 patient satisfaction indicators.

RESULTS

The public sector performed better for some conditions (diarrhoea, cough and asthma) and the private sector performed better for others (hypertension, diabetes, URTI and tonsillitis). Overall quality was similar between the sectors in the domains of history taking, examination and investigations and management, but the private sector performed much better on patient education (57 vs 12%). Overall patient satisfaction was high in both sectors (98%), although the private sector performed much better in interpersonal satisfaction (94 vs 84%) and system-related indicators (95 vs 84%). Comparisons with studies from other countries suggest that both sectors perform considerably better than India, and similarly in many indicators to high-income countries.

CONCLUSIONS

Quality of outpatient primary care in Sri Lanka is generally high for a lower-middle income developing country. The public and private sectors perform similarly, except that private sector patients have longer consultations, are more likely to receive education and advice, and obtain better interpersonal satisfaction. The public system, with its limited funding, is able to deliver care in diagnosis and management that is similar to the private sector, while private sector patients, who spend more on their healthcare receive better quality care in non-clinical areas.

Multiple medication use in older patients in post-acute transitional care: a prospective cohort study

Background

Older adults with a range of comorbidities are often prescribed multiple medications, which may impact on their function and cognition and increase the potential for drug interactions and adverse events.

Aims

This study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post-discharge transitional home care and explored the associations of polypharmacy with patient characteristics, functional outcomes, and frailty.

Methods

A prospective observational study was conducted of 351 patients discharged home from hospital with support from six Transition Care Program (TCP) sites in two states of Australia. A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI Home Care assessment tool, with frailty measured using an index of 57 accumulated deficits. Medications from hospital discharge summaries were coded using the World Health Organization Anatomical Therapeutic Chemical Classification System.

Results

Polypharmacy (5–9 drugs) was observed in 46.7% and hyperpolypharmacy (≥10 drugs) in 39.2% of patients. Increasing numbers of medications were associated with greater number of comorbid conditions, a higher prevalence of diabetes mellitus, coronary heart disease, chronic obstructive pulmonary disease, dizziness, and dyspnea and increased frailty. At discharge from the program, the non-polypharmacy group (<5 drugs) had improved outcomes in Activities of Daily Living, Instrumental Activities of Daily Living and fewer falls, which was mediated because of lower levels of frailty. The commonest drugs were analgesics (56.8%) and antiulcer drugs (52.7%). The commonest potentially inappropriate medications were tertiary tricyclic antidepressants.

Conclusion

Polypharmacy is common in older patients discharged from hospital. It is associated with frailty, falls, and poor functional outcomes. Efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning. Whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials.

A new lexicon for polypharmacy: Implications for research, practice, and education

Previous research suggests that polypharmacy is a significant challenge for health care systems. However, polypharmacy has been defined in at least 24 distinct ways, which has understandably caused confusion among researchers, educators, and students in health care. Previous definitions of polypharmacy capture what could be both inappropriate therapy, i.e. too many medications, as well as evidence-based therapy that is appropriate. Previous research has tried to focus on the number of medications a patient is prescribed to define polypharmacy; however only focusing on the number of medications a patient is taking may be of limited value in determining whether that patient will experience an adverse event. This paper proposes a lexicon change for polypharmacy. It suggests that in future research, polypharmacy be defined as patients going to more than one pharmacy for their prescriptions. The authors also proffer a new term, 'extraordinary prescribing,' to define patients who are taking medications that are either grossly excessive or not beneficial for that patient. This definition is different than the current use of polypharmacy because the number of medications a patient is taking is irrelevant, especially if that patient has multiple chronic diseases. This paper is meant to start a dialog within the health services research community to inform future research that examines why inefficient prescribing may harm patients and the broader health care system.

Potentially inappropriate medication use in older people with cancer: prevalence and correlates

OBJECTIVES

Potentially inappropriate medication (PIM) use has been associated with an increase in adverse drug events, hospitalization and mortality. This study investigated the prevalence and factors associated with PIM use in patients presenting to a medical oncology outpatient clinic.

