Polypharmacy and health outcomes among older adults discharged from hospital: Results from the CRIME study

Medication Discrepancies among Older Hospitalized Adults Discharged from Post-Acute Care Facilities to Home

OBJECTIVES

The epidemiology of medication discrepancies during transitions from post-acute care (PAC) to home is poorly described. We sought to describe the frequency and types of medication discrepancies among hospitalized older adults transitioning from PAC to home.

DESIGN

A nested cohort analysis.

SETTING AND PARTICIPANTS

Included participants enrolled in a patient-centered deprescribing trial, for patients (aged ≥50 years and taking at least 5 medications) transitioning from one of 22 PACs to home.

METHODS

We assessed demographic and medication measures at the initial hospitalization. The primary outcome measure was medication discrepancies, with the PAC discharge list serving as reference for comparison to the participant's self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies and were organized by common medication classes and risk of harm (eg, 2015 Beers Criteria). Ordinal logistic regression assessed for patient risk factors for PAC discharge discrepancy count.

RESULTS

A total of 184 participants had 7-day PAC discharge medication data. Participants were predominately female (67%) and Caucasian (83%) with a median of 16 prehospital medications [interquartile range (IQR) 11, 20]. At the 7-day follow-up, 98% of participants had at least 1 medication discrepancy, with a median number of 7 medication discrepancies (IQR 4, 10) per person, 4 (IQR 2, 6) of which were potentially inappropriate medications as defined by the Beers Criteria. Higher medication discrepancies at index hospital admission and receipt of caregiver assistance with medications were 2 key predictors of medication discrepancies in the week after PAC discharge to home.

CONCLUSIONS AND IMPLICATIONS

Older patients transitioning home from a PAC facility are at high risk for medication discrepancies. This study underscores the need for interventions targeted at this overlooked transition period, especially as patients resume responsibility for managing their own medications after both a hospital and PAC stay.

Patients' Characterization, Pattern of Medication Use, and Factors Associated with Polypharmacy: A Cross-Sectional Study Focused on Eight Units of the Portuguese National Network for Long-Term Integrated Care

The Portuguese National Network for Long-term Integrated Care (RNCCI) comprises several Units for Integrated Continuous Care (UCCIs) that provide medical, nursing, and rehabilitation care. This study aimed to evaluate the demographic and medical characteristics of patients admitted to the RNCCI, their patterns of medication use, and factors associated with polypharmacy. An observational, retrospective, cross-sectional, multicenter study was performed. This study population consisted of 180 patients. Polypharmacy status was divided into two groups: non-polypharmacy (taking ≤ 4 drugs) and polypharmacy (taking ≥ 5 drugs). Bivariate analysis and multivariate logistic regression analysis were used to determine the influence of predictor factors such as demographic and medical characteristics on the polypharmacy status during the UCCI stays. This study population (mean age of 78.4 ± 12.3 years, range 23-102 years, 59% female) was prescribed a median of 8 medications. Approximately 89.4% of the patients were taking ≥ 5 drugs, demonstrating that polypharmacy is highly prevalent in Portuguese RNCCI residents of the eight UCCIs studied. A subsequent analysis with multivariate logistic regression found that polypharmacy status was significantly associated with the unit of internment (facility) when compared to facility E with H and with the Charlson Comorbidity Index (CCI). The high prevalence of polypharmacy and the associated factors show that it is urgent to improve pharmacotherapy regimens through periodic monitoring and review of patients' therapeutic lists, an area in which pharmacists play a very important role.

Polypharmacy in patients with multiple sclerosis and the impact on levels of care and therapy units

Background

The aim of this study was to examine the societal costs of polypharmacy in patients with multiple sclerosis (MS). We therefore focused on the association between the number of medications on the level of care (LOC), the German classification of the need for care, and the number of therapy sessions (TTU).

Methods

In addition to demographic information and medication, 101 MS patients performed the Multiple Sclerosis Health Resource Utilization Survey (MS-HRS). Medications were subdivided into a total number of medications (TD), MS-related medication [MSD, i.e., disease-modifying drugs (DMDs) and symptomatic treatment (SD)], and medication for comorbidities (CDs). Multivariate linear regression models were performed to estimate if the amount of each medication type affects LOC or TTU.

Results

Polypharmacy appeared in 54 patients at the time of the survey. The relative risk (RR) of LOC 1 increased significantly by 2.46 (p = 0.001) per TD and by 2.55 (p = 0.004) per MSD, but not per CD (RR 1.44; p = 0.092). The effect of RR on MSD was driven by SD (RR 2.2; p = 0.013) but not DMD (RR 2.6; p = 0.4). RR of MSD remained significant for LOC 2 (1.77; p = 0.009) and LOC 3/4 (1.91; p = 0.015), with a strong trend in RR of SD, but not DMD. TTU increased significantly per MSD (p = 0.012), but not per TD (p = 0.081) and CD (p = 0.724).

Conclusion

The number of MSDs is related to the likelihood of a higher level of care and the number of therapy sessions and is therefore a good indication of the extent of the societal costs.

Prevalence of polypharmacy in heart failure patients: A retrospective cross-sectional study in a tertiary hospital in Saudi Arabia

Background

Cardiovascular disease is the leading cause of death and disability worldwide. It is a general term used to describe a group of disorders that affect the heart or blood vessels. This study aimed to evaluate the prevalence and predictors of polypharmacy in patients with heart failure.

Methods

We conducted a cross-sectional study in a tertiary hospital in Saudi Arabia. Data was extracted from an electronic database between January 2019, and December 2022. The study included all adult patients with heart failure who visited outpatient clinics; individuals with cancer were excluded. The outcome variable in our study was "polypharmacy" which was defined as the use of eight or more medications. Descriptive analysis was performed using frequencies and percentages for categorical variables. In addition, Multivariate logistic regression was used to assess the covariates associated with polypharmacy.

Results

A total of 331 patients with heart failure were included in this study. The prevalence of polypharmacy among our HF population was 39.88 %. Most participants were male (60.73 %), and 60 years or older (68 %). The most frequently used medications were beta-blockers (67.98 %) and diuretics (58.31 %), whereas the least frequently used medications were hydralazine and histamine H2 blockers (5.74, and 3.02 %, respectively). Polypharmacy was likely to be a non-significantly higher in individuals aged between 60 and 69 years (adjusted odds ratio (AOR) = 1.52; 95 % confidence interval (CI) 0.78-2.98) and suffering from hypertension (AOR = 1.48; 95 % CI 0.83-2.64). However, patients with heart failure and diabetes mellitus had a significant six-fold higher of polypharmacy than those without diabetes mellitus (AOR = 6.55; 95 % CI 3.71-11.56).

Conclusion

Patients with heart failure often use multiple medications. Patients with heart failure together with diabetes have a higher risk of polypharmacy. Therefore, healthcare professionals should manage polypharmacy to improve the outcomes in patients with heart failure.

Polypharmacy and potentially-inappropriate medications are prevalent in the elderly cancer patients receiving systemic cancer therapy and they co-relate with adverse outcomes

OBJECTIVES

Cancer is the disease of the ageing. Most of the elderly cancer patients have pre-existing illnesses requiring complexity of medical care. Excessive medications would lead not only futility, but also result in adverse outcomes especially if such over-prescription is not appropriate. This study was intended to determine the prevalence of polypharmacy (PP) and potentially-inappropriate medications (PIMs) among elderly cancer patients eligible for active cancer care and their associations with hospitalization and mortality.

