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102 .&%"3)tORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
ORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly
Patients
Alma Alic1, Nurka Pranjic2, Enisa Ramic3
Educational Center of Family Medicine, Primary Health Care Center Zenica, Bosnia and Herzegovina1
Department of Occupational Medicine, Medical Faculty, University of Tuzla, Tuzla, Bosnia and Herzegovina2
Educational Center of Family Medicine, Primary Health Care Center Tuzla, Bosnia and Herzegovina3
Goal: To estimate the prevalence of poly pharmacy and poly pharmacy
eect on decline in cognitive abilities of randomly selected group of
people over 65. Methodology: A preliminary pilot study was based
on the results of other researchers. 54 patients over 65 were randomly in-
terviewed. Poly pharmacy was dened as using ≥3 drugs. “A short portable
mental status questionnaire“ was used in estimating decline of cognitive abili-
ties. Results: According to the study results it was concluded that prevalence
of poly pharmacy by the elderly is signicant–48.1%. Most present drugs are
the ones treating cardiovascular disease, anti diabetic, anti-inammatory
drugs, long acting benzodiazepines, antihistamines. Of the total respondents
33.3% of them live alone and do not have adequate supervision. We have
found that poly pharmacy resulted in decline of cognitive abilities in 23 of
54 patients tested in rapid mental status check. Conclusion: It is necessary
to conduct future research on this issue. K : ,
, .
Corresponding author: Alma Alic, MD, Health center Zenica, Zenica, Talica brdo 8a, B&H. E-mail:dralic@yahoo.com
1. INTRODUCTION
Today there is a higher prevalence of
symptomatic treatment than the caus-
ative, and the clinical signs are atypical,
so poly therapy or polypharmacy is in-
evitable. Unfort unately, very often at yp-
ical symptoms that are complains of ge-
riatric patients are signs of adverse reac-
tions to medications. Polypharmacy in
patients is almost a regular occurrence,
adherence to guidelines on pharmaco-
therapy in dicult, often using com-
plicated schemes, drug dosing inter-
vals are dierent, thus further increas-
ing the risk of ineciencies and dier-
ent side eects (1). In aging organism
certain bodily functions are reduced.
erefore, a therapy that was preventa-
tive and rational can be obsolete in ge-
riatric patients (>65 years) (2). Elderly
patients are often inadequately treated
even with the condition that they have
the correct diagnosis. Predisposing fac-
tors are psychological changes associ-
ated with agi ng, and multiple patholog-
ical conditions requiring complex drug
therapy (3). Geriatric patients generally
have a number of dierent diseases and
symptoms. ey have prescribed dier-
ent medications sometimes even for the
natural signs of aging. at is the rea-
son that the symptoms and the disease
eventually do not respond to treatment.
For example, edema due to cardiovas-
cular disease may not require medica-
tion if a person loses weight or is not
subject to the same physical eort as
before (4, 5).
Polypharmacy (lat. polypragmasia)
is the administration of multiple med-
ications together (2, 6, 7, 8, 9). e ag-
ing process aects the systemic eect
of drugs in humans: slows down the ab-
sorption, metabolism and elimination
of drugs which can delay the beginning
of eective action. Due to the decline of
renal function there is reduced elimi-
nation, and increased accumulation and
toxicity of the drug especially after tak-
ing repeated doses (4). ere are more
and more new drugs and the spread
of unapproved indications. It’s getting
harder to know the toxicology of the
drug and/or drug-drug interactions (6).
