Prescribing patterns and predictors of high-level polypharmacy in the elderly population: A prospective surveillance study from two teaching hospitals in India

Prevalence of polypharmacy among older adults in Ethiopia: a systematic review and meta-analysis

Polypharmacy is a significant concern for older adults. Taking multiple medicines to prevent and treat comorbidities is very common in older adults, potentially leading to polypharmacy. Polypharmacy is associated with the development of geriatric syndromes, including cognitive impairment, delirium, falls, frailty, urinary incontinence, and weight loss. The prevalence of polypharmacy varies according to the literature. There is a paucity of data regarding the prevalence of polypharmacy among older adults. Therefore, this study aimed to estimate the pooled prevalence of polypharmacy among older adults in Ethiopia. A comprehensive search of databases, including PubMed, MEDLINE, EMBASE, Hinari, Cumulative Index to Nursing and Allied Health Literature, International Scientific Indexing, Cochrane library and Web of Science, and Google Scholar, was conducted. STATA statistical software (version 17) was used to analyze the data. Forest plot and I2 heterogeneity test were computed to examine the existence of heterogeneity. Subgroup analysis and sensitivity analysis were done to explore the source of heterogeneity. Publication bias was evaluated by using funnel plots and Egger's test. A random effect model was used to determine the pooled prevalence of polypharmacy. After reviewing 123 studies, 13 studies with a total of 3547 older adults fulfilled the inclusion criteria and were included in this meta-analysis. The result from 13 studies revealed that the pooled prevalence of polypharmacy among older adults in Ethiopia was 37.10% (95CI: 28.28-45.91). A Subgroup Meta-analysis showed that the heterogeneity level was slightly lower among studies done in Oromia region (I2 = 46.62, P-value = 0.154). Higher pooled polypharmacy prevalence was found among older adults with cardiovascular disorders (42.7%) and admitted patients (51.4%). In general, it was found that the pooled prevalence of polypharmacy among older adults in Ethiopia was high. More than one in three older adults take five or more medications at a time. Thus, intervention focusing on rational geriatric pharmacotherapy is significant to prevent unnecessary pill burden, adverse drug events, medical costs, geriatric morbidity, and mortality. Furthermore, enhancing pharmacist roles towards medication therapy management and safety monitoring in older adults is also indicated.

Risk prediction model of polypharmacy for community-dwelling elderly patients: An assessment tool for early detection

Background: Polypharmacy has become a major and growing public health issue, with significant implications for health outcomes and expenditure on healthcare resources. In this study, a risk prediction model of polypharmacy represented by a nomogram for community-dwelling elderly patients based on the Chinese population was constructed.

Methods: A cross-sectional study was conducted in Shanghai, China. The variables data affecting polypharmacy were fetched from the information system database of health government departments in Shanghai. The Least Absolute Shrinkage Selection Operator (LASSO) regression analysis was used to select the predictor variables, and multivariate logistic regression was used to establish the prediction model. A visual tool of the nomogram was established for predicting the risk of polypharmacy in the elderly population. In addition, the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to estimate the performance of the model.

Results: A total of 80,012 elderly patients were included in this study. Eight variables, containing age, residential area, preferred medical institutions, number of visits to tertiary hospitals, number of visits to secondary hospitals, number of visits to community health centers, number of diagnoses, and main types of disease, were included in the risk prediction model of nomogram. The area under the curve (AUC) of the nomogram was 0.782 in both sets, demonstrating that the model has a good discriminant ability. The calibration chart shows that the prediction model fits well with the validation set. DCA results displayed that the threshold probabilities of the two sets in the prediction model reached up to 90%, implying that the model had a preferable application value.

Conclusion: This study explored the risk factors for polypharmacy among the elderly in Shanghai, China, and applied the nomogram to establish a predictive model via eight variables, which provided an effective tool for early screening and timely prevention of polypharmacy. Family physicians or pharmacists could scientifically use the tool to closely observe community-dwelling elderly patients, decreasing the adverse health effects caused by medication for the elderly.

