How Chronic Is Polypharmacy in Old Age? A Longitudinal Nationwide Cohort Study

The impact of an integrative healthcare system on longevity in a nonagenarian population in Northern Mexico: an observational study

BACKGROUND

Despite the growth in the older population, there is a noticeable research gap regarding integrative health systems for older people and their impact on longevity in nonagenarians. This study aimed to evaluate the effect of an integrative health system consisting of medical services, recreational facilities, and housing on longevity in a population of nonagenarians in Northern Mexico.

METHODS

This was a cross-sectional, retrospective, descriptive-analytical study in which we measured and analyzed medical history such as number of hospitalizations, visits to geriatric consultation, hypertension, history of chronic pain, polypharmacy, dementia, rheumatic disease, diabetes mellitus, insomnia, depression, ischemic cardiomyopathy, among others. We also measured social engagement and number of caregivers. A logistic regression was performed to evaluate the predictors of mortality in this population.

RESULTS

We included one hundred and ninety-five nonagenarians with a mean (SD) age of 94 (4.2) years and of which 112 (55.7%) were female. The findings from logistic regression analysis indicated that a higher frequency of hospitalizations was associated with an elevated mortality risk (OR = 1.272, p = 0.049). Conversely, increased visits to geriatric consultation services as primary care were linked to a reduced mortality risk (OR = 0.953, p = 0.002). Additionally, social engagement displayed a protective effect (OR = 0.336, p = 0.05).

CONCLUSIONS

This study highlighted the role of systemic health approaches in extending life through insights into nonagenarian patients' involvement in primary care, as measured by consultation frequency, and participation in social activities, mitigating mortality risks. Meanwhile, it emphasized the potential consequences of higher hospitalization rates on increased mortality risk.

A comparative analysis of medication counting methods to assess polypharmacy in medico-administrative databases

BACKGROUND

The variety of methods for counting medications may lead to confusion when attempting to compare the extent of polypharmacy across different populations.

OBJECTIVE

To compare the prevalence estimates of polypharmacy derived from medico-administrative databases, using different methods for counting medications.

METHODS

Data were drawn from the Québec Integrated Chronic Disease Surveillance System. A random sample of 110,000 individuals aged >65 was selected, including only those who were alive and covered by the public drug plan during the one-year follow-up. We used six methods to count medications: #1-cumulative one-year count, #2-average of four quarters' cumulative counts, #3-count on a single day, #4-count of medications used in first and fourth quarters, #5-count weighted by duration of exposure, and #6-count of uninterrupted medication use. Polypharmacy was defined as ≥5 medications. Cohen's Kappa was calculated to assess the level of agreement between the methods.

RESULTS

A total of 93,516 (85 %) individuals were included. The prevalence of polypharmacy varied across methods. The highest prevalence was observed with cumulative methods (#1:74.1 %; #2:61.4 %). Single day count (#3:47.6 %), first and fourth quarters count (#4:49.5 %), and weighted count (#5:46.6 %) yielded similar results. The uninterrupted use count yielded the lowest estimate (#6:35.4 %). The weighted method (#5) showed strong agreement with the first and fourth quarters count (#4). Cumulative methods identified higher proportions of younger, less multimorbid individuals compared to other methods.

CONCLUSION

Counting methods significantly affect polypharmacy prevalence estimates, necessitating their consideration when comparing and interpretating results.

Analysis of longitudinal patterns and predictors of medicine use in residential aged care using group-based trajectory modelling: The MEDTRAC-Polypharmacy longitudinal cohort study

AIMS

Polypharmacy serves as a quality indicator in residential aged care facilities (RACFs) due to concerns about inappropriate medication use. However, aggregated polypharmacy rates at a single time offer limited value. Longitudinal analysis of polypharmacy patterns provides valuable insights into identifying potential overuse of medicines. We aimed to determine long-term trajectories of polypharmacy (≥9 medicines) and factors associated with each polypharmacy trajectory group.

METHODS

This was a longitudinal cohort study using electronic data from 30 RACFs in New South Wales, Australia. We conducted group-based trajectory modelling to identify and characterize polypharmacy trajectories over 3 years. We evaluated the model fitness using the Bayesian Information Criterion, entropy (with a value of ≥0.8 considered ideal) and several other metrics.

RESULTS

The study included 2837 permanent residents (median age = 86 years, 61.7% female and 47.4% had dementia). We identified five polypharmacy trajectory groups: group 1 (no polypharmacy, 46.0%); group 2 (increasing polypharmacy, 9.4%); group 3 (decreasing polypharmacy, 9.2%); group 4 (increasing-then decreasing polypharmacy, 10.0%), and group 5 (persistent polypharmacy, 25.4%). The model showed excellent performance (e.g., entropy = 0.9). Multinomial logistic regressions revealed the profile of each trajectory group (e.g., group 5 residents had higher odds of chronic respiratory disease compared with group 1).

CONCLUSIONS

Our study identified five polypharmacy trajectory groups, including one with over a quarter of residents following a persistently high trajectory, signalling concerning medication overuse. Quality indicator programs should adopt tailored metrics to monitor diverse polypharmacy trajectory groups, moving beyond the current one-size-fits-all approach and better capturing the evolving dynamics of residents' medication regimens.

