Optimizing elderly pharmacotherapy: polypharmacy vs. undertreatment. Are these two concepts related?

Potentially inappropriate prescribing in polymedicated older adults with atrial fibrillation and multimorbidity: a Swedish national register-based cohort study

Introduction

Current research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults.

Methods

Swedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls.

Results

PIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88-2.07]) and overall mortality (HR = 2.09 [2.03-2.16]), CV (HR = 1.34 [1.30-1.37]) and overall hospitalisation (HR = 1.48 [1.46-1.51]), stroke (HR = 1.93 [1.78-2.10]), bleeding (HR = 1.10 [1.01-1.21]), and falls (HR = 1.63 [1.56-1.71]).

Conclusion

The present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population.

Feasibility study of a clinical decision support system for polymedicated patients in primary care

Age-related changes in pharmacokinetics and pharmacodynamics, multimorbidity, frailty, and cognitive impairment represent challenges for drug treatments. Moreover, older adults are commonly exposed to polypharmacy, leading to increased risk of drug interactions and related adverse events, and higher costs for the healthcare systems. Thus, the complex task of prescribing medications to older polymedicated patients encourages the use of Clinical Decision Support Systems (CDSS). This paper evaluates the CDSS miniQ for identifying potentially inappropriate prescribing in poly-medicated older adults and assesses the usability and acceptability of the system in health care professionals, patients, and caregivers. The results of the study demonstrate that the miniQ system was useful for Primary Care physicians in significantly improving prescription, thereby reducing potentially inappropriate medication prescriptions for elderly patients. Additionally, the system was found to be beneficial for patients and their caregivers in understanding their medications, as well as usable and acceptable among healthcare professionals, patients, and caregivers, highlighting the potential to improve the prescription process and reduce errors, and enhancing the quality of care for elderly patients with polypharmacy, reducing adverse drug events, and improving medication management.

A Video-Based Mobile App as a Health Literacy Tool for Older Adults Living at Home: Protocol for a Utility Study

BACKGROUND

People aged ≥65 years are more likely to have health problems related to aging, polypharmacy, and low treatment adherence. Moreover, health literacy levels decrease with increasing age.

OBJECTIVE

The aim of this study is to assess an app's utility in promoting health-related knowledge in people aged ≥65 years.

METHODS

We developed a simple, intuitive, and video-based app (DigiAdherence) that presents a recipe, nutritional counseling, and content on physical activity, cognitive exercise, motivation to adhere to treatment, fall prevention, and health literacy. A convenience sample of 25 older adults attending the Personalized Health Care Unit of Portimão or the Family Health Unit of Portas do Arade (ACeS Algarve II - Barlavento, ARS Algarve, Portugal) will be recruited. Subjects must be aged ≥65 years, own a smartphone or tablet, be willing to participate, and consent to participate. Those who do not know how to use or do not have a smartphone/tablet will be excluded. Likewise, people with major cognitive or physical impairment as well as those living in a long-term care center will not be included in this study. Participants will have access to the app for 4 weeks and will be evaluated at 3 different timepoints (V0, before they start using the app; V1, after using it for 30 days; and V2, 60 days after stopping using it). After using the app for 30 days, using a 7-point Likert scale, participants will be asked to score the mobile tool's utility in encouraging them to take their medications correctly, improving quality of life, increasing their health-related knowledge, and preventing falls. They will also be asked to assess the app's ease of use and visual esthetics, their motivation to use the app, and their satisfaction with the app. Subjects will be assessed in a clinical interview with a semistructured questionnaire, including questions regarding user experience, satisfaction, the utility of the app, quality of life (EQ-5D-3L instrument), and treatment adherence (Morisky scale). The proportion of participants who considered the app useful for their health at V1 and V2 will be analyzed. Regarding quality of life and treatment adherence perceptions, comparisons will be made between V0 and V1, using the t test for dependent samples. The same comparisons will be made between V0 and V2.

RESULTS

This study was funded in December 2019 and authorized by the Executive Board of ACeS Algarve II - Barlavento and by the Ethics Committee of NOVA Medical School (99/2019/CEFCM, June 2020). This protocol was also approved by the Ethics Committee for Health (16/2020, September 2020) and the Executive Board (December 2020) of the Regional Health Administration of the Algarve, IP (Instituto Público). Recruitment was completed in June 2021.

CONCLUSIONS

Since the next generation of older adults may have higher digital literacy, information and communication technologies could potentially be used to deliver health-related content to improve lifestyles among older adults.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/29675.

Under-prescription of medications in older adults according to START criteria: A cross-sectional study in Lebanon

Background and Aims

Under-prescription is defined as the exclusion of medications indicated for the treatment of certain conditions without any rationale for not prescribing them. The under-prescription of medications is highly prevalent among older adults (≥65 years) receiving polypharmacy. This study aimed to assess the prevalence of the under-prescription of medications using the Screening Tool to Alert to Right Treatment (START) criteria version 2 and to identify the predictors of having potential prescribing omissions (PPOs).

Methods

This cross-sectional, face-to-face interview study was carried out between September 2021 and February 2022. The study comprised community-dwelling older adults taking at least one medication on a regular basis. The study questionnaire included the patients' demographics, clinical data, and comorbidities. PPOs were identified using the START criteria. The χ 2 test was used to assess the association between under-prescription of medication and the demographic/clinical variables. Multivariable logistic regression was performed to explore factors associated with under-prescription of medications as the dependent variable and taking all variables that showed a p < 0.05 in the bivariate analysis as independent.

Results

A total of 444 older adults agreed to participate in this study. The mean age of participants was 71 ± 8.6; the majority of them, 305 (68.7%), were men. Polypharmacy was present in 261 patients (58.8%) and underprescribing of medications in 260 patients (58.6%). The highest percentage of under-prescribing of medications was reported with statins in 115 patients (44.2%) followed by aspirin in 93 (35.7%), and angiotensin-converting enzyme inhibitors in 61 (23.4%). The results of the multivariable analysis showed that patients with underprescribed medications had higher odds of polypharmacy (odds ratio [OR]: 2.015, confidence interval [CI] 95% 1.362-2.980, p < 0.001) and higher Charlson Comorbidity Index (OR 2.807, CI 95% 1.463-5.85, p = 0.02).