Pharmacy students knowledge about aging and rational geriatric pharmacotherapy in India: A cross-sectional study

This study was conducted to compare the knowledge of aging and rational geriatric pharmacotherapy among Bachelor of Pharmacy (BPharm) and Doctor of Pharmacy (PharmD) students in Telangana state, India. A multi-school, cross-sectional study was conducted among final year BPharm and PharmD students from 136 institutions between February and June 2017. A 15-item Geriatric Knowledge Assessment Scale (GKAS) was used to assess aging and rational geriatric pharmacotherapy knowledge among 600 pharmacy students. A total of 530 students participated in the survey, with a response rate of 88.3%, and their mean age was 23.5 (0.5 standard deviation) years. Three-fourth (73%) of the participants were PharmD and 27% were BPharm students. Adequate knowledge about aging was identified in only 41.1% of PharmD students and 16.1% of BPharm students. Both PharmD (73.1%) and BPharm (86.7%) demonstrated poor rational geriatric pharmacotherapy knowledge. Male gender [Adjusted Odds Ratio (AOR): 2.9, 95% CI (1.46-5.71)], students aged <22 years [AOR: 3.5, (2.08-6.03)] and studying PharmD [AOR: 3.3, (1.87-5.78)] were significantly associated with higher knowledge on aging and geriatric pharmacotherapy. Inadequate knowledge may be due to a lack of geriatric content in the pharmacy curriculum and insufficient training in this area.

Risk Factors Related to Serious Adverse Drug Reactions Reported through Electronic Submission during Hospitalization in Elderly Patients

Background

Many studies have assessed the risk factors for adverse drug reactions (ADRs) in elderly patients. However, most of these studies have focused on risk factors for ADRs, not serious ADRs (s-ADRs). s-ADRs are commonly found in hospitalized patients. s-ADRs warrant imminent but thorough investigations, given their critical impact on patient health. Therefore, this retrospective study aimed to assess the associated risk factors for s-ADRs in elderly hospitalized patients.

Methods

In-patients aged >65 years having ADRs during hospitalization at a university hospital in Korea between 2010 and 2012 were included. Medical professionals spontaneously reported ADRs using an electronic submission system at the study hospital. Further, all descriptions of ADRs were characterized and categorized through the screening of electronic medical records. We compared the characteristics of patients having s-ADRs with those of patients not having s-ADRs.

Results

There were 353 cases of ADRs, 67 of which were s-ADRs. Patients taking more than eight concomitant drugs showed the highest odds ratio (OR, 11.99; 95% confidence interval [CI], 3.42–42.03). The ratio of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) was also significantly related to s-ADRs (OR, 2.78; 95% CI, 1.33–5.81). The use of antibiotics (OR, 2.39; 95% CI, 1.13–5.02) and antineoplastics (OR, 4.17; 95% CI, 1.09–15.94) were significant risk factors.

Conclusion

Our findings highlight the importance of polypharmacy. Liver function tests (AST/ALT ratio) must be monitored carefully within high-risk groups for ADRs.

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group. Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary. Data sources: Articles published between January 2010-March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults. Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems. Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no "gold standard" is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

Attitudes and beliefs of patients and primary caregivers towards deprescribing in a tertiary health care facility

Background

Good prescribing practices form the essence of drug therapy for better patient care. The major aim of better prescribing is to improve rational prescribing. Deprescribing gained momentum in recent decades.

Objective

This study aimed to explore the attitude and beliefs of deprescribing among patients and their caregivers forming dyads in a tertiary health care facility.

Methods

Cross-sectional, questionnaire-based prospective study done for two months. Attitude towards deprescribing was assessed by using validated rPATD (revised Patient attitude towards deprescribing) questionnaire. Cohen's kappa coefficient was used to measure the agreement between the views of people and their caregivers forming dyads about medication cessation.

Results

312 patients and caregivers (156 forming dyads) participated in the study. Among 156 patients, 25.6% were hypertensives & 21.2% had diabetes. 41.7% were between 36-50 years of age. Only 16.7% belong to the elderly age group. 2.5% were taking >5 medications. 43.6% of patients and 62.2% of caregivers were female. 51.3% of the patients were willing to stop one or more of their regular medicine(s) under the treating physician's advice, but 62% were satisfied with their current medicine(s). 33.4% were reluctant to stop taking medicines for a long time.

Conclusions

In our study, more than 50% of people and their caregivers were willing to try medication cessation under their physician's recommendation. There was moderate agreement between patients and their caregivers in the trial of medication cessation. Thus, the results obtained from this study may help towards improving rationalized prescribing practices in the institutional setup.

Chronic kidney disease (CKD) -a brand ambassador/alarming bell for potentially inappropriate medication in elderly inpatients

BACKGROUND

In the past decade, the prevalence of Potentially Inappropriate Medication (PIM) among elderly inpatients has increased drastically. However, limited data is available on PIM indicators, and PIMs use among the elderly in patients with Chronic Kidney Disease (CKD).