Spousal bereavement and four-year trajectories of medication use: A nationwide register-based study in Swedish older adults

BACKGROUND

Medication use around widowhood has been poorly described for most medication classes. Medication use patterns can reflect health consequences of spousal loss, as previously shown for psychotropic drugs.

METHODS

We used data from nationwide health registers (2008-2020) to describe the patterns of use of dispensed medications in all widowed Swedes aged ≥65 years followed between 2 years before and 2 years after spousal death. All prescription drugs used by at least 5% of the cohort were considered according to their therapeutic subgroups (Anatomical Therapeutic Chemical [ATC] classification system 2nd level). We used group-based trajectory models to cluster widowed individuals into up to 4 distinct longitudinal patterns of monthly medication use. We ranked the therapeutic subgroups with similar patterns according to their plausibility to reflect potential health effects of spousal loss, compared to those of psycholeptics (mainly anxiolytics, hypnotics) and psychoanaleptics (mainly antidepressants) as the references.

RESULTS

From 212,111 widowed adults included (68% female and 70% aged ≥75 years), we observed a significant increasing trend in medication use, especially after spousal death, for 21 out of the 39 different therapeutic subgroups that were used by at least 5% (most represented pharmacological groups: cardiovascular system, nervous system, and alimentary tract and metabolism). This increasing trend often concerned only a small proportion of individuals, with varying magnitude and speed of change in medication use across therapeutic subgroups. The patterns of use of antiepileptics, laxatives, skin emollients/protectives, analgesics, and drugs for anemia, constipation, or peptic ulcers, were the closest to those of references, displaying the largest changes in use, and were therefore ranked as the most likely to reflect health effects of spousal loss.

CONCLUSION

Our results confirmed the increase in psychotropic medications' use in widowed older adults and identified several potential physical health effects of spousal loss that warrant further research.

The association of degree of polypharmacy before and after among hospitalised internal medicine patients and clinical outcomes: a retrospective, population-based cohort study

OBJECTIVES

To determine the prevalence and incidence of polypharmacy/hyperpolypharmacy and which medications are most prescribed to patients with varying burden of polypharmacy.

DESIGN

Retrospective, population-based cohort study.

SETTING

Iceland.

PARTICIPANTS

Including patients (≥18 years) admitted to internal medicine services at Landspitali - The National University Hospital of Iceland, between 1 January 2010 with a follow-up of clinical outcomes through 17 March 2022.

MAIN OUTCOMES MEASURES

Participants were categorised into medication use categories of non-polypharmacy (<5), polypharmacy (5-10) and hyperpolypharmacy (>10) based on the number of medications filled in the year predischarge and postdischarge. The primary outcome was prevalence and incidence of new polypharmacy. Secondary outcomes were mortality, length of hospital stay and re-admission.

RESULTS

Among 85 942 admissions (51% male), the median (IQR) age was 73 (60-83) years. The prevalence of preadmission non-polypharmacy was 15.1% (95% CI 14.9 to 15.3), polypharmacy was 22.9% (95% CI 22.6 to 23.2) and hyperpolypharmacy was 62.5% (95% CI 62.2 to 62.9). The incidence of new postdischarge polypharmacy was 33.4% (95% CI 32.9 to 33.9), and for hyperpolypharmacy was 28.9% (95% CI 28.3 to 29.5) for patients with preadmission polypharmacy. Patients with a higher level of medication use were more likely to use multidose drug dispensing and have a diagnosis of adverse drug reaction. Other comorbidities, including responsible subspeciality and estimates of comorbidity and frailty burden, were identical between groups of varying polypharmacy. There was no difference in length of stay, re-admission rate and mortality.

CONCLUSIONS

Preadmission polypharmacy/hyperpolypharmacy and postdischarge new polypharmacy/hyperpolypharmacy is common amongst patients admitted to internal medicine. A higher level of medication use category was not found to be associated with demographic, comorbidity and clinical outcomes. Medications that are frequently inappropriately prescribed were among the most prescribed medications in the group. An increased focus on optimising medication usage is needed after hospital admission.

TRIAL REGISTRATION NUMBER

NCT05756400.

TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer

PURPOSE

Polypharmacy is a significant problem in patients with incurable cancer and a method to optimize pharmacotherapy in this patient group is lacking. Therefore, a drug optimization tool was developed and tested in a pilot test.

METHODS

A multidisciplinary team of health professionals developed a "Tool to Optimize Pharmacotherapy in Patients with Incurable Cancer" (TOP-PIC) for patients with a limited life expectancy. The tool consists of five sequential steps to optimize medications, including medication history, screening for medication appropriateness and drug interactions, a benefit-risk assessment using the TOP-PIC Disease-based list, and shared decision-making with the patient. For pilot testing of the tool, 8 patient cases with polypharmacy were analyzed by 11 oncologists before and after training with the TOP-PIC tool.

RESULTS

TOP-PIC was considered helpful by all oncologists during the pilot test. The median additional time required to administer the tool was 2 min per patient (P < 0.001). For 17.4% of all medications, different decisions were made by using TOP-PIC. Among possible treatment decisions (discontinuation, reduction, increase, replacement, or addition of a drug), discontinuation of medications was the most common. Without TOP-PIC, physicians were uncertain in 9.3% of medication changes, compared with only 4.8% after using TOP-PIC (P = 0.001). The TOP-PIC Disease-based list was considered helpful by 94.5% of oncologists.