MATERIALS AND METHODS

This was a prospective cohort study conducted among the elderly non-hematologic cancer patients (≥ 65 years old) whom a medical oncologist had decided suitable for systemic cancer therapy. Demographic data including age, sex, primary site of cancer, cancer stage at diagnosis, Charlson Comorbidity Index (CCI), numbers and kinds of medications used both prior to and during cancer treatment were recorded. Hospitalizations not related to systemic cancer therapy administration and mortality were prospectively monitored. All of the patients had to be followed at least one year after cancer diagnosis.

RESULTS

There were 180 eligible participants. Median age in years (IQR) was 68 (65-73). One hundred patients (55.56%) were male and 80 patients (44.44%) were female. Breast (35, 19.44%), lung (31, 17.22%) and colorectal (18, 10%) cancers were the most common diagnoses. Eighty-six patients (47.78%) had metastatic disease at cancer diagnosis. One hundred twenty-two patients (67.78%) had PP (5 or more medications a day) and thirty-six patients (20%) had hyper-PP (10 or more medications a day). One hundred twenty five of the whole cohort (69.4%) had PIMs. Patients with more serious CCI scores were associated with PP and hyper-PP. While patients with primary lung cancer was only the only factor associated with PIMs. When excluding opioids, laxatives and anti-emetics, the most frequently prescribed drugs during cancer treatment, the so-called corrected PP did not associate with worse 1-year survival. Factors correlated with 1-year mortality were more advanced age group (70 years old or more) (OR 2.24; 95% C.I., 1.14-4.41; p = 0.019), primary lung cancer (OR 2.89; 95% C.I., 1.45-5.78; p = 0.003), metastatic disease at cancer diagnosis (OR 4.57; 95% C.I., 1.90-10.97; p = 0.001), and unplanned hospitalizations (OR 3.09; 95% C.I.,1.60-5.99; p = 0.001). While male gender (OR 2.35; 95% C.I., 1.17-4.71; p = 0.016), metastatic stage at cancer diagnosis (OR 2.74; 95% C.I., 1.33-5.66; p = 0.006) and corrected PP (OR 1.90; 95% C.I. 1.01-3.56; p = 0.046) were the significant predictive factors of unplanned hospitalizations.

CONCLUSION

Among elderly cancer patients suitable for systemic cancer therapy, around two thirds of patients had PP and PIMs. Higher CCI score was the only significant predictor of PP and hyper-PP; while primary lung cancer was the sole independent factor predicting PIMs. PP was associated with unplanned hospitalizations, albeit not the survival.

Increase in Chronic Medications and Polypharmacy-The Multifaceted Burden of COVID-19 Disease on Public Health Care

The long-term impact of COVID-19 disease is becoming a major global concern. In this retrospective monocentric analysis, we included consecutive subjects admitted to our COVID-19 Post-Acute Care Service for a SARS-CoV-2 infection that occurred between three and twelve months before. A home medication list relative to the period before SARS-CoV-2 infection (baseline) was recorded and compared with that one relative to the time of outpatient visit (follow-up). Drugs were coded according to the Anatomical Therapeutic Chemical Classification (ATC) System. In a total of 2007 subjects, at follow-up, a significant increase with respect to baseline was reported in the total median number of chronic medications (two [0-4] vs. one [0-3]) and in specific ATC-group drugs involving the alimentary, blood, cardiovascular, genitourinary, muscle-skeletal, nervous and respiratory systems. In a multivariate analysis, COVID-19 disease severity and age > 65 years resulted in the best predictors for an increase in the number of medications, while anti-SARS-CoV-2 vaccination played a significant protective role. The long-term care of patients infected by COVID-19 may be more complex than reported so far. Multidisciplinary and integrated care pathways should be encouraged, mainly in older and frailer subjects and for patients experiencing a more severe disease. Vaccination may also represent a fundamental protection against long-term sequelae.

Epidemiology and association with outcomes of polypharmacy in patients undergoing surgery: retrospective, population-based cohort study

BACKGROUND

The aim of this study was to determine the prevalence of preoperative polypharmacy and the incidence of postoperative polypharmacy/hyper-polypharmacy in surgical patients and their association with adverse outcomes.

METHODS

This was a retrospective, population-based cohort study among patients older than or equal to 18 years undergoing surgery at a university hospital between 2005 and 2018. Patients were categorized based on the number of medications: non-polypharmacy (fewer than 5); polypharmacy (5-9); and hyper-polypharmacy (greater than or equal to 10). The 30-day mortality, prolonged hospitalization (greater than or equal to 10 days), and incidence of readmission were compared between medication-use categories.

RESULTS

Among 55 997 patients, the prevalence of preoperative polypharmacy was 32.3 per cent (95 per cent c.i. 33.5 to 34.3) and the prevalence of hyper-polypharmacy was 25.5 per cent (95 per cent c.i. 25.2 to 25.9). Thirty-day mortality was higher for patients exposed to preoperative hyper-polypharmacy (2.3 per cent) and preoperative polypharmacy (0.8 per cent) compared with those exposed to non-polypharmacy (0.6 per cent) (P < 0.001). The hazards ratio (HR) of long-term mortality was higher for patients exposed to hyper-polypharmacy (HR 1.32 (95 per cent c.i. 1.25 to 1.40)) and polypharmacy (HR 1.07 (95 per cent c.i. 1.01 to 1.14)) after adjustment for patient and procedural variables. The incidence of longer hospitalization (greater than or equal to 10 days) was higher for hyper-polypharmacy (11.3 per cent) and polypharmacy (6.3 per cent) compared with non-polypharmacy (4.1 per cent) (P < 0.001). The 30-day incidence of readmission was higher for patients exposed to hyper-polypharmacy (10.2 per cent) compared with polypharmacy (6.1 per cent) and non-polypharmacy (4.8 per cent) (P < 0.001). Among patients not exposed to polypharmacy, the incidence of new postoperative polypharmacy/hyper-polypharmacy was 33.4 per cent (95 per cent c.i. 32.8 to 34.1), and, for patients exposed to preoperative polypharmacy, the incidence of postoperative hyper-polypharmacy was 16.3 per cent (95 per cent c.i. 16.0 to 16.7).

CONCLUSION

Preoperative polypharmacy and new postoperative polypharmacy/hyper-polypharmacy are common and associated with adverse outcomes. This highlights the need for increased emphasis on optimizing medication usage throughout the perioperative interval.

REGISTRATION NUMBER

NCT04805151 (http://clinicaltrials.gov).

Higher levels of multimorbidity are associated with increased risk of readmission for older people during post-acute transitional care

PURPOSE

Older patients are at high risk for poor outcomes after an acute hospital admission. The Transitional Aged Care Programme (TACP) was established by the Australian government to provide a short-term care service aiming to optimise functional independence following hospital discharge. We aim to investigate the association between multimorbidity and readmission amongst patients on TACP.

METHODS

Retrospective cohort study of all TACP patients over 12 months. Multimorbidity was defined using the Charlson Comorbidity Index (CCI), and prolonged TACP (pTACP) as TACP ≥ 8 weeks.

RESULTS

Amongst 227 TACP patients, the mean age was 83.3 ± 8.0 years, and 142 (62.6%) were females. The median length-of-stay on TACP was 8 weeks (IQR 5-9.67), and median CCI 7 (IQR 6-8). 21.6% were readmitted to hospital. Amongst the remainder, 26.9% remained at home independently, 49.3% remained home with supports; < 1% were transferred to a residential facility (0.9%) or died (0.9%). Hospital readmission rates increased with multimorbidity (OR 1.37 per unit increase in CCI, 95% CI 1.18-1.60, p < 0.001). On multivariable logistic regression analysis, including polypharmacy, CCI, and living alone, CCI remained independently associated with 30-day readmission (aOR 1.43, 95% CI 1.22-1.68, p < 0.001).

