Factors associated with polypharmacy in elderly home‐care patients

Aim

Polypharmacy, which is often observed in elderly patients, has been associated with several unfavorable outcomes, including an increased risk of potentially inappropriate medications, medication non‐adherence, drug duplication, drug–drug interactions, higher healthcare costs and adverse drug reactions. A significant association between polypharmacy and adverse outcomes among older people living in the community has also been confirmed. A reduction in the number of medications should thus be pursued for many older individuals. Nevertheless, the factors associated with polypharmacy in elderly home‐care patients have not been reported. Here, we investigated those factors in elderly home‐care patients in Japan.

Methods

We used the data of the participants in the Observational Study of Nagoya Elderly with Home Medical investigation. Polypharmacy was defined as the current use of six or more different medications. We carried out univariate and multivariate logistic regression analyses to assess the associations between polypharmacy and each of several factors.

Results

A total of 153 home‐care patients were registered. The mean number of medications used per patient was 5.9, and 51.5% of the patients belonged to the polypharmacy group. The multivariate model showed that the patients’ scores on the Charlson Comorbidity Index and the Mini‐Nutrition Assessment Short Form were inversely associated with polypharmacy, and potentially inappropriate medication was most strongly associated with polypharmacy (odds ratio 4.992).

Conclusions

The present findings showed that polypharmacy was quite common among the elderly home‐care patients, and they suggest that home‐care physicians should prescribe fewer medications in accord with the deterioration of home‐care patients’ general condition. Geriatr Gerontol Int 2018; 18: 33–41 .     

Polypharmacy: Misleading,but manageable

The percentage of the population described as elderly is growing, and a higher prevalence of multiple, chronic disease states must be managed concurrently. Healthcare practitioners must appropriately use medication for multiple diseases and avoid risks often associated with multiple medication use such as adverse effects, drug/drug interactions, drug/disease interactions, and inappropriate dosing. The purpose of this study is to identify a consensus definition for polypharmacy and evaluate its prevalence among elderly outpatients. The authors also sought to identify or develop a clinical tool which would assist healthcare practitioners guard against inappropriate drug therapy in elderly patients. The most commonly cited definition was a medication not matching a diagnosis. Inappropriate was part of definitions used frequently. Some definitions placed a numeric value on concurrent medications. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication. The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use. A structured approach to identify and manage inappropriate polypharmacy is suggested and a clinical tool is provided.     

Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction

BackgroundComplex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States.MethodsWe conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition.ResultsThe prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition.ConclusionIn addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.     

Polypharmacy prevalence among older adults based on the survey of health,ageing and retirement in Europe

Polypharmacy, a common condition among the elderly, is associated with adverse outcomes, including increased healthcare costs, due to higher mortality, falls and hospitalizations rates, adverse drug reactions, drug–drug reactions and medication nonadherence. This study aims to evaluate the prevalence and factors related to polypharmacy in older adults across 17 European countries, plus Israel.In this cross-sectional analysis, we used data from participants aged 65 or more years from Wave 6 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) database. Polypharmacy was defined as the concurrent use of five or more medications. Age, gender, education, physical inactivity, number of limitations with activities of daily living, network satisfaction, quality of life, depression, number of chronic diseases and difficulty taking medication variables were found to be associated with polypharmacy.Our results showed a prevalence of polypharmacy ranging from 26.3 to 39.9%. Switzerland, Croatia and Slovenia were the countries with the lowest prevalence, whereas Portugal, Israel and the Czech Republic were the countries where the prevalence of polypharmacy was the highest. Age, gender, number of limitations with activities of daily living, number of chronic diseases, quality of life, depression, physical inactivity, network satisfaction, difficulty in taking medications, years of education and shortage of money were significant variables associated with polypharmacy.Polypharmacy is a highly prevalent condition in the elderly population. Identification of variables associated with polypharmacy, such as those identified in this study, is important to identify and monitor elderly groups, which are most vulnerable to polypharmacy.     