MATERIALS AND METHODS

Consecutive patients (n=385) aged ≥ 70 years referred to a medical oncology outpatient clinic between January 2009 and July 2010 completed a structured data collection instrument. The instrument assessed medication use, diagnoses, self-reported falls in the previous six months, pain (10-point visual analog scale [VAS]) and distress (10-point VAS). Frailty was defined using exhaustion, weight loss, Karnofsky Performance Scale, instrumental activities of daily living and physical function. PIM use was defined by the Beers Criteria. Logistic regression was used to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with PIM use.

RESULTS

In total, 26.5% (n=102) of the sample used ≥1 PIM. The five most prevalent classes of PIMs were benzodiazepines (n=34, 8.8%), tricyclic antidepressants (n=16, 4.2%), alpha-adrenoreceptor antagonists (prazosin) (n=15, 3.9%), propulsives (metoclopramide) (n=15, 3.9%) and non-steroidal anti-inflammatory drugs (n=14, 3.6%). In multivariate analyses, PIM use was associated with age 75-79 years (OR 1.83; 95%CI 1.02-3.26) compared to age 70-74 years, using ≥ 5 medications (OR 4.10; 95%CI 2.26-7.44) compared to <5 medications and being frail (OR 3.05; 95%CI 1.18-7.87) compared to being robust.

CONCLUSION

More than one quarter of older people with cancer used one or more PIMs, and this was associated with being frail compared to being robust.

Polypharmacy and potentially inappropriate medication use in older adults with cancer undergoing chemotherapy: effect on chemotherapy-related toxicity and hospitalization during treatment

OBJECTIVES

To evaluate the prevalence of polypharmacy and potentially inappropriate medication (PIM) use and the association between these and chemotherapy-related adverse events in older adults with cancer undergoing chemotherapy.

DESIGN

Secondary analysis of prospectively collected data.

SETTING

Outpatient oncology clinics in seven academic medical centers.

PARTICIPANTS

Adults aged 65 and older with cancer undergoing chemotherapy.

MEASUREMENTS

Measures included number of daily medications (polypharmacy); PIM use based on three indices (Beers, Zhan, and Drugs to Avoid in the Elderly criteria), and use of six "high risk" medication classes for adverse drug events (anticoagulants, antiplatelet agents, opioids, insulin, oral hypoglycemics, antiarrhythmics). Using multivariate logistic regression, the relations were evaluated between these criteria and Grade 3 to 5 chemotherapy-related toxicity and between these criteria and hospitalization during chemotherapy.

RESULTS

Participants (N=500; mean age 73, 61% Stage IV disease) took a mean of 5±4 daily medications (range 0-23). PIM use was common (up to 29% according to Beers criteria). No association was found between number of daily medications (reference 0-3 medications) and toxicity (4-9 medications, odds ratio (OR)=1.34, 95% confidence interval (CI)=0.92-1.97; ≥10 medications, OR=0.82, 95% CI=0.45-1.49) or hospitalization (≥4 medications, OR=1.34, 95% CI=0.82-2.18, P=.24). There was also no association between PIM use and toxicity (P=.93) or hospitalization (P=.98). No medication class was associated with either outcome.

CONCLUSIONS

Polypharmacy and PIM use were common but were not associated with chemotherapy-related toxicity or hospitalization in older adults with cancer.

Chronic condition comorbidity and multidrug therapy in general practice populations: a cross-sectional linkage study

OBJECTIVES

The study investigated (1) the association between comorbidity and multidrug prescribing compared with the index condition, and (2) the association between vascular comorbidity and non-vascular condition key drug prescribing.

DESIGN

Cross-sectional study linking anonymised computer consultations with prescription records for a 2-year time period.

SETTING

11 general practices in North Staffordshire, England.

PARTICIPANTS

Study groups aged 40 years and over (N=12 875). Within six conditions, comorbid group with the other five conditions was compared with an 'alone' group without them. Additionally, how the 'vascular' (one of diabetes, cardiovascular disease and cerebrovascular disease) comorbidity influenced chronic obstructive pulmonary disease (COPD), osteoarthritis (OA) or depression drug prescribing was investigated.