Conclusion

The present findings highlight that PPOs are highly prevalent among community-dwelling older adults in Lebanon. Multimorbidity and polypharmacy were the identified predictors for under-prescription of medications in this population.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Observational Evidence of the Prevalence and Association of Polypharmacy and Drug Administration Errors in Hospitalized Adult Patients

Objective To describe the prevalence of polypharmacy and medication administration errors (MAEs) in adult inpatients and explore the association between polypharmacy and MAEs. Polypharmacy and MAEs are common phenomena in hospital settings. Different MAE contributing factors have been suggested by previous studies. Polypharmacy, however, is not always assessed by studies exploring medication error risk factors, and it may deserve further attention. Methods This was a descriptive observational study. The medication administration process in two adult medical wards of a tertiary hospital was recorded by two observers, with parallel review of patients' medication records. Any deviation from prescriber's order, manufacturers' administration instructions, or relevant institutional policies were recorded as errors. Chi square and regression analysis were used to explore associations between polypharmacy and MAEs. Results Six hundred sixty-five medication administrations were observed. The mean number of drugs prescribed per patient was 8.7. Most inpatients were prescribed more than 5 drugs (92.6%). Almost half of the inpatients were prescribed more than 9 drugs (45.1%) and some more than 12 drugs (22.6%). In total, 2,371 errors were detected, and the mean number of errors per administration was 3.5. When patients received more than 9 (the odds ratio is 1.57, [95%] CI 1.08-2.27; P = 0.02) or more than 12 (the odds ratio is 1.53, [95%] CI 1.04-2.30; P = 0.04) drugs, the occurrence of a higher number of errors per administration was significantly increased. Conclusion Polypharmacy is common in adult medical wards and can be associated with the occurrence of a higher number of MAEs. Future interventions aiming for the prevention of MAEs should consider addressing polypharmacy by improving prescribing practices and optimizing pharmacotherapy.

Polypharmacy in Patients With Inflammatory Bowel Disease: Prevalence and Outcomes in a Single-center Series

BACKGROUND

Polypharmacy can complicate the course and management of chronic diseases, and has been little explored in patients with inflammatory bowel disease (IBD) to date.

AIM

The aim of this study was to determine the prevalence of polypharmacy in a series of IBD patients, describing associated factors and its correlation with poor disease outcomes.

MATERIALS AND METHODS

Retrospective study of a single-center series. Polypharmacy was defined as the simultaneous use of 5 or more drugs. Disease outcomes, IBD treatment nonadherence and undertreatment were evaluated at 1 year.

RESULTS

A total of 407 patients were included [56% males, median age: 48 y (interquartile range, 18 to 92 y)], of whom 60.2% had Crohn's disease; Chronic comorbidity and multiple comorbidities were present in 54% and 27% of patients, respectively. Median number of prescriptions per patient was 3 (range: 0 to 15). Polypharmacy was identified in 18.4% of cases, inappropriate medication in 10.5% and use of high-risk drugs in 6.1% (mainly opioids). In multivariate analysis, polypharmacy was associated with chronic comorbidity [odds ratio (OR)=10.1, 95% confidence interval (CI): 2.14-47.56; P˂0.003], multiple comorbidities (OR=3.53, 95% CI: 1.46-8.51; P=0.005) and age above 62 years (OR=3.54, 95% CI: 1.67-7.51; P=0.001). No association with poor disease outcomes was found at 12 months. However, polypharmacy was the only factor associated with IBD treatment nonadherence (OR=2.24, 95% CI: 1.13-4.54, P=0.02).

CONCLUSIONS

Polypharmacy occurs in around 1 in 5 patients with IBD, mainly in older adults and those with comorbidity. This situation could interfere with adherence to IBD treatment and therapeutic success.

Cardiovascular care of older adults

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.

The effects of in-hospital deprescribing on potential prescribing omission in hospitalized elderly patients with polypharmacy

No studies to investigate the effect of a deprescribing intervention on the occurrence of potential prescribing omissions (PPOs) among elderly patients with polypharmacy have been conducted. Therefore, the effect of deprescribing on PPOs among elderly patients with polypharmacy was investigated. All 121 consecutive elderly patients who received in-hospital deprescribing interventions were evaluated. The primary outcome was any occurrence of PPOs based on the 2015 STOPP/START criteria. The proportion of patients who had any PPOs significantly increased after the deprescribing interventions (52.9% vs 77.7%, p < 0.001). In the multivariable analysis, older age was the only independent risk factor associated with an increased risk of any PPOs after the deprescribing interventions (OR 1.08, 95% CI 1.01 to 1.16). In-hospital deprescribing interventions for elderly patients with polypharmacy may increase the occurrence of PPOs. Further study is warranted to investigate the effects on clinical outcomes of the increased occurrence of PPOs due to the deprescribing intervention.

Underprescription of medications in older adults: causes, consequences and solutions-a narrative review

PURPOSE

Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it.

METHODS

A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies.

RESULTS

Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription.

CONCLUSION

Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.

Potential prescribing omissions of anti-osteoporosis drugs is associated with rehabilitation outcomes after fragility fracture: Retrospective cohort study

AIM

We investigated the association between rehabilitation outcomes and polypharmacy, potentially inappropriate medications and potential prescribing omissions in older adults with fragility fractures.

