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Cashion W, McClellan W, Judd S, Goyal A, Kleinbaum D, Goodman M, Prince V, Muntner P, Howard G. Polypharmacy and mortality association by chronic kidney disease status: The REasons for Geographic And Racial Differences in Stroke Study. Pharmacol Res Perspect 2021; 9:e00823. [PMID: 34339112 PMCID: PMC8328192 DOI: 10.1002/prp2.823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/28/2021] [Indexed: 11/18/2022] Open
Abstract
Many Americans take multiple medications simultaneously (polypharmacy). Polypharmacy's effects on mortality are uncertain. We endeavored to assess the association between polypharmacy and mortality in a large U.S. cohort and examine potential effect modification by chronic kidney disease (CKD) status. The REasons for Geographic And Racial Differences in Stroke cohort data (n = 29 627, comprised of U.S. black and white adults) were used. During a baseline home visit, pill bottle inspections ascertained medications used in the previous 2 weeks. Polypharmacy status (major [≥8 ingredients], minor [6-7 ingredients], and none [0-5 ingredients]) was determined by counting the total number of generic ingredients. Cox models (time-on-study and age-time-scale methods) assessed the association between polypharmacy and mortality. Alternative models examined confounding by indication and possible effect modification by CKD. Over 4.9 years median follow-up, 2538 deaths were observed. Major polypharmacy was associated with increased mortality in all models, with hazard ratios and 95% confidence intervals ranging from 1.22 (1.07-1.40) to 2.35 (2.15-2.56), with weaker associations in more adjusted models. Minor polypharmacy was associated with mortality in some, but not all, models. The polypharmacy-mortality association did not differ by CKD status. While residual confounding by indication cannot be excluded, in this large American cohort, major polypharmacy was consistently associated with mortality.
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Affiliation(s)
- Winn Cashion
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | - William McClellan
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | - Suzanne Judd
- Department of BiostatisticsUniversity of Alabama at Birmingham School of Public HealthBirminghamALUSA
| | - Abhinav Goyal
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | - David Kleinbaum
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | - Michael Goodman
- Department of EpidemiologyEmory University Rollins School of Public HealthAtlantaGAUSA
| | - Valerie Prince
- Department of Pharmacy PracticeSamford University McWhorter School of PharmacyBirminghamALUSA
| | - Paul Muntner
- Department of EpidemiologyUniversity of Alabama at Birmingham School of Public HealthBirminghamALUSA
| | - George Howard
- Department of BiostatisticsUniversity of Alabama at Birmingham School of Public HealthBirminghamALUSA
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5
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Huang YT, Steptoe A, Wei L, Zaninotto P. Dose-response relationships between polypharmacy and all-cause and cause-specific mortality among older people. J Gerontol A Biol Sci Med Sci 2021; 77:1002-1008. [PMID: 34079992 PMCID: PMC9071388 DOI: 10.1093/gerona/glab155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Yun-Ting Huang
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Paola Zaninotto
- Department of Epidemiology and Public Health, University College London, London, UK
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7
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Assari S, Wisseh C, Saqib M, Bazargan M. Polypharmacy Is Associated with Lower Memory Function in African American Older Adults. Brain Sci 2020; 10:brainsci10010049. [PMID: 31963177 PMCID: PMC7017256 DOI: 10.3390/brainsci10010049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 12/15/2022] Open
Abstract
Although previous research has linked polypharmacy to lower cognitive function in the general population, we know little about this association among economically challenged African American (AA) older adults. This study explored the link between polypharmacy and memory function among AA older adults. This community-based study recruited 399 AA older adults who were 65+ years old and living in economically disadvantaged areas of South Los Angeles. Polypharmacy (taking 5+ medications) was the independent variable, memory function was the outcome variable (continuous variable), and gender, age, living arrangement, socioeconomic status (educational attainment and financial strain), health behaviors (current smoking and any binge drinking), and multimorbidity (number of chronic diseases) were the covariates. Linear regression was used for data analyses. Polypharmacy was associated with lower scores on memory function, above and beyond covariates. Among AA older adults, polypharmacy may be linked to worse cognitive function. Future research should test the mechanisms by which polypharmacy is associated with lower levels of cognitive decline. There is a need for screening for memory problems in AA older adults who are exposed to polypharmacy.