CONCLUSIONS

CCI is independently associated with a 30-day hospital readmission in TACP cohort. Identifying vulnerability to readmission, such as multimorbidity, may allow future exploration of targeted interventions.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Factors related to polypharmacy and hyper-polypharmacy for the elderly: A nationwide cohort study using National Health Insurance data in South Korea

Polypharmacy may cause adverse health outcomes in the elderly. This study examined the prevalence of continuous polypharmacy and hyper-polypharmacy, factors associated with polypharmacy, and the most frequently prescribed medications among older adults in South Korea. This was a retrospective observational study using National Health Insurance claims data. In total, 7,358,953 Korean elderly patients aged 65 years and older were included. Continuous polypharmacy and hyper-polypharmacy were defined as the use of ≥5 and ≥10 medications, respectively, for both ≥90 days and ≥180 days within 1 year. A multivariate logistic regression analysis was conducted with adjustment for general characteristics (sex, age, insurance type), comorbidities (12 diseases, number of comorbidities, and Elixhauser Comorbidity Index [ECI] classification), and healthcare service utilization. Among 7.36 million elderly patients, 47.8% and 36.9% had polypharmacy for ≥90 and ≥180 days, and 11.9% and 7.1% of patients exhibited hyper-polypharmacy for ≥90 and ≥180 days, respectively. Male sex, older age, insurance, comorbidities (cardio-cerebrovascular disease, diabetes mellitus, depressive disorder, dementia, an ECI score of ≥3), and healthcare service utilization were associated with an increased probability of polypharmacy. The therapeutic class with the most prescriptions was drugs for acid-related disorders (ATC A02). The number of outpatient visit days more strongly influenced polypharmacy than hospitalizations and ED visits. This study provides health policymakers with important evidence about the critical need to reduce polypharmacy among older adults.

Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial

Background

Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as ‘Potentially Inappropriate Medications’ (PIMs) and ‘Potential Prescribing Omissions’ (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established.

Methods

As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the ‘Screening Tool of Older Persons’ Prescription Criteria / Screening Tool To Alert to Right Treatment’ (STOPP/START) Version 2, with functional disability assessed using the ‘World Health Organization Disability Assessment Schedule 2.0’ (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity.

Results

Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis.

Conclusions

The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.

Use of an Electronic Medication Management Support System in Patients with Polypharmacy in General Practice: A Quantitative Process Evaluation of the AdAM Trial

Polypharmacy is associated with a risk of negative health outcomes. Potentially inappropriate medications, interactions resulting from contradicting medical guidelines, and inappropriate monitoring, all increase the risk. This process evaluation (PE) of the AdAM study investigates implementation and use of a computerized decision-support system (CDSS). The CDSS analyzes medication appropriateness by including claims data, and hence provides general practitioners (GPs) with full access to patients’ medical treatments. We based our PE on pseudonymized logbook entries into the CDSS and used the four dimensions of the Medical Research Council PE framework. Reach, which examines the extent to which the intended study population was included, and Dose, Fidelity, and Tailoring, which examine how the software was actually used by GPs. The PE was explorative and descriptive. Study participants were representative of the target population, except for patients receiving a high level of nursing care, as they were treated less frequently. GPs identified and corrected inappropriate prescriptions flagged by the CDSS. The frequency and intensity of interventions documented in the form of logbook entries lagged behind expectations, raising questions about implementation barriers to the intervention and the limitations of the PE. Impossibility to connect the CDSS to GPs’ electronic medical records (EMR) of GPs due to technical conditions in the German healthcare system may have hindered the implementation of the intervention. Data logged in the CDSS may underestimate medication changes in patients, as documentation was voluntary and already included in EMR.

Preoperative Polypharmacy in Geriatric Patients is Associated with Increased 90-Day All-Cause Hospital Readmission After Surgery for Adult Spinal Deformity Patients

OBJECTIVE

To investigate the effect of preoperative polypharmacy (PP) on 90-day all-cause readmission rate in older adults undergoing corrective surgery for ASD.

METHODS

Older adults with a diagnosis of ASD undergoing spinal surgery at a quaternary medical center from January 2016 to March 2019 were enrolled in this study. Patients were dichotomized into two groups stratified by the number of preoperative prescription medications; with PP defined as 5 or more prescription medications. The primary outcome measure was 90-day all-cause readmission rate. Secondary outcomes included postoperative changes in health-related quality of life measures.

RESULTS

Among 161 patients (mean [SD], 69.59[8.79] years), 97 patients were included in PP cohort and 64 in non-polypharmacy (non-PP) cohort. Both groups were balanced at baseline. The duration of hospital (5.82[1.93] vs. 6.50[4.00] days), mean number of fusion levels, and duration of surgery was statistically similar between both groups (p>0.05). There was no difference in the proportion of patients discharged directly home (31.25% vs. 40.42%, p=0.36). 90-day all-cause readmission rate was 3-fold higher in the PP cohort compared with the non-PP cohort. After adjusting for preoperative patient optimization, ASA grade, surgical invasiveness, smoking, depression and baseline functional disability, older adults with PP had a 9.79 increased odds of 90-day all-cause hospital readmission (p=0.04). Change in HRQOL measures were similar between both groups.

CONCLUSION

This study's findings indicate that despite preoperative optimization, older adults exposed to polypharmacy are at a significantly increased risk of hospital readmission within 90-days of surgery.

Polypharmacy definition and prevalence in heart failure: a systematic review

Polypharmacy and heart failure are becoming increasingly common due to an ageing population and the rise of multimorbidity. Treating heart failure necessitates prescribing of multiple medications, in-line with national and international guidelines predisposing patients to polypharmacy. This review aims to identify how polypharmacy has been defined among heart failure patients in the literature, whether a standard definition in relation to heart failure could be identified and to describe the prevalence. The Healthcare Database Advanced Search (HDAS) was used to search EMBASE, MEDLINE, PubMed, Cinahl and PsychInfo from inception until March 2021. Articles were included of any design, in patients ≥ 18 years old, with a diagnosis of heart failure; that explicitly define and measure polypharmacy. Data were thereafter extracted and described using a narrative synthesis approach. A total of 7522 articles were identified with 22 meeting the inclusion criteria. No standard definition of polypharmacy was identified. The most common definition was that of " ≥ 5 medications." Polypharmacy prevalence was high in heart failure populations, ranging from 17.2 to 99%. Missing or heterogeneous methods for defining heart failure and poor patient cohort characterisation limited the impact of most studies. Polypharmacy, most commonly defined as ≥ 5 medications, is highly prevalent in the heart failure population. There is a need for an internationally agreed definition of polypharmacy, allowing accurate review of polypharmacy issues. Whether an arbitrary numerical cut-off is a suitable definition, rather than medication appropriateness, remains unclear. Further studies are necessary to understand the relationship between polypharmacy with specific types of heart failure and related comorbidities.

Unveiling the Burden of Interactions Among Clinical Risk Factors for 1-Year Mortality in Hospitalized Older Patients

Background: Hospitalized older patients are particularly exposed to adverse health outcomes.

Objective: In this study, we aimed at investigating the prognostic interactions between disability in basic activities of daily living (BADL), cognitive impairment, low handgrip strength, anticholinergic cognitive burden (ACB), and depression on 1-year mortality.