OBJECTIVE

To determine the prevalence of PIMs in elderly hospitalized patients with CKD.

METHODS

A cross-sectional study was carried out on 102 patients in a tertiary care hospital. PIMs were identified using Beers criteria 2019. A Chi-square test was used to determine the association between variables and PIMs use.

RESULTS

PIMs, as assessed according to AGS updated Beers criteria 2019 was found to be in more than 68.6% of patients of median age 65years and 3 number of diagnoses and seven days median length of stay. Most of the patients (47.1%) had ≥four diagnoses. The most common comorbidities in the patient were diabetes mellitus (n=54) and hypertension (n=55). Most of the subjects (66.7%) were on polypharmacy (5-9 medications/day), and 25.5% were on a higher level of polypharmacy (>10 medicines/day). Approximately 90% of the patients had very low CrCl < 21ml/min (calculated with the help of Cockcroft- Gault formula). A significant association between PIM use and an increased number of diagnoses, polypharmacy or high-level polypharmacy, was observed.

CONCLUSION

The prevalence of PIMs in elderly inpatients suffering from CKD is relatively high. The study indicates negligence/ lack of awareness amongst physicians leading to increase PIM use. The authors propose that the CKD patients should attract the special attention of the physician and should be treated as brand ambassadors or alarming bells for PIM use.

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.

Prevalence of Drug-Related Problems and Complementary and Alternative Medicine Use in Malaysia: A Systematic Review and Meta-Analysis of 37,249 Older Adults

Drug-related problems (DRPs) in the elderly include polypharmacy, potentially inappropriate medications, nonadherence, and drug-related falls. In this systematic review and meta-analysis, the prevalence of DRPs and complementary and alternative medicine (CAM) use among the Malaysian elderly was estimated. PubMed, Scopus, Web of Science, and Google Scholar databases were searched to identify studies published since their inception up to 24 August 2020. A random-effects model was used to generate the pooled prevalence of DRPs along with its corresponding 95% confidence interval (CI). The heterogeneity of the results was estimated using the I² statistics, and Cochran’s Q test and sensitivity analyses were performed to confirm the robustness of the results. We identified 526 studies, 23 of which were included in the meta-analysis. (n = 29,342). The pooled prevalence of DRPs among Malaysian elderly was as follows: (1) polypharmacy: 49.5% [95% CI: 20.5–78.6], (2) potentially inappropriate medications: 28.9% [95% CI: 25.4–32.3], (3) nonadherence to medications: 60.6% [95% CI: 50.2–70.9], and (4) medication-related falls 39.3% [95% CI: 0.0–80.8]. Approximately one in two Malaysian elderly used CAM. The prevalence of polypharmacy and potentially inappropriate medications among the Malaysian elderly population was high, calling for measures and evidence-based guidelines to ensure the safe medication use.

Outpatient prescribing trends, rational use of medicine and impact of prescription audit with feedback at a tertiary care centre in India

BACKGROUND

Rational use of medicines (RUM) is highly desired worldwide yet many shortcomings are found. This study aims to evaluate prescription pattern and RUM using World Health Organisation (WHO) prescribing indicators. The impact of audit and feedback has also been studied, along with comparison with published data.

METHODS

A cross-sectional observational study was conducted in the outpatient department setting of a tertiary care centre in central India. Data were collected from 2719 prescriptions across different departments from hospital pharmacies from 2016 to 2018 at different time periods. The data was analysed using WHO core prescribing indicators.

RESULTS

Average number of drugs per prescription was found to be 2.53 ± 1.23 (WHO optimal value ≤ 2). The mean values of prescribing indicators for antibiotics (19.82% vs. ≤ 30%) and injection prescribing (1.98% vs. ≤10%) were within optimal values. Generic prescribing (15.96% vs. 100%) and prescribing from National List of Essential Medicines (NLEM; 37.37% vs. 100%) were found to be significantly lesser. Annual audit and feedback showed improvement in generic prescribing and prescribing from NLEM, but the other trends continued to be similar.

CONCLUSION

While use of antibiotics and injections among outpatients was found to be rational, there is scope of improvement in most domains that can be addressed with appropriate interventions.

