Objective Polypharmacy has been linked to a myriad of adverse consequences, and escalating rates of polypharmacy present an emerging concern, particularly among older adults. This systematic review and meta-analysis summarizes the existing literature concerning the association between polypharmacy and mortality. Data sources A systematic literature review was done by searching the EMBASE, PubMed, Scopus, and International Pharmaceutical databases to identify studies assessing the association between polypharmacy and death published until June 2016. Study selection Studies that investigated the association between polypharmacy and mortality were eligible for this systematic review and meta-analysis. Data extraction Data were extracted by the first and second authors independently using a data extraction form. Disagreement was resolved by consensus. A meta-analysis was performed using random effect models. Heterogeneity was assessed using the I2 statistic. Results Forty-seven studies were included in this meta-analysis. The underlying populations were heterogeneous (I2= 91.5%). When defined as a discrete variable, pooled risk estimates demonstrated a significant association between polypharmacy and death (pooled-adjusted odds ratio [aOR] 1.08 [95% CI 1.04-1.12]). When defined categorically, a dose-response relationship was observed across escalating thresholds for defining polypharmacy. Categorical thresholds for polypharmacy using values of 1-4 medications, 5 medications, and 6-9 medications were significantly associated with death (P Conclusions Pooled risk estimates from this meta-analysis reveal that polypharmacy is associated with increased mortality risk, using both discrete and categorical definitions. The causality of this relationship remains unclear, but it emphasizes the need for approaches to health care delivery that achieve an optimal balance of risk and benefit in medication prescribing.

Association between polypharmacy and death: A systematic review and meta-analysis

Aims
Little is known about the impact of inappropriate prescribing (IP) in community-dwelling adults, aged 80 years and older. The prevalence at baseline (November 2008September 2009) and impact of IP (misuse and underuse) after 18 months on mortality and hospitalization in a cohort of community-dwelling adults, aged 80 years and older (n = 503) was studied.

Methods
Screening Tool of Older People's Prescriptions (STOPP-2, misuse) and Screening Tool to Alert to Right Treatment (START-2, underuse) criteria were cross-referenced and linked to the medication use (in Anatomical Therapeutic Chemical coding) and clinical problems. Survival analysis until death or first hospitalization was performed at 18 months after inclusion using Kaplan–Meier, with Cox regression to control for covariates.

Results
Mean age was 84.4 (range 80–102) years. Mean number of medications prescribed was 5 (range 0–16). Polypharmacy (≥5 medications, 58%), underuse (67%) and misuse (56%) were high. Underuse and misuse coexisted in 40% and were absent in 17% of the population. A higher number of prescribed medications was correlated with more misused medications (rs = .51, P < 0.001) and underused medications (rs = .26, P < 0.001).

Mortality and hospitalization rate were 8.9%, and 31.0%, respectively. After adjustment for number of medications and misused medications, there was an increased risk of mortality (HR 1.39, 95% CI 1.10, 1.76) and hospitalization (HR 1.26, 95% CI 1.10, 1.45) for every additional underused medication. Associations with misuse were less clear.

Conclusion
IP (polypharmacy, underuse and misuse) was highly prevalent in adults, aged 80 years and older. Surprisingly, underuse and not misuse had strong associations with mortality and hospitalization.

https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.13055

Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community-dwelling oldest old.

Polypharmacy is common in older people and associated with potential harms. The aim of this study was to analyse the characteristics of an older multimorbid population with polypharmacy and to identify factors contributing to excessive polypharmacy in these patients. This cross-sectional analysis is based on the PRIMA-eDS trial, a large randomised controlled multicentre study of polypharmacy in primary care. Patients’ baseline data were used for analysis. A number of socioeconomic and medical data as well as SF-12-scores were entered into a generalized linear mixed model to identify variables associated with excessive polypharmacy (taking ≥10 substances daily). Three thousand nine hundred four participants were recruited. Risk factors significantly associated with excessive polypharmacy were frailty (OR 1.45; 95% CI 1.22–1.71), > 8 diagnoses (OR 2.64; 95% CI 2.24–3.11), BMI ≥30 (OR 1.18; 95% CI 1.02–1.38), a lower SF-12 physical health composite score (OR 1.47; 95% CI 1.26–1.72), and a lower SF-12 mental health composite score (OR 1.33; 95% CI 1.17–1.59) than the median of the study population (≤36.6 and ≤ 48.7, respectively). Age ≥ 85 years (OR 0.83; 95% CI 0.70–0.99) led to a significantly lower risk for excessive polypharmacy. No association with excessive polypharmacy could be found for female sex, low educational level, and smoking. Regarding the study centres, being recruited in the UK led to a significantly higher risk for excessive polypharmacy compared to being recruited in Germany 1/Rostock (OR 1.71; 95% CI 1.27–2.30). Being recruited in Germany 2/Witten led to a slightly significant lower risk for excessive polypharmacy compared to Germany 1/Rostock (OR 0.74; 95% CI 0.56–0.97). Frailty, multimorbidity, obesity, and decreased physical as well as mental health status are risk factors for excessive polypharmacy. Sex, educational level, and smoking apparently do not seem to be related to excessive polypharmacy. Physicians should especially pay attention to their frail, obese patients who have multiple diagnoses and a decreased health-related quality of life, to check carefully whether all the drugs prescribed are evidence-based, safe, and do not interact in an unfavourable way. This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559).

