Polypharmacy and prescribing quality in older people.

Division of Geriatrics, San Francisco Veterans Affairs Medical Center, and Department of Medicine, University of California at San Francisco, California 94121, USA.
Journal of the American Geriatrics Society (Impact Factor: 3.98). 11/2006; 54(10):1516-23. DOI: 10.1111/j.1532-5415.2006.00889.x
Source: PubMed

ABSTRACT 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.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Pharmacotherapy in the elderly is very complex owing to age-related physiologic changes, the presence of multiple comorbidities, the use of multiple medications, the involvement of multiple prescribers and pharmacies, and an increased prevalence of cognitive deficits. The treatment of cancer and the management of symptoms related to therapy-induced toxicity significantly add to this complexity, with an increased risk of drug interactions, using potentially inappropriate medications (PIMs), and adverse drug reactions. There are several ways to evaluate inappropriate prescribing, with various levels of support for their use. We review the most widely used. Older adults are more susceptible than younger ones to chemotherapy toxicity, and may require dose modifications. Before starting therapy, the goals of care should be clearly defined and the general state of the patient should be assessed using some form of geriatric evaluation. Changes in the pharmacokinetics of the drugs related to aging and the possibility of end-organ dysfunction must be taken into consideration, particularly the age-related decline of glomerular filtration rate that is not always reflected by an increase in serum creatinine. The treatment plan for the older adult needs to be carefully defined in order to prevent adverse events, and allow the patient to benefit from treatment without a major impact on quality of life.
    Clinical advances in hematology & oncology: H&O 05/2014; 12(5):309-318.
  • [Show abstract] [Hide abstract]
    ABSTRACT: To analyze the prescription profile and the factors associated with multiple medications (polypharmacy) and non-adherence in patients with advanced chronic diseases. Longitudinal cross-sectional study including 41 Spanish hospitals (PALIAR project). Polypharmacy was defined as a prescribed treatment with five or more drugs, and excessive polypharmacy when the number was ten or more. The adherence was evaluated using a questionnaire completed by the patients or their caregivers. Description of drug prescription profile and analysis was performed on the risk factors associated with multiple medications and non-adherence. The study included 1847 patients, and 1778 (96.2%) completed the questionnaire. Mean age was 78.74±10 years. Antihypertensives (82.6%), gastroprotectives (73.8%), anti-platelets/anticoagulants (70.3%), and psychotropic drugs (51.8%) were the most frequently prescribed drugs. Prevalence of polypharmacy/excessive polypharmacy was 86.2%/31.3%, with a mean of 8±3.5 drugs per patient. Errors in treatment compliance were detected in 48.2% of patients, but 38.5% and 9.6% referred to an occasional or almost daily failure, respectively. Factors associated with non-adherence were: to be a patient with multiple diseases, cognitive impairment, three or more 3 hospital admissions in the last three months, and having polypharmacy. Factors associated with polypharmacy were: to be a patient with multiple diseases, an ECOG score <3, age <85 years, and 3 or more hospital admissions. Factors associated with excessive polypharmacy were: to be a patient with multiple diseases and previous frequent hospital admissions. The prevalence of polypharmacy in patients with advanced chronic diseases is high, and mistakes in treatment compliance are frequent. Further studies with better defined objectives and more specific therapeutic limits are needed.
    Revista Española de Geriatría y Gerontología 03/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: Poor adherence may have a major impact on clinical outcome, contributing to substantial worsening of disease, increased health care costs and even death. With increasing numbers of medications, low adherence is a growing concern, seriously undermining the benefits of current medical care. Little is known about medication adherence among older adults living at home and requiring complex medication regimens. The aim of this study was to describe adherence to drug prescriptions in a cohort of elderly patients receiving polypharmacy, discharged from an internal medicine ward. A sample of elderly patients (65 years of age or older) discharged from an internal medicine ward in Italy throughout 2012 were enrolled. They were followed for 3 months after discharge with a structured telephone interview to collect information on drug regimens and medication adherence 15-30 days (first follow-up) and 3 months (second follow-up) after discharge. Demographic variables including age, sex, marital status and caregiver were collected. Among 100 patients recruited, information on medication adherence was available for, respectively, 89 and 79 patients at the first and second follow-ups. Non-adherence was reported for 49 patients (55.1 %) at the first follow-up and for 55 (69.6 %) 3 months from discharge. Voluntary withdrawal of a drug and change of dosage without medical consultation were the main reasons for non-adherence at both follow-ups. The number of drugs prescribed at discharge was related to medication non-adherence at both follow-up interviews. No association was found between age and non-adherence. Only 25 patients (28.1 %) at the first follow-up and 20 (25.3 %) at the second understood the reasons for their medications. Low medication adherence is a real, complex problem for older patients receiving polypharmacy. We found that the increasing number of drugs prescribed at hospital discharge is correlated to non-adherence and a high percentage of patients did not understand the purpose of their medications. Simplification of drug regimens and reduction of pill burdens as well as better explanations of the reason for the medications should be targets for intervention.
    Drugs & Aging 03/2014; · 2.50 Impact Factor


Available from