Interplay of multimorbidity and polypharmacy on a community dwelling frail elderly cohort in the peri-urban slums of Delhi, India

The United Nations Population Fund suggests that the number of elderly persons is expected to grow to 173 million by 2026. The aging phase is further made adverse by conditions such as failty, multimorbidity and polypharmacy.

Survey on Polypharmacy and Drug-Drug Interactions Among Elderly People with Cardiovascular Diseases at Yekatit 12 Hospital, Addis Ababa, Ethiopia

Background

Elderly people are most commonly associated with cardiac disease. Cardiovascular diseases are interlinked with co-morbidities which require multiple drug therapy in addition to cardiovascular drugs. This results to polypharmacy which carries a high risk of potential drug-drug interactions. Elderly patients are at a particular risk of drug related problems because of increased level of polypharmacy and the physiological changes which accompany aging. This study was aimed to assess polypharmacy and potential drug-drug interactions (DDIs) among elderly people with cardiovascular diseases at Yekatit 12 hospital.

Methodology

A retrospective cross-sectional study using patients chart review was conducted on all elderly people with cardiovascular diseases at Yekatit 12 hospital in the period between March 2018 and March 2019. The types, seriousness and level of potential DDIs were checked using Medscape online drug interaction checker.

Results

The mean number of drugs per prescription was 4.25 ± 1.754 and the prevalence of polypharmacy (concurrent use of 5 and more drugs) was 42.7%. Polypharmacy and potential DDIs were significantly associated with polymorbidity (P = 0.000), being hospitalized (P = 0.047) and congestive heart failure (P = 0.016). A total of 850-potential DDIs were identified, the mean number of potential DDIs was 3.37 per prescription. The potential DDIs were mainly significant (73.29%) in nature and pharmacodynamics (73.06%) in mechanism. The prevalence of total and serious potential DDIs were 84.3% and 17.3%, respectively. Most commonly interacting drug combination was aspirin + enalapril (30.2%).

Conclusion

A higher incidence of polypharmacy and increased risk of potential DDIs in elderly people with cardiovascular disease are major therapeutic issues at Yekatit 12 hospital.

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.

Magnesium and Drugs

Several drugs including diuretics and proton-pump inhibitors can cause magnesium loss and hypomagnesemia. Magnesium and drugs use the same transport and metabolism pathways in the body for their intestinal absorption, metabolism, and elimination. This means that when one or more drug is taken, there is always a potential risk of interaction with the magnesium status. Consequently the action of a drug may be adversely affected by magnesium (e.g., magnesium, calcium, and zinc can interfere with the gastrointestinal absorption of tetracycline antibiotics) and simultaneously the physiological function of minerals such as magnesium may be impaired by a drug (e.g., diuretics induce renal magnesium loss). Given the ever-increasing number of drugs on the market and the frequency with which they are used, greater attention must be paid in daily medical and pharmaceutical practice focused in particular on the adverse effects of drug therapy on magnesium status in order to minimize the potential risk to the health of patients.

Important drug-micronutrient interactions: A selection for clinical practice

Interactions between drugs and micronutrients have received only little or no attention in the medical and pharmaceutical world in the past. Since more and more pharmaceutics are used for the treatment of patients, this topic is increasingly relevant. As such interactions - depending on the duration of treatment and the status of micronutrients - impact the health of the patient and the action of the drugs, physicians and pharmacists should pay more attention to such interactions in the future. This review aims to sensitize physicians and pharmacists on drug micronutrient interactions with selected examples of widely pescribed drugs that can precipitate micronutrient deficiencies. In this context, the pharmacist, as a drug expert, assumes a particular role. Like no other professional in the health care sector, he is particularly predestined and called up to respond to this task. The following article intends to point out the relevance of mutual interactions between micronutrients and various examples of widely used drugs, without claiming to be exhaustive.

Prevalence, risk factors and health outcomes associated with polypharmacy among urban community-dwelling older adults in multi-ethnic Malaysia

BACKGROUND

Polypharmacy has been associated with increased morbidity and mortality in the older population.

OBJECTIVES

The aim of this study was to determine the prevalence, risk factors and health outcomes associated with polypharmacy in a cohort of urban community-dwelling older adults receiving chronic medications in Malaysia.

