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Polypharmacy and decreased cognitive abilities in elderly patients

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To estimate the prevalence of poly pharmacy and poly pharmacy effect on decline in cognitive abilities of randomly selected group of people over 65. A preliminary pilot study was based on the results of other researchers. 54 patients over 65 were randomly interviewed. Poly pharmacy was defined as using 23 drugs. "A short portable mental status questionnaire" was used in estimating decline of cognitive abilities. According to the study results it was concluded that prevalence of poly pharmacy by the elderly is significant--48.1%. Most present drugs are the ones treating cardiovascular disease, anti diabetic, anti-inflammatory 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. It is necessary to conduct future research on this issue.
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102 .&%"3)tORIGINAL 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
eect 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 dened 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 signicant–48.1%. Most present drugs are
the ones treating cardiovascular disease, anti diabetic, anti-inammatory
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 dicult, often using com-
plicated schemes, drug dosing inter-
vals are dierent, thus further increas-
ing the risk of ineciencies and dier-
ent side eects (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 dierent diseases and
symptoms. ey have prescribed dier-
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 eort as
before (4, 5).
Polypharmacy (lat. polypragmasia)
is the administration of multiple med-
ications together (2, 6, 7, 8, 9). e ag-
ing process aects the systemic eect
of drugs in humans: slows down the ab-
sorption, metabolism and elimination
of drugs which can delay the beginning
of eective 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 signicant relationship be-
tween the number of drugs used by the
women and increased risk of side eects
103
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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
eects impute disease and prescribe a
new drug. Because of unnecessary new
therapies patients are exposed to the
risk of new side eects. Sometimes it
is unfortunate that the patient suers
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 dierent types of neuropsy-
chiatric disorders exist among the el-
derly. Changes in mental status may
have long-lasting eect on elderly pa-
tients and their families (15). e term
dementia, namely dementia syndrome
denotes a complex disorder of dierent
cognitive activities to reect 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 aect 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, indierence, 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 aects the
physical and social function of the pa-
tient and its relations with others (18).
Elderly people often suer 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 eect of any medication on the
patient’s electrolyte prole 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 conrmed 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 eects 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
conrmed 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
signicantly 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 dierent 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 eects 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)tORIGINAL 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
Classication 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 signicance of 95% (p<0.05).
3. RESULTS
e population of B&H is an older
society, which is conrmed 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%),
aective 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 signicant dierence 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-inam-
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 signicant 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 dierence was not sta-
tistically signicant (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 eective drugs with
known side eects. Many of the dis-
eases from which suer 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 eective
medicines. Variations can be caused by
dierent 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)tORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
the site of action or dierent responses
to the same drug concentration. e
rst type of variations is pharmacoki-
netic, which arise due to dierences 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 inuences the eect of the
drug is the fact that the elimination of
the drug is less eective in newborns
and the elderly, and drug causes long-
lasting and powerful eect in these age
groups (14). Some pathological factors
such as hypothermia, which is common
in older people, also change the eect 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 signicant 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 justication to treat
every symptom of disease, so there is no
justication, 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 dierent 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-specic
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 eects) 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
benecial and harmful eects 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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... • The prevalence of PHP was influenced by variables such as age over 80 years, living in the city, high number of chronic diseases, and poor physical performance. Alic et al. (2011) [31] Bosnia and Herzegovina ...
... PHP is one of the important reasons for the high prevalence of unwanted drug side effects in the elderly, which itself leads to malnutrition, dysfunction, falls and fractures, re-hospitalization, and causes death in the elderly. [14,30,31] ...