CONCLUSIONS

TOP-PIC provides a detailed, disease-based benefit-risk assessment with recommendations specific for cancer patients with limited life expectancy. Based on the results of the pilot study, the tool seems practicable for day-to-day clinical decision-making and provides evidence-based facts to optimize pharmacotherapy.

Prevalence and global trends of polypharmacy in patients with chronic liver disease: A systematic review and meta-analysis

BACKGROUND

Despite its central role in drug metabolism, the exact prevalence estimates and factors affecting global trends of polypharmacy in patients with chronic liver disease (CLD) have remained unexamined. The aim of this systematic review and meta-analysis is to estimate the prevalence of polypharmacy in patients with CLD and to comprehensively synthesize the socio-demographic factors that drive this.

METHODS

We conducted a comprehensive search of relevant databases (PubMed, EMBASE, Science citation index, Cochrane Database of Systematic Reviews, and database of abstracts of reviews of effectiveness) for studies published from inception to May 30, 2022 that reported on prevalence estimates of polypharmacy in patients with CLD. The risk of bias was conducted utilizing Loney criteria. The primary outcome was the pooled prevalence of polypharmacy in patients with CLD. We subsequently performed a systematic review and weighted meta-analysis to ascertain the exact pooled prevalence of polypharmacy among patients with CLD.

RESULTS

We identified approximately 50 studies from the initial literature search, of which 7 (enrolling N = 521,435 patients) with CLD met the inclusion criteria; of these, 58.7% were male, with a mean age of 53.9 (SD ± 12.2) years. The overall pooled prevalence of polypharmacy among patients with CLD was 31% (95% confidence interval [CI]: 4%-66%, I2 = 100%, τ2 ≤ 0.001, P ≤ .0001). We found higher pooled prevalence estimates among patients aged 50 years and older compared to their younger cohorts (42%, [CI 10-77]; I2 = 100%, P = <.001 vs 21%, [CI 0-70]; I2 = 100%, P = <.001).

CONCLUSION

In an examination of multiple community- and hospital-based databases of patients with CLD, we found a pooled prevalence estimate of polypharmacy of approximately 31%. This represents a case burden within the range reported in the general population and will likely respond to mitigation strategies employed thus far for patients in that population.

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).

Polypharmacy is differentially associated with 20-year mortality among community-dwelling elderly women and men: The Israel Glucose Intolerance, Obesity and Hypertension cohort study

BACKGROUND

Elderly individuals are characterized by multimorbidity and high medication intake, entailing risks for adverse events. We examined the overall and sex-specific association of polypharmacy (≥5 drugs concurrently) with 20-year mortality among community-dwelling older adults.

METHODS

Survivors of the longitudinal Israel Study of Glucose Intolerance, Obesity, and Hypertension underwent extensive evaluation during 1999-2004, and were followed-up for all-cause mortality until 2019. Cox regression examined association of polypharmacy with all-cause mortality.

RESULTS

Data included 1210 participants (mean baseline age 72.9 ± 7.4 years, 53% females), 50.7% of them died over a median follow-up of 12.8 years. Women received a higher mean number of drugs (4.3 vs 3.5; p < 0.0001), were twice more likely to take vitamins, and had higher comorbidity. Polypharmacy prevalence was 38.3%, and more frequent with age, female sex, European-American origin, sedentary lifestyle and poor self-rated health. Polypharmacy was independently associated with mortality in women only (HR=1.41, 95%CI:1.05-1.89). An interaction was found with sex (p = 0.045).

CONCLUSIONS

Polypharmacy was more prevalent in older women than men and associated with increased 20-year mortality in women only. Sex-specific adaptation of guidelines for appropriate drug use among community-dwelling older adults is warranted.

Old Age, Female Sex, and Psychotropic Medications Predict Hyposalivation But Not Heart Rate Variability

OBJECTIVE

To explore risk factors for dry mouth and examine the clinical utility of the heart rate variability (HRV) test in the prediction of dry mouth.

METHODS

Every outpatient, who underwent tests for both unstimulated salivary flow and HRV, was retrospectively reviewed. After excluding seven subjects, the demographics and clinical factors in 70 total patients were collected. Based on objective salivary flow rates, patients were classified into normal (≥0.2 mL/min) or hyposalivation groups (<0.2 mL/min), and inter-group comparisons were performed with a two-tailed statistical significance of 0.05.

RESULTS

Patients with subjective dry mouth were significantly more likely to show hyposalivation. Advanced age, female sex, and current use of psychotropic medications were identified as risk factors for dry mouth. However, dry mouth was not associated with any HRV parameters.

CONCLUSION

HRV test did not demonstrate a clinical utility in predicting dry mouth. Because subjective dry mouth is significantly associated with objective hyposalivation, a simple probing question would be useful for early recognition of dry mouth. Clinical attention is required for patients meeting criteria of older age, female, and/or using psychotropic prescriptions. Prompt management of hyposalivation may improve quality of life and clinical outcome by enhanced treatment adherence.

