Polypharmacy in older people: time to take action

Prevalence of potentially inappropriate medications and prescription dynamics in elderly hospitalized patients in Spain

PURPOSE

In recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75.

PATIENTS AND METHODS

This was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria.

RESULTS

A total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed.

CONCLUSION

In this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge. These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.

The Association of Gabapentin Initiation with Cognitive and Behavioral Changes in Older Adults with Cognitive Impairment: A Retrospective Cohort Study

BACKGROUND

Although gabapentin has been increasingly prescribed to older adults, the relation between gabapentin initiation and longer-term neurocognitive changes is not well understood. Thus, this study aimed to examine the association of gabapentin initiation with cognitive and motor function decline in older adult participants with cognitive impairment.

METHODS

A retrospective cohort study was conducted using the National Alzheimer's Coordinating Center Uniform Data Set (2005-March 2023). Participants with cognitive impairment at the visit of gabapentin initiation (i.e., index visit) were included. Using the incidence density sampling method, up to nine non-users were randomly selected for each initiator. Cognitive decline over 1 year was defined as any increase in Clinical Dementia Rating global score (CDR®GLOB) or a 1-point increase in CDR® sum of boxes (CDR®SB). Functional status decline over 1 year was defined as at least a 3-point increase in the Functional Activities Questionnaire (FAQ) sum or a 0.3-point increase of mean of FAQ. Motoric decline over 1 year was defined as new clinician reports of gait disorder, falls, and slowness. To mitigate confounding and selection bias, joint stabilized inverse probability of treatment weights and censoring weights were used. Analyses compared index with index + 1 and index + 2 visits.

RESULTS

For the study of cognitive and functional status decline, we included 505 initiators (mean age [SD] 78.8 [7.4]; male = 45%) and 4545 non-users (79.2 [7.6]; 50.1%). For the study of motor decline, we included 353 initiators (78.3 [7.2]; 42.8%) and 3177 non-users (78.5 [7.4]; 48.1%). Gabapentin initiation was not statistically associated with decline on CDR®GLOB, CDR®SB, FAQ sum, or mean FAQ at the index + 1 or index + 2 visits. However, gabapentin initiation was significantly associated with increased odds of new falls at the index + 2 visit (odds ratio [95% confidence interval] 2.5 [1.3, 4.6]).

CONCLUSIONS

Over 1 or 2 years of follow-up, gabapentin initiation was not associated with decline in cognitive or functional status but was associated with increased odds of falling among research participants with cognitive impairment.

Validation of MyFORTA: An Automated Tool to Improve Medications in Older People Based on the FORTA List

BACKGROUND

Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list.

METHODS

331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters.

RESULTS

The FORTA scores were 9.01 ± 2.91 (mean ± SD, MF) versus 6.02 ± 2.52 (GS) (p < 0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5 ± 2.7 (MF) versus 5.98 ± 2.55 (GS) (p < 0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF.

CONCLUSION

MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints.

Cognitive and functional trajectories in geriatric outpatients after a pharmacologic multidisciplinary intervention: A study protocol

BACKGROUND

Polypharmacy is a common condition among older adults and is associated with adverse drug reactions and health outcomes, including falls, functional and cognitive impairment, and frailty.

METHODS

A prospective observational study will be conducted on older adults with polypharmacy. The aim is to assess the impact of a specialized outpatient clinic focused on pharmacotherapy optimization recently integrated into daily clinical practice in a Spanish public tertiary teaching hospital on patients' functional and cognitive abilities. Patients who attend a first consultation and meet inclusion criteria (≥75 years old, have a life expectancy≥3 months, and polypharmacy (≥5 prescribed medications) will be invited to participate in the study, until reach a calculated sample size of 104 participants. Patients will be excluded if they are enrolled in a clinical trial related to medication or in the event of a no-show or cancellation of the appointment at the first visit. Participants will receive usual care: a first consultation including multidisciplinary pharmacological optimization in the context of a CGA and subsequent face-to-face and/or telephone follow-up (∼3 and ∼6 months). The primary endpoint will be the functional (Barthel index) and cognitive change in capacities (IPCR - Índice de Incapacidad psíquica de la Cruz Roja). Secondary endpoints include medication changes, changes in patients' quality of life, rate of falling, and use of healthcare resources.

DISCUSSION

We expect that the close collaboration between professionals from different disciplines working together will be an effective strategy to improve the functional and cognitive abilities of older adults.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05408598 (March 1, 2022).

