Pharmaceutical strategies towards optimising polypharmacy in older people

Selection of outcome measurement instruments for a core outcome set for trials aimed at improving appropriate polypharmacy in older people in primary care: a Delphi consensus study

BACKGROUND

Despite developing a polypharmacy core outcome set (COS) in primary care, it is not clear how these outcomes should be measured.

AIM

To select outcome measurement instruments (OMIs) for a COS targeting appropriate polypharmacy in older patients in primary care.

METHOD

Following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline, OMIs were identified from a Cochrane review focusing on appropriate polypharmacy. The quality of OMIs was assessed using a published checklist. Subsequently, two rounds of Delphi questionnaires were conducted via the SoGoSurvey® platform, engaging stakeholders (researchers, clinicians and journal editors specialising in geriatric primary care) to achieve consensus on OMIs using a scale encompassing "agree", "disagree", or "unsure". Consensus was achieved if 70% or more participants chose "agree" and 15% or fewer chose "disagree."

RESULTS

The quality of 20 OMIs identified from the Cochrane review was evaluated. Seven OMIs were selected based on meeting the COSMIN guideline's minimum requirements. Out of 188 potential participants, 57 (30.3%) consented to participate. Rounds 1 and 2 of Delphi exercises were completed by 50 respondents, achieving agreement on three OMIs: 'number of serious adverse drug reactions (ADRs)' (98%), 'number of deaths' (76%), and 'number of patients who fell' (70%) for measuring 'serious ADRs,' 'mortality,' and 'falls,' respectively. No agreement was reached for 'medication appropriateness,' 'medication side-effects,' 'quality of life,' and 'medication regimen complexity.'

CONCLUSION

OMIs were selected for a limited number of outcomes in the polypharmacy COS. Future research should identify suitable OMIs for the remaining four outcomes.

Prevalence of cognitive impairment and associated factors in older people

BACKGROUND

Older people are the fastest-growing age group, with the highest risk of cognitive impairment. This study assessed the prevalence and associated factors with cognitive impairment in community-dwelling older people.

METHODS

Older people were interviewed and accomplished through sociodemographic and health questionnaires. The quantitative variables were described by mean and standard deviation or median and interquartile range. The significance level adopted was 5 % (p < 0.05). The association between the quantitative variables was evaluated using the Pearson or Spearman correlation coefficients.

RESULTS

The research population comprised 165 long-lived adults aged ≥80. The youngest one was 80, and the oldest one was 94 years old. The participants were 84.8 ± 3.6 years old, female (63 %) with a mean of education of 2.9 ± 1.8 years. A poor performance in the Mini-Mental State Examination (MMSE) was found in 58 (35.2 %) individuals when adjusted for educational level. After adjustment for confounding factors, body mass index (BMI) (p = 0.09), total older adults' income (up to 1 minimum wage [mw], p = 0.023; over 1 to 2 mw, p = 0.023), functional disability (Moderate dependence 75 %, p = 0.038; Moderate dependence 50 %, p = 0.081; Moderate dependence 25 %, p = 0.054), and the anxiety scale (p = 0.032), remained associated with cognitive impairment.

CONCLUSIONS

This study showed that BMI, total older adults' income, functional disability, and anxiety are related to cognitive impairment in long-lived adults. This study has some limitations, such as the fact that it is a cross-sectional study, the reduced number of individuals, and the fact that there were no comparisons among different ages and populations.

Using group based trajectory modeling for assessing medication adherence to nintedanib among idiopathic pulmonary fibrosis patients

BACKGROUND AND OBJECTIVE

Adherence to antifibrotic medications has been evaluated in a few studies using annual proportion of days covered (PDC), a common adherence metric. However, PDC alone cannot identify and distinguish between different patterns of adherence over time, which can be accomplished using group-based trajectory models (GBTM) of monthly PDC. The objective is to assess nintedanib adherence trajectories using GBTM and identify characteristics of patients within each trajectory group.

METHODS

Individuals with idiopathic pulmonary fibrosis (IPF) who initiated nintedanib during 10/1/2014-12/31/2018 were identified in 100% Medicare claims and enrollment data. The sample consisted of community-dwelling older adults (≥ 66 years) with continuous coverage in Medicare Parts A, B and D for one year before (baseline) and after (follow-up) initiating nintedanib. A series of GBTMs of adherence was estimated to identify the best-fitting specification. Patients were then grouped based on their estimated adherence trajectories. Associations between baseline patient characteristics, including demographics, comorbidities, and health care use, and group membership probabilities were quantified as odds ratios using fractional multinomial logit modeling.

