The prevalence of polypharmacy in older Europeans: A multi-national database study of general practitioner prescribing

AIMS

The aims of this study were to measure the prevalence of polypharmacy and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care.

METHODS

This was a multinational retrospective cohort study across six countries: Belgium, France, Germany, Italy, Spain and the UK. We used anonymized longitudinal patient-level information from general practice databases hosted by IQVIA. Patients ≥65 years were included. Polypharmacy was defined as having 5-9 and ≥10 distinct drug classes (ATC Level 3) prescribed during a 6-month period. Selected medications were: opioids, antipsychotics, proton pump inhibitors (PPI), benzodiazepines (ATC Level 5). We included country experts on the healthcare context to interpret findings.

RESULTS

Age and gender distribution was similar across the six countries (mean age 75-76 years; 54-56% female). The prevalence of polypharmacy of 5-9 drugs was 22.8% (UK) to 58.3% (Germany); ≥10 drugs from 11.3% (UK) to 28.5% (Germany). In the polypharmacy population prescribed ≥5 drugs, opioid prescribing ranged from 11.5% (France) to 27.5% (Spain). Prescribing of PPI was highest with almost half of patients receiving a PPI, 42.3% (Germany) to 65.5% (Spain). Benzodiazepine prescribing showed a marked variation between countries, 2.7% (UK) to 34.9% (Spain). The healthcare context information explained possible underreporting for selected medications.

CONCLUSIONS

We have found a high prevalence of polypharmacy with more than half of the older population being prescribed ≥5 drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, worryingly high usage of PPIs and benzodiazepines supports current efforts to improve polypharmacy management across Europe.

Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis

Introduction

Polypharmacy is commonly associated with adverse health outcomes. There are currently no meta-analyses of the prevalence of polypharmacy or factors associated with polypharmacy. We aimed to estimate the pooled prevalence of polypharmacy and factors associated with polypharmacy in a systematic review and meta-analysis.

Methods

MEDLINE, EMBASE, and Cochrane databases were searched for studies with no restrictions on date. We included observational studies that reported on the prevalence of polypharmacy among individuals over age 19. Two reviewers extracted study characteristics including polypharmacy definitions, study design, setting, geography, and participant demographics. The risk of bias was assessed using the Newcastle-Ottawa Scales. The main outcome was the prevalence of polypharmacy and factors associated with polypharmacy prevalence. The pooled prevalence estimates of polypharmacy with 95% confidence intervals were determined using random effects meta-analysis. Subgroup analyses were undertaken to evaluate factors associated with polypharmacy such as polypharmacy definitions, study setting, study design and geography. Meta-regression was conducted to assess the associations between polypharmacy prevalence and study year.

Results

106 full-text articles were identified. The pooled estimated prevalence of polypharmacy in the 54 studies reporting on polypharmacy in all medication classes was 37% (95% CI: 31-43%). Differences in polypharmacy prevalence were reported for studies using different numerical thresholds, study setting, and publication year. Sex, study geography, study design and geographical location were not associated with differences in polypharmacy prevalence.

Discussion

Our review highlights that polypharmacy is common particularly among older adults and those in inpatient settings. Clinicians should be aware of populations who have an increased likelihood of experiencing polypharmacy and efforts should be made to review the appropriateness of prescribed medications and occurrence of adverse effects potentially associated with polypharmacy.

Conclusions and implications

Clinicians should be aware of the common occurrence of polypharmacy and undertake efforts to minimize inappropriate polypharmacy whenever possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03279-x.

Potentially Inappropriate Medication and Associated Factors Among Older Patients with Chronic Coronary Syndrome at Hospital Discharge in Beijing, China

Purpose

Medication therapy is crucial in the management of chronic coronary syndrome (CCS). The use of potentially inappropriate medications (PIMs) contributes to poor outcomes in older patients, making it a major public health concern. However, few studies are available on PIMs use in older Chinese CCS patients. To investigate the frequency of prescribed PIMs at discharge and explore risk factors in older adults with CCS.

Patients and Methods

The cross-sectional study was conducted in a tertiary hospital in China over three months, from 1st October to 31st December, 2019. CCS patients aged over 60 years who were discharged alive were recruited. Information on demographics and medications at discharge was collected. Clinical data including diagnoses, frailty status, New York Heart Association (NYHA) class and age-adjusted Charlson Comorbidity Index (ACCI) were evaluated in each patient. PIMs were identified using the 2019 Beers criteria. Binary logistic regression was performed to recognize variables related to PIMs.