METHODS

In total, we registered 217 older adults with fragility fractures (hip or vertebral) retrospectively and examined the association between rehabilitation outcome and polypharmacy, potentially inappropriate medications and potential prescribing omissions. Polypharmacy was defined as five or more drugs. Potentially inappropriate medications and potential prescribing omissions were defined by the Beers criteria (2015) and the screening tool to alert to treatment criteria version 2, respectively. The outcome was functional independence measure gain (functional independence measure at discharge - functional independence measure at admission).

RESULTS

Multiple regression analyses revealed no association between functional independence measure gain and polypharmacy (crude: β = 0.058, P = 0.858; adjusted model: β = 0.013, P = 0.869) or potentially inappropriate medications (crude: β = 0.100, P = 0.144; adjusted model: β = 0.084, P = 0.260). However, there was a significant association between functional independence measure gain and potential prescribing omissions (crude: β = 0.167, P = 0.014; adjusted model: β = 0.180, P = 0.016). Participants without potential prescribing omissions (in other words, participants who were prescribed anti-osteoporosis drugs) had a greater functional independence measure gain than participants with potential prescribing omissions (in other words, those that were not prescribed anti-osteoporosis drugs).

CONCLUSION

To the best of our knowledge, this study is the first to report that participants without potential prescribing omissions had significantly improved rehabilitation outcomes. Geriatr Gerontol Int 2021; 21: 386-391.

Prevalence and Associated Factors of Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

In Spain, there has been a progressive increase in aging. Specifically, Leon has been one of the Spanish provinces with the highest aging index. Polypharmacy is highly prevalent among the elderly, with significant consequences for safety. The aim of this study was to assess the consumption of drugs in a nursing home in the province of Leon and establish the relationship between polypharmacy and the most common comorbid diseases. A descriptive, observational, and cross-sectional study design was used. Residents' information and treatments were collected by reviewing on medical charts, completed with clinical information obtained from the physician of the nursing home. The mean age of residents was 86.8 years, and 63.8% were female. Mean medical consumption amounted to 7.02 prescriptions. Polypharmacy was observed in 54.9% of residents, and excessive polypharmacy in 22.1%. The most commonly used medications (ATC classification) were those acting on the cardiovascular system (84.4%) and the nervous system (82.8%). A high-level of drug consumption was observed in the nursing home. Interventions should focus on those residents hospitalized the last year and with recent contact with a general practitioner. There is a need to develop a comprehensive monitoring system to assess the quality of prescriptions for nursing home residents.

Polypharmacy, potentially inappropriate medication and pharmacogenomics drug exposure in the Rhineland Study

AIM

High medication use may contribute to the efficiency of drug therapy in general, but it could also increase the burden of adverse drug reactions. We aimed to assess medication use and the prevalence of three risk factors for adverse drug reactions: the use of polypharmacy, potentially inappropriate medication in the elderly and pharmacogenomic polymorphisms affecting the metabolism of drugs.

METHODS

Cross-sectional interview-based medication data (including over-the-counter drugs) was collected in a large population-based cohort (≥30 years of age) in Bonn, Germany.

RESULTS

Analyses were based on the first 5000 participants of the Rhineland Study (mean age 55 years, 57% women). Of our participants, 66.0% reported the use of a drug regularly, which increased to 87.4% in participants aged ≥65 years (n = 1301). The rates of use of polypharmacy, potentially inappropriate medication and pharmacogenomic drugs were 15.9%, 6.4% and 20.5%, respectively. In participants <65 years, 16.0% (95% CI 14.8, 17.3) had at least one risk factor. In participants aged ≥65 years, 54.1% (95% CI 51.4, 56.8) had at least one and 27.4% (95% CI 25.0, 29.9) had at least two risk factors. Extrapolating these numbers to the German population implies that around 9 million of the 17 million individuals aged 65 years or older are potentially at an elevated risk for adverse drug reactions, of which 4.6 million are at a potentially highly elevated risk for adverse drug reactions.

CONCLUSION

Our study shows that drug use is common and the individual risk for an adverse drug reaction in our population is high. This suggests room for improvement in general medication use.

Polypharmacy and pattern of medication use in community-dwelling older adults: A systematic review

AIM

To synthesise current study findings on the diseases and the corresponding medications that are potentially associated with polypharmacy in community-dwelling older adults.

BACKGROUND

Polypharmacy is receiving increased attention as a potential problem for the older population. Although several scientific investigations have studied polypharmacy, most of them were carried out in long-term care facilities or mixed settings rather than in community settings solely.

METHODS

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Relevant studies published in the English language in peer-reviewed journals were identified from searches of seven electronic databases for the period of January 2000 through December 2019. Inclusion criteria were: (1) Participants were older adults aged 65 years and older; (2) Polypharmacy was defined by medication count; (3) Medication classes associated with polypharmacy were revealed; (4) Studies were conducted in outpatient care or community settings. The Joanna Briggs Institute critical appraisal checklists for cross-sectional studies and for cohort studies were used to assess the methodological quality.

RESULTS

Ten studies were considered having appropriate and acceptable quality to be reviewed, comprising nine cross-sectional studies and one cohort study. Polypharmacy was most defined as concurrently using five or more medications. Polypharmacy prevalence ranged between 7%-45%. Older age, comorbidity, poor self-perceived health status, limitations in physical activity, history of falls, depression, and pain were positively associated with polypharmacy. The most prevalent medication taken by older adults with polypharmacy was cardiovascular drugs.

CONCLUSIONS

The prevalence of polypharmacy in older adults varying widely may be due to geographical locations, clinical practice guidelines, and polypharmacy definition used.

RELEVANCE TO CLINICAL PRACTICE

Validated measurements to investigate medications associated with polypharmacy are required. How polypharmacy develops over time needs to be investigated in longitudinal studies in order to formulate strategies for reducing polypharmacy.

Potentially inappropriate medications and potentially prescribing omissions in Chinese older patients: Comparison of two versions of STOPP/START

WHAT IS KNOWN AND OBJECTIVE

The aim of this study was to compare the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in elderly Chinese patients identified by the Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) version 2 (v2) and version 1 (v1). The secondary objective was to analyse the risk factors associated with the PIMs/PPOs.