RESULTS

Among the 1,798 patients initiating nintedanib, mean age was 75.4 years, 61.1% were male, and 91.1% were non-Hispanic white. The best-fitting GBTM had five adherence trajectory groups: high adherence (43.1%), moderate adherence (11.9%), high-then-poor adherence (10.4%), delayed-poor adherence (13.2%), and early-poor adherence (21.5%). The principal factors associated with higher odds of being in at least one of the poor-adherence groups were older age, female sex, race and ethnicity other than non-Hispanic white, and number of medications during baseline.

CONCLUSIONS

GBTM identified distinct patterns of nintedanib adherence for the IPF patient cohort. Identifying adherence trajectory groups and understanding the characteristics of their members provide more actionable information to personalize interventions than conventional metrics of medication adherence.

Parameters to Consider for Successful Medication Use in Older Adults - an AGePOP Review

Older adults are the main users of medicine and due to their multimorbidity are often faced/confronted with a complex medication management. This review article provides a brief overview on aspects of medication management such as maintaining a stock of the required medicine, understanding and following the instructions for use, coping with the primary and secondary packaging as well as preparation prior to use. The main focus however is on the drug intake itself and provides an overview about the current understanding of real life dosing conditions of older adults and geriatric patients. Furthermore, it elaborates the acceptability of dosage forms, in particular solid oral dosage forms as they represent the majority of dosage forms taken by these patient populations. An improved understanding of the needs of older adults and geriatric patients, their acceptability of various dosage forms and the circumstances under which they manage their medications, will make the design of more patient-centric drug products possible.

Safety of Non-Steroidal Anti-Inflammatory Drugs in the Elderly: An Analysis of Published Literature and Reports Sent to the Portuguese Pharmacovigilance System

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently used agents to treat musculoskeletal disorders (principally by the elderly), thus raising the risk of adverse drug reactions (ADRs). This work aims to monitor NSAIDs safety profile in older people by using literature and pharmacovigilance data. Published clinical studies reporting the NSAIDs safety in elderly patients (age ≥ 65) were identified by a literature search and were then deeply analyzed. In addition, suspected ADRs reports submitted to the Portuguese Pharmacovigilance System (PPS) involving patients aged ≥65 with at least one NSAID as suspected drug were explored in detail. Most studies concluded that the risk of gastrointestinal, cardiovascular, and renal ADRs was significantly lower with cyclooxygenase-2 (COX-2)-selective NSAIDs use than with nonselective NSAIDs. The PPS data analysis showed that serious gastrointestinal ADRs occurred mostly in patients taking more than one NSAID and/or another concomitant drug that increases the incidence of these events, in the absence of gastroprotection. The results suggest that while NSAID toxicity is well understood, their safe use needs to be monitored in clinical practice. Furthermore, the pharmacovigilance data analyzed also showed that monitoring NSAIDs use in elderly remains essential to mitigate the associated risks, especially in those with comorbidities and under polytherapy.

Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience

BACKGROUND

Palliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown.

METHODS AND RESULTS

We explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62-80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms.

CONCLUSIONS

In a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.

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.

Trends and Determinants of Polypharmacy and Potential Drug-Drug Interactions at Discharge From Hospital Between 2009-2015

BACKGROUND

Polypharmacy (PP) and excessive polypharmacy (EPP) are increasingly common and associated with risk of drug-drug interactions (DDIs). We aimed to measure the trends and determinants of PP and DDIs among patients discharged from the Department of Internal Medicine of the Lausanne University Hospital.

METHODS

The retrospective study included 17,742 adult patients discharged between 2009 and 2015. Polypharmacy and EPP were defined as the concomitant prescription of five or more and ten or more drugs, respectively. Drug-drug interactions were defined as any combination of a drug metabolized by a cytochrome P450 or P-glycoprotein, and a drug considered as strong inductor or inhibitor of the corresponding enzyme was defined as a potential interaction.