Setting and Subjects: Our series consisted of 503 older patients discharged from acute care hospitals.

Methods: Disability in at least one BADL, ACB, depression, cognitive impairment, and low handgrip strength was considered in the analysis. One-year mortality was investigated by Cox regression analysis and prognostic interactions among study variables were assessed by survival tree analysis.

Results: Basic activities of daily living disability, ACB, cognitive impairment, and low handgrip strength were significantly associated with 1-year mortality. Survival tree analysis showed that patients with BADL disability and high ACB carried the highest risk of poor survival [hazard ratio (HR): 16.48 (2.63–74.72)], followed by patients with BADL disability and low ACB (HR: 8.43, 95% CI: 1.85–38.87). Patients with cognitive impairment and no BADL disability were characterized by a lower but still significant risk of mortality (HR: 6.61, 95% CI: 1.51–28.97) and those with high ACB scores and good cognitive and functional performance (HR: 5.28, 95% CI: 1.13–24.55).

Conclusion: Basic activities of daily living dependency, cognitive impairment, and ACB score were the three main predictors of 1-year mortality among patients discharged from acute care hospitals; the interaction between BADL dependency and ACB score was

found to significantly affect survival. Early identification of such high-risk patients may help tailor targeted interventions to counteract their detrimental effects on prognosis.

Prevalence and Factors Associated With Polypharmacy Use Among Adult Patients in Saudi Arabia

BACKGROUND

Polypharmacy is very common in clinical practice, especially among adult patients. The use of multiple medications may increase the risk of adverse drug events, medication cost, and medication errors. In addition, polypharmacy exacerbates treatment complexity, which consequently leads to poor patients' adherence to their medications. Despite being a well-recognized problem, few studies have investigated the prevalence and predictors of polypharmacy in Saudi Arabia.

OBJECTIVES

The aims of the study were to investigate the prevalence of polypharmacy among adult patients in a tertiary teaching hospital and to determine patients' characteristics that are associated with polypharmacy.

METHODS

This was a retrospective cross-sectional study using data extracted from the electronic health records database for a period of 6 months between January and June 2016 in outpatient setting. Descriptive statistics were used to analyze the study sample. A multivariate logistic regression model was used to examine the association between different variables and polypharmacy. Statistical analysis software (SAS 9.2) was used to analyze the study data.

RESULTS

A total of 17,237 observations (67.2% females) were included in the final analysis. Of these, nearly 54% (n = 9222) of reported observations were found using up to four prescription drugs and the other 46% (n = 8015) were using five or more prescription drugs. Interestingly, the prevalence of polypharmacy use was doubled among adults with hypertension as compared with those without hypertension (odds ratio [OR] = 2.68, 95% confidence interval [CI] = 2.51-2.87). In addition, polypharmacy use was two times more prevalent among adults with diabetes as compared with those without diabetes (OR = 2.31, 95% CI = 1.99-2.28) and five times more prevalent in patient with dementia (OR = 5.57, 95% CI = 1.26-24.7). Moreover, polypharmacy in adult patients was significantly influenced by sex (OR = 1.69, 95% CI = 1.59-1.80) and nationality (OR = 2.15, 95% CI = 2.00-2.31).

CONCLUSIONS

Polypharmacy is common among adult patients especially those who are older than 60 years. Polypharmacy may affect the overall process of drug therapy. It can be a risk factor to develop undesirable adverse drug events, especially in those with chronic health conditions. A special care should be taken to manage polypharmacy among adults in Saudi Arabia.

Effectiveness of the application of an electronic medication management support system in patients with polypharmacy in general practice: a study protocol of cluster-randomised controlled trial (AdAM)

INTRODUCTION

Clinically complex patients often require multiple medications. Polypharmacy is associated with inappropriate prescriptions, which may lead to negative outcomes. Few effective tools are available to help physicians optimise patient medication. This study assesses whether an electronic medication management support system (eMMa) reduces hospitalisation and mortality and improves prescription quality/safety in patients with polypharmacy.

METHODS AND ANALYSIS

Planned design: pragmatic, parallel cluster-randomised controlled trial; general practices as randomisation unit; patients as analysis unit. As practice recruitment was poor, we included additional data to our primary endpoint analysis for practices and quarters from October 2017 to March 2021. Since randomisation was performed in waves, final study design corresponds to a stepped-wedge design with open cohort and step-length of one quarter.

SCOPE

general practices, Westphalia-Lippe (Germany), caring for BARMER health fund-covered patients.

POPULATION

patients (≥18 years) with polypharmacy (≥5 prescriptions).

SAMPLE SIZE

initially, 32 patients from each of 539 practices were required for each study arm (17 200 patients/arm), but only 688 practices were randomised after 2 years of recruitment. Design change ensures that 80% power is nonetheless achieved.

INTERVENTION

complex intervention eMMa.

FOLLOW-UP

at least five quarters/cluster (practice). recruitment: practices recruited/randomised at different times; after follow-up, control group practices may access eMMa.

OUTCOMES

primary endpoint is all-cause mortality and hospitalisation; secondary endpoints are number of potentially inappropriate medications, cause-specific hospitalisation preceded by high-risk prescribing and medication underuse.

STATISTICAL ANALYSIS

primary and secondary outcomes are measured quarterly at patient level. A generalised linear mixed-effect model and repeated patient measurements are used to consider patient clusters within practices. Time and intervention group are considered fixed factors; variation between practices and patients is fitted as random effects. Intention-to-treat principle is used to analyse primary and key secondary endpoints.

ETHICS AND DISSEMINATION

Trial approved by Ethics Commission of North-Rhine Medical Association. Results will be disseminated through workshops, peer-reviewed publications, local and international conferences.

TRIAL REGISTRATION

NCT03430336. ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03430336).

Dose-response relationships between polypharmacy and all-cause and cause-specific mortality among older people

Background

Although medicines are prescribed based on clinical guidelines and expected to benefit patients, both positive and negative health outcomes have been reported associated with polypharmacy. Mortality is the main outcome, and information on cause-specific mortality is scarce. Hence, we investigated the association between different levels of polypharmacy and all-cause and cause-specific mortality among older adults.

Method

The English Longitudinal Study of Ageing is a nationally representative study of people aged 50+. From 2012/2013, 6 295 individuals were followed up to April 2018 for all-cause and cause-specific mortality. Polypharmacy was defined as taking 5–9 long-term medications daily and heightened polypharmacy as 10+ medications. Cox proportional hazards regression and competing-risks regression were used to examine associations between polypharmacy and all-cause and cause-specific mortality, respectively.

Results

Over a 6-year follow-up period, both polypharmacy (19.3%) and heightened polypharmacy (2.4%) were related to all-cause mortality, with hazard ratios of 1.51 (95% CI: 1.05–2.16) and 2.29 (95% CI: 1.40–3.75) respectively, compared with no medications, independently of demographic factors, serious illnesses and long-term conditions, cognitive function, and depression. Polypharmacy and heightened polypharmacy also showed 2.45 (95% CI: 1.13–5.29) and 3.67 (95% CI: 1.43–9.46) times higher risk of cardiovascular disease deaths, respectively. Cancer mortality was only related to heightened polypharmacy.

Conclusion

Structured medication reviews are currently advised for heightened polypharmacy, but our results suggest that greater attention to polypharmacy in general for older people may reduce adverse effects and improve older adults’ health.

