Polypharmacy and Prescribing Quality in Older People

Department of Medicine, University of California, San Francisco, San Francisco, California, United States
Journal of the American Geriatrics Society (Impact Factor: 4.57). 11/2006; 54(10):1516-23. DOI: 10.1111/j.1532-5415.2006.00889.x
Source: PubMed


To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients.
Cross-sectional study.
Veterans Affairs Medical Center.
One hundred ninety-six outpatients aged 65 and older who were taking five or more medications.
Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses.
Mean age was 74.6, and patients used a mean+/-standard deviation of 8.1+/-2.5 medications (range 5-17). Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative. Medication underuse was observed in 125 patients (64%). Together, inappropriate use and underuse were simultaneously present in 82 patients (42%), whereas 25 (13%) had neither inappropriate use nor underuse. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate.
Inappropriate medication use and underuse were common in older people taking five or more medications, with both simultaneously present in more than 40% of patients. Inappropriate medication use is most frequent in patients taking many medications, but underuse is also common and merits attention regardless of the total number of medications taken.

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Available from: Charles Seth Landefeld, Feb 20, 2015
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    • "Polypharmacy may be necessary to properly manage certain diseases (Aronson, 2006). However, it can also indicate over-and inappropriate prescribing (Steinman et al., 2006), exposing patients to risks of drug interactions and adverse drug reactions (ADRs) (Hanlon et al., 2006). Polypharmacy has also been highlighted as a major determinant of poor medication adherence in the elderly (Vik et al., 2004), although studies have found specific medications like tamoxifen are better adhered to by those with polypharmacy (Barron et al., 2007). "
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    DESCRIPTION: Among community-dwelling people aged over 50 in Ireland, 69% report taking medications regularly. The median number of medications taken regularly in the over 50s is 2, in the over 65s is 3 and in the over 75s is 4. One in five of those over 50 years regularly take five or more medications (i.e. polypharmacy). Polypharmacy potentially puts the ageing population at greater risk of inappropriate prescribing, non-adherence and adverse drug reactions. This report examines the prevalence and associations with polypharmacy for the population aged 50 years or more in 2010. In addition it presents an analysis of the potential cost savings of generic substitution for those who take five or more medicatiosn regularly (polypharmacy)
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    • "In addition, medications are sometimes prescribed at inappropriately high doses or for longer time periods than recommended [34]. In the study by Steinman et al. [17], involving 196 community-dwelling seniors aged ‡ 65 years who were prescribed ‡ 5 medications daily, 65% were using ‡ 1 inappropriate medications; 57% were taking medications that were ineffective, not indicated, or therapeutically duplicative; and 37% were taking medications considered to be inappropriate according to the Beers criteria. A meta-analysis of 19 studies, 14 of which used the Beers criteria to assess appropriateness, found that majority of prescriptions given to older persons could be considered inappropriate [35]. "
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    ABSTRACT: Abstract The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug-drug or drug-disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.
    Postgraduate Medicine 12/2014; 127(3):1-8. DOI:10.1080/00325481.2014.996112 · 1.70 Impact Factor
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    • "Our study demonstrated that polypharmacy is associated with the under-prescribing of indicated medicines even when adjusting for age, gender and co-morbid conditions. Similar findings have been reported in other studies, particularly those with co-morbid conditions [24, 25]. However, these findings warrant further investigation. "
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    ABSTRACT: We sought to estimate the prevalence of potentially inappropriate prescriptions (PIP) and potential prescribing omissions (PPOs) using a subset of the STOPP/START criteria in a population based sample of Irish adults aged ≥65 years using data from The Irish LongituDinal Study on Ageing (TILDA). A subset of 26 PIP indicators and 10 PPO indicators from the STOPP/START criteria were applied to the TILDA dataset. PIP/PPO prevalence according to individual STOPP/START criteria and the overall prevalence of PIP/PPO were estimated. The relationship between PIP and PPOs and polypharmacy, age, gender and multimorbidity was examined using logistic regression. The overall prevalence of PIP in the study population (n = 3,454) was 14.6 %. The most common examples of PIP identified were NSAID with moderate-severe hypertension (200 participants; 5.8 %) and aspirin with no history of coronary, cerebral, or peripheral vascular symptoms or occlusive event (112 participants; 3.2 %). The overall prevalence of PPOs was 30 % (n = 1,035). The most frequent PPO was antihypertensive therapy where systolic blood pressure consistently >160 mmHg (n = 341, 9.9 %), There was a significant association between PIP and PPO and polypharmacy when adjusting for age, sex and multimorbidity (adjusted OR 2.62, 95 % CI 2.05-3.33 for PIP and adjusted OR 1.46, 95 % CI 1.23-1.75 for prescribing omissions). Our findings indicate prescribing omissions are twice as prevalent as PIP in the elderly using a subset of the STOPP/START criteria as an explicit process measure of potentially inappropriate prescribing and prescribing omissions. Polypharmacy was independently associated with both PPO and PIP. Application of such screening tools to prescribing decisions may reduce unnecessary medication, related adverse events, healthcare utilisation and cost.
    European Journal of Clinical Pharmacology 02/2014; 70(5). DOI:10.1007/s00228-014-1651-8 · 2.97 Impact Factor
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