OUTCOME MEASURES

Based on the British National Formulary, five main drug chapters constituted a measure of drug counts, with low count as 2 or less and high multidrug count as 3 or more. Key drugs prescribed for COPD, OA and depression were derived from guidelines.

RESULTS

The adjusted associations between the comorbid groups and higher multidrug count compared with their respective 'alone' group were: odds ratio (OR) 7.1 (95% CI 5.6 to 9.0) for depression, OR 5.4 (95% CI 4.6 to 6.3) for cardiovascular disease, OR 3.7 (95% CI 2.8 to 5.0) for cerebrovascular disease, OR 3.6 (95% CI 3.1 to 4.3) for OA, OR 3.5 (95% CI 3.0 to 4.2) for diabetes and OR 3.2 (95% CI 2.6 to 4.0) for COPD. In COPD, vascular comorbidity was associated with a significant reduction in key COPD drug treatments (adjusted OR 0.6 (95% CI 0.4 to 0.8). In depression, vascular comorbidity was associated with a reduction in key depression drug treatments (OR 0.6 (95% CI 0.4 to 0.7)).

CONCLUSIONS

Our findings show that multidrug prescribing for different body systems is higher with comorbidity and may be associated with lower likelihood of prescribing for specific conditions. Further research is required on whether multidrug prescribing influences the outcomes of care for chronic conditions.

Importance of frailty in patients with cardiovascular disease

Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality. With the ageing population, the prognostic determinants among others include frailty, health status, disability, and cognition. These constructs are seldom measured and factored into clinical decision-making or evaluation of the prognosis of these at-risk older adults, especially as it relates to high-risk interventions. Addressing this need effectively requires increased awareness and their recognition by the treating cardiologists, their incorporation into risk prediction models when treating an elderly patient with underlying complex CVD, and timely referral for comprehensive geriatric management. Simple measures such as gait speed, the Fried score, or the Rockwood Clinical Frailty Scale can be used to assess frailty as part of routine care of elderly patients with CVD. This review examines the prevalence and outcomes associated with frailty with special emphasis in patients with CVD.

Nonsteroidal anti-inflammatory drugs (NSAIDs) in older people: prescribing patterns according to pain prevalence and adherence to clinical guidelines

The evidence on the patterns of nonsteroidal anti-inflammatory drug (NSAID) use according to pain prevalence and clinical guidelines in older people is sparse. This cross-sectional study examined the patterns of NSAID use according to pain prevalence and concordance with clinical guideline recommendations for safe NSAID use in older people, in relation to duration of use, patterns of use, concomitant use of proton pump inhibitors (PPIs), and prevalence of specific drug interactions. Community-dwelling men (n=1696) age ≥ 70 years living in Sydney were studied. 8.2% (n=139) of participants reported regular NSAID use compared with 2.9% (n=50) reporting as-needed use. The mean treatment duration for regular NSAID use was 4.9 years, suggesting long-term rather than short-term use as recommended by the guidelines. Although guidelines recommend use of PPIs together with an NSAID, only 25.2% of regular NSAID users reported PPI use. Regular NSAID users were significantly more likely to report use of opioid analgesics (P<.0001) compared with nonregular users. In relation to pain prevalence, regular NSAID users were significantly more likely to report chronic pain (P<.0001), recent pain (P=.0001), and chronic intrusive pain (P<.0001) compared with nonregular users. The findings of this study indicate that NSAID prescribing practices do not align with clinical guidelines for safe use in older people. This difference between the guideline recommendations and what is happening in the real world should be explored further.

An educational intervention on drug use in nursing homes improves health outcomes resource utilization and reduces inappropriate drug prescription

OBJECTIVE

Inappropriate drug prescription is a common problem in people living in nursing homes and is linked to adverse health outcomes. This study assessed the effect of an educational intervention directed to nursing home physicians in reducing inappropriate prescription and improving health outcomes and resource utilization.

DESIGN

Prospective, randomized, multicenter study.

SETTING

A private organization of nursing homes in Spain.

PARTICIPANTS

Sixty nursing home physicians caring for approximately 3900 nursing home residents in 37 centers were randomized to receive an educational intervention (30) or as a control group (30).