Results

A total of 447 eligible patients with 2947 medications were included. The prevalence of PIMs use was 38%. Medications to be avoided, to be used with caution, and with drug–drug interactions were 38.4%, 48.9% and 12.7% of the PIMs, respectively. Medications with drug–disease/syndrome interactions and those adjusted for kidney function were not identified. The common PIMs were diuretics (37.1%), benzodiazepines and benzodiazepine receptor agonist hypnotics (15.2%), glimepiride (13.1%), and co-prescription of potassium-sparing diuretics and renin-angiotensin system (RAS) inhibitors (9.7%). Individuals with frailty syndrome, polypharmacy, multiple comorbidities, atrial fibrillation, psychiatric disorders and greater NYHA class severity were more likely to receive PIMs.

Conclusion

Prescription of PIMs was a common burden in older adults. A CCS multidisciplinary team is needed to control PIMs, especially in vulnerable older patients.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases

Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.

Potentially inappropriate medications involved in drug-drug interactions at hospital discharge in Croatia

Background The potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) can significantly affect patient safety in the elderly, especially at transition of health care. Objective The aim of this study is to evaluate PIMs involved in potentially clinically significant DDIs in prescribed pharmacotherapy of elderly patients at hospital discharge. Setting Internal Medicine Clinic of University Hospital Dubrava, Zagreb, Croatia. Method During a 16-month period, the pharmacotherapy data were assessed using Lexicomp Online screening software to identify category C (monitor drug therapy), D (consider therapy modification) and X (avoid combination) DDIs. The European Union (EU)(7)-PIM criteria were applied to detect inappropriately prescribed medications involved in DDIs. Clinical pharmacists obtained data from patients' medical records and patient/caregiver interviews. Main outcome measure The incidence of PIMs involved in potentially clinically significant DDIs. Results A total of 364 consecutive elderly patients were enrolled in the study. The mean number of prescription medications at discharge was 9.3. Overall, 2833 potentially clinically significant DDIs were identified: 2445 (86.3%) of them were category C, 347 (12.3%) category D and 41 (1.4%) were category X interactions. A total of 1164 PIMs were involved in 31.2% of category C interactions, 60.2% of category D interactions and 43.9% of category X interactions. The most frequent PIMs involved in potentially clinically significant DDIs were tramadol, benzodiazepines, moxonidine, vildagliptin and metoclopramide. Conclusion A very high incidence of DDIs in elderly patients and a high incidence of PIMs involved in DDIs was determined at hospital discharge.

A Gap Between Asthma Guidelines and Management for Adolescents and Young Adults

BACKGROUND

For adolescents, asthma management can be challenging during the transition to adulthood, and changes in health care and pharmacological treatment may occur.

OBJECTIVE

To investigate asthma-related health care consumption and pharmacological dispensation during the transition process.

METHODS

In a Swedish birth cohort study, questionnaire and clinical data from the 16- and 24-year follow-ups were linked to national and regional registries for asthma-related health care consumption and dispensed medications during an 8-year period: 4 years before and after age 18 y, respectively.

RESULTS

In the study population (n = 1808), 14% fulfilled the study definition of current asthma at the 16- and 24-year follow-up and 8% (n = 147) had persistent asthma. Among them, register data showed that in the 4-year period before their 18th birthday, 39% (58 of 147) had at least 1 consultation, similar to 37% (55 of 147) in the following 4-year period. The mean number of consultations before age 18 years was 1.6, compared with 1.0 after age 18 years (P = .02). At least 1 dispensation of any inhaled corticosteroid before age 18 years was found for 73% (107 of 147), compared with 50% (74 of 147) after age 18 years. The mean number of dispensed any inhaled corticosteroid was 3.1 before 18 years and 2.1 after 18 years (P < .01). Only 3% (5 of 147) had a regular dispensation of any inhaled corticosteroid once a year during the 8-year period.

CONCLUSIONS

Health care consultations were fewer than recommended in guidelines and decreased after the transition to adult health care. Almost no one had dispensed regular asthma medications during the 8-year period.