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A BSTRACT The evaluation of adverse effects caused by poly-pharmacy (PHP) in patients, especially in the elderly group, is very important. The purpose of the present study was to evaluate the prevalence and factors affecting PHP in elderly patients. This study was conducted as a narrative review. Related articles were downloaded using reliable international databases and specialized mesh terms. Finally, the results of 29 articles were extracted based on the authors’ names, study location, sample size, and key results. The findings of the study showed that the prevalence of PHP in the elderly was higher after discharge from the hospital than during hospitalization. In addition, the prevalence of PHP in the elderly who lived in care centers was higher than in those who lived at home. Based on the findings, there was a relationship between the source of obtaining information about drugs and the pattern of PHP consumption. The findings of the present study showed that PHP leads to serious complications in the elderly. Based on the results of the study, it can be concluded that some variables such as age, sex, health level, financial status, place of residence, type of disease, number of simultaneous diseases, hospitalization, duration of hospitalization, level of awareness of the elderly and their caregivers, the care place of elderly, and the number of visits of the elderly to the physician can be effective in the prevalence of PHP. Strategies such as choosing treatment goals for each patient in preventing unnecessary drug use, identifying at-risk groups, and periodically monitoring the benefits and side effects of drugs can be effective in reducing drug complications caused by PHP in the elderly.
... Depression and cognitive disorders, including dementia, are common in aging [12,13]. Most research on PIM has focused on the elderly rather than depression and dementia specifically [14,15]. ...
... Most research on PIM has focused on the elderly rather than depression and dementia specifically [14,15]. Barbiturates, phenytoin, and benzodiazepines are some examples of drug classes that cause deterioration of several basic human abilities: concentration, mental energy, mood and memory [13]. ...
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AIMS: To establish the frequency potentially inappropriate medications use and the associated factors, such as signs and symptoms of depression and cognitive deficit among middle-aged and elderly people.METHODS: A cross-sectional population study was performed with 2,350 people, aged between 55-103 years, registered in the primary health care. Potentially inappropriate medications were defined by updated 2019 Beers criteria. Studied variables were sociodemographic, lifestyle and health, and signs and symptoms of depression and cognitive deficit. Multinomial regression analysis was executed.RESULTS: The frequency of potentially inappropriate medications use was 65.4%. Former and current smokers, regular self-perception of health, polypharmacy, and individuals with signs and symptoms of depression and cognitive deficit were significantly associated with potentially inappropriate medications use. Antiarrhythmics, antihistamines and antiadrenergic agents were the highest potentially inappropriate medications classes used for individuals with signs and symptoms of depression and cognitive deficit.CONCLUSIONS: The frequency of use of potentially inappropriate medications is high among middle-aged people, a population that was previously under-researched, as well as among elderly people. Cognitive impairment alone or together with depression symptoms were associated factor for a potentially inappropriate medications use. Knowledge of the pharmacoepidemiology of potentially inappropriate medications is an important for the promotion of the rational use of drugs in public health.
... Comorbidities were assessed using survey results data on hypertension, diabetes, chronic lung disease, heart disease, liver disease, cerebrovascular disease, cancer, arthritis and rheumatism, psychiatric disorders, prostate disease, urinary incontinence, and eye diseases. Each disease was coded as 1 if diagnosed by a doctor and 0 otherwise, with the total score ranging from 0 to 12. Polypharmacy was defined as taking three or more medications prescribed by a doctor [30], categorized into 0, 1-2, and 3 or more [33]. Body mass index (BMI) was calculated using measured weight and height and categorized as underweight (<18.5), ...
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Background/Objectives: To identify joint trajectories of physical frailty and cognitive impairment among community-dwelling older adults and to determine modifiable factors for each trajectory. Methods: Data were utilized from the Korean Longitudinal Study of Aging, which was conducted between 2006 and 2018. Physical frailty was assessed using the Fried phenotype, and cognitive impairment was evaluated using the Korean version of the Mini-Mental State Examination. Group-based trajectory modeling and logistic regression were employed for the analyses. Results: Based on longitudinal data, 415 participants averaging 72.2 years of age were analyzed. Three trajectories of physical frailty were identified: mild physical frailty, moderate physical frailty, and improving frailty. Two trajectories of cognitive impairment were identified: stable cognitive impairment and improving cognitive impairment. Factors influencing physical frailty trajectories included the number of medications taken, being overweight or obese, and depression. Education level was found to be associated with cognitive impairment trajectories. Conclusions: This study provides evidence for the distinct identification of joint trajectories of physical frailty and cognitive impairment, which can inform the target groups for intervention. It offers a basis for including modifiable physical and mental factors in intervention components for physical frailty trajectories.