INTERVENTION

10 hours educational program, followed by on demand support by phone.

OUTCOME MEASUREMENTS

Outcomes were assessed in 1018 randomly selected nursing home residents. Appropriateness of drug use [measured by the Screening Tool of Older Persons Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria], incidence of selected geriatric syndromes (falls, delirium) and health resource utilization (visits to physicians and nursing homes, visits to the emergency room, days of hospitalization) were recorded for 3 months before the intervention started and 3 months after the intervention finished.

RESULTS

O total of 716 residents finished the study (344 cared for by the intervention group physicians, 372 cared for by control physicians). Mean age was 84.4 ± 12.7 years; 73% were women. The mean number of inappropriate drugs (STOPP criteria) was higher at the end of the study in the control than in the intervention group (1.29 ± 1.56 vs 0.81 ± 1.13), as was the number of residents on 6 or more drugs (76.5% vs.67.0%), using antipsychotics (9.1% vs 3.2%) or duplicate medications (32.5% vs 9.2%). The number of fallers increased in the control group (from 19.3% to 28%) and did not significantly change in the intervention group (from 25.3% to 23.9%); the number of residents with delirium increased in the control group (from 3.8% to 9.1%) and decreased in the intervention group (from 6.1% to 3.2%). The number of visits to a physician did not change in the control group (-0.22, P = .3) but were significantly reduced in the intervention group (-0.76, P = .01), the same happened with the number of visits to a nurse (-0.38, P = .4 in controls, -1.43 in the intervention group, P < .001). Visits to the emergency room and days in hospital significantly increased in the control group (+0.12 and +0.38) but were unchanged in the intervention group (+0.03 and +0.01).

CONCLUSIONS

An educational intervention on drug use is feasible in nursing home physicians and improves the use of inappropriate drugs, use of antipsychotics, and drug duplications in their residents. It may also improve the risk of delirium and falls, and reduce the use of health care resources.

Polypharmacy in multiple sclerosis: relationship with fatigue, perceived cognition, and objective cognitive performance

OBJECTIVE

Patients with multiple sclerosis (MS) commonly use a variety of medications to slow disease progression, alleviate symptoms, and treat comorbid conditions. Polypharmacy has been linked to adverse outcomes in other patient groups, but has not been studied extensively in MS. We investigated the impact of polypharmacy on fatigue, objective neuropsychological performance, and subjective cognitive impairment in a sample of patients with MS.

METHODS

MS patients (n=85) completed a medication inventory, self-report questionnaires, and a battery of neurocognitive tests. MS patients with polypharmacy were compared to MS patients without polypharmacy, using multivariate analysis of covariance (MANCOVA).

RESULTS

After controlling for disease characteristics, MS patients with polypharmacy (n=28) exhibited prospective memory deficits and reported significantly more fatigue and subjective cognitive problems than MS patients without polypharmacy.

CONCLUSION

Clinicians and patients should carefully weigh the costs and benefits of prescribing multiple medications, as these may contribute to iatrogenic fatigue and cognitive problems in MS. Moreover, researchers should account for polypharmacy when conducting studies examining fatigue and cognition in MS.

Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center

Objective:

The objective of this study was to assess the prevalence of polypharmacy (PP) and the associated factors in medical outpatients.

Materials and Methods:

A cross-sectional, observational, descriptive study was carried out in adult medical outpatients attending internal medicine clinics at King Abdulaziz Medical City, Riyadh, Saudi Arabia from 1 March 2009 to 31 December 2009. PP was defined as the concomitant use of ≥5 medications daily. The number of medications being currently taken by patient was recorded. Effect of patients’ age, gender, educational level, number of prescribers, disease load and disease type on PP was assessed by multivariate analysis using Statistical Package for Social Sciences Incorporated (SPSS Inc) Version 18.

Results:

Out of 766 patients included in the study, 683 (89%) had PP. The mean number of prescribed medications, oral pills and doses was 8.8, 9.6 and 12.1, respectively. Factors significantly associated with PP included age (≥61 years), disease load and the number of prescribers. Gender had no impact on PP while education beyond primary education significantly decreased PP. Hypertension, diabetes mellitus and dyslipidemia alone and as a cluster increased PP.