Implementation of a complex intervention to improve hospital discharge: process evaluation of a cluster randomised controlled trial

OBJECTIVES

To study the implementation of a cluster randomised controlled effectiveness-implementation hybrid trial testing the effectiveness of a medication review at hospital discharge combined with a communication stimulus between hospital physicians (HPs) and general practitioners (GPs) on rehospitalisation of multimorbid older patients.

DESIGN

Extension of Grant's mixed method process evaluation framework to trials with multilevel clustering.

SETTING

General internal medicine wards in Swiss hospitals.

PARTICIPANTS

Convenience samples of 15 chief physicians (of 21 hospitals participating in the effectiveness trial), 60 (74) senior HPs, 65 (164) junior HPs and 187 (411) GPs.

IMPLEMENTATION STRATEGY

Two-hour teaching sessions for senior HPs on a patient-centred, checklist-guided discharge routine.

PROCESS EVALUATION COMPONENTS

Data collection on recruitment, delivery and response from chief physicians (semistructured interviews), senior HPs, junior HPs, GPs (surveys) and patients (via HPs). Quantitative data were summarised using descriptive statistics, and interviews analysed using thematic analysis.

OUTCOME MEASURES

Intervention dose (quantitative), implementation fidelity (qualitative), feasibility and acceptability, facilitators and barriers, implementation support strategies.

RESULTS

Recruitment of hospitals was laborious but successful, with 21 hospitals recruited. Minimal workload and a perceived benefit for the clinic were crucial factors for participation. Intervention dose was high (95% of checklist activities carried out), but intervention fidelity was limited (discharge letters) or unknown (medication review). Recruitment and retention of patients was challenging, partly due to patient characteristics (old, frail) and the COVID-19 pandemic: Only 612 of the anticipated 2100 patients were recruited, and 31% were lost to follow-up within the first month after discharge. The intervention was deemed feasible and helpful by HPs, and the relevance of the topic appreciated by both HPs and GPs.

CONCLUSIONS

The results from this evaluation will support interpretation of the findings of the effectiveness study and may inform researchers and policy makers who aim at improving hospital discharge.

TRIAL REGISTRATION NUMBER

ISRCTN18427377.

Acceptability of a Novel Telemedication Review for Older Adults in Nursing Homes in France: A Qualitative Study

Purpose

In France, polypharmacy among older people living in nursing homes (NH) is a major public health concern. In this context, the randomized controlled trial TEM-EHPAD was recently launched in various NH in southern France to evaluate the impact of implementing a novel telemedication review (TMR) on hospital admission rates of NH residents at high risk of iatrogenic disease. A qualitative study was integrated into the main trial study to assess general practitioners' (GP) and other NH healthcare professionals' (HP) acceptability of the proposed TMR before its implementation.

Material and Methods

A qualitative study using face-to-face semi-structured interviews was conducted with 16 HP before the beginning of the intervention. A manual thematic analysis was performed on the transcribed interviews.

Results

Four main themes emerged from the thematic analysis: HP perceptions of the TMR, difficulties related to medication management for NH residents, HP perceptions of the roles of different professionals, and facilitators of good practices. Most participants were favorable to the TMR, but some GP expressed fears about loss of control over their prescription writing.

Conclusion

This study fulfilled its objective to assess pre-intervention acceptability by GP and other HP. Results provided important information about how to adapt the TMR intervention to make it more acceptable to HP who will be involved in TEM-EHPAD. One of the main recommendations is the importance of providing participating GP with the opportunity to take part in the process of reviewing prescriptions.

The influence of integrated geriatric outpatient clinics on the health care utilization of older people

Background

The number of people aged greater than 65 years is growing in many countries. Taiwan will be a superaged society in 2026, and health care utilization will increase considerably. Our study aimed to evaluate the efficacy of the geriatric integrated outpatient clinic model for reducing health care utilization by older people.

Methods

This was a retrospective case-control study. Patients aged greater than 65 years seen at the geriatric outpatient clinic (Geri-OPD) and non-geriatric outpatient clinic (non-Geri-OPD) at a single medical centre were age and sex matched. Data on the number of outpatient clinic visits, emergency department visits, hospitalizations and medical expenditures were collected during the first and second years. A subgroup analysis by Charlson comorbidity index (CCI) and older age (age≧80 years) was performed, and the results were compared between the Geri-OPD and non-Geri-OPD groups.

Results

A total of 6723 patients were included (3796 women and 2927 men). The mean age was 80.42 ± 6.39 years. There were 1291 (19.2%) patients in the Geri-OPD group and 5432 (80.8%) patients in the non-Geri-OPD group. After one year of regular follow-up, the Geri-OPD patients showed a significant reduction in the types of drugs included in each prescription (5.62 ± 10.85) and the number of clinic visits per year (18.18 ± 48.85) (P < 0.01). After a two-year follow-up, the number of clinic visits, emergency department visits, and hospitalizations and the annual medical costs were still decreased in the Geri-OPD patients. The Geri-OPD patients had more comorbidities and a higher rate of health care utilization than the non-Geri-OPD patients. In the subgroup analysis, patients with more comorbidities (CCI≧2) and an older age (≧80 years) in the Geri-OPD group showed a significant reduction in health care utilization. The Geri-OPD patients also showed a significant decrease in medical utilization in the second year compared with the non-Geri-POD patients.

Conclusion

The Geri-OPD reduced medical costs, the number of drugs prescribed, and the frequency of outpatient clinic visits, emergency department visits and hospitalizations in older patients with complicated conditions. The effect was even better in the second year.

Patient Characteristics Associated With Readmission to 3 Neurology Services at an Urban Academic Center

Background and Purpose

Hospital 30-day readmissions in patients with primary neurological problems are not well characterized. We sought to determine patient characteristics associated with readmission across 3 different inpatient neurology services at New York University Langone Hospital.

Methods

We retrospectively reviewed all 30-day readmissions from the General Neurology, Epilepsy, and Stroke services at NYULH Brooklyn and Manhattan campuses from 2016-2017 and compared them to a random sample of non-readmitted neurology patients. We used univariate analyses to compare demographics, clinical characteristics, disease specific metrics, and discharge factors of non-readmitted and readmitted groups and binomial logistic regression to examine specific variables with adjustment for confounders.

Results

We included 284 patients with 30-day readmissions and 306 control patients without readmissions matched by discharge location and service. After adjusting for confounders, we found that the following factors were associated with increased readmission risk: a recent hospital encounter increased risk for all services, increased number of medications at discharge, intensive care unit stay, higher length of stay, and prior history of seizure for the General Neurology Service, increased number of medications at discharge for the Epilepsy Service, and active malignancy and higher discharge modified Rankin Scale score for the Stroke Service.

Conclusion

This study identifies potential risk factors for readmission in patients across multiple neurology services. Further research is needed to establish whether these risk factors hold across multiple institutions.

Readmission of High-Risk Discharged Patients at a Tertiary Hospital in Korea

This study aims to investigate the readmission rates of major disease groups as stated by the Centers for Medicare and Medicaid Services and to identify risk factors related to readmission in Korea. We studied 2,973 patients discharged from a 2,200-bed tertiary referral hospital in South Korea, from April 1, 2016, to March 31, 2017. Using electronic medical records, we calculated the 30-day readmission rates of seven diseases: acute myocardial infarction, chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, stroke, coronary artery bypass graft (CABG), and total hip arthroplasty/total knee arthroplasty. We used Cox proportional hazards regression analysis to identify risk factors affecting readmission in this retrospective, observational study. For 2,973 consecutively discharged patients, the 30-day unplanned readmission rate was 10.3%. The readmission rate of HF (19.0%) was the highest, followed by pneumonia (13.7%), CABG (12.0%), and COPD (10.5%). Factors associated with readmission were polypharmacy (hazard ratio [HR]: 2.06; 95% confidence interval [CI]: 1.60-2.64), hospitalization history in the previous 6 months (HR: 1.81; 95% CI: 1.41-2.32), and comorbidity (HR: 1.16; 95% CI: 1.11-1.23). Therefore, the discharge intervention program for high-risk discharge patients with polypharmacy, admission history, and comorbidity should include medication reconciliation.

Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis

Objective

To undertake a systematic review and meta-analysis examining the impact of polypharmacy on health outcomes in atrial fibrillation (AF).

Data sources

PubMed and Embase databases were searched from inception until 31 July 2019. Studies including post hoc analyses of prospective randomised controlled trials or observational design that examined the impact of polypharmacy on clinically significant outcomes in AF including mortality, hospitalisations, stroke, bleeding, falls and quality of life were eligible for inclusion.

Results

A total of six studies were identified from the systematic review, with three studies reporting on common outcomes and used for a meta-analysis. The total study population from the three studies was 33 602 and 37.2% were female. Moderate and severe polypharmacy, defined as 5–9 medicines and >9 medicines, was observed in 42.7% and 20.7% of patients respectively, and was associated with a significant increase in all-cause mortality (Hazard ratio [HR] 1.36, 95% CI 1.20 to 1.54, p<0.001; HR 1.84, 95% CI 1.40 to 2.41, p<0.001, respectively), major bleeding (HR 1.32, 95% CI 1.14 to 1.52, p<0.001; HR 1.68, 95% CI 1.35 to 2.09, p<0.001, respectively) and clinically relevant non-major bleeding (HR 1.12, 95% CI 1.03 to 1.22, p<0.01; HR 1.48, 95% CI 1.33 to 1.64, p<0.01, respectively). There was no statistically significant association between polypharmacy and stroke or systemic embolism or intracranial bleeding. Among other examined outcomes, polypharmacy was associated with cardiovascular death, hospitalisation, reduced quality of life and poorer physical function.

Conclusions

Polypharmacy is highly prevalent in the AF population and is associated with numerous adverse outcomes.

PROSPERO registration number

CRD42018105298.

Evaluating quality of overall care among older adults with diabetes with comorbidities in Ontario, Canada: a retrospective cohort study

OBJECTIVES

This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations.

DESIGN

A population-based, retrospective cohort study.

SETTING

The province of Ontario, Canada.

PARTICIPANTS

We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010.

MAIN OUTCOME MEASURES

The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations.

RESULTS

The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions.

CONCLUSIONS

There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression).

The spatial dimensions of medication management by home-dwelling older adults after hospital discharge

Ageing in place raises pressing questions about medication practices at home. Understanding how medication practices are integrated into older adults' domestic settings requires an interest in where activities linked to medication take place and why. This study aimed to describe the medication practices and spatial dimensions of medication management for home-dwelling older adults after hospital discharge, using a qualitative research design. Semi-structured interviews were carried out with ten older adults aged 65 years old or more and discharged home from hospital, together with nine informal caregivers. Thematic content analysis identified two main themes dealing with the spatial dimensions of medication management in this specific context: the process of integrating medication changes into routines and familiar spaces, and the individual and collective management of medication changes linked to a renegotiation of the boundaries between public and private spaces.

Polypharmacy in Patients with Ovarian Cancer

OBJECTIVE

Polypharmacy has been associated with morbidity and mortality in patients with cancer. Data about polypharmacy among patients with ovarian cancer are limited. The primary objective of this study was to evaluate polypharmacy in a cohort of patients with ovarian cancer and to assess the evolution of polypharmacy from initial presentation to 2 years posttreatment. A secondary objective was to evaluate differences in polypharmacy between a subset of patients primarily treated in our comprehensive cancer center (CCC) and our safety net hospital (SNH).

METHODS

Women treated for ovarian cancer between January 1, 2011, and December 31, 2016, were included. Data were abstracted from the electronic medical record. Medication safety was assessed using the established Anticholinergic Burden (ACB) scale and the Beers criteria. Statistical analyses were performed using paired t tests and Cox proportional hazards models, with significance set at p < .05.

RESULTS

The study included 152 patients. The majority of patients had high-grade serous carcinoma. Hypertension was the most common medical problem. The mean number of medications at the time of diagnosis was 3.72. Paired testing demonstrated significant patient-level increases in the number medications at 2 years following initial diagnosis (4.16 vs. 7.01, p < .001). At the CCC, 47.4% of patients met criteria for polypharmacy at diagnosis compared with 19.4% at the SNH (p < .001). By 2 years postdiagnosis, 77.6% of patients at the CCC met criteria for polypharmacy compared with 43.3% at the SNH (p = .001). The use of any medications on the ACB scale (p < .001) increased significantly between initial diagnosis and 2 years for the entire population. Polypharmacy was not a significant predictor of overall survival.

CONCLUSION

Polypharmacy worsens as women go through ovarian cancer treatment. Both at initial presentation and at 2 years postdiagnosis, rates of polypharmacy were higher at the CCC. Polypharmacy did not have an effect on survival in this cohort.

IMPLICATIONS FOR PRACTICE

Awareness of escalating numbers of medications and potentially adverse interactions is crucial among women with ovarian cancer, who are at high risk for polypharmacy.

Polypharmacy Definitions for Multimorbid Older Adults Need Stronger Foundations to Guide Research, Clinical Practice and Public Health

There are numerous definitions of polypharmacy to describe the use of many medications among older adults, but there is a need to clarify if they are purposive and meaningful. By means of a systematic review, we identified definitions of polypharmacy used in multimorbid older adults (≥65 years). We evaluated if the definitions align among the domains of research, clinical practice, and public health and appraised whether concepts of polypharmacy are based on strong foundations. More than 46 definitions of polypharmacy were retrieved from 348 publications (research: n = 243; clinical practice: n = 88; public health: n = 17). Several thresholds based on the number of medications were mentioned. The majority of the publications (n = 202, 58%) used a minimal threshold of five medications. Heterogeneous qualitative definitions were identified, mostly stating that polypharmacy is “more drugs than needed”. There was no significant divergence between domains as to the type of definitions used, although qualitative definitions were more common in clinical practice. Nearly half (n = 156, 47%) of the publications provided no justification for the polypharmacy definition used. The wide variety of definitions for polypharmacy precludes comparisons, appropriate identification and management of polypharmacy in multimorbid older adults. Standardized definitions would allow more coherent judgments regarding the individual and collective stakes of polypharmacy.

Polypharmacy among Older Individuals with COPD: Trends between 2000 and 2015 in Quebec, Canada

The treatment of chronic obstructive pulmonary disease (COPD) and concomitant diseases requires several medications. Yet there is little data on how the pharmacological burden progressed over time among older individuals with COPD. We aimed to: 1) describe the proportion of older adults with COPD in Quebec, Canada, that were exposed to polypharmacy (≥10, ≥15 or ≥20 medications/year) between 2000 and 2015; 2) calculate the proportion of individuals receiving specific prescriptions for COPD during this period. We conducted a population-based cohort study with the Quebec Integrated Chronic Disease Surveillance System. Individuals aged ≥66 years with COPD and covered by the universal public drug plan were included. We calculated the total number of drugs used at least once by each individual during each of the studied years, and used age-standardized proportions to compare proportions of users between the years. The average number of drugs used increased from 12.0 in 2000 to 14.8 in 2015. The proportion of individuals exposed to polypharmacy increased (≥10 drugs: 62.0% to 74.6%;≥15 drugs: 31.2% to 45.4%; ≥20 drugs: 12.3% to 22.4%). The proportion of individuals receiving long-acting bronchodilators increased from 18.7% in 2000 to 69.6% in 2015. The use of short-acting bronchodilators decreased from 81.5% to 67.9%, and that of inhaled corticosteroids from 60.6% to 26.0%. The proportion of users of methylxanthines decreased from 15.0% to 1.9%. Older individuals with COPD are increasingly exposed to polypharmacy. Identifying which polypharmacy is beneficial is a priority.