METHODS

This was a retrospective cross-sectional study, and all patients were aged ≥65 years and discharged from internal medical wards of Beijing Chaoyang Hospital in December 2018. STOPP/START v2 and STOPP/START v1 were used to detect PIMs/PPOs. The concordance between the two versions was calculated using kappa tests. A logistic regression analysis was carried out to determine variables independently associated with PIM/PPO use.

RESULTS AND DISCUSSION

In the 662 patients included, the median age was 73 years and 361 were male (54.53%). PIMs were present in 36.1% and 47.7% of participants according to the STOPP v1 and STOPP v2, respectively. The prevalence of PPOs was 42.0% and 64.2% according to the START v1 and START v2, respectively. Drug prescribed without indication was the most common item in PIMs, whereas ACEIs were the drugs most frequently involved with PPOs according to the STOPP/START v2. Two versions of the STOPP criteria indicated a moderate coherence, whereas two versions of the START criteria showed poor accordance. Age (OR 1.029, 1.004-1.054), gender (OR 1.536, 1.103-2.138) and the number of prescribed medications (<5: OR 1; 5-9: OR 2.503, 1.173-5.342; ≥10: OR 4.324, 2.204-9.235) were associated factors with PIMs identified by the STOPP v2, whereas PPOs identified by the START v2 were independently associated with age (OR 1.039, 1.012-1.066), activities of daily living (ADL) score (OR 2.713, 1.818-4.048), the number of prescribed medications (<5: OR 1; 5-9: OR 2.704, 1.524-4.795; ≥10: OR 3.075, 1.704-5.549) and Charlson Comorbidity Index (OR 1.302, 1.110-1.529).

WHAT IS NEW AND CONCLUSION

This study showed a high prevalence of PIMs/PPOs in aged internal medical ward inpatients in China, which was associated with various correlates. The STOPP/START v2 had a higher detection rate than v1.

[Usefulness of the summary of product characteristics as a tool to improve prescription in elderly patients]

BACKGROUND AND OBJECTIVE

The Drug Technical Data Sheet should contribute to a safe and effective use of medications in the elderly, providing accurate information on the prescription, on the possible benefits or risks of the medications, or failing that, communicating the lack of information on their use in this group. The aim of this article was to quantify the specific information for people over 65 years of age included in the data sheets of the drugs available in Spain, and enables an adequate prescription in this population.

MATERIALS AND METHODS

A multidisciplinary group reviewed all the Technical Data Sheets of drugs approved by the Spanish Agency for Medicines and Health Devices (AEMPS). The quality of the information was classified into 4 categories: information specifically referring to the population over 65 years old; information specifically referring to the population over 80 years old; recommendations not specific to the elderly; and specific information for the elderly.

RESULTS

A total of 1,462 Technical Sheets were reviewed, of which 48% had information regarding prescription in the elderly. Information on the use in patients over 80 years old was present in 1.23% of the sheets. Only 6.83% of all the sheets reviewed included specific recommendations for the elderly.

CONCLUSIONS

There is little specific information regarding prescription in the elderly in the technical data sheets of drugs prescribed/sold in Spain. To improve knowledge in this field, data must be provided in the sheets that are based on the scientific literature, clinical trials for the elderly, or pharmacovigilance studies focused on this population.

Enhanced learning and retention of medical information in Alzheimer's disease after differential outcomes training

BACKGROUND

Adherence to treatment is a crucial factor for patients who have chronic illnesses or multiple morbidities and polypharmacy, which is frequently found in older adults. The non-adherence to medications has important economic and social consequences as well as impacts on the health of the patients. One of the reasons that can explain the low adherence to treatment, is the memory deficits that are characteristics of this population and that are even more evident in cases that involve neurodegenerative diseases.

METHODS AND FINDINGS

In this study, we explore whether the differential outcomes procedure (DOP), which has been shown to be useful in improving discriminative learning and memory in different populations, may facilitate learning and retention of medical recommendations in older adults who have been diagnosed with Alzheimer's disease. The results demonstrate that when this procedure was applied, the patients showed improvements in learning and long-term retention of two pill/time of day associations in a situation that simulates adherence to medical prescriptions.

CONCLUSIONS

These findings contribute new data about the potential benefits of the DOP in patients with neurodegenerative disorders, highlighting the important role that this procedure could play in addressing important issues related to the health and quality of life of older adults, with or without neurodegenerative diseases, such as low adherence to medical treatments.

Polypharmacy and Pharmacological Treatment of Diabetes in Older Individuals: A Population-Based Study in Quebec, Canada

Our objectives were to describe the use of pharmacological treatments in older adults with diabetes and to identify the factors associated with the use of a combination of hypoglycemic, antihypertensive and lipid-lowering agents. Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study among individuals aged 66-75 years with diabetes in 2014-2015. We described the number of medications and the classes of medications used and calculated the proportion of individuals using at least one medication from each of these classes: hypoglycemics, antihypertensives and lipid-lowering agents. We identified the factors associated with the use of this combination of treatments by performing robust Poisson regressions. The 146,710 individuals used an average of 12 (SD 7) different medications, mostly cardiovascular (91.3% of users), hormones, including hypoglycemic agents (84.5%), and central nervous system medications (79.8%). The majority of individuals (59%) were exposed to the combination of treatments and the factor most strongly associated was the presence of cardiovascular comorbidities (RR: 1.29; 99% CI: 1.28-1.31). Older individuals with diabetes are exposed to a large number of medications. While the use of the combination of treatments is significant and could translate into cardiovascular benefits at the population level, the potential risk associated with polypharmacy needs to be documented.

Inappropriate medication use in hospitalised oldest old patients across transitions of care

BACKGROUND

Oldest old patients aged 85 years and over are at risk of experiencing potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) across transitions of care. Geriatricians also face enormous challenges in prescribing medications for these patients.