... History of accidentally falling asked during the previous year (Blake et al., 1988). Polypharmacy was defined as the concurrent use of 3 or more drugs (Alic et al., 2011;Masnoon et al., 2017). ...
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Investigate the risk factors for frailty in Iranian older adult outpatients. In this cross-sectional study, face-to-face interviews were conducted with 364 outpatients aged 60≥ at a geriatric clinic and health centers. The study included an assessment of demographic characteristics, polypharmacy, Fried Frailty Index, and various parameters from the Comprehensive Geriatric Assessment (CGA), including Geriatric Depression Scale-15 (GDS-15), Abbreviated Mental Test (AMT), Body Mass Index (BMI), Barthel Index for Activities of Daily Living (ADL), and Lawton-Brody Instrumental Activities of Daily Living (IADL). Assessment of other geriatric syndromes involved eye and hearing impairments, incontinency, pain, sleep disorders, fall, and vertigo. Data analysis was conducted using SPSS ver.27.0. A notable correlation was observed between sex, physical dependency, depression, polypharmacy, and BMI with frailty. Several geriatric syndromes including pain, incontinency, eye-impairments, vertigo, falls, and sleep disorders were found to be linked with frailty. The older adults with polypharmacy, hearing-impairment, incontinency, depression, dementia, and pain were shown to have a higher likelihood of developing frailty. Among the Fried Frailty indicators, low grip strength and weight loss in male, slow walking speed in female, and exhaustion in both gender exhibited a significant association with age. The older adults with pain had a 4.39 times higher risk of frailty compared to those without pain (p < 0.001, 95% CI = 2.31-8.36). This study found that frailty was associated with sex, physical dependency, depression, polypharmacy, obesity, and various geriatric syndromes including pain, vertigo, incontinency, falls, sleep disorders, eye and hearing impairment, and polypharmacy in older outpatients.
... The present study defined comorbidity as 2 or more chronic diseases. Polypharmacy refers to the daily use of 3 or more prescription drugs [24]. IADL was assessed using the Korean IADL scale. ...
Article
Background/objectives: Older men who live alone are more vulnerable to poor nutrition. However, little attention has been paid to malnutrition among this population. This study aimed to examine malnutrition and its associated factors among community-dwelling older men living alone. Subjects/methods: This cross-sectional descriptive study used cohort data of community-dwelling older adults living alone in South Korea. A total of 230 older men aged 65 and over were included in this study. Nutritional status was assessed using the Mini Nutritional Assessment-Short Form. Multidimensional factors (sociodemographic, health-related, psychosocial, and lifestyle characteristics) were evaluated. Hierarchical logistic regression analyses were conducted to identify the malnutrition-related factors. Results: The prevalence of malnutrition was 32.2% in older men living alone. Low income (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.01-5.90), polypharmacy (OR, 2.23; 95% CI, 1.16-4.28), suicidal ideation (OR, 2.13; 95% CI, 1.02-4.45), meal skipping (OR, 3.26; 95% CI, 1.60-6.64), and smoking (OR, 2.86; 95% CI, 1.43-5.73) were significantly associated with malnutrition. Conclusion: Malnutrition is a severe health problem in older men living alone. This study highlights the importance of comprehensive and tailored interventions to mitigate malnutrition among older men living alone.
... General and sociodemographic data were provided in the form of descriptive statistics. The chi-square test with the calculation of the prevalence ratio (PR) was performed to assess an association between xerostomia and dysgeusia ( dependent variables) with polypharmacy (independent variable), defined as the use of 3 or more medications 17 . The binomial logistic regression was performed to verify the association between the medications most used by the participants and the presence of xerostomia and dysgeusia. ...
