Health outcomes and polypharmacy in elderly individuals: an integrated literature review

Relationship of in-hospital medication modifications of elderly patients to postdischarge medications, adherence, and mortality

BACKGROUND

Medication regimens are constantly modified and updated during a patient's hospitalization. These modifications and those made after discharge might increase the risk for nonadherence, polypharmacy, and poor outcomes among elderly patients.

OBJECTIVES

To investigate the extent of in-hospital modification of medication regimens of elderly patients and its relationship to medication adherence as well as one-month postdischarge drug regimen modifications and to examine the relationship of the modifications, adherence, and polypharmacy to mortality and readmissions 3 months postdischarge.

METHODS

Clinical and demographic data, postdischarge medication modifications, and adherence were prospectively obtained in 212 elderly patients. Inhospital drug regimen modifications were retrospectively recorded.

RESULTS

The average +/- SD in-hospital medication regimen modification rate was 49.8% +/- 28.4. No modifications were found in 9.7% of the patients. Using demographic and clinical parameters, we performed regression analysis and found that patients who were admitted with polypharmacy, discharged home, and cognitively normal experienced fewer medication modifications (p < 0.05). At one month postdischarge, the average medication regimen modification rate was 37.5% +/- 25.4. In- and posthospital modifications were directly correlated (p = 0.047). Three months postdischarge, 17 patients had died and 50 had been readmitted. The independent risk factors for mortality were in-hospital modification rate of 50% or greater (OR 6.4; 95% CI 1.3 to 29.7), impaired cognition (OR 4.2; 95% CI 1.4 to 12.3), and each chronic disease (OR 1.2; 95% CI 1 to 1.5). No relationships were found between in-hospital medication regimen modifications and readmissions or with postdischarge modifications, adherence, and polypharmacy to mortality and readmissions.

CONCLUSIONS

Hospitalization of elderly patients is characterized by extensive medication regimen modifications, which are directly correlated with postdischarge modifications and may indicate an increased risk of mortality.

A 30-year survey of drug use in the 1914 birth cohort in Glostrup County, Denmark: 1964-1994

BACKGROUND AND AIMS

Use of drugs increases with age. Several drugs as well as multiple drug intake are recognized risk factors for symptoms, disability, hospitalizations, and even mortality, due to side effects and problems with compliance. Yet, little is known about the long-term effects. As a first step, this longitudinal study of a general population gives insight into consumption patterns including multiple drug intake ("polypharmacy") and individual adherence to drug use over a 30-year period.

METHODS

This is a study based on the first large longitudinal population study of the health of adult Danes. Examinations were performed at 50, 60, 70 and 80 years of age. The Statistical Package for the Social Sciences (SPSS) was used to check participants' individual adherence to each of six main drug categories, calculated stepwise.

RESULTS

802 persons were included at 50 years of age in 1964. Of these, 213 were still participating in the study in 1994. The general use of drugs increased for all drug categories with age. Women used statistically significantly more drugs than men and showed a higher degree of polypharmacy. The individual adherence to antihypertensives was greater than the corresponding adherences to analgesics, psychoactive drugs, or hypnotics. At least two-thirds of all remaining initial users of antihypertensives still took them at 80 years of age. For other drug categories, the corresponding values were half or less.

CONCLUSIONS

For the initial population studied over a period of 30 years, the use of drugs increased with age, but the drugs were not prescribed for the same people over time. During the 30-year period, individual patients' drug adherence habits were in accordance with scientific evidence: patients adhered to long-term use of antihypertensive drugs, but used analgesics, psychoactive drugs and hypnotics for only shorter periods.

Indications for Dual Antiplatelet Therapy with Aspirin and Clopidogrel: Evidence-Based Recommendations for Use

OBJECTIVE:

To review the literature assessing dual antiplatelet therapy with aspirin and clopidogrel and subsequently provide evidence-based recommendations for appropriate indications and length of therapy.

DATA SYNTHESIS:

An English-language MEDLINE search (1950–December 2007) was conducted using the search terms antiplatelet, aspirin, thienopyridine, and clopidogrel to identify articles assessing dual antiplatelet therapy. Evaluation of references from identified trials for possible inclusion was also conducted.

STUDY SELECTION AND DATA EXTRACTION:

All studies that assessed treatment with the combination of aspirin and clopidogrel for any indication were included.