METHODS

A mixed-methods, sequential explanatory design was undertaken of electronic medical records and semi-structured interviews with geriatricians at a public teaching hospital. Data were collected at four time points using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START).

RESULTS

Of 249 patients, the prevalence of at least 1 PIM varied between 36.9 and 51.0%, while the prevalence of at least 1 PPO varied between 36.9 and 44.6%. The most common PIM was use of proton pump inhibitors while the most common PPO was omission of vitamin D supplements in housebound patients or patients experiencing falls. Poisson regression analysis showed that PIMs were significantly associated with use of mobility aids, 1.430 (95% CI 1.109-1.843, p = 0.006), and number of medications prescribed at admission, 1.083 (95% CI 1.058-1.108, p < 0.001). PPOs were significantly associated with comorbidities, 1.172 (95% CI 1.073-1.280, p < 0.001), medications prescribed at admission, 0.989 (95% CI 0.978-0.999, p = 0.035), and length of stay, 1.004 (95% CI 1.002-1.006, p < 0.001). Geriatrician interviews (N = 9) revealed medication-related, health professional-related and patient-related challenges with managing medications.

CONCLUSIONS

Inappropriate prescribing is common in oldest old patients. Greater attention is needed on actively de-prescribing medications that are not beneficial and commencing medications that would be advantageous. Tailored strategies for improving prescribing practices are needed.

Prevalence and predictors of polypharmacy prescription among type 2 diabetes patients at a tertiary care department in Ningbo, China: A retrospective database study

Objectives

To determine the prevalence of polypharmacy prescription among type 2 diabetes (T2DM) patients at a tertiary care department in Ningbo, China, and to determine factors that independently predict this polypharmacy prescription.

Methods

A retrospective cross-sectional study was conducted using an existing computerised medical records database. This database was screened from 2012 to 2017 for adult patients with T2DM and parameters like prescribed medicines and socio-demographic, behavioural and other medical information. Polypharmacy prescription was defined as the simultaneous prescription of ≥5 medicines by the clinician at the time of discharge for daily usage by the patient as part of his/her long-term treatment plan.

Results

The study inclusion criteria were satisfied by 3370 T2DM patients. Over a 5-year period, 72.2% (n = 2432) of T2DM patients were prescribed polypharmacy. On an average, eight medicines were prescribed to them. The odds of polypharmacy prescription increased with patients’ age (18–39 years: 1; 40–59 years: OR 1.86, 95% CI 1.28–2.71; and ≥60 years: 2.42, 1.65–3.55), duration of T2DM (≤1 year: 1; >5–10 years: 1.70, 1.10–2.62; and >10 years: 2.55, 1.68–3.89), and length of hospital stay (≤5 days: 1; >5–10 days: 2.43, 1.86–3.17; and >10 days: 2.99, 2.24–3.99), and were higher in those with poor blood glucose level (2.09, 1.67–2.62) and with comorbidities like other endocrine, nutritional and metabolic diseases (2.24, 1.76–2.85), circulatory system diseases (4.35, 3.62–5.23), skin and subcutaneous tissue diseases (1.64, 1.04–2.59), and musculoskeletal system and connective tissue diseases (1.61, 1.27–2.03). The odds of polypharmacy prescription were lower in those with comorbidities like neoplasms (0.51, 0.36–0.70) and during pregnancy, childbirth and the puerperium (0.06, 0.01–0.49).

Conclusions

Around three fourth of T2DM patients at the tertiary care department were prescribed polypharmacy, and the predictors were identified. The study findings could be taken into consideration in future interventional studies aimed at supporting medicines optimisation (and deprescribing) among these patients.

Evaluation of Inappropriate Prescribing in Patients Older than 65 Years in Primary Health Care

To asses inappropriate prescribing and its predisposing factors in polymedicated patients over the age of 65 in primary health care. Design: cross-sectional study. Setting: Primary care centres in the Costa del Sol Health District and Northern Health Area of Malaga in southern Spain. Participants: Patients older than 65 years who use multiple medications. Data collection was conducted during 1 year in a population of 425 individuals who comprised a stratified randomized sample of the population of health care users in the study area. The data were collected by interview on a structured data collection form. Study variables. Dependent variable: Potentially inappropriate prescribing (PIP) (STOPP/START criteria). Predictor variables: Sociodemographic characteristics, clinical characteristics and medication use. A descriptive analysis of the variables was performed. Statistical inference was based on bivariate analysis (Student’s t or Mann-Whitney U test and chi-squared test) and multivariate analysis was used to control for confounding factors. 73.6% of participants met one or more STOPP/START criteria. According to information about prescribed treatments, 48.5% of participants met at least one STOPP criterion and 43.30% of them met at least one START criterion. The largest percentage of inappropriate prescriptions was associated with cardiovascular treatments. More than three-quarters of the participants had one or more inappropriate prescriptions for medicines in primary care, according to STOPP/START criteria. In addition, PIP was directly related to the number of prescribed medications, gender and specific pathologies (diabetes).

An update on the clinical consequences of polypharmacy in older adults: a narrative review

INTRODUCTION

Polypharmacy, the use of multiple medications by one individual, is increasingly common among older adults. Caring for the growing number of older people with complex drug regimens and multimorbidity presents an important challenge in the coming years.

AREAS COVERED

This article reviews the international trends in the prevalence of polypharmacy, summarizes the results from previous reviews on polypharmacy and negative health outcomes, and updates a previous review on the clinical consequences of polypharmacy by focusing on studies published after 2013. This narrative review, which is based on a literature search in MEDLINE and EMBASE from January 1990 to June 2018, was undertaken to identify relevant articles. Search terms included variations of polypharmacy and multiple medications.