METHODS

This was a baseline study in the Malaysian Elders Longitudinal Research cohort. The inclusion criteria were individuals aged ≥55years and taking at least one medication chronically (≥3 months). Participants were interviewed using a structured questionnaire during home visits where medications taken were reviewed. Health outcomes assessed were frequency of falls, functional disability, potential inappropriate medication use (PIMs), potential drug-drug interactions (PDDIs), healthcare utilisation and quality of life (QoL). Risk factors and health outcomes associated with polypharmacy (≥5 medications including dietary supplements) were determined using multivariate regression models.

RESULTS

A total of 1256 participants were included with a median (interquartile range) age of 69(63-74) years. The prevalence of polypharmacy was 45.9% while supplement users made up 56.9% of the cohort. The risk factors associated with increasing medication use were increasing age, Indian ethnicity, male, having a higher number of comorbidities specifically those diagnosed with cardiovascular, endocrine and gastrointestinal disorders, as well as supplement use. Health outcomes significantly associated with polypharmacy were PIMS, PDDIs and increased healthcare utilisation.

CONCLUSION

A significant proportion of older adults on chronic medications were exposed to polypharmacy and use of dietary supplements contributed significantly to this. Medication reviews are warranted to reduce significant polypharmacy related issues in the older population.

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 and potentially inappropriate prescriptions identified by Beers and STOPP criteria in co-morbid older patients at hospital discharge

RATIONALE, AIMS AND OBJECTIVES

The objective of this study was to evaluate the prevalence of potentially inappropriate prescriptions (PIP) and the association with polypharmacy (more than six drugs prescribed) in co-morbid older patients in a critical moment of care transition such as hospital discharge by means of two explicit criteria (Beers 2012 and STOPP 2008).

METHOD

Cross-sectional study carried out in an older patients' population (≥65 years old) discharged from a university hospital in Spain. We recorded patients' information regarding demographics, diagnosis, drugs prescribed and associated pathological conditions and calculated the Charlson co-morbidity index. Data were obtained from the electronic medical records of hospital discharge. Beers (2012) and STOPP criteria (2008) were applied for PIP detection. The strength of association between polypharmacy and the presence of PIP was assessed by calculating the crude and adjusted odds ratio and its 95% confidence interval.

RESULTS

From 1004 patients of a 15% random sample, just 624 that fulfilled the inclusion criteria were included in the study. The number of prescribed drugs was a risk factor for PIP according to both criteria, even after adjusting for confounding variables. PIP frequency was higher in patients who received more than 12 medications (Beers: 34.8%, STOPP: 54.4%). Each additional medication increased the risk of PIP by 14 or 15% (Beers or STOPP).

CONCLUSIONS

Our results suggest that the strategies used for PIP reduction in co-morbid older patients should focus on the management of polypharmacy. Medication review at hospital discharge is highly recommended for patients taking more than six drugs.

Excessive polypharmacy and survival in polypathological patients

PURPOSE

The purpose of this study was to determine whether excessive polypharmacy is associated with a higher survival rate in polypathological patients.

PATIENTS AND METHODS

An observational, prospective, and multicenter study was carried out on those polypathological patients admitted to the internal medicine and acute geriatrics departments between March 1 and June 30, 2011. For each patient, data concerning age, sex, comorbidity, Barthel and Lawton-Brody indexes, Pfeiffer's questionnaire, socio-familial Gijon scale, delirium, number of drugs, and number of admissions during the previous year were gathered, and the PROFUND index was calculated. Polypharmacy was defined as the use of ≥ 5 drugs and excessive polypharmacy as the use of ≥ 10. A 1-year long follow-up was carried out. A logistic regression model was performed to analyze the association of variables with excessive polypharmacy and a Cox proportional hazard model to determine the association between polypharmacy and survival.

RESULTS

We included 457 polypathological patients. Mean age was 81.0 (8.8) years and 54.5% were women. The mean number of drugs used was 8.2 (3.4). Excessive polypharmacy was directly associated with heart disease [hazard ratio (HR) 2.33 95% CI 1.40-3.87; p =0.001], respiratory disease [HR 1.87 95% CI 1.13-3.09; p = 0.01], peripheral artery disease/diabetes with retinopathy and/or neuropathy [HR 2.02 95% CI 1.17-3.50; p = 0.01], and the number of admissions during the previous year [HR 1.21 96%CI 1.01-1.44; p = 0.04]. It was inversely associated with delirium [HR 0.48 95% CI 0.25-0.91; p = 0.02]. There were no statistical differences regarding the probability of 1-year survival between patients with no polypharmacy, with simple polypharmacy, and with excessive polypharmacy (0.66, 0.60, and 0.57, respectively, p = 0.12).