DATA SYNTHESIS:

Aspirin and clopidogrel have complementary mechanisms of action to inhibit platelet function. Indications that have been studied include coronary artery disease (CAD), atherosclerotic ischemic stroke, and atrial fibrillation. This combination has been beneficial in patients with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI), and in PCI patients without an acute event. There is a small but significant risk for increased bleeding with dual antiplatelet therapy for these indications. When used in patients with a history of atherosclerotic ischemic stroke or for prevention of cardioembolic stroke in patients with atrial fibrillation, this combination has been shown to increase bleeding, providing no clinical benefit, and to increase outcomes including stroke, myocardial infarction, and death, respectively.

CONCLUSIONS:

There is evidence to support use of aspirin in combination with clopidogrel for patients presenting with all ACS types, as well as for patients presenting with PCI for any indication. The treatment duration varies, but patients who have received stenting should receive at least 1 year of combination therapy. There is no evidence to support this combination for primary prevention of CAD or atherosclerotic ischemic events, secondary prevention of stable CAD, or prevention of cardioembolic stroke in patients with atrial fibrillation. The possible benefits of dual antiplatelet therapy also must be weighed against the risk of bleeding.

Polypharmacy in elderly patients

BACKGROUND

Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly.

OBJECTIVE

The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults.

METHODS

Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy.

RESULTS

The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy.

CONCLUSIONS

Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept

Geriatricians have embraced the term "geriatric syndrome," using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors-older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility-were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.

Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems

AIM

To investigate whether polypharmacy defined as a definite number of drugs is a suitable indicator for describing the risk of occurrence of drug-related problems (DRPs) in a hospital setting.

METHODS

Patients admitted to six internal medicine and two rheumatology departments in five hospitals were consecutively included and followed during the hospital stay, with particular attention to medication and DRPs. Comparisons were made between patients admitted with five or more drugs and with less than five drugs. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions.

RESULTS

Of a total of 827 patients, 391 (47%) used five or more drugs on admission. Patients admitted with five or more and less than five drugs were prescribed the same number of drugs after admission: 4.1 vs. 3.9 drugs [P = 0.4, 95% confidence interval (CI) - 0.57, 0.23], respectively. The proportion of drugs used on admission which was associated with DRPs was similar in the patient group admitted with five or more drugs and in those admitted with less than five drugs. The number of DRPs per patient increased approximately linearly with the increase in number of drugs used; one unit increase in number of drugs yielded a 8.6% increase in the number of DRPs (95% CI 1.07, 1.10).

CONCLUSION

The number of DRPs per patient was linearly related to the number of drugs used on admission. To set a strict cut-off to identify polypharmacy and declare that using more than this number of drugs represents a potential risk for occurrence of DRPs, is of limited value when assessing DRPs in a clinical setting.

Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents

OBJECTIVE

Polypharmacy is a well-known risk factor for adverse drug reactions (ADRs). The objective of this study was to determine the relationship between the use of > or = 9 different scheduled medications and the occurrence of ADRs in geriatric nursing home residents.

METHODS

This was a retrospective cohort study conducted in a 1200-bed, county-owned and -operated, longterm care skilled nursing facility Participants were 335 subjects aged > or = 65 years who were present at the facility during the index month of October 1998. Hospice, respite care, and rehabilitation patients were excluded. Use of > or = 9 different scheduled medications was defined a priori as routinely administered medications, excluding as-needed agents, topical agents, 1-time administration, and vaccinations. ADRs were identified by voluntary reporting and by chart review during a 12-month period. ADRs were assessed individually by 2 clinical pharmacists applying the Naranjo ADR probability scale.

RESULTS

A total of 207 ADRs were identified. The cohort receiving > or = 9 scheduled medications (n = 43) experienced 53 ADRs, compared with 154 ADRs in the control group receiving <9 medications (n = 292). The demographic distribution was similar in both cohorts, with white as the dominant ethnicity; 45% were white in the control group and 51% were white in the cohort group receiving > or = 9 scheduled medications. The sex distribution was also similar, with women outnumbering men in both cohorts: 60% and 81% were women in the control and cohort groups, respectively. The mean age was 72 years (range, 65-100 years). After the data were adjusted for the number of days each subject was at risk for experiencing an ADR, subjects using > or = 9 different scheduled medications were 2.33 times more likely than controls to experience an ADR (95% CI, 1.54-3.52; P < 0.001).

CONCLUSION

A positive correlation between the use of >/=9 different scheduled medications and ADRs was found among these geriatric nursing home residents.