Prevalence and clinical implications of polypharmacy and potentially inappropriate medication in elderly patients with heart failure: results of six months' follow-up

OBJECTIVES

To investigate the prevalence of polypharmacy and potentially inappropriate medication (PIM) in elderly patients with heart failure (HF) and their impact on readmission and mortality.

METHODS

We conducted a study of 274 participants aged 60 years or older with HF. The prevalence of polypharmacy (defined as the use of five or more medications) was calculated, and the 2019 American Geriatrics Society Beers criteria were applied to access PIMs. Medications and PIMs were characterized at admission and discharge, and changes in prescriptions during hospitalization were compared. The impact of polypharmacy and PIM on readmission and mortality were investigated.

RESULTS

The median age of this study population was 68 years old. The median number of prescribed drugs was 7 at admission and 10 at discharge. At discharge, 99.27% of all patients were taking five or more drugs. The incidence of composite endpoint and cardiovascular readmission increased with the number of polypharmacy within 6 months. The use of guideline-directed medical therapy reduced the incidence of composite endpoint events and cardiovascular readmission, while the use of non-cardiovascular medications increased the composite endpoint events. The frequency of PIMs was 93.79% at discharge. The incidence of composite endpoint events increased with the number of PIMs. "PIMs in older adults with caution" increased cardiovascular readmission and "PIMs based on kidney function" increased cardiovascular mortality. Several comorbidities were associated with cardiovascular mortality or non-cardiovascular readmission.

CONCLUSIONS

Polypharmacy and PIM were highly prevalent in elderly patients with HF, and their use was associated with an increased risk of composite endpoint events, readmission and mortality. Non-cardiovascular medications, "PIMs in older adults with caution", "PIMs based on kidney function" and several comorbidities were important factors associated with hospital readmission and mortality. Our findings highlight the importance of medication optimization in the management of HF in elderly patients.

Recent Updates on Risk and Management Plans Associated with Polypharmacy in Older Population

The concept of polypharmacy encompasses adverse drug reactions and non-adherence factors in elderly individuals. It also leads to the increased use of healthcare services and negative health outcomes. The problem is further alleviated by the odds of potentially inappropriate medications (PIM), which lead to the development of drug-related problems. Since polypharmacy is more commonly observed in the elderly population, urgency is required to introduce operative protocols for preventing and managing this problem. The family medicine model of care can be associated with favorable illness outcomes regarding satisfaction with consultation, treatment adherence, self-management behaviors, adherence to medical advice, and healthcare utilization. Hence, interventions built on family medicine models can provide significant support in improving the outcomes of the older population and their quality of life. In this regard, the authors have taken up the task of explaining the accessible resources which can be availed to improve the application of health care services in the field of geriatric medicine.

Identifying key prescribing cascades in older people (iKASCADE): a transnational initiative on drug safety through a sex and gender lens-rationale and design

PURPOSE

To describe the objectives, methods and expected impact of an international consortium (iKASCADE) whose purpose is to improve drug safety for older adults by addressing prescribing cascades through a sex and gender lens.

METHODS

To create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the consortium has created a modified Delphi procedure where international experts in prescribing and managing pharmacotherapy for older adults will rank a list of prescribing cascades as to their clinical importance. We will use administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex internationally, in the hospital, long-term care and community settings. Finally, we will use semi-structured interviews and realistic, country-specific vignettes, each incorporating a prescribing cascade with identified sex differences, to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades.

RESULTS

The consortium will synthesize the quantitative and qualitative results to produce a position paper and products-aimed at knowledge users within and outside of academia-designed to elevate the importance of integrating a gender dimension in the identification and prevention of prescribing cascades.

CONCLUSION

Findings will improve our understanding of how adverse drug events are different between older women and men and inform the development and dissemination of tailored knowledge translation products to reduce the frequency and impact of prescribing cascades.

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.

Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences

BACKGROUND

The number of older adults has been constantly growing around the globe. Consequently, multimorbidity and related polypharmacy have become an increasing problem. In the absence of an accepted agreement on the definition of polypharmacy, data on its prevalence in various studies are not easily comparable. Besides, the evidence on the potential adverse clinical outcomes related to polypharmacy is limited though polypharmacy has been linked to numerous adverse clinical outcomes. This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy.