CONCLUSIONS

A greater use of drugs may not be harmful but is also not associated with a higher probability of survival in polypathological patients.

Newest Vital Sign as a proxy for medication adherence in older adults

OBJECTIVE

To assess the utility of the Newest Vital Sign (NVS) as a proxy for medication adherence in community-dwelling older adults.

DESIGN

Descriptive cross-sectional study.

SETTING

12 adult day care centers in the Lisbon metropolitan area, Portugal, between March and May 2009.

PARTICIPANTS

100 white community-dwelling older adults.

INTERVENTION

Participants were administered the NVS, Single Item Literacy Screener (SILS), and self-reported Measure of Adherence to Therapy (MAT).

MAIN OUTCOME MEASURES

Health literacy and medication adherence.

RESULTS

The mean (±SD) age of the respondents was 73.3 ± 7.8 years and 71% were women. The NVS score was 0.81 ± 0.10 (of 6 possible points), and 95% of the respondents scored in the three lowest possible scores, indicating a notable floor effect. Age was found to be inversely correlated with NVS score (P = 0.003). The MAT score was 36.2 ± 4.7 (range 17-42). No statistically significant association between the NVS and level of education (P = 0.059 [Kruskal-Wallis]), gender (P = 0.700 [Mann-Whitney]), SILS (P = 0.167), or MAT (P = 0.379) was identified.

CONCLUSION

The utility of the NVS as a proxy for medication adherence in community-dwelling older adults is limited because of a floor effect that hinders its predictive power for medication adherence.

Polypharmacy in the elderly: can comprehensive geriatric assessment reduce inappropriate medication use?

Polypharmacy is a problem of growing interest in geriatrics with the increase in drug consumption in recent years, particularly among people aged >65 years. The main reasons for polypharmacy are longer life expectancy, co-morbidity and the implementation of evidence-based clinical practice guidelines. However, polypharmacy also has important negative consequences, such as a higher risk of adverse drug reactions and a decline in medication efficacy because of reduced compliance. Comprehensive geriatric assessment (CGA) has proved effective in reducing the number of prescriptions and daily drug doses for patients by facilitating discontinuation of unnecessary or inappropriate medications. CGA has also demonstrated an ability to optimize treatment by increasing the number of drugs taken in cases where under-treatment has been identified. Greater multidimensional and multidisciplinary efforts are nonetheless needed to tackle polypharmacy-related problems in frail elderly patients. CGA should help geriatrics staff identify diseases with higher priority for treatment, thereby achieving better pharmacological treatment overall in elderly patients. The patient's prognosis should also be considered in the treatment prioritization process. The most appropriate medication regimen should combine existing evidence-based clinical practice guidelines with data gathered from CGA, including social and economic considerations. Furthermore, for prescriptions to remain appropriate, the elderly should periodically undergo medication review, particularly as the risk or presence of multiple co-morbidities increases. This article aims to highlight the increasing impact of polypharmacy in the elderly and to underscore the role of CGA in achieving the most appropriate pharmacological treatment in this age group.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Polypharmacy and nutritional status in elderly people

PURPOSE OF REVIEW

Increasing use of drugs among elderly people has raised concerns about possible negative health outcomes, including malnutrition, associated with polypharmacy. Evidence about the association of polypharmacy with nutritional status is scarce. This review summarizes the relevant evidence regarding polypharmacy and nutritional status in elderly people.

RECENT FINDINGS

The probability of nutritional problems as a consequence of drugs is highest in elderly people suffering from several diseases. Drug treatment may contribute to poor nutritional status by causing loss of appetite, gastrointestinal problems, and other alterations in body function. Some recently published studies add evidence on possible association between increasing number of drugs and malnutrition. Studies indicate also an association between polypharmacy and weight changes. In addition, there are available studies that have shown deficits in the intake of specific macronutrients and micronutrients (e.g. fiber, glucose, and specific vitamins) for those with a high number of drugs in use.

SUMMARY

On the basis of available evidence, the role of polypharmacy on nutritional status among elderly people is unclear. Some diseases promote malnutrition; thus, the independent role of drugs for nutritional status is challenging to determine. Longitudinal studies with careful adjustment for underlying diseases are needed to explore association between polypharmacy and malnutrition. Nutritional evaluation should be a routine part of comprehensive geriatric assessment that is conducted ideally in multiprofessional teams, including physician, pharmacist, and dietitian.