Recommendations for outcome measurement for deprescribing intervention studies

Interpreting results from deprescribing interventions to generate actionable evidence is challenging owing to inconsistent and heterogeneous outcome definitions between studies. We sought to characterize deprescribing intervention outcomes and recommend approaches to measure outcomes for future studies. A scoping literature review focused on deprescribing interventions for polypharmacy and informed a series of expert panel discussions and recommendations. Twelve experts in deprescribing research, policy, and clinical practice interventions participating in the Measures Workgroup of the US Deprescribing Research Network sought to characterize deprescribing outcomes and recommend approaches to measure outcomes for future studies. The scoping review identified 125 papers reflecting 107 deprescribing studies. Common outcomes included medication discontinuation, medication appropriateness, and a broad range of clinical outcomes potentially resulting from medication reduction. Panel recommendations included clearly defining clinically meaningful medication outcomes (e.g., number of chronic medications, dose reductions), ensuring adequate sample size and follow-up time to capture clinical outcomes resulting from medication discontinuation (e.g., quality of life [QOL]), and selecting appropriate and feasible data sources. A new conceptual model illustrates how downstream clinical outcomes (e.g., reduction in falls) should be interpreted in the context of initial changes in medication measures (e.g., reduction in mean total medications). Areas needing further development include implementation outcomes specific to deprescribing interventions and measures of adverse drug withdrawal events. Generating evidence to guide deprescribing is essential to address patient, caregiver, and clinician concerns about the benefits and harms of medication discontinuation. This article provides recommendations and an initial conceptual framework for selecting and applying appropriate intervention outcomes to support deprescribing research.     

Rehabilitation pharmacotherapy: A scoping review

Many patients in rehabilitation facilities are affected by polypharmacy. Polypharmacy is associated with rehabilitation outcomes and functional recovery. Consequently, a combination of rehabilitation and pharmacotherapy may improve the outcomes of older people undergoing rehabilitation. A recent report described the concept of rehabilitation pharmacotherapy. The concept envisages helping frail older people and people with disabilities to achieve the highest possible body function, activity level and quality of life. There are two key tenets of rehabilitation pharmacotherapy: “pharmacotherapy in consideration of rehabilitation” and “rehabilitation in consideration of pharmacotherapy.” “Pharmacotherapy in consideration of rehabilitation” includes use of drugs to treat impairment, activity limitation and participation restriction based on the International Classification of Functioning, Disability, and Health. “Rehabilitation in consideration of pharmacotherapy” refers to tailoring of rehabilitation considering the content of pharmacotherapy. With respect to drugs and motor dysfunction, anticholinergic drugs are associated with dysphagia and fractures. Increased use of potentially inappropriate medications may adversely affect the nutritional status. With respect to activities of daily living, polypharmacy and use of potentially inappropriate medications negatively affect the improvement in motor function during rehabilitation. Potent anticholinergic drugs are more likely to impede the improvement in cognitive function. In this review, we address the concept of rehabilitation pharmacotherapy and discuss its importance from the perspective of polypharmacy, the effect of drugs on disability and disease, nutritional status and activities of daily living. Geriatr Gerontol Int 2020; 20: – .     

Polypharmacy and potentially inappropriate medications among elderly patients in the geriatric department at a single-center in China: A retrospective cross-sectional study

The aging of the population has become a worldwide concern, especially in China. Polypharmacy and potentially inappropriate medications (PIMs) are prominent issues in elderly patients. Therefore, the aim of this study was to investigate the prevalence of polypharmacy and PIMs in older inpatients and further to explore the factors associated with PIM use.A retrospective, single-center, cross-sectional study was conducted. A total of 1200 inpatients aged 65 years or older admitted from January 2015 to December 2015 were included. The prevalence of polypharmacy (5–9 medications) and hyperpolypharmacy (10 or more medications) was calculated. The 2019 American Geriatric Society Beers criteria were applied to assess PIMs use. Multivariate logistic regression was used to determine the independent factors of PIM use, while zero-inflated negative binomial regression was performed to evaluate the relationship between polypharmacy and PIM use.The median age of the study population was 76 years (interquartile range = 71–81). The median number of medications was 9 (interquartile range = 7–12). 91.58% of the patients took 5 or more medications simultaneously, and 30.08% of the patients were subjected to one or more PIMs. Spironolactone, furosemide, and zopiclone were the top 3 most frequently encountered PIMs. Hyperpolypharmacy and older age were identified as independent factors associated with PIM use. The risk of PIMs rises with the number of medications prescribed.Polypharmacy and PIM use were common in our study, and the risk of PIM use correlated with an increase in the number of medications already prescribed.     

