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4 © 2019 Indian Journal of Community and Family Medicine | Published by Wolters Kluwer - Medknow
Prevalence of polypharmacy: Comparing the status of Indian
states
Priya Sharma1, N. L. Gupta2, H. S. Chauhan1
1Centre for Public Health and Healthcare Administraon, Eternal University, 2Department of Psychology, Eternal University, Baru Sahib,
Himachal Pradesh, India
Perspective
Introduction: The word “poly” is Greek and means many or much. However, the term polypharmacy has
been given definitions connected both to the use of more than a certain number of drugs concomitantly
and to the clinical appropriateness of drug use. Polypharmacy is the use of multiple medications by a
patient, generally older adults (those aged 60 or over 65 years). More specifically, it is often defined
as the use of 5 or more regular medications. It sometimes alternatively refers to purportedly excessive
or unnecessary prescriptions. The term polypharmacy lacks a universally consistent definition with an
increasing share of population in this age group, it is natural to expect an increase in the problems
associated with them as well. Health problems are supposed to be the major concern of this section
of the society, and it is reported that use of medications has increased significantly among the elderly
in the last decade.
Objective: The objective of this study is to assess the prevalence of polypharmacy among elderly patients
in different Indian states, to make a comparison, and also to study the patterns of polypharmacy and its
associated aspects.
Materials and Methods: Literature review comprising of original articles, reviews, and case studies was
studied to identify articles which correspond to research done on polypharmacy in various different
ways published between the years 2010 and 2018. As the review focuses on the geriatric population, so
considerable data were searched and collected for the use of medication in geriatrics to assess what makes
them prone to polypharmacy, what pattern of polypharmacy they follow, and how they are affected by the
consequences.
Results: Uttaranchal, Karnataka, and Telangana reported a higher level of polypharmacy with 93.14%, 84.6%,
and 82.8%, respectively, whereas Andaman and Nicobar Islands (2%) and West Bengal (5.82%) showed the
lowest polypharmacy.
Conclusion: Overall comparisons made show that there are more studies needed to assess the level of
polypharmacy and ways and measures should be incorporated by the government in states showing high
polypharmacy.
Keywords: Cascade, elderly, India, polytherapy, states
Abstract
Address for correspondence: Dr. Priya Sharma, Centre for Public Health and Healthcare Administraon, Eternal University, Baru Sahib,
Himachal Pradesh, India.
E‑mail: priyasharma2022.ps@gmail.com
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DOI:
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How to cite this article: Sharma P, Gupta NL, Chauhan HS. Prevalence of
polypharmacy: Comparing the status of Indian states. Indian J Community
Fam Med 2019;5:4-9.
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Sharma, et al.: Polypharmacy status in indian states
Indian Journal of Community and Family Medicine | Volume 5 | Issue 1 | January-June 2019 5
INTRODUCTION
Elderly population is increasing worldwide. In India, the
size of elderly population is fast growing; from 5.6% in
1961, it is projected to rise to 12.4% of the population by
the year 2026.[1] India has witnessed a remarkable growth
in the life expectancy in the last century. In the early
1930s, the average life expectancy of an Indian adult was
only 32 years. Against a global average life expectancy of
75 years, currently, the life expectancy in India is about
67 years. The life expectancy in India is expected to reach
75 years by 2025. Further, the United Nations projections
indicate that elderly Indian population will rise to 21.2%
of the total by 2055 (from 7.2% estimated in 2005).
This increase in life expectancy may be one of the most
signicant achievements of Indian health-care system. At
the same time, it also poses a major public health issue.
With the increase in the aging population, the drug-related
problems have also increased. The health-care needs of
this growing population are based on the presence of
age-related diseases, increase in the chances of hospital
admissions, longer hospital stays, and more extensive drug
therapies.[2] In India, an estimated 50% of elderly people
suffer from at least one chronic disease that requires
lifelong medication.[3] The term “elderly” or “geriatrics”
refers to a population with a chronological age of >65 years
in most of the developed nations, while this does not
adapt very well to the underdeveloped or developing
nations. The United Nations thus recommends no standard
numerical criterion but agreed a cutoff of >60 years as
elderly population. In January 1999, the Government of
India adopted the “National Policy on Older Persons” by
which “senior citizen” or “elderly” is dened as persons
who are of the chronological age of 60 years or above.