Assessment of Potentially Inappropriate Medications Using the EU (7)-PIM List, in a Sample of Portuguese Older Adults' Residents in Nursing Homes

Abstract

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.

Purpose

This work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.

Methods

Retrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.

Results

Of the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).

Conclusion

The high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Conclusions and implications

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

Supplementary Information

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

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Medication use problems among older adults at a primary care: A narrative of literature review

Appropriate medication use is one of the most significant challenges among the older population. Although medication use problems are well documented at the secondary and tertiary health care level, the evidence at the primary care level of OECD region is limited. A narrative review of existing literature was conducted through a nonsystematic search for original articles through electronic search databases, Ovid Medline, Google Scholar from 2001 to 2021, and a combination of citation references. Medication use problems are prevalent in older adults at the primary care level. The main issues of medication use identified were as follows; nonadherence, adverse drug events, accessibility, polypharmacy, inappropriate medications, belief about medications, lack of knowledge and awareness, and lack of deprescribing. In addition, the current review has identified the possibilities of the problems: many medications, forgetfulness, lack of deprescribing, lack of communication, poor understanding, and limited awareness of inappropriate medications. This review found that various medication use problems subclusters were identified to impact the health care need among older adults. Therefore, effective interventions targeting these issues need to be developed to reduce medication use problems among older adults at a primary care level.

Tools supporting polypharmacy management in Italy: Factors determining digital technologies' intention to use in clinical practice

Background and Aims

INTERCheckWEB is one of the most outstanding digital technologies, that could be implemented at the hospital level, supporting the clinicians in the evaluation of the therapy appropriateness, reducing the potentially inappropriate prescriptions, for the improvement of the clinical decision‐making process. The paper aims at investigating the relationship between clinicians' behaviors towards digital decision support system in therapy appropriateness for elderly patients in polytherapy in medical departments, defining the factors that could influence clinicians to use INTERCheckWEB, for supporting drugs' prescription.

Methods

A questionnaire was administered to 70 clinicians referring to Internal Medicine wards, of four Italian hospitals. The authors assessed how perceived usefulness, perceived ease of use, image, and output quality, would affect INTERCheckWeb intention to use. Inferential statistics, by means of a regression analysis, were conducted to define the main aspects useful to understand the factors impacting on such digital technology adoption in clinical practice.

Results

The regression analysis reported that image, perceived ease of use and perceived usefulness, as well as the moderator effect of the voluntary use between the perceived usefulness and the intention to use, are the factors that most influence the use of INTERCheckWEB (adjusted R² = 0.870).

Conclusions

Results demonstrated that clinicians would use INTERCheckWEB, when available, to identify all the information on situations that could be dangerous for the patients, thus limiting the drug–drug interactions, optimizing the overall patient's clinical pathway. Furthermore, the implementation of INTERCheckWEB could also contribute to the proper management of COVID‐19 patients, since both hospitalized and symptomatic COVID‐19 patients are frequently older, with comorbidities.

Is polypharmacy associated with mortality in the very old: findings from the Newcastle 85+ Study

Polypharmacy is common in the very old (≥85 years), where little is known about its association with mortality. We aimed to investigate the association between polypharmacy and all-cause mortality in the very old, over an 11-year time period. Data were drawn from the Newcastle 85+ Study (741), a cohort of people who were born in 1921 and turned 85 in 2006. Survival analysis was performed using Cox proportional hazards models with time-varying covariates, wherein polypharmacy was operationalised continuously. Each additional medication prescribed was associated with a 3% increased risk of mortality (HR: 1.03, 95% CI: 1.00-1.06). Amongst the very old, the risks and benefits of each additional medication prescribed should be carefully considered.

Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study

BACKGROUND

Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults.

METHODS

The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk.

RESULTS

Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use.

CONCLUSIONS

Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.

Health Impacts and Characteristics of Deprescribing Interventions in Older Adults: Protocol for a Systematic Review and Meta-analysis

Background

Deprescribing, a relatively recent concept, has been proposed as a promising solution to the growing issues of polypharmacy and use of medications of questionable benefit among older adults. However, little is known about the health outcomes of deprescribing interventions.

Objective

This paper presents the protocol of a study that aims to contribute to the knowledge on deprescribing by addressing two specific objectives: (1) describe the impact of deprescribing in adults ≥60 years on health outcomes or quality of life; and (2) determine the characteristics of effective interventions in deprescribing.

Methods

Primary studies targeting three concepts (older adults, deprescribing, and health or quality of life outcomes) will be included in the review. The search will be performed using key international databases (MEDLINE, EMBASE, CINAHL, Ageline, PsycInfo), and a special effort will be made to identify gray literature. Two reviewers will independently screen the articles, extract the information, and evaluate the quality of the selected studies. If methodologically feasible, meta-analyses will be performed for groups of intervention studies reporting on deprescribing interventions for similar medications, used for similar or identical indications, and reporting on similar outcomes (eg, benzodiazepines used against insomnia and studies reporting on quality of sleep or quality of life). Alternatively, the results will be presented in bottom-line statements (objective 1) and a matrix outlining effective interventions (objective 2).