Polypharmacy in patients with multiple sclerosis: a gender-specific analysis

Background

Multiple sclerosis (MS) affects about three times more women than men. Due to variable MS courses, multiple therapies are necessary in clinical practice.

Objective

We aimed at conducting sex-specific analyses of MS patients regarding polypharmacy (≥ 5 drugs) and at identifying differences in the medication spectrum.

Methods

Clinico-demographic data were gathered from 306 patients using clinical examinations, structured patient interviews, and patient records. Statistical data analyses were performed to evaluate whether the same or different factors are associated with polypharmacy in both genders.

Results

Women (N = 218) and men (N = 88) showed similar polypharmacy rates (56.0% vs. 58.0%; p = 0.799). For both genders, higher age, severe disability degrees, comorbidities, and inpatient treatment were significantly associated with a higher polypharmacy risk. Low educational levels were predictors of polypharmacy only in women. Fampridine (p < 0.021) and antispasmodics (p < 0.010) were used more often by men, while women took more frequently thyroid medications (p < 0.001) and contraceptives (p < 0.001). The age-related increase in medication use was much stronger in women (p < 0.001).

Conclusion

Male and female MS patients with older age, comorbidities, higher disability degree, and inpatient treatment are at greater risk of polypharmacy. Future studies should examine the occurrence of clinically relevant drug interactions in MS patients stratified by sex.

A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial

BACKGROUND

Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients.

METHODS

The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status.

DISCUSSION

The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities.

TRIAL REGISTRATION

This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.

Multi-drug use among patients with multiple sclerosis: A cross-sectional study of associations to clinicodemographic factors

Multiple sclerosis (MS) is the most prevalent immune-mediated disease affecting the central nervous system. A treatment strategy with multiple therapies is a frequent clinical scenario. Unmonitored multi-drug use can lead to adverse outcomes, higher health care costs and medication non-adherence. The primary aim of this study was to evaluate the frequency of polypharmacy and related clinicodemographic factors in a single-center MS patient cohort. Furthermore, medication aspects of therapy management were examined. After the patients agreed to participate in the study, data were collected through patient interviews, patient records and clinical investigations. Subsequently, a statistical data analysis regarding various medication subgroups and polypharmacy (use of at least five drugs) was performed. Polypharmacy was observed in 56.5% of the patients (N = 306). High degrees of disability (odds ratio [OR] = 1.385), comorbidities (OR = 4.879) and inpatient treatment (OR = 5.146) were associated with a significantly higher risk of polypharmacy (p ≤ 0.001). Among patients with polypharmacy, disease-modifying drugs, antihypertensives, gastrointestinal drugs, thrombosis prophylactics, osteoporosis medications and sedatives were frequently used. In summary, polypharmacy plays a large role in MS patients, especially in those with higher degrees of disability, those with comorbidities and those treated in an inpatient setting.

Polypharmacy in elderly cancer patients: Challenges and the way clinical pharmacists can contribute in resource-limited settings

The aim of this study was to address the problems associated with polypharmacy in elderly cancer patients and to highlight the role of pharmacists in such cases in resource-limited settings. A narrative review of existing literature was performed to summarize the evidence regarding the impact of polypharmacy in elderly cancer patients and the pharmaceutical strategies to manage it. This review emphasizes the significance of polypharmacy, which is often ignored in real clinical practice. Polypharmacy in the elderly cancer population is mainly due to: chemotherapy with one or more neoplastic agents for cancer treatment, treatment for adverse drug reactions due to neoplastic agents, the patient's comorbid conditions, or drug interactions. The role of the clinical pharmacist in specialized oncology hospitals or oncology departments of tertiary care hospitals is well established; however, this is not the case in many developing countries. A clinical pharmacist can contribute to solving the problems associated with polypharmacy by identifying the risks associated with polypharmacy and its management in resource-limited settings. As in many developed countries, the involvement of a clinical pharmacist in cancer care for elderly patients may play a vital role in the recognition and management of polypharmacy-related problems. Further research can be conducted to support this role.

Polifarmacia en adulto mayor, impacto en su calidad de vida. Revision de literatura

Objetivo Conocer mediante el análisis del estado del conocimiento, el impacto de polifarmacia en calidad de vida de adultos mayores y cuál ha sido el rol de enfermería frente a esta problemática de salud.Métodos Revisión descriptiva de 62 artículos originales de diversos diseños metodológicos, en bases de datos: EBSCO, PubMed, Web of Science, SciELO, Elsevier, SCOPUS y Dialnet.Resultados La polifarmacia en adultos mayores se presenta con mayor frecuencia en el sexo femenino, en personas con bajo nivel de escolaridad, sumados a factores socioeconómico. Un gran porcentaje de adultos mayores presenta efecto cascada en consumo de fármacos, por cantidad de medicamentos consumidos y número de médicos consultados, produciendo interacciones farmacológicas, afectando funcionalidad y calidad de vida.Conclusiones Es necesario mayor control de medicamentos consumidos por adultos mayores, para evitar efectos nocivos. Los profesionales de enfermería deben tener un rol educativo en este grupo etario, para disminuir polifarmacia e impulsar estilos de vida que fomenten el envejecimiento saludable.

Improving Care Transitions for Hospitalized Veterans Discharged to Skilled Nursing Facilities: A Focus on Polypharmacy and Geriatric Syndromes

Geriatric syndromes and polypharmacy are common in older patients discharged to skilled nursing facilities (SNFs) and increase 30-day readmission risk. In a U.S.A. Department of Veterans Affairs (VA)-funded Quality Improvement study to improve care transitions from the VA hospital to area SNFs, Veterans (N = 134) were assessed for geriatric syndromes using standardized instruments as well as polypharmacy, defined as five or more medications. Warm handoffs were used to facilitate the transfer of this information. This paper describes the prevalence of geriatric syndromes, polypharmacy, and readmission rates. Veterans were prescribed an average of 14.7 medications at hospital discharge. Moreover, 75% of Veterans had more than two geriatric syndromes, some of which began during hospitalization. While this effort did not reduce 30-day readmissions, the high prevalence of geriatric syndromes and polypharmacy suggests that future efforts targeting these issues may be necessary to reduce readmissions among Veterans discharged to SNF.

Polypharmacy in outpatients with relapsing-remitting multiple sclerosis: A single-center study

Background

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. Given the chronic and heterogenous nature of the disease, treatment with various therapies is a frequent scenario in clinical practice. In persons with chronic morbidity such as MS patients, polypharmacy can give rise to considerable health problems.

Objectives

The aim of the present study was to examine the frequency of polypharmacy among relapsing-remitting (RR) MS patients as well as to analyse sociodemographic and clinical factors, which might be associated with polypharmacy (use of five or more medications). Differences in medication between MS patients with and without secondary illnesses (PwSI and Pw/oSI), between men and women and between patients with and without polypharmacy (PwP and Pw/oP) were examined.