Based on the 2011 census, the number of the elderly living
in India is 103.8 million (10.38 crores), which corresponds
to 8.6% of the total population. Polypharmacy as such
has no standard denition but is generally referred as
taking multiple medications together usually 5 or more
per day and/or administration of more medications than
that are clinically warranted, indicating unnecessary or
unwanted drug use. High level of polypharmacy is dened
as intake of 10 or more drugs.[4] Although polypharmacy
is practiced quite often, there is a lack of consensus
denition for polypharmacy. It is also not known as to the
concurrent use of how many medications are considered
as polypharmacy. Different thresholds have been used to
assess polypharmacy. Some of the authors use thresholds
of 3, 4, 5, or 10 medications to evaluate polypharmacy.
This denition is solely based on the count of medications
irrespective of clinical indications and conditions suffered
by the patient.[5]
Rationale
Elderly population constitute nearly 8% of the total
Indian population. However, this segment of population
is neglected in almost all the aspects of life. They are social
sufferers and are major victims of compromised health.
With this review, we will be able to assess the level of
polypharmacy that is prevalent among elderly population
in different states as the comparison will help the respective
states to improve their insights and focus on this segment
of population. The generated data of this study can then
be utilized in various programs to take adequate measures
to reduce adverse effects of polypharmacy. There should
be concern given to the optimal use of medication and to
improve the good communication among elderly patients
and health providers.
MATERIALS AND METHODS
Literature review comprising of original articles, reviews,
and case studies was studied to identify articles which
correspond to research done on polypharmacy in various
different ways published between the years 2010 and
2018 to give priority to the freshness of the article
as the most recent data will provide the best results.
Furthermore, the focus was laid on the work and data
pertaining to research done on this subject in the elderly.
Effort was put in to at least have data of one study from
each state, but some states were found to be having no
work on polypharmacy. Literature review was also done
to understand the general concept of polypharmacy
and the associated causes. Reference lists of the most
relevant articles were separated from the gray literature
and were sorted to identify other relevant articles. The
search strategy was developed in consultation with the
coauthors with a predetermined protocol for methods
to search and select relevant articles. The studies done
specically showing the prevalence of polypharmacy
were chosen and analyzed, and useful material was then
extracted from the collected material according to the
need of this review.
Data extraction
Data items extracted included the definition of
polypharmacy and associated causes and the prevalence
of polypharmacy in different states. The studies conducted
in different states were searched and compiled individually.
Later, these articles were studied and screened, and
then, the most similar articles were considered for nal
inclusion in the review. Once the primary data extraction
was complete, all authors reviewed the content for each
of the extracted studies, and later, the data were further
summarized in Table 1.
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Sharma, et al.: Polypharmacy status in indian states
6 Indian Journal of Community and Family Medicine | Volume 5 | Issue 1 | January-June 2019
Causes of polypharmacy
• An aging population with comorbidities requiring
several different medications and an increasing
availability of newer medications
• Patients self-medicating with over-the-counter
medications and herbal preparations without a clear
understanding of the adverse reactions and interactive
effects
• A “prescribing cascade” which occurs when patients take a
medication and exhibit side effects that are misinterpreted
by the health-care practitioner as symptoms of a disease
and requiring additional medication
• The patient sees several physicians and lls prescriptions
at different pharmacies, but there is a failure to keep
all parties informed about each other’s actions
• Ineffective communication and coordination between
health-care practitioners result in redundancy.[18]
RESULTS
The data above in the tabulation form shows the prevalence
of polypharmacy in various Indian states. It reveals the
range of medicines taken by the individuals mostly above
four which further goes upto the range of ten and in some
states even more than 10.
DISCUSSION
Although it is stated in literature that the use of even one
medicine which is not indicated by a practitioner is also
considered polypharmacy, most of the studies have taken
the use of >5 medicines as polypharmacy. Thus, this
review takes into account the use of 5 or more medications
as the base for dening polypharmacy. However, the
criteria for polypharmacy differed in all the studies with
respect to demographic variables. There was a considerable
amount of difference in prevalence rates depending on the
type of study, institution-based study, or community-based
study, but to maintain homogeneity of this review, the
most matching relevant available material was included
to understand the general prevalence and trend of
polypharmacy in Indian states. It was understood from the
literature that maximum studies related to the prevalence
of polypharmacy were done in southern states of India.