Results

The knowledge synthesis may be limited by the availability of high-quality clinical trials on deprescribing and their outcomes in older adults. Additionally, analyses will likely be affected by studies on the deprescribing of different types of molecules within the same indication (eg, different pharmacological classes and medications to treat hypertension) and different measures of health and quality of life outcomes for the same indication. Nevertheless, we expect the review to identify which deprescribing interventions lead to improved health outcomes among seniors and which of their characteristics contribute to these outcomes.

Conclusions

This systematic review will contribute to a better understanding of the health outcomes of deprescribing interventions among seniors.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42015020866; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015020866

International Registered Report Identifier (IRRID)

PRR1-10.2196/25200

Explaining the association between frailty and mortality in older adults: The mediating role of lifestyle, social, psychological, cognitive, and physical factors

•

Frailty in older adults is associated with adverse outcomes such as mortality.

•

Not much is known about underlying pathways of the frailty-mortality association.

•

We assessed the mediating role of a wide range of factors.

•

In both men and women, only polypharmacy was identified as explanatory factor.

•

Targeting polypharmacy in frail older adults could reduce their risk of mortality.

Frailty is associated with a higher risk of mortality, but not much is known about underlying pathways of the frailty-mortality association. In this study, we explore a wide range of possible mediators of the relation between frailty and mortality. Data were used from the Longitudinal Aging Study Amsterdam (LASA). We included 1477 older adults aged 65 years and over who participated in the study in 2008–2009 and linked their data to register data on mortality up to 2015. We examined a range of lifestyle, social, psychological, cognitive, and physical factors as potential mediators. All analyses were stratified by sex. We used causal mediation analyses to estimate the indirect effects in single-mediator analyses. Statistically significant mediators were then included in multiple-mediator analyses to examine their combined effect. The results showed that older men (OR = 2.79, 95% CI = 1.23;6.34) and women (OR = 2.31, 95% CI = 1.24;4.30) with frailty had higher odds of being deceased 6 years later compared to those without frailty. In men, polypharmacy (indirect effect OR = 1.21, 95% CI = 1.03;1.50) was a statistically significant mediator in this association. In women, polypharmacy, self-rated health, and multimorbidity were statistically significant mediators in the single-mediator models, but only the indirect effect of polypharmacy remained in the multiple-mediator model (OR = 1.16, 95% CI = 1.03;1.38). In conclusion, of many factors that were considered, we identified polypharmacy as explanatory factor of the association between frailty and mortality in older men and women. This finding has important clinical implications, as it suggests that targeting polypharmacy in frail older adults could reduce their risk of mortality.

Prevalence of Chronic Polypharmacy in Community-Dwelling Elderly People in Poland: Analysis of National Real-World Database Helps to Identify High Risk Group

Introduction: Multimorbidity often comes with age, making elderly people particularly prone to polypharmacy. Polypharmacy, in turn, is a risk factor for adverse drug reactions, drug-drug interactions, non-adherence to medication, negative health outcomes, and increased healthcare services utilization. The longer the exposure to polypharmacy is, the higher the risk of these consequences is. Therefore, a detailed assessment of the prevalence and drivers of chronic polypharmacy in the elderly is particularly important. Aim of study: To find out the prevalence of chronic polypharmacy in the elderly population of Poland, and to characterize the subgroup with the highest risk of this problem, using real-world data. Methodology: A retrospective analysis of data on dispensation and healthcare services utilization held by the national payer organization for the year 2018. Chronic polypharmacy was defined as possession, as a result of dispensation, of five or more prescribed drugs within 80% of each of the consecutive 6 months. Results: Chronic polypharmacy was found in 554.1 thousand patients, i.e. in 19.1% of the national 65+ cohort. On average, those patients were 76 years old, and 49.3% of them were female. The vast majority (68.6%) continued their polypharmacy for the period of the whole year. There was a marked variation in geographical distribution of chronic polypharmacy with the highest value of 1.7 thousand per 100,000 inhabitants in the Łódź Voivodeship. Patients exposed to chronic polypharmacy filled prescriptions from 4.5±2.36 healthcare professionals. The average number of drugs they used was 8.3±3.84 DDD per patient per day. The most often prescribed drugs were Metformin, Atorvastatin and Pantoprazole. The average annual hospitalisation rate in those patients was 1.03±2.4. Conclusion: This study was the first of this kind involving a nationwide assessment of chronic polypharmacy in Polish elderly people. We found that this problem affected one fifth of Polish older adults and it remains stable due to its direct relation to chronic conditions. Thus, our results confirm that this phenomenon is highly important for the national health policy and requires relevant interventions. The planned introduction of pharmaceutical care in Poland is expected to help in solving the problem.

Development, validation and evaluation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)©

OBJECTIVES

1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia; 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia.

METHODS

This study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building; b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia; and c) the evaluation phase, using mixed-methods analyses.

RESULTS

The exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability.

DISCUSSION AND CONCLUSIONS

Involving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software.