EXPERT OPINION

The prevalence of polypharmacy is increasing worldwide. More than half of the older population is exposed to polypharmacy in some settings. Polypharmacy is associated with a broad range of clinical consequences. However, methods to assess the dangers of polypharmacy should be refined. In our opinion, the issue of 'confounding by multimorbidity' has been underestimated and should be better accounted for in future studies. Moreover, researchers should develop more clinically relevant definitions of polypharmacy, including measures of inappropriate or problematic polypharmacy.

Factors associated with medication adherence in older patients: A systematic review

OBJECTIVE

Medication adherence is a major challenge in the treatment of older patients; however, they are under-represented in research. We undertook a systematic review focused on older patients to assess the reasons underlying non-adherence in this population.

METHODS

We searched multiple electronic databases for studies reporting reasons for non-adherence to medication regimens in patients aged 75 years and over. Our results were not limited to specific diseases, health-care settings, or geographical locations. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale. A narrative synthesis of findings was performed.

RESULTS

A total of 25 publications were included, all of which were in community settings. Frequent medication review and knowledge regarding the purpose of the medication were positively associated with adherence. Factors associated with poor adherence were multimorbidity, cognitive impairment, complex regimens with multiple prescribing physicians, and problems with drug storage or formulation.

CONCLUSION

These findings suggest that interventions to improve adherence could focus on medication review aimed at simplifying regimens and educating patients about their treatment. Groups with poor adherence that may benefit most from such a model include patients with multiple comorbidities and cognitive impairment.

Thirty-day hospital readmission rate amongst older adults correlates with an increased number of medications, but not with Beers medications

AIM

We sought to explore the relationship between the number of medications at hospital discharge and 30-day rehospitalization in older adults aged >65 years.

METHODS

This was a multicenter cohort study to determine whether an increased number of medications was associated with 30-day rehospitalization in patients aged >65 years. We explored the relationship between rehospitalization and other risk factors. Data were collected from a large health system in the New York metropolitan area from September 2011 to January 2013. The primary outcome was 30-day hospital readmission from the index hospitalization.

RESULTS

Patients had a mean ± SD age of 78 ± 9 years; 55% were women. The average length of stay after discharge from the hospital was 6 days. An increased number of medications was significantly associated with unplanned 30-day hospital readmission (P < 0.05). For each medication, the risk of rehospitalization increased by 4% (OR 1.04, 95% CI 1.03, 1.05). Patients discharged to rehabilitation centers were 32% more likely to be readmitted than patients discharged home (OR 1.39, 95% CI 1.27-1.51). Other risk factors significantly associated with 30-day rehospitalization were: cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Hypertension was negatively associated with 30-day unplanned rehospitalization (OR 0.88, 95% CI 0.82-0.95). No significant association between the number of Beers medications and 30-day rehospitalization was observed, after controlling for the number of medications and other covariates.

CONCLUSIONS

The number of discharge medications was significantly associated with 30-day hospital readmission among older adult patients. Important risk factors for 30-day rehospitalization were discharge location, cancer, intensive care unit, chronic heart failure, renal diseases and peripheral vascular diseases. Geriatr Gerontol Int 2018; 18: 1513-1518.

Prevalence and factors associated with polypharmacy in the older people: 2006-2014

AIMS AND OBJECTIVES

To analyse the prevalence, risk factors and evolution over time of polypharmacy and self-medication in the older people in Spain from 2006-2014.

BACKGROUND

Polypharmacy is a public health problem for older people worldwide which causes different negative effects on their health, increasing health costs and pharmaceutical spending. However, previous studies do not include nationally representative samples and none of them provide updated data.

DESIGN

Cross-sectional study with community-dwelling older adults (N = 26,277) who participated in the National Health Survey in Spain in 2006 and 2011/2012 and the European Health Survey in Spain in 2009 and 2014.

METHODS

Polypharmacy (defined as use of five or more medications in the last 2 weeks), excessive polypharmacy (defined as use of ten or more medications in the last 2 weeks) and self-medication (defined as use of medications without a prescription) were evaluated. A logistic regression was used for to know the association between polypharmacy and self-medication with the sociodemographic characteristic.

RESULTS

The participants were 62% female and 38% male. The mean medication consumption was 2.96 (SD ± 2.11). Prevalence of polypharmacy was present in 21.9%, prevalence of excessive polypharmacy was 0.6%, and prevalence of self-medication was 10.7%. The most commonly used medications were for blood pressure (51.6%), pain (42.8%) and cholesterol (28.2%). Polypharmacy is associated with sex (females), age, being separated/divorced/widowed, lack of education, higher body mass index, being bedridden during the last 2 weeks and self-medication.

CONCLUSIONS

The prevalence of polypharmacy and prevalence of self-medication are considerable, and they increased significantly from 2006-2014.

RELEVANCE TO CLINICAL PRACTICE

To deal with polypharmacy is a big challenge for nurses. These data suggest to establish innovative clinical strategies in which the health professionals and the patients are involved to improve the personal behaviour with medicines and to reduce the risks and costs of polypharmacy and self-medication.

A Pharmacist-Led Program to Evaluate and Reduce Polypharmacy and Potentially Inappropriate Prescribing in Older HIV-Positive Patients

OBJECTIVE

The goal of this pharmacist-led study was to utilize two validated instruments, Beers Criteria and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP), to assess potentially inappropriate prescribing (PIP) in older patients infected with the human immunodeficiency virus (HIV) and evaluate pharmacist interventions.

DESIGN

Prospective randomized interventional trial.

SETTING

Large urban clinic providing interdisciplinary primary and HIV care for ~2700 HIV-positive publicly insured patients.

DATA SOURCE

A computerized electronic record search was conducted for all patients who met the two search criteria: 50 years and older, and a primary care appointment within the last 12 months.

PATIENTS

After identification of 857 patients meeting the search criteria, 324 patients were randomly selected and contacted, resulting in 248 patients assessed.