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Xerostomia is defined as the perception of dry mouth, and dysgeusia, as a change in taste. Both are common complaints in the elderly, especially among those making use of polypharmacy drug combinations. Aim: This study aimed to determine the prevalence of xerostomia and dysgeusia and to investigate their association with polypharmacy in the elderly. Methods: older people under follow-up at the Multidisciplinary Elderly Center of the University Hospital of Brasília were interviewed and asked about health problems, medications used, presence of xerostomia and dysgeusia. Descriptive statistics were used to determine the prevalence of the symptoms surveyed. The chi-square test was used to investigate the relationship between xerostomia and dysgeusia and polypharmacy. Secondary associations were performed using binomial logistic regression. Results: Ninety-six older people were evaluated and of these, 62.5% had xerostomia and 21.1%, had dysgeusia. The average number of medications used was 4±3 medications per individual. Polypharmacy was associated with xerostomia but not dysgeusia. It was possible to associate xerostomia with the use of antihypertensive drugs. Conclusion: Xerostomia was a frequent complaint among elderly people making use of polypharmacy, especially those using antihypertensives. Antihypertensives and antidepressants were used most drugs by the elderly and exhibited interactions with drugs most prescribed in Dentistry. Two contraindications were found between fluconazole and mirtazapine; and between erythromycin and simvastatin.
... Furthermore, polypharmacy causes ADRs and drug-drug interactions and negatively affects treatment costs [29,30,31,32]. It has also been noted that polypharmacy causes cognitive problems and is associated with an increased risk of hip fractures [33,34]. ...
... Some of these data show that the prevalence of polypharmacy (defined: ≥ 5 medicines) was found to be 10.4% in seniors in Serbia (Gazibara et al., 2013). Studies in Bosnia and Herzegovina found that this prevalence in population aged ≥ 65 years was 3.6% (Marković-Peković and Škrbić, 2016) and 48.1% (Alic et al., 2011). Another study in this country, found polypharmacy (defined: ≥ 3 medicines) in 74% of the hospitalized patients aged from 45 -50 years (Trumic et al., 2012). ...
Article
Ageing is a multidisciplinary studied process characterized with a gradual increased time of homeostasis and decreased time of reaction and performance. Expected life expectancy is an important measure of a populations’ health status and healthcare system’s performance, which is characterized with a gradual increase in the modern world. This increasing trend changes between different countries and societies, while being affected by several internal, external and behavioral factors. This narrative review analyses and compares the countries of Western Balkans, all of whom classified as middle income countries. Increasing physical activity, avoiding smoking as well as decreasing overweight and obesity present reliable mechanisms to invest in terms of providing a better lifestyle and quality of life. Polypharmacy presents another integral player into this process, which affects and interacts with each and every other factor. Altogether should be taken in consideration in policy makings, healthcare approaches and intervention plans. Keywords: life expectancy, polypharmacy, western Balkan, overweight, obesity
... Benzodiazepines as a drug class have been identified as an independent risk factor for adverse drug effects (Gregg et al., 2016). They can impair cognition, balance and driving ability among community dwelling seniors and can increase the risk of falls (Alic et al., 2011;Gregg et al., 2016;Nana et al., 2015;National Institute of Health, 2015;Rubenstein & Josephson, 2002). The effects of benzodiazepine medications on the elderly patient population are of particular concern given their effects on mobility and driving, and the importance of these two factors in the maintenance of autonomy and independence (Parker et al., 2002). ...