A multidimensional measure of polypharmacy for older adults using the Health and Retirement Study

Polypharmacy is commonly defined based on the number of medications taken concurrently using standard cut-offs, but several studies have highlighted the need for a multidimensional assessment. We developed a multidimensional measure of polypharmacy and compared with standard cut-offs. Data were extracted for 2141 respondents of the 2007 Prescription Drug Survey, a sub-study of the Health Retirement Study. Latent classes were identified based on multiple indicators of polypharmacy, including quantity, temporality and risk profile. A four-class model was selected based on fit statistics and clinical interpretability: 'High risk, long-term' (Class 1), 'Low risk, long-term' (Class 2), 'High risk, short-term' (Class 3), and 'High risk for drug interactions, medium-term, regular' (Class 4). Classes differed regarding sex, cohabitation, disability and multimorbidity. Participants in the 'low risk' class tended to be male, cohabitating, and reported fewer health conditions, compared to 'high risk' classes. Polypharmacy classes were compared to standard cut-offs (5+ or 9+ medications) in terms of overlap and mortality risk. The three 'high risk' classes overlapped with the groups concurrently taking 5+ and 9+ medications per month. However, the multidimensional measure further differentiated individuals in terms of risk profile and temporality of medication taking, thus offering a richer assessment of polypharmacy.

Prevalence and Age Structure of Polypharmacy in Poland: Results of the Analysis of the National Real-World Database of 38 Million Citizens

Introduction: Polypharmacy is a risk factor for adverse health outcomes, higher use of medical services and additional costs. The problem has gained attention as a consequence of aging and related multimorbidity. Therefore, there is an urgent need to adopt effective interventions aimed at reducing its burden. In order to achieve this, in-depth understanding of the prevalence of polypharmacy is required. Of particular interest is, however, assessing prevalence of polypharmacy in various age groups, to reach the right target for these interventions. So far, only limited data on polypharmacy among non-elderly individuals have been available.

Aim of study: To assess overall prevalence of polypharmacy in Poland as well as its distribution in various age groups using real-world data.

Methodology: A retrospective analysis of complete dispensation data of national payer organization for the years 2018–2019. The analyzed dataset included data on dispensation of reimbursed drugs, and exclusively for 2019, also non-reimbursed drugs. Polypharmacy was defined as dispensation of ≥5 prescription medications within six months.

Results: In the analyzed national cohort of 38 million Polish citizens, the prevalence of polypharmacy was found to be 11.7% in 2018 and 11.6% in 2019. With age, the prevalence of polypharmacy increased, reaching the value of 56.0% in those aged 80+ in 2018, and 55.0% in 2019. Altogether, among those aged 65+, the polypharmacy was present in 43.1% in 2018, and 42.1% in 2019. In the youngest group of citizens, i.e., among those aged below 20 years, polypharmacy was found in 0.9%, and 0.8% in 2018 and 2019, respectively. Prevalence of polypharmacy, calculated for 2019 according to dispensation of five or more reimbursed and non-reimbursed drugs for the whole Polish population, was 21.8% for January-June, and 22.4% for July-December 2019. Among those aged 65+, the relevant numbers were 62.3%, and 62.9%, respectively.

Conclusion: This study, being the first nationwide assessment of polypharmacy in Poland, confirmed its high prevalence. We found polypharmacy present in over one fifth of Polish society. Peaking in the elderly, polypharmacy occurred in each age group. These results lay the foundations for future interventions focused on reducing the scope of this problem in Poland.

[Prevalence of prescription of anticholinergic/sedative burden drugs among older people with dementia living in nursing homes]

BACKGROUND AND OBJECTIVE

Dementia is one of the most frequent diseases in the elderly, being its prevalence of up to 64% in institutionalized people. In this population, in addition to antidementia drugs, it is common to prescribe drugs with anticholinergic/sedative burden that, due to their adverse effects, could worsen their functionality and cognitive status. The objective is to estimate the prevalence of the use of drugs with anticholinergic/ sedative burden in institutionalized older adults with dementia and to assess the associated factors.

MATERIALS AND METHODS

A cross-sectional study developed in older with dementia living in nursing homes. The prevalence of prescription of anticholinergic/sedative drugs was estimated according to the Drug Burden Index (DBI). A comparative analysis of the DBI score was performed between different types of dementia as well as among various factors and according to the anticholinergic/sedative risk, establishing as a cut-off point of DBI≥1 (high anticholinergic/sedative risk).

RESULTS

178 residents were included. 83.7% had some drug with anticholinergic/sedative burden according to DBI. 50% had a DBI≥1 score. Residents with vascular dementia had a mean DBI of 1.34 (SD 0.84), a significantly higher score than residents with Alzheimer's disease (0.41, 95% CI 0.04-0.78).). Likewise, a higher DBI was associated with more polypharmacy (3.36; 95% CI 2.64-4.08), more falls, hospital admissions and emergency room visits (P<.05).

CONCLUSIONS

Polypharmacy and prescription of anticholinergic/sedative drugs is frequent among institutionalized older adults with dementia, finding an association between DBI, falls and hospital admissions or emergency department visits. Therefore, it is necessary to propose interdisciplinary pharmacotherapeutic optimization strategies.