MEASUREMENTS AND MAIN RESULTS

Patients had a mean age of 58 years, 71% male, 44% white, and a mean CD4 count of 536 cells/mm³ . Common comorbidities included hypertension (56%), depression (52%), asthma/chronic obstructive pulmonary disease (48%), dyslipidemia (39%), coronary artery disease (27%), and diabetes (22%). Patients sampled were prescribed a mean of 11.6 ± 5.7 concomitant medications (excluding antiretrovirals) with 35% receiving at least 16 medications. PIP was identified in 54% and 63% of patients using the STOPP and Beers Criteria, respectively. Twenty-five contraindicated drug interactions were identified in 20 patients. After the pharmacist visit, at least 69% of patients had at least one medication discontinued with almost 10% having six or more medications discontinued. More than 40% of patients had at least one Beers or STOPP criteria that required immediate correction by the pharmacist.

CONCLUSIONS

Results suggest that targeting individuals with 11 or more chronic medications would have the highest yield and greatest impact. Pharmacist-led review of medication prescribing using Beers and STOPP criteria revealed a large number of PIP, many amenable to immediate clinical pharmacist intervention.

Number of medications or number of diseases: what influences underprescribing?

PURPOSE

An increasing number of older adults suffer from multimorbidity and receive multiple medications. Despite that, underprescribing of potentially beneficial medications is widespread in this population. Our aim was to examine influence of polypharmacy and multimorbidity on the presence of prescribing omissions (PO) in general practice attenders.

METHODS

We conducted a cross-sectional study of older adults attending general practices in Slovenia who were regularly prescribed at least one medication. Patients' data was entered into a computer application evaluating the presence of START (Screening Tool to Alert doctors to Right Treatment) criteria for PO. Demographic data, CIRS-G (Cumulative Illness Rating Scale for geriatric patients) questionnaire, number of medications, and healthcare utilization data were also collected. We defined polypharmacy as five or more concurrent medications.

RESULTS

Five hundred three patients were enrolled, 258 (56.7%) female. The average age was 74.9 and average value of CIRS-G index 1.48 (± 0.6). Patients took on average 5.6 medications and 216 (42.9%) patients had at least one PO according to START criteria. In bivariate analysis, there was a significant association between age, number of medications, polypharmacy and CIRS-G index measures, and presence of PO. In multivariate analysis, only age and number of affected CIRS-G categories significantly predicted PO (p < 0.05).

CONCLUSIONS

Older patients with more affected CIRS-G categories were at higher risk for PO. Polypharmacy was not an independent risk factor for the presence of PO. A possible reason is that in multimorbid older people, physicians and patients set individual priorities to treatment instead of treating all diseases and conditions.

Assessing Potentially Inappropriate Prescribing in Community-Dwelling Older Patients Using the Updated Version of STOPP-START Criteria: A Comparison of Profiles and Prevalences with Respect to the Original Version

Emerging and changing evidence made it necessary to update STOPP-START criteria, and version 2 was published recently. In this study the objectives were to determine the prevalence of potentially inappropriate medication prescribing (PIM) in primary care using STOPP versions 1 (v1) and 2 (v2), as well as 2012 AGS Beers criteria, and analyze the factors associated with inappropriate prescribing according to STOPP/START v2. A cross-sectional study was carried out including community-dwelling older adults over the age of 65. Sociodemographic, clinical, functional and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. This variable was measured using three tools: STOPP v1, 2012 AGS Beers criteria and STOPP v2. Similarly, the percentage of patients receiving at least one potential prescribing omission (PPO) was calculated using START versions 1 and 2. A total of 1,615 prescriptions were reviewed. The median number of medications per patient was 7.1 drugs (±3.8). The prevalence of elderly people exposed to polypharmacy (≥5 medications) was 72.9%, whereas 28.4% of the participants took ≥10 drugs regularly. PIM were present in 18.7%, 37.3% and 40.4% of participants, according to the STOPP v1, 2012 Beers criteria and STOPP v2, respectively. According to STOPP v2, the number of medications taken (OR: 1.14, 1.06–1.25), the presence of a psychological disorder (OR: 2.22, 1.13–4.37) and insomnia (OR: 3.35, 1.80–6.32) were risk factors for taking a PIM. The prevalence of PPOs was 34.7% and 21.8% according to version 1 and 2, respectively. In conclusion, STOPP-START criteria have been remarkably modified, which is evidenced by the different prevalence rates detected using version 2, as compared to version 1. In fact, the level of agreement between version 1 and the updated version is only moderate. Special attention should be paid on benzodiazepines, which keep being the most frequent PIM.

Prevalence and Covariates of Polypharmacy in Elderly Patients on Discharge from a Tertiary Care Hospital in Oman

OBJECTIVES

To evaluate the prevalence of polypharmacy in relation to gender, comorbidity, and age among elderly patients upon discharge from an academic tertiary care hospital in Muscat, Oman.

METHODS

This cross-sectional study was conducted at Sultan Qaboos University Hospital between February and July 2014. We reviewed the electronic medical records of elderly patients aged ≥ 60 years who were admitted to any of the hospital's medical wards during the study period and collected data on age, gender, and diagnoses. We also collected information on the medications prescribed on discharge. Polypharmacy was defined as the concurrent use of ≥ 5 medications.

RESULTS

A total of 431 elderly inpatients were enrolled, of which approximately 50% were female. Polypharmacy was identified in 76.3% of discharge prescriptions. Gender (adjusted odds ratio (aOR), 1.17; 95% CI 0.73, 1.88, p = 0.502) and age (aOR, 0.98; 95% CI 0.95, 1.00, p = 0.075) had no impact on polypharmacy. On the other hand, a significant association between polypharmacy and comorbidity was observed (aOR, 1.31; 95% CI 1.12, 1.54, p = 0.001). Cardiovascular diagnosis on admission was also identified as being associated with polypharmacy (aOR, 2.66; 95% CI 1.49, 4.75, p = 0.001). More patients had cardiovascular diseases on admission (31.0%), followed by infections (23.0%), and gastrointestinal diseases (13.0%). The most commonly prescribed drugs on discharge were cardiovascular drugs (48.0%), followed by drugs acting on the gastrointestinal system (11.0%), endocrine system (9.2%), and nutrition and blood (7.5%).