RESULTS

Three most commonly classes of drugs prescribed were "alimentary tract and metabolism (including insulins)," "nervous system," and "blood and blood forming organs." Polypharmacy decreased from 45% in 2009 to 41% in 2015, whereas EPP increased from 40% to 46%. In 2015, 13% of patients received 15 or more drugs. Age, coming from other health care settings, higher Charlson Index, number of comorbidities, and quartiles of length of stay were significantly and independently associated with PP and EPP. The risk of having at least one DDI decreased from 67.0% (95% confidence interval = 64.8-69.0) in 2009 to 59.3% (57.6-62.0) in 2015 (P < 0.001). Multivariate analysis showed number of drugs (odds ratio and 95% confidence interval = 3.68 [3.3-4.1], 9.39 [8.3-10.6], and 20.5 [17.3-28.4] for [5-9], [10-14], and 15+ drugs, respectively), gastrointestinal disease (3.13 [2.73-3.58]), and cancer (1.37 [1.18-1.58]) to be positively associated, and lung (0.82 [0.74-0.90]) and endocrinological (0.62 [0.52-0.74]) diseases to be negatively associated with risk of DDI.

CONCLUSIONS

The pattern of drug prescription has changed and most prescribed groups increased during the study period. Excessive polypharmacy is increasing among hospital patients. The decrease in the overall risk of DDI could be due to an improved management of multidrug therapy.

A systematic review of general practice-based pharmacists' services to optimize medicines management in older people with multimorbidity and polypharmacy

BACKGROUND

Few studies have evaluated roles of general practice-based pharmacists (PBPs), particularly in optimizing medicines management for older people with both multimorbidity and polypharmacy.

OBJECTIVE

To explore the types and effectiveness of services provided by PBPs, either alone or in collaboration with other primary health care professionals, that sought to optimize medicines management for older people with multimorbidity and polypharmacy.

METHODS

Eight electronic databases and three trial registries were searched for studies published in English until April 2020. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and controlled before-and-after studies of services delivered by PBPs in primary care/general practice, for patients aged ≥65 years with both multimorbidity and polypharmacy that focused on a number of outcomes. The Cochrane risk of bias tool for randomized trials (RoB 1) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool were used for quality assessment. A narrative synthesis was conducted due to study heterogeneity.

RESULTS

Seven studies met inclusion criteria. All included studies employed PBP-led medication review accompanied by recommendations agreed and implemented by general practitioners. Other patient-level and practice-level interventions were described in one study. The limited available evidence suggested that PBPs, in collaboration with other practice team members, had mixed effects on outcomes focused on optimizing medicines management for older people. Most included studies were of poor quality and data to estimate the risk of bias were often missing.

CONCLUSION

Future high-quality studies are needed to test the effects of PBP interventions on a well-defined range of medicines management-related outcomes.

Protocol for a process evaluation of an external pilot cluster randomised controlled trial of a theory-based intervention to improve appropriate polypharmacy in older people in primary care: the PolyPrime study

Background

The PolyPrime intervention is a theory-based intervention aimed at improving appropriate polypharmacy in older people (aged ≥65 years) in primary care. The intervention consists of an online video which demonstrates how general practitioners (GPs) can prescribe appropriate polypharmacy during a consultation with an older patient and a patient recall process, whereby patients are invited to scheduled medication review consultations with GPs. The aim of the process evaluation is to further examine the implementation of the PolyPrime intervention in primary care. This will involve investigating whether the PolyPrime intervention can be delivered as intended across two healthcare systems, how acceptable the intervention is to GPs, practice staff and patients, and to identify the intervention’s likely mechanisms of action.

Methods

The PolyPrime study is an external pilot cluster randomised controlled trial (cRCT) which aims to recruit 12 GP practices across Northern Ireland [NI] (n=6) and the six counties in the Republic of Ireland (ROI) that border NI (n=6). Practices have been randomised to intervention or usual care. An embedded process evaluation will assess intervention fidelity (i.e. was the intervention delivered as intended), acceptability of the intervention to GPs, practice staff and patients and potential mechanisms of action (i.e. what components of the intervention were perceived to be effective). Quantitative data will be collected from data collection forms completed by GPs and practice staff and a feedback questionnaire completed by patients from intervention arm practices, which will be analysed using descriptive statistics. Qualitative data will be collected through semi-structured interviews with GPs and practice staff and audio-recordings of medication review appointments from the intervention arm practices which will be transcribed and analysed using the framework method. Quantitative and qualitative data will be triangulated to provide an overall assessment of intervention fidelity, intervention acceptability, and mechanisms of action.

Discussion

This process evaluation will add to feasibility data from the pilot cRCT by providing evidence on the fidelity of implementing the intervention package across two healthcare systems, the acceptability of the intervention and potential mechanisms of action.