Targeting continuity of care and polypharmacy to reduce drug-drug interaction

Drug–drug interaction (DDI) is common among the elderly, and it can have detrimental effects on patients. However, how DDI can be targeted has been under-researched. This study investigates whether DDI can be reduced by targeting continuity of care (COC) through reducing polypharmacy. Population claims data of Taiwan National Health Insurance were used to conduct a 7-year-long longitudinal study on patients aged ≥ 65 years (n = 2,318,766). Mediation analysis with counterfactual method and a 4-way decomposition of the effect of COC on DDI was conducted. Mediation effect through excessive polypharmacy differed from that through lower-level polypharmacy. Compared with the low COC group, the high COC group demonstrated reduced excess relative risk of DDI by 26% (excess relative risk =  − 0.263; 95% Confidence Interval (CI) =  − 0.263 to − 0.259) to 30% (excess relative risk =  − 0.297; 95% CI =  − 0.300 to − 0.295) with excessive polypharmacy as the mediator. The risk only reduced by 8% (excess relative risk =  − 0.079; 95% CI, − 0.08 to − 0.078) to 10% (excess relative risk =  − 0.096; 95% CI, − 0.097 to − 0.095) when the mediator was changed to lower-level polypharmacy. The effect of COC on DDI was mediated by polypharmacy, and the mediation effect was higher with excessive polypharmacy. Therefore, to reduce DDI in the elderly population, different policy interventions should be designed by considering polypharmacy levels to maximize the positive effect of COC on DDI.

Long-term trajectories of medicine use among older adults experiencing polypharmacy in Australia

AIMS

To explore longitudinal changes in the number and type of medicines used among older people who experience polypharmacy.

METHODS

We used pharmaceutical claims for a 10% sample of Australian Pharmaceutical Benefits Scheme beneficiaries to identify people aged 70 years and older who were exposed to 5 or more medicines on 15 February 2014. Using group-based trajectory modelling, we explored changes in the quarterly number and type of medicines used over a 5-year period (2014-2018).

RESULTS

In our cohort of 98 539 people, we identified 2 predominant groups of medicine use: sustained polypharmacy (77% of people, 4 trajectories); and decreasing medicine use (23%, 3 trajectories). Within the sustained polypharmacy group, people in trajectories with a lower mean number of medicines (e.g. 6 unique medicines) had relatively stable trajectories, while those using a higher number of medicines (e.g. 15 unique medicines) experienced greater seasonal variation in the number and type of medicines used. On average, people continued to use 2/3 of their medicines (chemical substance level) across adjacent quarters. Within groups of decreasing medicine use, the most common trajectory was a slight drop in medicines within 3 months. Overall, 79% of people still experienced polypharmacy after 1 year.

CONCLUSION

Polypharmacy among older people is a sustained phenomenon, reflecting the chronic nature of multimorbidity within this population. However, there is an underlying volatility in the nature of medicines involved, reflecting both changes in treatment and seasonal fluctuation in dispensing. Ongoing prescribing vigilance is required, particularly for patients using very large amounts of medicines.

Chronic polypharmacy impairs explorative behavior and reduces synaptic functions in young adult mice

A major challenge in the health care system is the lack of knowledge about the possible harmful effects of multiple drug treatments in old age. The present study aims to characterize a mouse model of polypharmacy, in order to investigate whether long-term exposure to multiple drugs could lead to adverse outcomes. To this purpose we selected five drugs from the ten most commonly used by older adults in Sweden (metoprolol, paracetamol, aspirin, simvastatin and citalopram). Five-month-old wild type male mice were fed for eight weeks with control or polypharmacy diet. We report for the first time that young adult polypharmacy-treated mice showed a significant decrease in exploration and spatial working memory compared to the control group. This memory impairment was further supported by a significant reduction of synaptic proteins in the hippocampus of treated mice. These novel results suggest that already at young adult age, use of polypharmacy affects explorative behavior and synaptic functions. This study underlines the importance of investigating the potentially negative outcomes from concomitant administration of different drugs, which have been poorly explored until now. The mouse model proposed here has translatable findings and can be applied as a useful tool for future studies on polypharmacy.

The relationship between common geriatric syndromes and potentially inappropriate medication use among older adults

BACKGROUND/AIM

Polypharmacy and inappropriate medication use in older adults is a major public health problem associated with morbidity and mortality. Aging is associated with metabolic changes and decreased drug clearance, increased drug-drug interactions, prescribing cascades, and potentially inappropriate medication (PIM) use. The purpose of this study was to evaluate the association between a common geriatric syndromes and PIM use among older adults.

METHODS

Study participants were recruited among patients admitted to Istanbul Medical School Geriatrics outpatient clinic between June 2000 and June 2014 and were evaluated retrospectively by a geriatrician using the patients' records according to Beers 2012 criteria.

RESULTS

Among the 667 enrolled patients, 421 (63.1%) were women and 246 (36.9%) were men. The use of PIM was not associated with age or sex. Polypharmacy (OR 4.86, 95% CI 3.25-7.27, p < 0.001), malnutrition (OR 2.69, 95% CI 1.52-4.76, p = 0.001), depression (OR 2.61, 95% CI 1.7-3.95, p < 0.001), presence of fall in the previous year (OR 2.24, 95% CI 1.51-3.32, p < 0.001), and dementia (OR 1.69, 95% CI 1.08-2.65, p = 0.021) were independently associated with the use of PIM.

DISCUSSION/CONCLUSIONS

The results of our study suggest that PIM use is independently associated with presence of polypharmacy, malnutrition, depression, falls and dementia in older outpatients. Identifying the association of inappropriate medication use with common geriatric syndromes in older people can help to prevent, delay, and reduce PIM use and related adverse health outcomes.