Consumption of drugs in older pa-
tients is proportionally higher accord-
ing to their proportion in the popula-
tion. In Sweden on the total population,
the prevalence of elderly persons was
8%, and they use 25% of all prescribed
drugs (7, 8, 9). It turned out that 90% of
the elderly take at least one drug. Out-
patients taking the average of three
drugs, and residents of homes for the
elderly even eighth most commonly
prescribed drugs for senior gastroin-
testinal diseases, cardiovascular dis-
eases, analgesics, anti-rheumatic and
anti-depressants. e use of these drugs
increases with age (9, 10). ere was a
statistically signicant relationship be-
tween the number of drugs used by the
women and increased risk of side eects
103
.&%"3)tORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
(10). Approximately 10-14% of geriatric
patients are hospitalized because of ad-
verse reactions (11). Sometimes there is
classic oversight so unrecognized side
eects impute disease and prescribe a
new drug. Because of unnecessary new
therapies patients are exposed to the
risk of new side eects. Sometimes it
is unfortunate that the patient suers
from side effects for months, which
gradually leads to functional disability
(12). It is simila r with drug interactions.
e number of interactions increases
with the number of drugs (13, 14).
Two of the common mental status
changes in geriatric patients are de-
mentia or cognitive decline and depres-
sion. Today it is estimated that more
and more dierent types of neuropsy-
chiatric disorders exist among the el-
derly. Changes in mental status may
have long-lasting eect on elderly pa-
tients and their families (15). e term
dementia, namely dementia syndrome
denotes a complex disorder of dierent
cognitive activities to reect changes
in the normal function of the human
brain. Dementia is characterized by
deterioration of previously acquired
mental functions, which lead to reduc-
tion of or inability to perform daily ac-
tivities. is is one of the most serious
disorders that aect people of third age
(16). It is characterized by weakening of
memory and reducing the functiona lity
usually in two or more areas of cogni-
tion. ere may be various changes in
behavior, indierence, inaction, or ir-
ritability. Mood swings are often pres-
ent, sometimes as apathy or depres-
sion or inappropriately elevated mood.
It should be said that the emergence
of mild forgetfulness do not automati-
cally mean dementia. Forgetfulness is
not always a sign of illness, so if it over
6 months does not worsen is not on the
initial degree of dementia (16, 17). Lack
of cognitive function due to dementia is
important to the extent that aects the
physical and social function of the pa-
tient and its relations with others (18).
Elderly people often suer from de-
pression, and that their environment
does not notice because they do not
connect their symptoms with a mental
illness. Most often complain of phys-
ical problems such as problems with
digestion, headaches, joint pain, mus-
cle and back pain. Detailed examina-
tion and questions about sleep distur-
bance, loss of appetite, concentration,
memory, and to a lesser extent due to
pr evio us ac tivit y i s de tecte d by reduced
motivation and depression. Depression
is more common in the elderly with
a prevalence of 20%. ere is greater
number of complications including in-
ability to care for themselves and their
own health. More common is the de-
velopment of psychotic symptoms and
the number of completed suicides (15).
e eect of any medication on the
patient’s electrolyte prole may contrib-
ute to changes in mental status (19-21).
Elderly patients are more susceptible to
common therapeutic concentrations of
benzodiazepines. Barbiturates, phenyt-
oin, and benzodiazepines are the cause
of deterioration of some basic human
abilities: concentration, mental energy,
mood and memory. For benzodiaze-
pines was conrmed causality of an-
terograde amnesia (22). After cimeti-
dine was rst used in the treatment of
peptic ulcer treatment have been pub-
lished reports about the eects of a drug
to chang e th e co gn itiv e st atus w hen the
drug is used in large doses (23). It was
conrmed that the adverse reaction of
beta-blockers is mental depression, and
barbiturates can cause confusion and
decrease cognitive abilities (21, 22, 23)
(Table 1). Ever since the introduction
of reserpine in 1950 it was clear that
it empty the depot of catecholamine
and serotonin and can cause depres-
sion (4,19).
is study was undertaken as a re-
search of this complex public health
problem of polypharmacy that can if
preventive actions are not taken, to
signicantly reduce the quality of life
of geriatric patients and their families.
Polypharmacy can be a major cause of
irreparable damage and lead to dimin-
ishing functional ability and indepen-
dence of elderly patients. is is because
the polypharmacy resulting in decline
of cognitive ability and depression. A
special task of this study was to assess
the current situation.