CONCLUSIONS

The prevalence of polypharmacy among elderly medical patients discharged from our hospital was high (76.3%) and was associated with a number of comorbidities and cardiovascular disease as a cause of admission, but not with age or gender. The prevalence of polypharmacy in our institution raises significant concerns over its potential impact on patients' health outcomes and requires further investigation. Raising physicians' awareness of health implications of polypharmacy may help reduce the incidence of medication-related adverse events and improve treatment outcomes.

Polypharmacy in elderly patients with type 2 diabetes receiving oral antidiabetic treatment

AIM

Polypharmacy in older diabetics can have detrimental effects linked to poor adherence and the risk of drug interaction or more serious/frequent side effects. The aim of this study was to identify the characteristics associated with polypharmacy in a cohort of elderly diabetic patients being treated with oral hypoglycemic agents.

METHODS

The study population consisted of 1342 diabetic patients consecutively enrolled in 57 diabetes centers in Italy participating in the METABOLIC Study. Patients meeting the following inclusion criteria were enrolled: diagnosis of type 2 diabetes mellitus, age ≥65 years, and receiving oral antidiabetic treatment. Data concerning diabetes duration and complications, the medications the patients were taking, and the number of hypoglycemic events were registered. Multidimensional impairment was assessed using the Multidimensional Prognostic Index.

RESULTS

The mean age of the participants was 73.3 ± 5.5 years. Polypharmacy, defined as being prescribed contemporaneously at least five drugs, was found in 57.1 % of the study population. According to a multivariable logistic model, the female gender was significantly associated with polypharmacy, as were living in Northern Italian regions, diabetes duration longer than 4 years, and having a body mass index ≥30 kg/m(2). Comorbidities, diabetes complications, a better cognitive performance on the Short Portable Mental Status Questionnaire, and being malnourished/at risk of malnourishment according to the mini nutritional assessment were associated with polypharmacy.

CONCLUSIONS

Polypharmacy, a condition that may lead to many potential detrimental outcomes in older diabetic subjects, was significantly associated with some risk factors that may be useful to identify subjects at risk.

Pharmacotherapy in the ageing patient: The impact of age per se (A review)

A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.

Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study

OBJECTIVES

To examine: (1) changes in polypharmacy in 1997, 2002, 2007 and 2012 and; (2) changes in potentially inappropriate prescribing (PIP) prevalence and the relationship between PIP and polypharmacy in individuals aged ≥65 years over this period in Ireland.

METHODS

This repeated cross-sectional study using pharmacy claims data included all individuals eligible for the General Medical Services scheme in the former Eastern Health Board region of Ireland in 1997, 2002, 2007 and 2012 (range 338,025-539,752 individuals). Outcomes evaluated were prevalence of polypharmacy (being prescribed ≥5 regular medicines) and excessive polypharmacy (≥10 regular medicines) in all individuals and PIP prevalence in those aged ≥65 years determined by 30 criteria from the Screening Tool for Older Persons' Prescriptions.

RESULTS

The prevalence of polypharmacy increased from 1997 to 2012, particularly among older individuals (from 17.8% to 60.4% in those aged ≥65 years). The adjusted incident rate ratio for polypharmacy in 2012 compared to 1997 was 4.16 (95% CI 3.23 to 5.36), and for excessive polypharmacy it was 10.53 (8.58 to 12.91). Prevalence of PIP rose from 32.6% in 1997 to 37.3% in 2012. High-dose aspirin and digoxin prescribing decreased over time, but long-term proton pump inhibitors at maximal dose increased substantially (from 0.8% to 23.8%). The odds of having any PIP in 2012 were lower compared to 1997 after controlling for gender and level of polypharmacy, OR 0.39 (95% CI 0.39 to 0.4).

CONCLUSIONS

Accounting for the marked increase in polypharmacy, prescribing quality appears to have improved with a reduction in the odds of having PIP from 1997 to 2012. With growing numbers of people taking multiple regular medicines, strategies to address the related challenges of polypharmacy and PIP are needed.

Longitudinal prevalence of potentially inappropriate medicines and potential prescribing omissions in a cohort of community-dwelling older people

Purpose

This study aims to compare the prevalence of potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) using several screening tools in an Irish community-dwelling older cohort, to assess if the prevalence changes over time and to determine factors associated with any change.

Methods

This is a prospective cohort study of participants aged ≥65 years in The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data (n = 2051). PIM and PPO prevalence was measured in the year preceding participants’ TILDA baseline interviews and in the year preceding their follow-up interviews using the Screening Tool for Older Persons’ Prescriptions (STOPP), Beers criteria (2012), Assessing Care of Vulnerable Elders (ACOVE) indicators and the Screening Tool to Alert doctors to Right Treatment (START). Generalised estimating equations were used to determine factors associated with change in prevalence over time.

Results

Depending on the screening tool used, between 19.8 % (ACOVE indicators) and 52.7 % (STOPP) of participants received a PIM at baseline, and PPO prevalence ranged from 38.2 % (START) to 44.8 % (ACOVE indicators), while 36.7 % of participants had both a PIM and PPO. Common criteria were aspirin for primary prevention (19.6 %) and omission of calcium/vitamin D in osteoporosis (14.7 %). Prevalence of PIMs and PPOs increased at follow-up (PIMs range 22–56.1 %, PPOs range 40.5–49.3 %), and this was associated with patient age, female sex, and numbers of medicines and chronic conditions.

Conclusions

Sub-optimal prescribing is common in older patients. Ongoing prescribing review to optimise care is important, particularly as patients get older, receive more medicines or develop more illnesses.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1815-1) contains supplementary material, which is available to authorized users.