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Aim: The aim of this paper is to discuss the use of benzodiazepine medications among the elderly, and the role of a nurse practitioner within this patient population. Background: Benzodiazepines are well known to have a negative impact on the mobility of elderly patients and to contribute to increased falls. These medications also have an impact on elderly patients’ ability to perform activities of daily living and to drive. Nurse practitioners offer holistic care to elderly patients. This includes prescribing medications, monitoring therapy, deprescribing medications and identifying opportunities for safe alternatives to treat a variety of conditions. Methods: This paper presents a narrative review focused on the effect of benzodiazepine medications on the elderly patient population, with an emphasis on the use of benzodiazepines in insomnia. Conclusions: Findings of this review confirm the known risks associated with the use of benzodiazepines in the elderly and that these medications should be carefully considered in ongoing management. The conclusions of this review support the use of nurse practitioners in the enhancement of the healthcare of the elderly through the continuum of assessment, monitoring, deprescribing of benzodiazepine medications when appropriate, as well as opportunities to implement alternative treatments.
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Objective To investigate comorbidities among hospitalized patients with dementia. Method Data were extracted from the discharge records in our hospital. Comorbidities based on ICD-10 were selected from the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). The distributions of these comorbidities were described in dementia inpatients and age- and sex-matched nondementia controls, as well as in inpatients with Alzheimer’s disease and vascular dementia. A logistic regression model was applied to identify dementia-specific morbid conditions. Results A total of 3355 patients with dementia were included, with a majority of 1503 (44.8%) having Alzheimer's disease, 395 (11.8%) with vascular dementia, and 441 (13.1%) with mixed dementia. The mean number of comorbidities was 3.8 in dementia patients (vs. 2.9 in controls). The most prevalent comorbidities in inpatients with dementia compared with those without dementia were cerebral vascular disease (73.0% vs. 35.9%), hypertension (62.8% vs. 56.2%), and peripheral vascular disease (53.7% vs. 31.2%). Comorbidities associated with dementia included epilepsy (OR 4.8, 95% CI 3.5–6.8), cerebral vascular disease (OR 4.1, 95% CI 3.7–4.5), depression (OR 4.0, 95% CI 3.2–5.0), uncomplicated diabetes (OR 1.5, 95% CI 1.4–1.7), peripheral vascular disease (OR 1.8, 95% CI 1.6–2.0), rheumatoid arthritis collagen vascular disease (OR 1.7, 95% CI 1.3–2.3), and anemia (OR 1.2, 95% CI 1.04–1.3). Some comorbidities suggested a protective effect against dementia. They were hypertension (OR 0.8, 95% CI 0.7–0.9), COPD (OR 0.6, 95% CI 0.5–0.6), and solid tumor without metastasis (OR 0.4, 95% CI 0.3–0.4). Vascular dementia has more cardiovascular and cerebrovascular comorbidities than Alzheimer's disease. Conclusion Patients with dementia coexisted with more comorbidities than those without dementia. Comorbidities (esp. cardio-cerebral vascular risks) in patients with vascular dementia were more than those in patients with AD. Specifically, vascular and circulatory diseases, epilepsy, diabetes and depression increased the risk of dementia.
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1 Škola narodnog zdravlja "Andrija Štampar" 10000 Zagreb, Rockefellerova 4 2 Centar za gerontologiju Zavoda za javno zdravstvo Grada Zagreba – Referentni centar Ministarstva zdravstva i socijalne skrbi Hrvatske za zaštitu zdravlja starijih ljudi 10000 Zagreb, Mirogojska c. 16 Summary The share of the elderly in the overall population of the Republic of Croatia has been continuously growing. The already known diffi culties that western countries have had to face, such as the insuffi cient number of health care providers and the inadequate education in gerontology and geriatrics, have led to the unpreparedness for special needs of elderly patients and have become a major problem in Croatia as well. We are also facing the disappearance of traditional families that were engaged in the care for the elderly to a large extent. The Programme for Defi nition, Monitoring and Studying of Health Needs and Functional Abilities of the Elderly, which is implemented by Centres for Gerontology of County Institutes of Public Health, should be developed and upgraded. The planning of geriatric health care should be suffi ciently fl exible to identify key social trends and development processes, adjust to them and thus be able to adequately meet the health requirements of the elderly in the future. Cooperation of professional associations, public sector and NGOs, as well as best practices applied abroad, should provide a good example. The solutions should be based on a bottom up approach, which is suffi ciently thorough to identify regional, geographical, demographic and economic differences and thus ensure quality and fair health care for everybody. The prerequisites for a successful planning of geriatric health care include the continuous monitoring of indicators, work in the community and the proactive approach of the public sector, primarily health care, social, economic, pension and education systems.