2. METHODS
Randomly were interviewed 54 pa-
tients-respondents, age >65 years, of
both sexes in the family medicine clinic
“Potok” in the Primary Health Care
Center Zenica i n the period f rom April
1st 2010 until May 1st 2010. e subjects
are regularly treated in the above clinic
and were using a dierent number and
types of medications. Factor in the se-
lection and comparability among the
respondents was polypharmacy. Poly-
pharmacy (lat.polypragmasia) is the
administration of multiple medica-
tions together. It means unjustified,
often found prescription drugs more
safely without present indications and
the likelihood that the patient will of-
ten have unwanted and toxic eects in
the interaction of these drugs (1). It is
estimated that older patients were sub-
jected to polypharmacy to a greater ex-
tent than necessary, so we wanted to
verify this hypothesis (2).
Design and research instruments
In the design of the research task
was to create and record lists of the
most commonly used drugs from 1-10
for each patient, record their prepara-
tions, body mass index-BMI, dose of
drugs used and the signature of the used
drugs. In the design of the research is
used a survey that contained additional
question s about living condition s (a lone
or in a family environment), on the
use of vitamins and other products for
self medication, alcohol consumption,
smoking, morbidity, disease history and
content of everyday activities. e sam-
ple was distributed to collect relevant
data on polypharmacy (the use of ≥ 3
drugs in tested population), treatment
and other relevant factors of impor-
tance for the study of medical records
in family medicine teams. Finally made
are two groups (those who use less than
three drugs and a group of patients with
three or more regularly used drugs) in
both groups was carried out Short Por-
table Mental Status Questionnaire. e
Short Portable Mental St atus Question-
naire-SPMSQ for the assessment of the
reduction of mental capacity in elderly
patients (25). e questionnaire was
completed by a health worker team se-
lected doctor, and does not require the
patient to ll out the questionnaire so it
can be applied to patients with physical
defects or for patients of limited mobil-
ity. Data on population and mental dis-
orders in geriatric patients have been
used by the projections of the Federal
104 .&%"3)tORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
Bureau of Statistics of B&H. Register-
ing of the disease was made according
to the tenth revision of International
Classication of Diseases, Injuries and
Causes of Death (ICD-10). Statisti-
cal analysis is done by the standard
tests of descriptive statistics with mea-
sures of central tendency and disper-
sion. Quantitative variables are tested
by Student t-test if they were normally
distributed or Mann-Whitney-test if
they were distributed asymmetrically.
Qualitative variables are tested by chi-
square test with continuity correction.
All tests were leveled with the level of
statistical signicance of 95% (p<0.05).
3. RESULTS
e population of B&H is an older
society, which is conrmed by the de-
mographics of increasing the participa-
tion of elderly in total population since
1961 until 2003 (3.5%, 15.4%). Partic-
ipation of elderly in the total popula-
tion was 15.4% (Table 2). Leading men-
tal disorders of the elderly people in the
FB&H are shown in Table 3. e most
common disorders are depression and
neurotic disorders, stress related (39%),
aective disorders (27%), dementia (5%)
and others. In the sample of randomly
selected 54 patients who regularly
come into the family medicine clinic
for check-ups, age >65 years (accord-
ing to their regular therapy), and pos-
sibly as patients with some new prob-
lems, there were 36 female and 18 male
patients (Table 4). ere was a statisti-
cally signicant dierence in partic-
ipation of women compared to men
(P=0.001). Within polypharmacy (with
three or more drugs used) were 26 pa-
tients, of which with 3 regularly taken
drugs were 17 patients, and 9 were us-
ing more than 3 drugs (Table 5). Of the
total number of patients who received
po ly pha rmac y 19 o f th em u se d 2 d ru gs,
ve were using 1 medication and only
4 patients were not generally used any
regularly used therapy.