Conclusion:

We found an extremely high level of PP in medical outpatients at our tertiary care center. The impact of PP on medication compliance and control of underlying diseases in Saudi Arabia is unknown and needs to be studied at different levels of care.

Medication transitions and polypharmacy in older adults following acute care

Background/objective

Medication changes at transitions of care and polypharmacy are growing concerns that adversely impact optimal drug use. We aimed to describe transitions and patterns of medication use before and 1 year after older patients were hospitalized for community-acquired pneumonia, the second-most common reason for admission in North America.

Materials and methods

This was an analysis of a population-based clinical registry of patients treated in any of the six hospitals or seven emergency departments in Edmonton, Alberta, Canada, comprising 2,105 patients 65 years and older with community-acquired pneumonia who had survived at least 1 year. The prevalence of polypharmacy (five or more unique prescription drugs), as well as new use and persistence of common drug classes were assessed.

Results

The mean age was 78 years (standard deviation 8 years), 50% were female, 62% were hospitalized, and 58% had severe pneumonia. Among the 2,105 patients, 949 (45%) were using five or more medications prior to hospitalization, increasing to 1,559 (74%) within 90 days postdischarge and remaining over 70% at 1 year. Overall, 1,690 (80%) patients newly started and 1,553 (74%) patients stopped at least one medication in the first 90 days of follow-up. The prevalence of the most common drug classes (ie, cardiovascular, alimentary/metabolism) remained stable, with the exception of anti-infective agents, whereby 25% of patients were dispensed an anti-infective agent 3 months to 1 year after hospitalization.

Conclusion

Most older patients with pneumonia are subject to polypharmacy, and almost every patient had a medication started or stopped during 1-year follow-up, with 25% using antibiotics again. The period following an episode of pneumonia represents an opportunity potentially to optimize pharmacotherapy.

[Drug prescription profile in patients with advanced chronic diseases]

OBJECTIVES

To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases.

MATERIAL AND METHODS

Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence.

RESULTS

The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions.

CONCLUSIONS

The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed.

Prevalence and factors associated with polypharmacy in older people with cancer

PURPOSE

Polypharmacy has been associated with drug-drug interactions, adverse drug events, hospitalisation and increased mortality. The purpose of this study was to investigate the prevalence and factors associated with polypharmacy in older people with cancer.

PATIENTS AND METHODS

Patients aged≥70 years (n=385) presenting to the medical oncology outpatient clinic at Royal Adelaide Hospital between January 2009 and July 2010 completed a structured data collection instrument. The instrument included domains related to medications, diagnoses, instrumental activities of daily living (IADLs), Karnofsky Performance Scale (KPS), physical function (SF-36), pain (ten-point visual analogue scale, VAS), weight loss (patient self-reported over previous 6 months), exhaustion (CES-D) and distress (ten-point VAS). Frailty was computed using Fried's frailty phenotype. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association between polypharmacy (defined as five or more self-reported daily medications) and clinical parameters.

RESULTS

Polypharmacy was present in 57% (n=221) of patients. When adjusting for age, gender and Charlson Comorbidity Index (CCI), polypharmacy was associated with being pre-frail (OR=2.35, 95%CI=1.43-3.86) and frail (OR=4.48, 95%CI=1.90-10.54) compared to being robust. When adjusting for age, gender, exhaustion, KPS, IADLs, pain and distress, polypharmacy was associated with higher CCI scores (OR=1.58, 95%CI=1.29-1.94) and poorer physical function (OR=1.13, 95%CI=1.06-1.20).

CONCLUSIONS

Polypharmacy is highly prevalent in older people with cancer and associated with impaired physical function and being pre-frail and frail compared to being robust. Research is needed to identify strategies to minimize patients' medication regimens.

The effect of free health care on polypharmacy: a comparison of propensity score methods and multivariable regression to account for confounding

PURPOSE

Differing healthcare access has implications for public health. In Ireland, eligibility for free public health care is means tested. Here, we examine the association between healthcare access and polypharmacy while accounting for underlying socio-economic and health status differences.