Thus, in states such as Bihar, Chhattisgarh, Haryana,
Meghalaya, Mizoram, Nagaland, Orissa, Rajasthan, Sikkim,
Jharkhand, Chandigarh, Dadra and Nagar Haveli, Daman
and Diu, and Delhi, Lakshadweep showed no relevant
data in relation to the prevalence of polypharmacy in the
literature studied.
The study done by Pandey and Saharan shows that the
prevalence of polypharmacy is 4.2% among the elderly
in India. Saldanha et al. revealed that the prevalence of
polypharmacy was 84.6% and the prevalence of high-level
polypharmacy was 11.1%.[12,25]
The study done by Kumar et al., 2015, revealed that
the prevalence of polypharmacy was 73.93%; among
this, minor polypharmacy (2–4 drugs) accounted
for 81.15% and major polypharmacy (≥5 drugs) for
18.85%. Mean (±standard deviation SD) number of
medication taken was 2.57 (±1.47), while the study done
by Dhanapal et al. revealed that out of 502 prescriptions,
61 (11.73%) prescriptions were minor polypharmacy and
457 (88.26%) prescriptions were major polypharmacy.
Furthermore, Radhika et al. revealed that polypharmacy
was observed in 82.8% and 5–8 drugs were prescribed
for most of the patients (42.6), followed by >8
drugs (40.2%). These studies showed dissimilarity to the
study conducted by Mohammad et al. which shows that
of 1003 prescriptions, 403 (40.18%) prescriptions were
found to be of minor polypharmacy and 600 (59.82%)
prescriptions were of major polypharmacy.[3,4,18,26]
Table 1: Comparison among the states in reference to
polypharmacy prevalence
State Region Study done by Prevalence (%)
Andhra Pradesh Kadapa Srikanth and
Sireesha, 2012[6]
40.77
Assam Guwahati Borah et al., 2017[7] 78
Goa GMC, Goa Khandeparkar and
Rataboli, 2017[8]
13.85
Gujarat Anand Shah et al., 2012[9] 52
Himachal
Pradesh
Kangra Priya et al., 2018[10] 33.7
J&K Jammu Gupta et al.,
2018 [11]
53.13
Karnataka Bangalore Saldanha et al.,
2 017 [12]
84.6
Kerala Kochi Rajeev et al.,
2018 [13]
22.9
Madhya
Pradesh
Bhopal Rambhade et al.,
2 012 [14]
8.73
Maharashtra Wardha Agrawal and
Nagpure, 2018[15]
26
Punjab SAS Nagar Kashyap et al.,
2 016 [16]
5 7. 9
Tamil Nadu Elayampalayam Tamilselvan et al.,
2018 [17]
43
Telangana Mahbubnagar Radhika et al.,
2018 [18]
82.8
Tripura Agartala Chakraborty et al.,
2 017 [19]
6.81
Uttaranchal Dehradun Singh et al., 2017[20] 93.14
Uttar Pradesh Bareilly Shalini and Joshi,
2 012 [21]
25.20
West Bengal Kolkata Indu et al., 2018[22] 5.82
Andaman and
Nicobar Islands
Andaman and
Nicobar
Vardhan et al.,
2 017 [23]
2
Pondicherry Pondicherry Kanagasanthosh
et al., 2015[24]
16.5
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Sharma, et al.: Polypharmacy status in indian states
Indian Journal of Community and Family Medicine | Volume 5 | Issue 1 | January-June 2019 7
The study done by Raut et al., 2013, revealed that
polypharmacy was observed in almost all cases, wherein
45% were prescribed 11–15 drugs and 32% patients were
with 6–10 drugs per prescription. Romana et al. study
showed that 18% of the patients received six drugs, 24%
of the patients received seven drugs, 20% of the patients
received eight drugs, and 38% of the patients received nine
drugs or >9 drugs.[27,28]
Battula et al. concluded that polypharmacy was observed
based on the number of drugs prescribed in each
participant and found that the average number of drugs
for prescription was found to be 9.92 ± 0.53 (95%
confidence interval). Polypharmacy was categorized
into four types (no polypharmacy [0–2 drugs], minor
polypharmacy [3–5 drugs], major polypharmacy [6–9
drugs], and excessive polypharmacy [≥10 days]). It was
found that 48% (n = 101) of participants had excessive
polypharmacy, 42% (n = 89%) had major polypharmacy,
and 10% (n = 21) had minor polypharmacy. This showed
similarity to the studies conducted by Harugeri et al.
and Joy et al. which revealed that polypharmacy and
high-level polypharmacy were prescribed in 366 (45.0%)
and 370 (45.5%) patients and the prevalence of poly
pharmacy and potentially inappropriate medication use
was 41% (n = 51) and 51% (n = 63), respectively. Shah
et al. revealed that polypharmacy and high polypharmacy
were prevalent in 52% and 23.25% of patients, respectively.