From the most commonly used
drugs were drugs for treatment of car-
diovascular diseases, antidiabetic, long-
acting benzodiazepines, anti-inam-
matory drugs (results not shown but are
comparable with Table 1). Out of the to-
tal number of respondents 36 living in
the family environment (house or at),
and 18 of them living alone (Table 6).
After analysis of results from Short
Portable Mental Status Questionnaire,
we found a signicant decline in cog-
nitive abilities in patients with poly-
pharmacy. Decline in cognitive abili-
ties is observed in 23 of 54 patients. In
tested group median functional demen-
tia scale was 30 with interquartile rang-
ing from 26 to 40, while in the control
group was 28 with interquartile range
of 24 to 37. is dierence was not sta-
tistically signicant (Mann-Whitney
test, Z=1.67, p=0.010) between groups.
4. DISCUSSION
In the treatment of elderly patients
should seek the correct diagnosis, from
which is derived a rational pharmaco-
therapy based on the guaranteed min-
imum number of eective drugs with
known side eects. Many of the dis-
eases from which suer patients of so
called elderly age cannot be treated
with medication. e same dose may
have due to individual characteristics
different effects in different patients.
Inter or even intra individual variations
are often much more pronounced. Doc-
tors must be aware of the origin of these
variations to prescribe safe and eective
medicines. Variations can be caused by
dierent concentrations of the drug at
Illness or health
disorder Drugs Effect
Cognitive
disorder
Barbiturates, anticholinergics (Atropine, Benytropine,
Benzhexol) Antihistamines, anticonvulsants (Phenitoin,
Carbamazepine, Clonazepam, Valproate, Vigabatrin),
Antiparkinsonics (Amanatadine, L-dopa, bromocriptine),
drugs for heart diseases (beta-blockers, Digoxin,
Theophzlline, diuretics, hypotension medications), anti-
INÞAMMATORYÙDRUGSÙ.3!)$ÙSTEROIDS
sympathomimetics (Ephedrine, amphetamine),
antispasmoic medications, Muscle relaxants, Antibiotics,
Antineoplastic agents, cimetidine, ranitidine, lithium,
stimulants of the central nervous system (CNS):
dextroamphetamine (Adderall), methylphenidate (Ritalin),
methamphetamine, pemolin
Causes a
change in the
effects on CNS
Depression
Long-acting benzodiazepines, simphatolitic agents:
methyldopa (Aldomet), reserpine, guanethidine (Ismelin),
hormones, cytostatics, steroid anti-rheumatics, drugs for
arthritis
Can initiate the
development
of depression
or facilitate
recurrent
depression
Table 1 Drugs that may have an adverse reaction to a high degree of risk in mental status and decline in
cognitive abilities in geriatric patients
Year percent of elderly in the population
1961 3.5%
2003 15.4%
Table 2 Population aged over 65 years in Bosnia
and Herzegovina in the period 1961-2003.
Mental disorders
Percent
of mental
disorders
depression and neurotic
disorders related to stress 39%
affective disorders 27%
dementia 5%
Table 3. Leading mental disorders in FB&H in
2008.
Gender No. Percent
M 18 33.4%
F 36 66.6%
Table 4 Distribution of respondents by gender
Patients in poly pharmacy (> or
= 3 drugs)
No. of
patients
3 regularly taken medications 17
> 3 drugs taken 9
Patients who are not in poly
pharmacy (<3 drugs)
2 regularly taken medications 19
1 regularly taken medication 5
Do not use drugs 4
Table 5. Distribution of respondents by number of
drugs used daily
Patient lives Number of patients
Alone 18
In family 36
Table 6 Distribution of respondents by way of
living: alone or in family
105
.&%"3)tORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
the site of action or dierent responses
to the same drug concentration. e
rst type of variations is pharmacoki-
netic, which arise due to dierences in
resorption, dist ribution, metaboli sm and
excretion. e second type is the phar-
macodynamic (1, 2, 3, 4). Important fac-
tors responsible for variations in the ef-
fects of the drug were: ethnic origin, age,
pregnancy, genetic factors, idiosyncrasy
reactions, disease and interactions be-
tween drugs (4, 22, 26). e main rea-
son that age inuences the eect of the
drug is the fact that the elimination of
the drug is less eective in newborns
and the elderly, and drug causes long-
lasting and powerful eect in these age
groups (14). Some pathological factors
such as hypothermia, which is common
in older people, also change the eect of
the drug. e composition of body u-
ids vary with age, adipose tissue is in a
higher percentage of body mass, and all
this leads to changes in the volume of
drug d istribution. e elderly take more
medications t han younger people, so the
potential for drug taking is greater (23).