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Affiliation(s)
- Shervin Assari
- Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA 90095, USA;
- Correspondence: ; Tel.: +1-734-858-8333
| | - Cheryl Wisseh
- Department of Pharmacy Practice, West Coast University School of Pharmacy, Los Angeles, CA 91606, USA;
| | - Mohammed Saqib
- Health Behavior & Health Education, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Mohsen Bazargan
- Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA 90095, USA;
- Department of Family Medicine, University of California Los Angeles (UCLA), Los Angeles, CA 90095, USA
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8
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Morin L, Calderon Larrañaga A, Welmer AK, Rizzuto D, Wastesson JW, Johnell K. Polypharmacy and injurious falls in older adults: a nationwide nested case-control study. Clin Epidemiol 2019; 11:483-493. [PMID: 31296999 PMCID: PMC6598933 DOI: 10.2147/clep.s201614] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/24/2019] [Indexed: 12/13/2022] Open
Abstract
Objective To determine whether or not the exposure to multiple drugs (polypharmacy) increases the risk of fall-related injury among older adults, beyond the effect of fall-risk increasing drugs and chronic multimorbidity. Methods Nested case-control study using linked register data with national coverage in Sweden. We defined cases as older adults (≥70 years) who had an incident non-elective admission due to a fall between 1 January and 31 December 2013. Cases were matched 1:1 on sex, age and index date to randomly selected controls from the general population. The number of prescription drugs during the 7 days preceding the index date was the main exposure. Results A total of 49,609 cases were included and matched to an equal number of controls. The number of prescription drugs was higher among cases than among controls (mean difference 1.2, 95% CI 1.16–1.26). While adjusting for potential confounders, we found that the risk of injurious falls increased in a nearly linear fashion for each additional drug (OR, 1.02; 95% CI, 1.01–1.03). When using a cut-off value of ≥4 drugs to define polypharmacy, the population attributable fraction for injurious falls was 5.2% (95% CI 2.8–7.6). Conclusion This study shows a monotonic dose-response relationship between the number of drugs and the risk of injurious falls. However, after comprehensive adjustment for known confounders (including fall-risk increasing drugs and chronic multimorbidity), this association is substantially weaker than previously reported. Moreover, even if the relationship between polypharmacy and injurious falls is really causal, the population attributable risk fraction is low.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | | | - Anna-Karin Welmer
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Allied Health Professionals, Function Area Occupational Therapy & Physiotherapy, Karolinska University Hospital, Stockholm, Sweden.,Stockholm Gerontology Research Center , Stockholm, Sweden
| | - Debora Rizzuto
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Jonas W Wastesson
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Eggebrecht L, Nagler M, Göbel S, Lamparter H, Keller K, Wagner B, Panova-Noeva M, Ten Cate V, Bickel C, Lauterbach M, Espinola-Klein C, Hardt R, Münzel T, Prochaska JH, Wild PS. Relevance of Polypharmacy for Clinical Outcome in Patients Receiving Vitamin K Antagonists. J Am Geriatr Soc 2018; 67:463-470. [PMID: 30536652 DOI: 10.1111/jgs.15712] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Lisa Eggebrecht
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Sebastian Göbel
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Heidrun Lamparter
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karsten Keller
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bianca Wagner
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marina Panova-Noeva
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Vincent Ten Cate
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christoph Bickel
- Department of Medicine I, Federal Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Michael Lauterbach
- Department of Medicine 3, Barmherzige Brüder Hospital Trier, Trier, Germany
| | - Christine Espinola-Klein
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Roland Hardt
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for General Medicine and Geriatric Medicine, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Münzel
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Jürgen H Prochaska
- Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp S Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
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