Trial registration

ClinicalTrials.govISRCTN41009897. Registered on 19 November 2019. ClinicalTrials.govNCT04181879. Registered 02 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05410-6.

Ten-Year Trend in Polypharmacy in the Lausanne Population

BACKGROUND

Aging and associated morbidities place individuals at higher risk of polypharmacy and drug-drug interactions (DDIs). How polypharmacy and DDIs change with aging is important for public health management.

OBJECTIVES

The aim of the study was to assess the 10-year trends in prevalence of polypharmacy and potential DDIs in a population-based sample.

METHODS

Baseline (2003-2006) and follow-up (2014-2016) data were obtained from a sample of 4512 participants (baseline age range = 35-75 y, 55.1% women) from the population of Lausanne, Switzerland. Polypharmacy and polyactive drug use were defined by the regular use of five or more medications and five or more pharmacologically active substances, respectively. Drug-drug interactions were defined according to the criteria of the Geneva University Hospital.

RESULTS

The percentage of participants taking at least one drug increased from 56.1% to 79.5% (P < 0.001). Among participants taking drugs, number of medications increased from 2.6 ± 1.9 (mean ± standard deviation) to 3.8 ± 2.9 after 10.9-year follow-up (P < 0.001); the corresponding values for active substances were 2.7 ± 2.0 and 4.0 ± 3.0 (P < 0.001). The prevalence of polypharmacy and polyactive substance use increased from 7.7% to 25.0% and from 8.8% to 27.1%, respectively (P < 0.001). The presence of at least one potential DDI increased from less than 1% to almost one sixth of all participants.

CONCLUSIONS

In a community-dwelling sample, the prevalence of polypharmacy and polyactive substance use tripled during a 10.9-year follow-up, with an even greater increase in the prevalence of potential DDIs. Increasing rates of polypharmacy and DDIS warns the importance of preventing potential DDIs throughout healthcare system through various interventions.

Headache as an Adverse Reaction to the Use of Medication in the Elderly: A Pharmacovigilance Study

There is a consensus that elderly individuals are quite vulnerable to adverse drug reactions (ADRs), and headaches are one of the most frequent clinical presentations of central nervous system problems in the general population, which can be an ADR. The purpose of our work was to analyze reports of "headache" associated ADRs in the elderly sent to the Portuguese Pharmacovigilance System (PPS), and also which drugs were more frequently associated with this adverse reaction. A retrospective analysis of suspected ADR reports involving patients aged 65 years or older received by the PPS in the last 10 years was conducted. A search of all the terms associated with the High Level Term "headache" was performed. All duplicate reports were excluded from the analysis. A total of 155 ADRs reports were included, in which 15 reported isolated "headache" as suspected ADR, while the remaining 140 ADRs reports reported "headache" together with several other adverse reactions. Most reports of "headache" ADR occurred in women (74.8%; n = 116). About half (46.5%; n = 72) of the ADR reports were considered serious. Anti-viral medication, anti-depressants, anti-dyslipidemic agents and central nervous system-acting analgesics were the most frequent drugs associated with "headache" ADR reports in this population. In elderly patients, most ADR reports involving headaches occurred in women and a high percentage (46.5%) were considered serious. Thus, it is important that healthcare professionals pay more attention to headaches reported as ADRs in the elderly and drugs suspected to cause them, in order to increase knowledge about this type of reaction and contribute towards safely using drugs in this age group.

Validation of a Novel Electronic Device for Medication Adherence Monitoring of Ambulatory Patients

Several methods exist for measuring medication adherence. The Time4Med^TM device (Adherence Innovations, Hong Kong) is a small, electronic card to affix on medication packaging that records date and time of intakes when a button is pushed. We aimed to validate the device with an emphasis on polypharmacy. Twenty volunteers used Time4Med^TM devices with a virtual thrice daily intake over 14 days. Diary-recorded date and time were compared to electronically-stored events. Functionality, reliability and recovery for different stress conditions were calculated. User‘s acceptability was assessed with the System Usability Scale (SUS). Eleven elderly outpatients (mean age 80.2 ± 8.1 years) taking >3 medications daily used the device over 4 weeks. Volunteers logged 847 events. Functionality (100%), sensitivity (94.9%), specificity (99.4%) and recovery (100%) were high. Dropping the smart card and storing it in a refrigerator caused either the recording of false events or no recording at all. The mean SUS score was 82.6 (SD 14.8), demonstrating excellent acceptability. Satisfaction was very high for volunteers and patients, except for pushing the button. Time4Med^TM devices are highly accurate in recording, retaining and delivering electronic data of multiple medication intake. They are well accepted by elderly patients. They can be recommended in clinical studies and for practitioners who desire to elucidate adherence patterns of ambulatory patients.