In the Federation of B&H since 1992
until 2008 the structure of the popula-
tion has greatly changed because of war
casualties in these areas. Killed was 250
000 people, 17 000 are missing and 2.2
million people were running f rom their
homes. However, older adults showed
an increasing trend (27).
Irrational and inappropriate is the
provision of more therapeutic agents
for which there is no evidence of the
usefulness of the treatment. Rational
drug therapy reduces the number of
unwanted interactions, but the pub-
lic pressure in terms of poly therapy,
polypharmacy in fact, is stronger. It is
not easy to resist therapeutic evange-
lism, which often comes from non-crit-
ical circles of experts. Using more than
three dr ugs pose a signicant risk factor
for the occurrence of adverse reactions
in elderly people. To assess that risk a
family doctor (family doctor and nu rse)
must pay special attention to drugs that
a patient is taking. Should always be
carefully evaluated, which drugs are
introduces in the last 4 weeks. Often
we forget to ask for drugs that are used
without prescription or herba l remedies
that can also cause adverse reactions:
sedatives, hypnotics, anxiolytics, espe-
cially long-acting benzodiazepines–di-
azepam (24).
As there is no justication to treat
every symptom of disease, so there is no
justication, for example, at the same
time to prescribe two drugs from the
same group. Older people usually take
4-5 medications daily. Sometimes it
comes to more than 6 dierent drugs
during the day, so the range is 3-12
drugs (3). It is necessary in the elderly
to seek the simplest possible applica-
tion of medicines, because some condi-
tions can have completely non-specic
symptoms. In particular, the patience
is necessary to communicate with pa-
tients, especially in older people who
have a fear that they will not under-
stand and remember the most impor-
tant (4). N ea rly thre e qua rt ers of e lde rly
people ta ke on their own initiative med-
ications that are not prescribed (5). Av-
erage number of prescribed drugs per
person increased from 67% in middle-
aged persons to 12.8% in those aged 65
and over (11). As a rule, older people
are more sensitive to the application
of conventional doses of drugs used in
middle age, but among them also un-
wanted drug reactions (side eects) and
drug poisoning is more frequent (4,28).
5. CONCLUSION
Health status, health needs and
functioning of the elderly population
varies considerably in relation to other
population groups. To estimate the risk
of adverse reactions that are harmful to
mental health by family practitioners
(doctors and nurses) need to pay spe-
cial attention to drugs that a patient is
taking. Always be careful to evaluate
the drug included in treatment during
the last four weeks. Often we forget to
ask for drugs that are used without pre-
scription or herbal remedies that can
also cause adverse reactions: sedatives,
hypnotics, anxiolytics especially long-
acting benzodiazepines-diazepam (24).
Overall, the treatment of older patients
is complex and rating of pharmacother-
apy was not an easy task. For success-
ful drug therapies, the key question is
in individual approach to every geriatric
patient. To successfully accomplish the
task, doc tor prescribing the medication
must be well acquainted with all the
benecial and harmful eects of each
drug (7-8). General Geriatric Question-
naire for future research should include
assessment of polypharmacy severity,
rapid questionnaire to assess cognitive
abilities decline, symptoms and signs of
geriatric depression, BMI records, and
questions about confounding variables,
smoking, alcohol and self-medication.
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