METHODS

The MEDLINE database was used to identify recent publications on the definition, prevalence and clinical consequences of polypharmacy using their respective common terms and their variations. Systematic reviews and original studies published between 2015 and 2020 were included.

RESULTS

One hundred and forty-three definitions of polypharmacy and associated terms were found. Most of them are numerical definitions. Its prevalence ranges from 4% among community-dwelling older people to over 96.5% in hospitalized patients. In addition, numerous adverse clinical outcomes were associated with polypharmacy.

CONCLUSION

The term polypharmacy is imprecise, and its definition is yet subject to an ongoing debate. The clinically oriented definitions of polypharmacy found in this review such as appropriate or necessary polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults, particularly in nursing home residents and hospitalized patients. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.

Potentially inappropriate medication in acute hospitalized elderly patients with polypharmacy: an observational study comparing PRISCUS, STOPP, and Beers criteria

PURPOSE

To compare the prevalence of potentially inappropriate medication (PIM) in the elderly according to the PRISCUS list, STOPP criteria, and Beers criteria. Secondary, to describe the differences using the three criteria focused on the inappropriate prescription of psychotropic drugs in the elderly.

METHODS

A retrospective study was performed at Severo Ochoa University Hospital. The study included 365 patients, aged 80 years and older, living in Madrid, Spain.

RESULTS

93.42% of patients received at least one PIM during hospitalization. Using the PRISCUS list, this changed from 32.6 to 2.7% at discharge. Applying STOPP criteria lowered the percentage from 65.20 to 10.95%, and with Beers criteria from 80.27 to 10.13. Lower Barthel index at admission was associated with an increased relative risk for receiving at least one PIM (OR 1.79, 95% CI 1.15-2.80, p = 0.024) using PRISCUS list as a tool in conjunction with STOPP criteria (OR 1.44, 95% CI 0.89-2.33, p = 0.037). Polypharmacy at admission predicted the presence of PIMs with STOPP criteria (OR 1.74, 95% CI 1.07-2.84, p = 0.001). Regarding psychotropic medicines, 208 patients (56.98%) received at least one psychotropic medicine during hospitalization. A total of 26.30% of patients were treated with psychotropic medicines, detected by the PRISCUS list, and 53.97% and 29.85% with STOPP and Beers, respectively.

CONCLUSIONS

Explicit criteria are a useful tool for identifying during hospitalization of the elderly patients. As indicated by the results, new research is needed to carry out an adaptation in our country that includes an evaluation of the strengths of the three tools to decrease PIMs and improve prescription in the elderly.

Polypharmacy, benzodiazepines, and antidepressants, but not antipsychotics, are associated with increased falls risk in UK care home residents: a prospective multi-centre study

Aim

To explore the link between polypharmacy, psychotropic medications, and falls risk in a cohort of UK care home residents.

Findings

Polypharmacy and psychotropic drugs are predictive of falls in UK care home residents.

Message

Deprescribing interventions relating to psychotropic drugs should continue to be encouraged.

Purpose

Falls and polypharmacy are both common in care home residents. Deprescribing of medications in residents with increased falls risk is encouraged. Psychotropic medications are known to increase falls risk in older adults. These drugs are often used in care home residents for depression, anxiety, and behavioural and psychological symptoms of dementia. However, a few studies have explored the link between polypharmacy, psychotropic medications, and falls risk in care home residents.

Methods

This was a prospective cohort study of residents from 84 UK care homes. Data were collected from residents’ care records and medication administration records. Age, diagnoses, gender, number of medications, and number of psychotropic medications were collected at baseline and residents were monitored over three months for occurrence of falls. Logistic regression models were used to assess the effect of multiple medications and psychotropic medication on falls whilst adjusting for confounders.

Results

Of the 1655 participants, mean age 85 (SD 8.9) years, 67.9% female, 519 (31%) fell in 3 months. Both the total number of regular drugs prescribed and taking ≥ 1 regular psychotropic medication were independent risk factors for falling (adjusted odds ratio (OR) 1.06 (95% CI 1.03–1.09, p < 0.01) and 1.39 (95% CI 1.10–1.76, p < 0.01), respectively). The risk of falls was higher in those taking antidepressants (p < 0.01) and benzodiazepines (p < 0.01) but not antipsychotics (p > 0.05).

Conclusion

In UK care homes, number of medications and psychotropic medications (particularly antidepressants and benzodiazepines) predicted falls. This information can be used to inform prescribing and deprescribing decisions.