Organization of care for persons with HIV-infection: a systematic review

The objective of this systematic review was to examine the effectiveness of the organization of care: case management, multidisciplinary care, multi-faceted treatment, hours of service, outreach programs and health information systems on medical, immunological, virological, psychosocial and economic outcomes for persons living with HIV/AIDS. We searched PubMed (MEDLINE) and 10 other electronic databases from 1 January 1980 to April, 2012 for both experimental and controlled observational studies. Thirty-three studies met the inclusion criteria. Eleven studies were randomized controlled trials (RCTs), three of which were conducted in low–middle income settings. Patient characteristics, study design, organization measures and outcomes data were abstracted independently by two reviewers from all studies. A risk of bias tool was applied to RCTs and a separate tool was used to assess the quality of observational studies. This review concludes that case management interventions were most consistently associated with improvements in immunological outcomes but case management demonstrates no clear association with other outcome measures. The same mixed results were also identified for multidisciplinary and multi-faceted care interventions. Eight studies with an outreach intervention were identified and demonstrated improvements or non-inferiority with respect to mortality, receipt of antiretroviral medications, immunological outcomes, improvements in healthcare utilization and lower reported healthcare costs when compared to usual care. Of the interventions examined in this review, sustained in-person case management and outreach interventions were most consistently associated with improved medical and economic outcomes, in particular antiretroviral prescribing, immunological outcomes and healthcare utilization. No firm conclusions can be reached about the impact of any one intervention on patient mortality.     

Renin-angiotensin-aldosterone system (RAAS) pharmacogenomics: implications in heart failure management

Blockade of the renin–angiotensin–aldosterone system (RAAS) with ACE inhibitors has been a cornerstone of heart failure therapy for over 15 years. More recently, further blockade of RAAS with aldosterone antagonists and angiotensin receptor blockers (ARBs) has been studied. While these therapies have certainly improved outcomes in the treatment of heart failure, morbidity and mortality remain extremely high. Furthermore, polypharmacy and complex regimens of seven medications on average is the norm for management of heart failure. This results in increased costs, patient burden, and uncertainty as to the best course of therapy. The ability to personalize patients’ therapeutic regimens using pharmacogenomics has the potential of providing more effective and efficient use of RAAS-modulating medications. This review highlights the implications of major RAAS pharmacogenetic studies, while outlining future directions for translation to practice.     

Multidisciplinary Team Deprescribing Intervention for Polypharmacy in Elderly Orthopedic Inpatients: A Propensity Score-matched Analysis of a Retrospective Cohort Study

Objective This study evaluated the effectiveness of a multidisciplinary team deprescribing intervention to reduce polypharmacy and potentially inappropriate medications (PIMs) in elderly orthopedic inpatients. Methods In this single-center retrospective observational study, orthopedic inpatients ≥75 years old and prescribed ≥6 different medications were enrolled as participants. Interventions comprised multidisciplinary team-led polypharmacy screening and suggestions regarding deprescribing any unnecessary medications during hospital stays. The primary outcome was reduction in the mean number of regular medicines and PIMs. Secondary outcomes included falls, delirium, and other adverse events during hospitalization as well as emergency department visits or unplanned hospital admissions within six months after discharge. Results After propensity score matching, 184 patients (intervention group, n=92; control group, n=92) were included in the analysis. The mean patient age was 83 years old. The mean number of prescribed medications and PIMs at admission were similar in both groups. The mean change in the number of regular medicines was -1.4 [standard deviation (SD), 2.3] in the intervention group and +0.2 (SD, 1.8) in the control group (p<0.001). The mean change in the number of PIMs was -0.5 (SD, 0.9) in the intervention group and +0.1 (SD, 0.8) in the control group (p<0.001). In-hospital adverse events other than falls and delirium were significantly less common in the deprescribing intervention group than in the control group. Conclusion Deprescribing intervention by our multidisciplinary team seems to have been effective in reducing the number of prescribed medicines and PIMs in elderly orthopedic inpatients, with some accompanying reduction in certain adverse events.     

Suboptimal prescribing in older inpatients and outpatients

Investigators searched Medline and HealthSTAR databases from January 1, 1985 through June 30, 1999 to identify articles on suboptimal prescribing in those age 65 years and older. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. The definitions for various types of suboptimal prescribing (polypharmacy, inappropriate, and underutilization) are numerous, and measurement varies from study to study. The literature suggests that suboptimal prescribing is common in older outpatients and inpatients. Moreover, there is significant morbidity and mortality associated with suboptimal prescribing for these older patients. Evidence from well-controlled studies suggests that multidisciplinary teams and clinical pharmacy interventions can modify suboptimal drug use in older people. Future research is necessary to measure and test other methods for tackling this major public health problem facing older people.     

Combining Quality Improvement and Geriatrics Training: The Nursing Home Polypharmacy Outcomes Project

To examine sustained effects of an educational intervention, the authors repeated a successful quality improvement (QI) project on medication safety and cost effectiveness. In October 2007 and August 2008, the facility leadership and geriatrics faculty identified all patients receiving nine or more medications (polypharmacy cohort) in a 170-bed teaching nursing home. They then taught Geriatric Medicine fellows (n = 12 in 2007, 11 in 2008) to (a) systematically collect medication data; (b) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers criteria) or drug–drug interaction programs; (c) discuss recommendations with patients’ attending physicians; and (d) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio [OR] = .78, 95% confidence interval [95% CI] [0.69, 0.88], p < .001), contraindicated medications (OR = .63, 95% CI [0.47, 0.85], p = .002) and medication costs (OR = .97, 95% CI [0.96, 0.99], p < .001). Findings suggest that programs planning educational QI projects for trainees may benefit from a multiyear approach to maximize clinical and educational benefits.     

Advancing the Science of Deprescribing: A Novel Comprehensive Conceptual Framework

Polypharmacy is common in older adults and associated with inappropriate medication use, adverse drug events, medication nonadherence, higher costs, and increased mortality compared with those without polypharmacy. Deprescribing, the clinically supervised process of stopping or reducing the dose of medications when they cause harm or no longer provide benefit, may improve outcomes. Although potentially beneficial, clinicians struggle to overcome structural, organizational, technological, and cognitive barriers to deprescribing, limiting its use in clinical practice. Deprescribing science would benefit from a unifying conceptual framework to prioritize research. Current deprescribing conceptual frameworks have made important contributions to the field but often with a focus on specific medication classes or aspects of deprescribing. To further this relatively nascent field, we developed a broader deprescribing conceptual framework that builds on prior frameworks and includes patient, prescriber, and system influences; the process of deprescribing; outcomes; and dissemination. Patient factors include patients' biology, experience, values, and preferences. Prescriber factors include rational (eg, based on explicit knowledge) and nonrational (eg, behavioral tendencies, biases, and heuristics) decision making. System factors include resources, incentives, goals, and culture that contribute to deprescribing. The framework separates the deprescribing decision from the deprescribing process. The framework captures the results of deprescribing by examining changes in clinical structures, performance processes, patient experience, health outcomes, and cost. Through testing and refinement, this novel, more comprehensive conceptual framework has the potential to advance deprescribing research by organizing the existing evidence, identifying evidence gaps, and categorizing deprescribing interventions and the settings in which they are applied. J Am Geriatr Soc 67:2018–2022, 2019     

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

BACKGROUND: Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. METHODS: This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. RESULTS: This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. CONCLUSIONS: This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.