This showed similarity to the studies of Kashyap et al.
and Gupta et al., with 57.9% and 53.13% of geriatrics,
respectively.[9,11,16,29-31]
Another study done by Agrawal and Nagpure revealed
that ≤4 number of drugs were prescribed to 74%
population, 5–9 number of drugs were prescribed to 25%
population, and 10–14 number of drugs were prescribed
to 1% population.[15]
Manjaly et al. revealed that 73.3% of patients were subject
to polypharmacy. The mean number of medications
consumed per day by the patients in the study group was
6.7 ± 3.1. This showed similarity to the study conducted
by Rathnakar et al. in which polypharmacy of 4 or more
drugs was found in 71.77% of prescriptions. Rakesh
et al. revealed that around 66.19% of patients were
receiving polypharmacy. A signicant number of patients
were receiving drugs which are to be avoided as well as
overprescribed and underprescribed.[32-34]
The study done by Kanagasanthosh et al. revealed that a total
of 1769 drugs were prescribed, giving an average of 2.98
drugs per person (range: 1–9). Polypharmacy (≥5 drugs)
was observed in 99 patients. Sehgal et al. revealed that a
total of 312 patients were on polypharmacy (5 or more
medications at the time of admission). The study done by
Khandeparkar and Rataboli revealed that the total number
of drugs per prescription ranged from minimum of 5 to
maximum of 16 drugs, with an average of 7.96 ± 1.75.
A large number of 596 prescriptions contained 6–9
drugs per prescription. Chakraborty et al. revealed that
90.9% of patients were on <6 medications, while 6.81%
and 2.27% of the patients were on 6–10 medications
and >10 medications, respectively. Vardhan et al. revealed
that the most number of prescriptions were containing 3
drugs accounting for 2360 (61%) prescriptions, followed
by 1120 (29%) prescriptions with 4 drugs, followed by
300 (8%) prescriptions with 2 drugs and the least number
were of prescriptions containing >4 drugs with 72 (2%)
prescriptions, and all these prescriptions were containing
at least 1.[8,18,23,24,35]
Nandagopal et al. revealed polypharmacy in geriatric
patients, with an average number of drugs per prescription
being 7.02. This deviates from the WHO standards of
1.6–4.8. Polypharmacy unfortunately is very common
in India and some other countries. It results in increased
cost of treatment, which may lead to nonadherence by
patients as they have more medicines than they can cope
with. It also increases the risk of signicant adverse drug
interaction.[36]
CONCLUSION
Polytherapy is often mandatory in the management of most
of the common ailments affecting geriatric patients. Drug
prescription in the elderly is a serious challenge as there
is an increased possibility of drug interaction resulting in
toxicity, treatment failure, or loss of drug effect. Duplicative
prescribing within the same drug class often occurs, and
unrecognized drug side effects are treated with more
drugs. To minimize polytherapy, periodic evaluation of
patients’ drug regimen is necessary. Prescribers need to
know what other prescriptions patient is taking including
herbs and teas. The small number of drugs in low doses
with a simple regimen is good for drug therapy in the
elderly. A signicant proportion of hospitalized geriatric
patients are exposed to substantial polypharmacy. Further
researches are required to identify the risk of adverse
drug effects following multiple drug administration and
specific potential drug–drug interaction. It would be
pertinent to develop country-specic list of medications
inappropriate for the elderly and include this list in national
drug formularies so as to reduce their prescription and use
in this age group.[37,38]
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Sharma, et al.: Polypharmacy status in indian states
8 Indian Journal of Community and Family Medicine | Volume 5 | Issue 1 | January-June 2019
Recommendations
There are few studies in the predictors of polypharmacy
among the elderly in India. With this review, the gross idea
of the level of polypharmacy that is prevalent among the
elderly population in India is assessed. The generated data
of this review can be utilized in various programs to take
adequate measures to reduce its adverse effects and misery
to the elderly. There should be concern given to the optimal
use of medication and to improve the good communication
among elderly patients and health providers. Findings of the
review will be helpful for the programs and policymakers,
researchers, academician, and social workers who are
working in the eld of health and geriatrics.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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