METHODS

Self-reported regular medication use, history of diagnosed health conditions, disability, socio-demographics, and objective measures of depression and anxiety for adults aged 50-69 years (n = 5796) were ascertained from the population-representative Irish Longitudinal Study on Ageing. Objective measures of frailty, cognition, hypertension, and body mass index were also assessed for 4241 participants. The associations between free healthcare access and polypharmacy and use of 15 medication classes were estimated using multivariable modified Poisson regression, adjustment for the propensity score, and inverse probability of treatment weighting by the propensity score.

RESULTS

Polypharmacy was reported by 22% and 7% of the 1932 and 3864 participants with and without public healthcare coverage. Public patients had a 21-38% greater risk of polypharmacy depending on the method used to account for confounding. Results were less robust using propensity score weighting. There was evidence that classes of cardiovascular drugs, drugs for acid-related disorders, and analgesics were used more commonly in public patients. Associations were mostly unaffected after also accounting for objective health measures but were significantly attenuated after accounting for frequency of healthcare visits.

CONCLUSIONS

Publically funded health care in Ireland leads to greater medication use in people aged 50-69 years. This may reflect over-prescribing to public patients or restricted use among those who pay out of pocket.

The treatment of hypertension in people with dementia: a systematic review of observational studies

BACKGROUND

Hypertension is very common in older people and a number of trials of antihypertensives have demonstrated benefit from treatment in even the oldest old. However, people with dementia were significantly under-represented in these studies and as a population are more likely to be physically frail, to suffer orthostatic hypotension and to experience adverse effects from polypharmacy at a lower drug count. It may be that different thresholds for commencement and cessation of treatment should be considered and may already be used for this group. Against this background this review sets out to describe the prevalence of hypertension in people with dementia, its treatment, change in treatment over time and the achievement of blood pressure (BP) control.

METHODS

The PubMed, Cochrane, Embase and PsychINFO databases were searched for observational studies involving people with dementia and a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onwards. Abstracts and titles were then reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analysed and appraised.

RESULTS

Thirteen articles were identified for analysis. The prevalence of hypertension in people with dementia was 45% (range 35%-84%). 73% of these were on at least one antihypertensive, with diuretics being the most common. The reported prevalence of hypertension in study populations remained unchanged over time. ACEi/ARBs and calcium channel blockers were prescribed more frequently in more recent studies whilst use of β-blockers and diuretics remained unchanged. Target blood pressure was achieved in 55% of those on treatment.

CONCLUSION

Hypertension is as common in people with dementia as in other populations and is as commonly treated with antihypertensive drugs. The findings presented here will support further work to establish the risk-benefit of antihypertensive treatment in patients with dementia and, if differing ratios are identified, to establish dementia-specific guidelines for management.

Polypharmacy and excessive polypharmacy in octogenarians and older acutely hospitalized patients

AIM

The aim of this study was to assess the occurrence of polypharmacy and excessive polypharmacy in very old hospitalized patients based on their comorbidities.

METHODS

The documentation of patients aged 80 years or older admitted to our department in the year 2010 was analyzed. Based on the Charlson index of comorbidity, a multiple logistic regression model with stepwise backward elimination was performed. Patients were stratified by gender and four age-groups, and factors of a change in the number of medications during the hospital stay were assessed.

RESULTS

Chronic pulmonary disease [odds ratio (OR): 2.40], diabetes mellitus with (OR: 4.65) or without (OR: 1.65) microvascular complications, congestive heart failure (OR: 2.37), connective tissue disease (OR: 3.02), and peripheral vascular disease (OR: 2.30) were statistically significantly associated with polypharmacy, while some of these diseases were also associated with excessive polypharmacy. The number of medications showed a gradual decrease with age, which was concordant with a decrease in total Charlson index score. "Admission for myocardial infarction" was associated with an increase in pharmaceuticals during hospital stay, whereas a known diagnosis of dementia or metastatic malignant disease was protective against a further increase in medications.

CONCLUSIONS

Several medical conditions seem to predispose to polypharmacy in very old patients. To attain old age seems to be associated with few comorbidities, which reduces the need for a high number of pharmaceuticals. Physicians should pay attention to the identified predictors in very old patients, as polypharmacy may lead to adverse events and unnecessary hospitalization.