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Croatia is one of the countries that are facing a considerable increase in the number of elderly people. Gerontological studies in Croatia show a high prevalence of four gerontological-public health problems in the elderly, i.e. immobility manifested as the geriatric immobility syndrome, instability due to a high rate of injuries and falls, dependence due to an increasing rate of dementia and Alzheimer’s disease in the oldest age group, and a high rate of urinary incontinence. Through implementation of an appropriate Programme of Primary, Secondary and Tertiary Prevention, focused on the systematic detection and elimination or modifi cation of risk factors associated with debilitating diseases, the leading gerontological public-health problems in the elderly can be prevented to a considerable extent. This is substantiated by the favourable effects of actions, which have been conducted in developed countries over the last few decades and which have addressed the factors of debilitating aging, on health improvement and preservation of functional ability to the very old age.
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In 1989 work began on merging finite and discrete elements. During 1990 algorithmic solutions for the new combined method were developed, together with a C-based implementation known as the Y code. In 2004 these developments and implementations were published as a textbook. Queen Mary University of London (QMUL) and Imperial College are currently engaged in a research project to make Y codes in both 2D and 3D available in Open Source format and with mainly geoscience problems in mind. The result is a set of Open Source tools for Geoscience (VGW), key components of which are summarised in this paper, together with illustrative range of simulation results.
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The development of clinical pharmacology (CP) started in Croatia in 1970-ies. CP today is an important factor in a constant fight for appropriate and rational drug prescribing. Its functions are practical (services), educational and investigational (research). Family physician (FP) should use all these closely related functions for his/her own sake. The basic condition for rational prescribing is regular, objective critical information on drugs. It, present already in the undergraduate studies, must be continued in the postgraduate studies and especially in continuous education of FP and pharmacists as well. Drug information must be based on feedback of prescribing profiles, which should be continuously analysed, and necessary measures (in the first place of the educational nature) taken. FP prescribes 80% of drugs used in Croatia, often under the not optimal influence of secondary and tertiary specialists. Objective source of information (Pharmaca, Drug bulletins) have a long tradition in Croatia but they reach only an insufficient number of FP. Their influence on prescribing is suboptimal and the National formulary still does not appear regularly. Counselling in individual cases and feedback information when reporting adverse reactions are examples of help offered to FP by CP. In clinical trials (of new agents or in investigation of new aspects of use old agents which often cannot be performed without FP) the collaboration of CP and FP is very important. CP must collaborate with the FP in the evaluation of its prescribing and the rationality of advices coming from specialists. The same is true in the work in various drug committees beginning with that of the Croatian Institute for Health Insurance (CIHI) and hospital drug committees. This collaboration should be present also in the various bodies of the Ministry of health. Without FP no law, rule or bylaw, which concerns his work, should be prepared! CP needs FP and vice versa. It is in interest of both that they use the possibilities that this collaboration enables.
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The paper deals with the some characteristics of drug treatment in the elderly. Some changes of pharmacokinetics, interactions, frequency of side effects and principles of drug use by aging are pointed out, with a special attention to those drugs which could have heavy and unusual side effects and have to be excluded from the therapy in the elderly whenever is possible: phenylbutazon, guanetidine, carbenoxolon, chlorpropamide, nitrofurantoin and pentazocin.