Methods

For 145 RRMS outpatients, we prospectively collected data by means of anamnesis, patient records, clinical examination and a structured patient interview. This was followed by comparative analyses of various patient subgroups (PwP vs. Pw/oP, PwSI vs. Pw/oSI, men vs. women).

Results

The proportion of included MS patients with polypharmacy (use of ≥5 medications) was 30.3%. PwP were significantly older than Pw/oP (45.9 vs. 41.7 years), had a lower level of education and showed a significantly higher median EDSS score (3.0 vs. 2.0). Comorbidities (p<0.001; odds ratio [OR] = 6.293) and higher EDSS scores (p = 0.029; OR = 1.440) were associated with a higher risk of polypharmacy. The proportion of polypharmacy among PwSI was approximately four times higher than among Pw/oSI (46.8% vs. 11.8%). Particularly in the use of antihypertensives, gastrointestinal drugs and dietary supplements, there were differences between Pw/oP and PwP.

Conclusion

We found a high burden of polypharmacy in patients with RRMS. This particularly applies to more severely disabled MS patients who suffer from comorbidities.

Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

BACKGROUND

Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.

METHODS

The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.

DISCUSSION

So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.

TRIAL REGISTRATION

ISRCTN, ISRCTN18427377 . Registered 11 January 2018.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Relevance of Polypharmacy for Clinical Outcome in Patients Receiving Vitamin K Antagonists

BACKGROUND

Although polypharmacy is associated with a negative clinical outcome in various settings and commonly observed in patients receiving oral anticoagulation therapy, evidence on the relevance for the clinical outcome of anticoagulated patients is currently limited. The aim of the study was to investigate the effect of polypharmacy on the clinical outcomes among patients taking phenprocoumon.

DESIGN

Prospective cohort study.

SETTING

Regular medical care.

PARTICIPANTS

Information on 2011 individuals receiving vitamin K antagonists was available for analysis from the prospective multicenter thrombEVAL study.

MEASUREMENTS

Data were obtained from clinical visits, computer-assisted interviews, and laboratory measurements. Information on clinical outcome was obtained during a 3-year follow-up period and subsequently validated via medical records.

RESULTS

The prevalence of polypharmacy (five drugs or more) was 84.1% (n = 1691). Quality of anticoagulation therapy assessed by time in therapeutic range was lower in individuals on five to eight drugs and nine drugs or more (70.7% and 64.7%, respectively) compared with subjects without polypharmacy (73.4%). In addition, a significantly higher variability of international normalized ratio measurements was found in the presence of polypharmacy. The cumulative incidence of bleeding, hospitalization, and all-cause mortality, but not for thromboembolic events, increased across groups of medication. In adjusted Cox regression analysis, polypharmacy is an independent risk factor for bleeding (hazard ratio [HR]_{≥ 9 drugs vs 1-4 drugs} = 1.62; 95% confidence interval [CI] = 1.04-2.52; p = .033); hospitalization (HR_{≥ 9 drugs vs 1-4 drugs} = 1.60; 95% CI = 1.26-2.03; p < .001; and all-cause mortality (HR_{≥ 9 drugs vs 1-4 drugs} = 2.16; 95% CI = 1.43-3.27; p < .001) in a dose-dependent relationship. Per additional drug, bleeding risk was increased by 4%.

CONCLUSIONS

Polypharmacy influences the quality of anticoagulation therapy and translates into an elevated risk of adverse events in anticoagulated patients. This suggests that additional medication intake in such patients should be critically reviewed by physicians, and it highlights the importance of initiating investigations aimed at reducing multiple medication intake. J Am Geriatr Soc 67:463-470, 2019.

Longitudinal associations between different dementia diagnoses and medication use jointly accounting for dropout

ABSTRACTBackground:Longitudinal studies of older adults are characterized by high dropout rates, multimorbid conditions, and multiple medication use, especially proximal to death. We studied the association between multiple medication use and incident dementia diagnoses including Alzheimer's disease (AD), vascular dementia (VD), and Lewy-body dementia (LBD), simultaneously accounting for dropout.

METHODS

Using the National Alzheimer's Coordinating Center data with three years of follow-up, a set of covariate-adjusted models that ignore dropout was fit to complete-case data, and to the whole-cohort data. Additionally, covariate-adjusted joint models with shared random effects accounting for dropout were fit to the whole-cohort data. Multiple medication use was defined as polypharmacy (⩾ five medications), hyperpolypharmacy (⩾ ten medications), and total number of medications.

RESULTS

Incident diagnoses were 2,032 for AD, 135 for VD, and 139 for LBD. Percentages of dropout at the end of follow-up were as follows: 71.8% for AD, 81.5% for VD, and 77.7% for LBD. The odds ratio (OR) estimate for hyperpolypharmacy among those with LBD versus AD was 2.19 (0.78, 6.15) when estimated using complete-case data and 3.00 (1.66, 5.40) using whole-cohort data. The OR reduced to 1.41 (0.76, 2.64) when estimated from the joint model accounting for dropout. The OR for polypharmacy using complete-case data differed from the estimates using whole-cohort data. The OR for dementia diagnoses on total number of medications was similar, but non-significant when estimated using complete-case data.

CONCLUSION

Reasons for dropout should be investigated and appropriate statistical methods should be applied to reduce bias in longitudinal studies among high-risk dementia cohorts.

Medication Exposure and Health Outcomes in Older Patients with End-Stage Kidney Disease: A Prospective Study Undertaken in New Zealand

BACKGROUND

The impact of multiple medication exposure on health outcomes among older patients with end-stage kidney disease (ESKD) is unknown.

OBJECTIVE

The objective of this study was to identify the impact of medicine exposure on hospitalisation rates and mortality in a prospective longitudinal observational study of older dialysis patients.

METHODS

Patient demographics, medication use, hospitalisation, mortality and co-morbidity data were collected through the prospective longitudinal cohort study DOS65 + (Dialysis Outcomes in those aged ≥ 65 years Study) (n = 225). Medication exposure was measured by the total number of individual medications and the number of predetermined 'medication groups'. Associations between medications prescribed at recruitment and health outcomes as measured by hospitalisation and mortality were assessed by univariate and multivariable regression analyses.

RESULTS

Older ESKD patients were exposed to a median of ten (0-20) medications and eight (0-15) medication groups. Multivariate analyses estimate each additional medication increased mortality risk by 8% (relative risk [RR] = 1.08; 95% confidence interval [CI] 1.07-1.09); each medication group increased mortality risk by 11% (RR = 1.11; 95% CI 1.09-1.12). Similar trends were observed for hospitalisation. Certain medication groups were associated with reduced hospitalisation rates, namely angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (RR = 0.62; 95% CI 0.53-0.72) and dihydropyridines (RR = 0.64; 95% CI 0.54-0.76). Warfarin, gastric acid suppressants, diuretics and β-blockers were associated with increased hospitalisation rates. Warfarin was associated with an increased mortality rate (RR = 1.40; 95% CI 1.19-1.65).

CONCLUSIONS

Multiple medication exposure was prevalent in this older ESKD population, and was associated with an increased risk of mortality and hospitalisation. While this study is not able to determine the cause of these relationships, review of medication use is warranted in this population.

TRIAL REGISTRATION

ACTRN12611000024943.

Shed-MEDS: pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient postacute care

BACKGROUND

Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results.

METHODS

This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively.

RESULTS

There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 (p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5-6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI -0.01 to 1.1) in the drug burden index.

CONCLUSIONS

A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.