Improving Medication Understanding and Adherence Using Principles of Memory and Metacognition: In Press - Policy Insights from Behavioral and Brain Sciences

More than half of older adults regularly take multiple medications. Rates of medication non-adherence are high, which undermines both patients' health and the economy. Memory and metacognitive factors (such as misplaced confidence) help explain why patients across the lifespan may not understand or follow prescribed regimens. These factors include difficulties in remembering confusing information; patients' and practitioners' potential overconfidence in memory; and misunderstandings about memory. Patients, practitioners, and the public can use these principles to improve memory, enhance understanding, and promote metacognitive accuracy with respect to complex medication information, which may increase the likelihood of adherence.

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study

Objectives

To provide baseline information on inappropriate prescribing (IP), and to evaluate whether potentially inappropriate medications (PIMs), as defined by STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, were associated with preventable adverse drug events (ADEs) and/or hospitalization.

Methods

We prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.

Results

IP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1–1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20–25.3).

Conclusion

The majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.

Case study: using participatory photographic methods for the prevention of medication errors

OBJECTIVE

To describe the experience of using participatory photographic research methods to engage nurses and researchers in a collaborative study to improve medication safety conditions, particularly in patients with feeding tubes in a nursing home for the elderly (NHE).

METHOD

This qualitative study was conducted in Brazil and proceeded in iterative phases of visual and textual data collection and analysis. Interviews, subsequent nurse-led photo-narrated walkabouts, and photo elicitation were used with nurses.

RESULTS

The need to transform the work design and the workplace to improve medication safety and improving medication processes through effective communication was identified. Unsafe workforce is a challenge in achieving safe medication administration practices; and lack of a patient safety culture is a barrier for adaptive learning and growth.

CONCLUSION

Our findings demonstrated the effectiveness of a restorative research approach for supporting nurses to study and act on medication safety.

Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia

AIMS

To determine the frequency of excessive polypharmacy (≥15 medications) in an outpatient population from Colombia and the variables associated with this condition.

METHODS

A cross-sectional study using a systematised database of 6.2 million affiliates of the Colombian Health System. All patients treated uninterruptedly with 15 or more medications for 3 months (January-March 2017) were included. Sociodemographic, pharmacological, potential drug interactions, and prescribers' variables were identified.

RESULTS

A total of 264 patients with prescriptions of ≥15 medications were identified; with an estimated prevalence of excessive polypharmacy of 108.4 per 100 000 people. The mean age was 67.7 ± 17.8 years and 60.6% were females. The mean number of medications per patient was 20.1 ± 4.5 and 48.9% (n = 129) had 20 or more. The most used were antiulcer medications (89.0%; n = 235), antihypertensives (85.6%; n = 226), analgesic/antipyretic (80.3%; n = 212), psychiatric/neurologic medications (78.5%; n = 207), statins (67.4%; n = 178), acetylsalicylic acid (59.5%; n = 157), and vitamins (57.2%; n = 151). On average, each patient had 21.0 ± 11.4 drug-drug interactions and were attended by 6.2 ± 3.1 physicians. Being treated by seven or more physicians (OR: 5.09; 95% CI: 1.64-15.79) increased the probability of receiving more than 20 medications.

CONCLUSIONS

Drugs for treatment of chronic conditions prevailed, especially in elderly patients with multiple chronic conditions; however, some groups of medications without clear indications, such as antiulcer medications or vitamin supplements, also had extensive use. A main factor that increases the probability of polypharmacy greater than 20 drugs is care by seven or more physicians, which shows a fragmentation in patient care by the country's health system, without achieving co-ordination and integration between the different agents involved in medical care, also influenced by different physicians' practice patterns.

Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators

BACKGROUND

Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence.

OBJECTIVES

This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists.

METHOD

Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg "Knowledge," "Emotion"). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods.

RESULTS

Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg "Social influences," "Memory, attention and decision processes," "Motivation and goals") and mapped to 11 intervention components (BCTs) to include in an intervention [eg "Social support or encouragement (general)," "Self-monitoring of the behaviour," "Goal-setting (behaviour)"].

CONCLUSION

This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies.