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 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.     

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.     

Overcoming problems with polypharmacy and drug misuse in the elderly.

Polypharmacy, the inappropriate use of multiple drug regimens, has a significant impact on the health of elderly individuals. Drug use increases with age, but suitability of therapy is sometimes difficult to define. In ambulatory and hospital care, there is some documentation of poor prescribing practices by physicians and drug misuse by patients. Sound data suggest that polypharmacy and drug misuse are highly prevalent in long-term care facilities. Psychotherapeutic agents are the most commonly misused drugs by physicians in this setting. Polypharmacy is associated with factors such as the number and severity of illnesses, hospitalization, number of physicians seen, number of pharmacies used, and possibly increased patient age. Methods to prevent polypharmacy and drug misuse have not been well studied. There is a need for intensive research to define effective methods to strengthen prescribing practice of physicians for elderly patients, to promote cooperation among health care personnel in ensuring optimal drug use by patients, and to enhance the role of patients as responsible partners in drug therapy. The authors are confident, however, that drug misuse and polypharmacy can be reduced in older persons by the use of current knowledge of risk factors associated with polypharmacy and by improved communication between the physician and patient.     

Prevalence of polypharmacy and associated factors among patients living with HIV infection in Spain: The POINT study

PurposeSurvival in people living with HIV (PLWH) has increased and thus people are aging with HIV, increasing the frequency of multimorbidity and polypharmacy. This cross-sectional study was conducted to evaluate the prevalence of polypharmacy among PLWH who were on antiretroviral treatment and were followed in an outpatient setting by the pharmacy department of several hospitals across Spain. In addition, we aimed to evaluate factors associated with polypharmacy and treatment complexity among this population.Material and methodsWe recorded information on demographic data, data on disease control including viral load and CD4 count at the time of inclusion, comorbidities, pharmacologic treatment and drugs interactions. Polypharmacy was defined as the use of 6 or more different drugs, including antiretroviral medication; major polypharmacy was defined as the use of ≥11 different drugs.ResultsOverall, 1225 PLWH were eligible in the study. The median (IQR) age was 49 (40–54). Comorbidities were present in 819 (67%) PLWH and 571 (47%) had two or more comorbidities. Overall, 397 (32.4%, 95% CI 29.8–34.9) PLWH met the criteria for polypharmacy, and 67 (5.5%, 95% CI, 4.2–6.7) had major polypharmacy. Several factors were associated with polypharmacy such as type of antiretroviral treatment, presence of potential interactions, the use of several types of medications and the number of comorbidities. Treatment complexity was also a factor strongly associated with polypharmacy; for each point increase in the medication regimen complexity index (MRCI), the likelihood of polypharmacy increased 2.3-fold.ConclusionsPolypharmacy is frequent among PLWH in Spain and contributes to a relevant extent to treatment complexity.     

Outcomes of polypharmacy in nursing home residents

This article provides a comprehensive review of the outcomes of polypharmacy in nursing homes. Our review had some limitations. First, we only included studies beginning in 1990, and significant earlier studies are not included. Only English language articles were included. We only researched studies from MEDLINE, and may have missed studies based on our search terms and search tools. There are many definitions of polypharmacy in the literature, including number of medications or inappropriate medications. In this review, we defined polypharmacy as a high number of medications, but not inappropriate medications. It was not surprising that polypharmacy was consistently associated with an increased number of potentially inappropriate drugs. The majority of studies were viewed showed that polypharmacy was associated with increased ADEs, increased DDIs, and increased hospitalizations. We were surprised that polypharmacy was not consistently linked with falls, fractures, and mortality. For the mortality studies, it has been postulated that perhaps some patients receiving 10 or more medications may have been moribund or receiving end-of-life or hospice care. It is possible that the number of medications is not as important as the number of potentially in appropriate drugs. There need to be more studies on these outcomes, using different definitions of polypharmacy. Polypharmacy was associated with increased costs. The drug-related morbidity and mortality, including those resulting from inappropriate medications and increased staff time, led to increased costs. Use of consultant pharmacists has been shown to decrease polypharmacy costs.     

Cumulative Cardiovascular Polypharmacy Is Associated With the Risk of Acute Kidney Injury in Elderly Patients

Polypharmacy is common in the elderly due to multimorbidity and interventions. However, the temporal association between polypharmacy and renal outcomes is rarely addressed and recognized. We investigated the association between cardiovascular (CV) polypharmacy and the risk of acute kidney injury (AKI) in elderly patients.We used the Taiwan National Health Insurance PharmaCloud system to investigate the relationship between cumulative CV medications in the 3 months before admission and risk of AKI in the elderly at their admission to general medical wards in a single center. Community-dwelling elderly patients (>60 years) were prospectively enrolled and classified according to the number of preadmission CV medications. CV polypharmacy was defined as use of 2 or more CV medications.We enrolled 152 patients, 48% with AKI (based upon Kidney Disease Improving Global Outcomes [KDIGO] classification) and 64% with CV polypharmacy. The incidence of AKI was higher in patients taking more CV medications (0 drugs: 33%; 1 drug: 50%; 2 drugs: 57%; 3 or more drugs: 60%; P = 0.05) before admission. Patients with higher KDIGO grades also took more preadmission CV medications (P = 0.04). Multiple regression analysis showed that patients who used 1 or more CV medications before admission had increased risk of AKI at admission (1 drug: odds ratio [OR] = 1.63, P = 0.2; 2 drugs: OR = 4.74, P = 0.03; 3 or more drugs: OR = 5.92, P = 0.02), and that CV polypharmacy is associated with higher risk of AKI (OR 2.58; P = 0.02). Each additional CV medication increased the risk for AKI by 30%.We found that elderly patients taking more CV medications are associated with risk of adverse renal events. Further study to evaluate whether interventions that reduce polypharmacy could reduce the incidence of geriatric AKI is urgently needed.     

Polypharmacy among people with rheumatoid arthritis: the role of age, disease duration and comorbidity

Background: People with rheumatoid arthritis (RA) often have comorbidities with associated disability and complex medication regimens. Little published evidence exists about why people with RA require so many medications, although it is logical to hypothesize that this may relate to older age, longer duration of RA, more active RA, worse functional disability and a greater number of comorbidities. Objectives: We set out to quantify polypharmacy in RA and identify its predictors in an observational cohort. Methods: The case notes of 348 people receiving secondary care for RA were reviewed to record polypharmacy. The 28-joint Disease Activity Score (DAS28) was calculated and the Health Assessment Questionnaire (HAQ) and the Self-administered Comorbidity Questionnaire (SCQ) were completed. Results: The mean total number of medications was 5.39, with a maximum of 16; of these, a mean of 2.41 medications were directly for RA. A mediational relationship was identified: older age and longer RA duration were significant predictors of a greater total number of medications, but these relationships were explained by the greater number of comorbidities in older participants and those with longer RA duration. Polypharmacy was not related to RA activity or functional disability. Conclusions: Polypharmacy is common among people with RA and associates with older age and longer RA duration through a greater number of comorbidities. Regular review of the full treatment plan of individuals with RA by pharmacists and other health professionals specializing in rheumatology, to weigh the benefits and risks of each medication and their interactions in light of RA activity and comorbidities, is advocated. Copyright © 2007 John Wiley & Sons, Ltd.     

Polypharmacy - we make it worse! A cross-sectional study from an acute admissions unit

Although polypharmacy is a major problem in the elderly, very few data have been published from Australasia. We retrospectively audited 68% of elderly patients admitted acutely to our medical unit (n= 424, mean age 80.3 ± 8 years) during a 30-day period (September, 2008). We found that long-term medications increased during hospital stay from 6.6 ± 4 to 7.7 ± 4 (P < 0.001). Adverse drug reactions were responsible for 24 admissions (5.7%). Polypharmacy is made worse by acute admission to hospital.     

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, adverse drug reactions, and geriatric syndromes

The elderly are at risk for polypharmacy, which is associated with significant consequences such as adverse effects, medication nonadherence, drug-drug and drug-disease interactions, and increased risk of geriatric syndromes. Providers should evaluate all existing medications at each patient visit for appropriateness and weigh the risks and benefits of starting new medications to minimize polypharmacy.     

Polypharmacy and risk of falls and fractures for patients with HIV infection and substance dependence

Although people with HIV infection (PLWH) are at higher risk of polypharmacy and substance use, there is limited knowledge about potential harms associated with polypharmacy such as falls and fractures in this population. The study objective was to determine whether polypharmacy, as measured by the number and type of medication, is associated with falls and fractures among PLWH and DSM-IV substance dependence in the past year or ever injection drug use (IDU). We identified the number of medications by electronic medical record review in the following categories: (i) systemically active, (ii) non-antiretroviral (non-ARV), (iii) sedating, (iv) non-sedating as well as any opioid medication and any non-opioid sedating medication. Outcomes were self-reported (1) fall/accident requiring medical attention and (2) fracture in the previous year. Separate logistic regression models were fitted for medications in each category and each outcome. Among 250 participants, the odds of a fall requiring medical attention were higher with each additional medication overall (odds ratio [OR] 1.12, 95% Confidence Interval [CI]?=?1.05, 1.18), each additional non-ARV medication (OR 1.13, 95%CI?=?1.06, 1.20), each additional sedating medication (OR 1.36, 95%CI?=?1.14, 1.62), and a non-opioid sedating medication (OR 2.89, 95%CI?=?1.06, 7.85) but not with an additional non-sedating medication or opioid medication. In receiver operating characteristic (ROC) curve analyses, optimal cutoffs for predicting falls were: ≥8 overall and ≥2 sedating medications. Odds ratios for fracture in the previous year were OR 1.05, 95%CI?=?0.97, 1.13 for each additional medication overall and OR 1.11, 95%CI?=?0.89, 1.38 for each additional sedating medication. In PLWH and substance dependence or ever IDU, a higher number of medications was associated with greater odds of having a fall requiring medical attention. The association appeared to be driven largely by sedating medications. Future studies should determine if reducing such polypharmacy, particularly sedating medications, lowers the risk of falls.     

Polypharmacy in Palliative Care for Advanced Heart Failure: The PAL-HF Experience

BackgroundPalliative care (PC) in advanced heart failure (HF) aims to improve symptoms and quality of life (QOL), in part through medication management. The impact of PC on polypharmacy (>5 medications) remains unknown.Methods and ResultsWe explored patterns of polypharmacy in the Palliative Care in HF (PAL-HF) randomized controlled trial of standard care vs interdisciplinary PC in advanced HF (N = 150). We describe differences in medication counts between arms at 2, 6, 12, and 24 weeks for HF (12 classes) and PC (6 classes) medications. General linear mixed models were used to evaluate associations between treatment arm and polypharmacy over time. The median age of the patients was 72 years (interquartile range 62–80 years), 47% were female, and 41% were Black. Overall, 48% had ischemic etiology, and 55% had an ejection fraction of 40% or less. Polypharmacy was present at baseline in 100% of patients. HF and PC medication counts increased in both arms, with no significant differences in counts by drug class at any time point between arms.ConclusionsIn a trial of patients with advanced HF considered eligible for PC, polypharmacy was universal at baseline and increased during follow-up with no effect of the palliative intervention on medication counts relative to standard care.     

Characteristics of inappropriate multiple medication use in older urological outpatients

ObjectivesTo investigate polypharmacy and potentially inappropriate medications (PIMs) in elderly patients visiting the urology department for lower urinary tract symptoms (LUTS).MethodsWe retrospectively analyzed digital medical records of individuals over the age of 65 who visited the urology department for LUTS. This cross-sectional study was conducted in 10 hospitals located in South Korea, between September 2017 and December 2017. All prescribed medications were analyzed using electronic medical records. The updated 2015 Beers criteria were used to identify and assess the appropriateness of the prescribed drugs in elderly patients.ResultsWe analyzed a total of 2143 patients aged over 65 years from 10 institutions. The mean age was 74.2 ± 6.26 years (65–97), 1634 (76.2%) were men. Patients took a mean of 6.48 ± 2.46 medications (range 0–18), and polypharmacy was found in 1762 patients (82.2%). The number of patients who received PIMs at least once was 1579 (73.7%). The average number of PIMs used per patient was 1.31 ± 1.25 (0–7). PIM use ratio was 18.9 ± 0.15% (0–67%). The number of chronic diseases, and concurrent medication and polypharmacy were predictive factors associated with PIM use.ConclusionOur multi-institutional results show that a substantial proportion of elderly patients took PIMs when visiting the urology department. Factors associated with PIMs were the number of chronic diseases and polypharmacy. Medication use in elderly patients, especially in urology, should be monitored carefully.     

Rationally decreasing the number of drugs seems to be a useful therapeutic approach in older adults: 6-month follow-up study

AimsOlder adults are at risk for polypharmacy, which has multidimensional safety, clinical and economic implications. Therefore, the optimization of drug therapy is one of the critical components of geriatrics clinical practice. This study is aimed to investigate the effect of drug rationalization on comprehensive geriatric assessment(CGA) parameters.Materials and MethodsThe study was a retrospective and longitudinal study examining the effect of change in drug number on functionality and physical performance. A total of 515 patients were included in the study. Detailed medication history, laboratory findings, CGA parameters were recorded in the first admission. Polypharmacy was accepted as concurrent usage of five or more drugs. Medications of each patient were reviewed with the guidance of CGA and Beers Criteria.ResultsThe mean age of patients was 74.13 ± 7.29 years, and 68.7% were female. The baseline mean number of drugs was 5.11 ± 3.34. The polypharmacy group(269 patients) had a higher rate of geriatric syndromes and lower CGA scores in the first admission. After optimization of medications, the mean drug number decreased to 4.76 ± 2.72. Depression, mobility and nutritional scores improved at the end of six months in the patients whose total number of drugs decreased, while global cognition, activities of daily living scores, and gait speed were preserved. Increasing the number of drugs was associated with lower mobility and functionality.ConclusionDrug rationalization guided with CGA improves the nutritional, physical, and psychosocial status of geriatric patients. Thus, medication reviews have key importance in the management of older patients.