Multidrug and optimal heart failure therapy prescribing in older general practice populations: a clinical data linkage study

OBJECTIVE

To investigate multidrug therapy in the cardiovascular disease (CVD) population and whether it was associated with suboptimal drug prescribing in heart failure (HF).

DESIGN

A population-based cross-sectional clinical data linkage study.

SETTING

The clinical database populations were registered with three general practices in North Staffordshire that are part of a research network.

PARTICIPANTS

3155 patients aged 50 years and over were selected on the basis of a CVD-related prescription and a CVD consultation code applied to their electronic medical record in a 2-year time period. All available diagnostic data were linked to all drugs prescribed data during this time period. Two study groups were: (1) HF and (2) non-HF CVD (reference group).

EXPOSURE

A standard drug formulary system was used to define four multidrug count categories based on the number of different British National Formulary drug chapters prescribed at the same time.

PRIMARY AND SECONDARY OUTCOME MEASURES

Optimal HF therapy was defined as the prescribing of ACE inhibitor (ACEi) or a combination of ACEi and β-blocker in the 2-year time window. An additional three specific CVD drug categories that are indicated in HF were also measured.

RESULTS

The HF group, compared with the reference group, had higher non-CVD multidrug therapy (26% with 7 or more counts compared with 14% in the non-HF CVD reference group). For the first-choice optimal drug treatment for HF with ACEi (64%) or ACEi and β-blocker combined therapy (23%), the multidrug-adjusted associations between the HF group and the reference group were OR 3.89; 95% CI 2.8 to 5.5 and 1.99; 1.4 to 2.9, respectively. These estimates were not influenced by adjustment for sociodemographic factors and multidrug counts.

CONCLUSIONS

Multidrug therapy prescribing is much higher in the HF group than in a comparable CVD group but did not influence optimal drug prescribing.

Visual acuity, self-reported vision and falls in the EPIC-Norfolk Eye study

PURPOSE

To examine the relationship between visual acuity (VA) and self-reported vision (SRV) in relation to falls in 8317 participants of the European Prospective Investigation into Cancer-Norfolk Eye study.

METHODS

All participants completed a health questionnaire that included a question regarding SRV and questions regarding the number of falls in the past year. Distance VA was measured using a logMAR chart for each eye. Poor SRV was defined as those reporting fair or poor distance vision. The relationship between VA and SRV and self-rated falls was analysed by logistic regression, adjusting for age, sex, physical activity, body mass index, chronic disease, medication use and grip strength.

RESULTS

Of 8317 participants, 26.7% (95% CI 25.7% to 27.7%) had fallen in the past 12 months. Worse VA and poorer SRV were associated with one or more falls in multivariable analysis (OR for falls=1.31, 95% CI 1.04 to 1.66 and OR=1.32, 95% CI 1.09 to 1.61, respectively). Poorer SRV was significantly associated with falls even after adjusting for VA (OR=1.28, 95% CI 1.05 to 1.57).

CONCLUSIONS

SRV was associated with falls independently of VA and could be used as a simple proxy measure for other aspects of visual function to detect people requiring vision-related falls interventions.

A tailored implementation intervention to implement recommendations addressing polypharmacy in multimorbid patients: study protocol of a cluster randomized controlled trial

Background

Multimorbid patients frequently receive complex medication regimens and are at higher risk for adverse drug reactions and hospitalisations. Managing patients with polypharmacy is demanding, because it requires coordination of multiple prescribers and intensive monitoring. Three evidence-based recommendations addressing polypharmacy in primary care are structured medication counselling, use of medication lists and medication reviews to avoid potentially inappropriate medication (PIM). Although promising to improve patient outcomes, these recommendations are not well implemented in German routine care. Implementation of guidelines is often hindered by specific “determinants of change”. “Tailored” interventions are designed to specifically address previously identified determinants. This study examines a tailored intervention tto implement the aforementioned recommendations into German primary care practices. This study is part of the European Tailored Interventions for Chronic Diseases project, which aims at contributing knowledge about the methods used for tailoring.