An Increasing Trend in the Prevalence of Polypharmacy in Sweden: A Nationwide Register-Based Study

Aim

Polypharmacy is becoming a global health problem. The aims of this study were to evaluate the temporal trends in the prevalence of polypharmacy in Sweden and to explore polypharmacy disparities by age, gender, education, and immigration status.

Methods

Polypharmacy and excessive polypharmacy were evaluated using data extracted from the Swedish Prescribed Drug Register between 2006 and 2014. Polypharmacy was defined as being exposed to five or more drugs and excessive polypharmacy was defined as being exposed to 10 or more drugs during 1 month respectively. Average annual percent change (AAPC) was calculated using Joinpoint Statistical Software.

Results

The prevalence of polypharmacy increased from 16.9% in 2006 to 19.0% in 2014 with an AAPC of 1.3; the prevalence of excess polypharmacy increased from 3.8% in 2006 to 5.1% in 2014 with an AAPC of 3.4. The prevalence of polypharmacy and excessive polypharmacy increased dramatically with age and peaked up to 79.6% and 36.4% in individuals aged 90 and above respectively. Females and individuals with lower education level were associated with a higher rate of polypharmacy and excessive polypharmacy. Immigrants from Middle-Eastern countries had the highest rate of polypharmacy and excessive polypharmacy, whereas individuals from Western Europe countries had the lowest rate.

Conclusion

The prevalence of polypharmacy has increased gradually in Sweden during the past decade. Individuals with older age, female sex, or lower education have a higher rate of polypharmacy and excessive polypharmacy. Immigrants from Middle-Eastern countries showed a higher rate of polypharmacy.

The analysis of the use of potentially inappropriate medications in elderly in the Slovak Republic

Background The prevalence of potentially inappropriate medications (PIM) using explicit criteria has been well documented in European countries, however, there is a lack of evidence in the Slovak Republic. There are no specific guidelines and there is a lack of geriatricians in Slovakia. Higher use of PIM leads to greater healthcare services use as well as increases healthcare costs. Objective The aim of this study was to perform an evaluation of the availability and the actual use of PIM by geriatric patients in the nursing homes in Slovakia. Setting Together 459 residents ≥ 65 years living in nursing homes in the Slovak Republic were included for analysis of their drug therapy. Methods Retrospective analysis of medical records of patients' therapy for evaluation of PIM use. Identification of PIM was based on the Renom-Guiteras EU7 PIM list published in 2015. Main outcome measure Potentially inappropriate medications use. The presence of polypharmacy in patients. Results Inappropriate drug use according to EU7 PIM list was identified in 90.60% (416) patients. The mean number of PIM was 2.34 ± 0.07 PIM/patient/day. Polypharmacy (use of ≥ 5 drugs by patient daily) was found in 83% of all patients. The mean number of prescribed drugs was 8.32 ± 0.17 drugs/patient/day. Out of all 282 PIM listed in EU7 PIM list, there are 150 (53.19%) available on the Slovak market and 86 (30.50%) were used in patients. Patients using at least one PIM took two times more drugs compared to patients without PIM (8.77 ± 0.17 vs. 3.98 ± 0.39 drugs/patient/day, p < 0.001). The most common PIM were PPI (36% of patients), piracetam (17.2%) and alprazolam (16.80%). Conclusions The risk of PIM was almost 9.5 times higher if polypharmacy was present in geriatric patients (OR 9.51, 95% CI, 4.86 - 18.61, p < 0.001). There was a strong, positive correlation (ρ = 0.65) between the number of drugs and the number of PIM (p < 0.01). There was neither association between age/gender of patient and polypharmacy; nor age/gender of patient and presence of PIM. The lack of geriatricians and national guidelines for inappropriate prescribing results in alarmingly high use of PIM in the Slovak Republic.

Polypharmacy: A general review of definitions, descriptions and determinants

Polypharmacy is considered as the administration of many drugs. It is a major public health concern, which is growing worldwide. The identification of polypharmacy relies on drug count on a given time window. Polypharmacy exists if this count exceeds a predefined threshold. Although there is no consensus among scientists, five is the most frequently used number. Depending on the time-windows, polypharmacy can be qualified as simultaneous, cumulative, or continuous. Drugs can be selected according to the duration or the recurrence of their use thereby introducing the concept of chronic polypharmacy. This general review aimed to compile data from the literature regarding descriptions and determinants of polypharmacy, according to used definitions and studied populations. The prevalence of polypharmacy varied according to the definition used (from 4% to 57%). It was high in elderly people but was also non negligible in younger subjects such as middle aged. Cardiovascular, digestive and metabolism drugs were among the most frequent drugs involved in polypharmacy. The determinants of polypharmacy included factors linked to the patient (sociodemographic parameters such as age, sex, income, and place of residence, ethnicity, behaviour), factors linked to the disease (certain diseases such as cardiovascular or metabolic disease, multiple comorbidity status), as well as factors linked to the healthcare system or to the physician. Finally, to date, little data is available regarding polypharmacy appropriateness, although these data are needed to have clinically important information beyond a quantitative estimation. Further research is warranted to fill this gap.

Polypharmacy and injurious falls in older adults: a nationwide nested case-control study

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.