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Three hundred and thirty-three consecutive patients in a medical ward were evaluated in a high-intensity monitoring scheme for drug events as a cause of hospitalization. Taking into consideration only ‘definite’ and ‘probable’ drug events, we found 36 cases (10.8%) of all admissions to be drug-related hospitalizations (DRH). Of these, 8.1% were adverse drug reactions and 2.7% were therapeutic failures due to ineffective dosage. In 8 cases (2.4%) the drug event could definitely have been avoided, and a further 13 cases (3.9%) were considered to have been potentially avoidable if appropriate measures had been taken by the health service. In 19 cases (53%) the referring physician was unaware of the drug-related problem. Those patients admitted because of a drug event were taking significantly more drugs than other individuals. The avoidable drug events pointed to the primary health care physicians as the appropriate targets for preventive measures in terms of intensified drug education. The study demonstrated that a reliable estimate of the DRH rate requires active data collection by a qualified health service worker in close collaboration with the patient's family doctor in cases of suspected DRH.
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Older patients hospitalized for treatment of an acute medical illness will have improved outcomes when approached in a comprehensive fashion focusing on the physical, social, and emotional aspects of life. When used by an interdisciplinary team, comprehensive functional assessment can address social, biomedical, nutrition, continence, mobility, pharmacotherapy, and psychological issues to enhance patient care. Although the appropriate use of medications is often cited as an important part of medical care for the older person, it has not been defined for this group of patients. This article outlines steps pharmacists can take to achieve optimal pharmacotherapy in older patients. Prior to attending a team conference, the pharmacist should interview the patient and review the chart. During the team conference, a comprehensive patient database will be generated that allows medications to be linked to diagnoses. To aid in selecting appropriate medications, the potential for drug-induced functional impairment of mobility, continence, and mental state is reviewed. Recommendations for therapy and establishment of therapeutic endpoints will conclude the patient conference. The pharmacist can contribute much in the process of comprehensive functional assessment and to the goal of achieving optimal pharmacotherapy in older patients.
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Clinical and electrical evidence of peripheral neuropathy may result from long term treatment with Phenytoin or barbiturates, especially in combination, or after repeated exposure to toxic blood concentrations of either drug. Prolonged acute toxicity with Phenytoin may rarely lead to permanent residual ataxia. Reversible dystonia may occasionally be precipitated by Phenytoin or carbamazepine; asterixis by Phenytoin, barbiturates or carbamazepine; and, more commonly, tremor by valproate. All the major anticonvulsant drugs, especially in combination, can produce occasional subacute cognitive or behavioural syndromes. In varying degrees, the drugs also impair attention, concentration, memory, mental speed or processing, or motor speed. Possible mechanisms of impaired mental function include neuronal damage, or disturbance of folic acid, monoamine or hormonal metabolism. The relative influence on neurological or psychological function is an important factor in the choice of anticonvulsant drug for the treatment of epilepsy.
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Over 10% of medically ill elderly persons have concurrent major depression, and medical illness is the most influential stressor contributing to depression in old age. The contribution of prescribed medications to depression in the medically ill is poorly understood. Most information on drug-induced depression is derived from case reports; 43 classes of medications have been implicated, including reserpine, β-blockers, levodopa, corticosteroids, and antipsychotics. However, large rigorously performed studies of some drugs, particularly antihypertensives, suggest that drug-induced depression is uncommon and idiosyncratic. There is no evidence that age is an independent risk factor for drug-induced depression. However, elderly persons are the largest consumers of prescribed drugs, and the burden of drug-induced depression is carried by the old. Because of the frequency of atypical presentations of mental disorders in the elderly, drug-induced depression is often misdiagnosed. Nevertheless, basic principles of geriatric medicine offer useful guidance to clinicians in evaluating the complex interrelationships between prescribed medications and depression. We recommend an approach that includes regular inquiry into the common symptoms of mood disorders, vigilance in assessing the contribution of drugs in their development, but scepticism in assessing a depressive episode as caused only by medication.
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Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions for the treatment of behavioural disturbances have been significantly reduced and non-pharmacists have a role to play in the appropriate management of medicines in elderly residents; they can improve patient care and be cost-effective. Identification of methods by which to improve awareness of inappropriate medication prescription and to avoid certain types of drugs is required. This review critically evaluates medication use in this population with specific reference to psychotropics and aims to raise awareness of the issue.