/pdf/polypharmacy-in-older-patients-with-chronic-diseases-a-cross-4mbh5toyvz.pdf

Polypharmacy in older patients with chronic diseases: a cross-sectional analysis of factors associated with excessive polypharmacy.

Objectives This study aims to review the evidence of sarcopenia as a predictor of all-cause mortality among nursing home residents. Design Systematic review and meta-analysis of observational cohort studies. Data sources PubMed, EMBASE and the Cochrane Library databases were searched for relevant articles. Participants Nursing home residents. Primary and secondary outcome measures All-cause mortality. Data analysis Summary-adjusted HRs or risk ratios (RRs) were calculated by fixed-effects model. The risk of bias was assessed by Newcastle-Ottawa Scale. Results Of 2292 studies identified through the systematic review, six studies (1494 participants) were included in the meta-analysis. Sarcopenia was significantly associated with a higher risk for all-cause mortality among nursing home residents (pooled HR 1.86, 95% CI 1.42 to 2.45, p Conclusion Sarcopenia is a significant predictor of all-cause mortality among older nursing home residents. Therefore, it is important to diagnose and treat sarcopenia to reduce mortality rates among nursing home residents. PROSPERO registration number CRD42018081668

https://bmjopen.bmj.com/content/bmjopen/8/11/e021252.full.pdf

Sarcopenia as a predictor of all-cause mortality among older nursing home residents: a systematic review and meta-analysis.

Polypharmacy is a frequent condition, but its prevalence and determinants in the Swiss mid-aged population are unknown. We aimed to evaluate the prevalence and determinants of polypharmacy in a large Swiss mid-aged population-based sample. Data from 4938 participants of the CoLaus study (53% women, age range 40–81 years) were collected between 2009 and 2012. Polypharmacy was defined by the regular use of five or more drugs. Polypharmacy was reported by 580 participants [11.8%, 95% confidence interval (10.9; 12.6)]. Participants on polypharmacy were significantly older (mean ± standard deviation: 66.0 ± 9.1 vs. 56.6 ± 10.1 years), more frequently obese (35.9% vs. 14.7%), of lower education (66.6% vs. 50.7%) and former smokers (46.7% vs. 36.4%) than participants not on polypharmacy. These findings were confirmed by multivariate analysis: odds ratio and (95% confidence interval) for age groups 50–64 and 65–81 relative to 40–49 years: 2.90 (2.04; 4.12) and 10.3 (7.26; 14.5), respectively, p for trend < 0.001; for low relative to high education: 1.56 (1.17; 2.07); for overweight and obese relative to normal weight participants: 2.09 (1.65; 2.66) and 4.38 (3.39; 5.66), respectively, p for trend < 0.001; for former and current relative to never smokers: 1.42 (1.14, 1.75) and 1.63 (1.25, 2.12), respectively, p for trend < 0.001. One out of nine participants of our sample is on polypharmacy. Increasing age, body mass index, smoking and lower education independently increase the likelihood of being on polypharmacy.

/pdf/prevalence-and-determinants-of-polypharmacy-in-switzerland-3g7k3ng7sx.pdf

Prevalence and determinants of polypharmacy in Switzerland: data from the CoLaus study

Objectives: Polypharmacy is highly prevalent among older people (65+), but little is known on the medication use of the oldest old (80+). This study explores the medication use of the Belgian community-dwelling oldest old in relation to their demographic, clinical and functional characteristics.Methods: Baseline data was used from the BELFRAIL study; a prospective, observational population-based cohort of Belgian community-dwelling patients (80+). General practitioners recorded clinical problems and medications. Medications were coded by the Anatomic Therapeutic Chemical classification.Results: Participants’ (n = 503) mean age was 84.4 years (range 80–102) and 61.2% was female. Median chronic medication use was 5 (range 0–16). Polypharmacy (≥5 medications) was high (57.7%), with excessive polypharmacy (≥10 medications) in 9.1%. Most commonly used medication group were antithrombotics, but also benzodiazepines and antidepressants were frequently consumed. Demographics related to polypharmacy (univa...

Polypharmacy in a Belgian cohort of community-dwelling oldest old (80+)

Mortality, hospitalisation, institutionalisation in community-dwelling oldest old: The impact of medication.

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community-dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008-September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time-to-event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan-Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80-102), and mean number of medications was 5 (range 0-16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0-4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi-morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi-morbidity and medication intake, multi-variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07-4.78) and hospitalization (HR 1.7; 95% CI: 1.13-2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community-dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months.

Anticholinergic Exposure in a cohort of adults aged 80 years and over Associations of the MARANTE scale with mortality and hospitalisation.

After the successful pilot EPD Project in 2002-2003, we decided to perform the EPD project in four additional countries: Belgium, Greece, Norway and Scotland. Before starting the EPD Project in Belgium, we installed a Belgium National EPD Board in order to support the practical organisation of this project. National coordinators were Luc Picavet (Chair) and Sylviane Boulle (Wallonia). The members of the Belgium National EPD Board were Jean-Yves De Vos (President of National Association, ORPADT Flanders), Hichem Marzougui (Link member, Association of Dialysis Technicians) and Luc Vonckx (President of Association of Dialysis Technicians).

Monique Elseviers

Papers

Polypharmacy in a Belgian cohort of community-dwelling oldest old (80+)

Mortality, hospitalisation, institutionalisation in community-dwelling oldest old: The impact of medication.

Anticholinergic Exposure in a cohort of adults aged 80 years and over Associations of the MARANTE scale with mortality and hospitalisation.

European Practice Database in Belgium.