Methods/Design

The study is designed as a cluster randomized controlled trial with primary care practices of general practitioners (GPs) who are organized in quality circles. Quality circles will be the unit of randomization with a 1:1 ratio. Follow-up time is 6 months. GPs and healthcare assistants in the intervention group will receive training on medication management. Each GP will create a tailored concept of how to implement the three recommendations into his/her practice. Evidence-based checklists for medication counselling and medication reviews will be provided for physicians. A tablet PC with an interactive educational tool and information leaflets will be provided for use by patients to inform about the necessity of continuous medication management. Control practices will not receive special training and will provide care as usual. Primary outcome is the degree of implementation of the three recommendations, which will be measured using a prespecified set of indicators. Additionally, the PIM prescription rate, patient activation, patients’ beliefs about medicine, medication adherence and patients’ social support will be measured.

Discussion

This study will contribute knowledge about the feasibility of implementing recommendations for managing patients with polypharmacy in primary care practices. Additionally, this study will contribute knowledge about methods for tailoring of implementation interventions.

Trial registration

Clinicaltrials.gov ISRCTN34664024

Axioms, Osteopathic Culture, and a Perspective From Geriatric Medicine

Osteopathic medicine is a rapidly growing discipline in health care that has much to offer the wider biomedical community. A distinction of the osteopathic medical profession is the importance of an overall guiding philosophy. Despite the osteopathic medical profession's success, there remains concern about the profession's ability to maintain its unique identity. Among many factors that have contributed to the profession's success, certain axioms from its earliest days are pertinent to the profession's identity. Maintaining a knowledge and appreciation of osteopathic axioms can play an important role in safeguarding the profession's identity. These axioms encapsulate osteopathic philosophy and, moreover, are universally useful for patient care. As osteopathic geriatricians, the authors explore the value and meaning of these axioms for anyone who treats patients, but especially for the care of the elderly. The authors also propose a new axiom, derived from the experience of 2 of the authors: “First try to blame it on the medications.”

Rates, variability, and associated factors of polypharmacy in nursing home patients

Objectives

To determine the rate and variability of polypharmacy in nursing home (NH) residents and investigate its relationship to age, sex, functional status, length of stay, and comorbidities.

Methods

We conducted a cross sectional, multicenter study that included six nursing homes. Demographic, clinical characteristics, Charlson comorbidity index (CCI), the number and classes of chronic medications, rate of polypharmacy >5 drugs (per day) and polypharmacy >7 drugs (per day) were recorded.

Results

Nine hundred and ninety-three residents were included; 750 (75.5%) fully dependent residents and 243 (24.5%) mobile demented residents requiring institutional care. The mean age was 85.04±7.55 (65–108) years. The mean rates of polypharmacy >5 drugs and polypharmacy >7 drugs were 42.6% and 18.6%, respectively. Differences in polypharmacy >5 drugs and polypharmacy >7 drugs were observed in NHs 24.7%–56% and 4.9%–30.4%, respectively (P<0.001). Mean number of chronic drugs per resident was 5.14±2.60 from 3.81±2.24 to 5.95±2.73 (P<0.001). No differences in polypharmacy were found between sex and fully dependent versus mobile demented residents. The most common medications taken were for gastrointestinal, neurological, and cardiovascular disorders. Regression analysis revealed four independent variables for polypharmacy >5 drugs: groups aged 75–84 and >85 relative to 65–74, odds ratio (OR) 0.46 (95% confidence interval [CI] 0.27–0.78) P=0.004, OR 0.35 (95% confidence interval 0.19–0.53), respectively, P<0.001; length of stay >2 years, OR 0.51 (95% CI 0.36–0.73) P<0.001; CCI, OR 1.58 (95% CI 1.42–1.75) P<0.001; and feeding tube versus normal feeding, OR 0.27 (95% CI 0.12–0.60) P=0.001.

Conclusion

Rates of polypharmacy in NHs are high with significant variability. Variability rates of polypharmacy, distinct residents’ characteristics, and excessive use of certain drug groups may indicate that a decrease in medication is potentially feasible.