Central nervous system (CNS) medications and polypharmacy in later life: cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA)

Polypharmacy in atrial fibrillation: A prospective analysis of mortality and ischemic stroke using the Clinical Practice Research Datalink

Background

Observational studies of polypharmacy and the risk of death or stroke in individuals with atrial fibrillation (AF) have produced inconsistent findings. By using propensity score matching (PSM) and Cox regression, this study aimed to determine whether polypharmacy (five to nine medicines) in the 3 months following AF diagnosis, is associated with an increased risk of death or ischemic stroke, compared to non-polypharmacy (one to four medicines).

Methods

A prospective cohort study using data from the Clinical Practice Research Datalink (2006-2019). Data from 23 629 individuals with AF were analyzed. Cox regression models were adjusted for age, gender, morbidities, obesity, alcohol, smoking, and wealth. In the PSM models, cases and controls with near identical health profiles were selected from the study pool. The risk of death and stroke were presented as hazard ratios (HRs) with 95% confidence intervals (CIs).

Results

68.9% (n = 16 271) of the participants had polypharmacy. PSM showed that polypharmacy was associated with an increased risk of death during follow-up (HR 1.32; 95% CI: 1.19-1.47, p < .01), but not ischemic stroke (HR 0.84; 95% CI: 0.69-1.02, p = .08).

Conclusion

Polypharmacy was associated with an increased risk of death during follow-up, but not ischemic stroke, in individuals with AF. The effects of comorbidity and other confounding factors were reduced by using PSM. This study focused on the overall medication burden; however, further research is needed to identify which specific medications in polypharmacy regimens increase the risk of mortality in AF. These findings could inform prescribing practices in the future.

Are there socioeconomic inequalities in polypharmacy among older people? A systematic review and meta-analysis

BACKGROUND

Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual's socioeconomic status.

METHODS

A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study.

RESULTS

Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories.

CONCLUSIONS

There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.

Drugs utilization profile in England and Wales in the past 15 years: a secular trend analysis

BACKGROUND

Medication use assessment has a critical role in promoting the effective and rational use of pharmaceutical medications. There are no studies that have explored the utilization of all medications in England and Wales in the past 15 years without restrictions in the age group being studied or class of medications.

AIM

To explore the medication utilization pattern of dispensed medications in England and Wales in the past 15 years.

METHOD

A secular trend analysis study using publically available dispensing data on the population level in England and Wales for the duration between 2004 and 2019. Medication dispensing data was extracted from the Prescription Cost Analysis database.

RESULTS

Medication prescriptions rate increased by 42.6% [from 1,345,095.75 (95% CI 1,345,004.25 - 1,345,187.26) in 2004 to 1,918,138.48 (95% CI 1,918,038.38 - 1,918,238.57) in 2019 per 100,000 persons, trend test, p < 0.001]. During the study period, the most common medication prescriptions were for the cardiovascular system, central nervous system, and endocrine system, which accounted for 30.2%, 18.8%, and 9.4%, respectively. The rate of medication prescriptions for skin, immunological products and vaccines, infections, and musculoskeletal and joint diseases decreased by 18.4%, 15.8%, 9.8%, and 5.7%, respectively.

CONCLUSION

The last two decades have witnessed a remarkable rise in the quantity of medications dispensed in community settings. Utilization of chronic disease medications has increased in the past 15 years, specifically, dispensed medications for the cardiovascular system, central nervous system, and endocrine system. It is necessary to conduct additional cohort studies to investigate the clinical outcomes and prescribing safety of these medications.

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.

An Update on Medication Use in Older Adults: a Narrative Review

PURPOSE OF REVIEW

The global phenomenon of population aging is impacting the health and care needs of society. The use of medications by older adults is acknowledged to be the most common form of medical intervention for many acute and chronic conditions and prescribing in this population continues to increase. In this narrative review, we summarise the age-related factors that should be considered when prescribing for older adults, address some of the perennial challenges related to medicine use in older people, and highlight important emerging research in this area.

RECENT FINDINGS

A range of age-related factors should be considered when prescribing for older adults. However, the evidence base still lacks data pertaining to older adults due to their continued under-representation in clinical trials. Multimorbidity, polypharmacy, and inappropriate prescribing continue to remain prevalent among older adults, although recent research has been focused on the development and evaluation of complex interventions to address these challenges.

SUMMARY

Further high-quality studies of interventions to improve and support medication use in older adults are needed, ensuring that older adults are well represented in such trials and consideration is given to the measurement of patient- and provider-focused outcomes.