Prevalence and predictors of polypharmacy among older primary care patients in Germany
TL;DR: This older general practice population in Germany is among the top pharmaceutical user group of European study samples and GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.
Abstract: Background Older people consume an increasing amount of medication. Polypharmacy is associated with an elevated risk of adverse health outcomes resulting in hospitalizations and sometimes death. Objectives To describe the prevalence of prescribed and over-the-counter (OTC) medications among older general practice patients living in the community. To determine predictors of polypharmacy (five or more prescribed drugs) from a variety of patient- and doctor-related factors. Methods Sixty-seven randomly selected practices in two areas of Germany and 466 of their older patients (70+ years) were recruited for a geriatric assessment study. A cross-sectional analysis of health problems, GPs' awareness and their interventions was conducted. In this post hoc analysis, we assessed the medication use as reported by older patients and compared it with doctors' perceived medication regimens for their respective patients. The detailed assessment of patients' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection. Results Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs. In all, 26.7% of patients used five and more chronically prescribed drugs. A set of five determinants predicted polypharmacy best: breathlessness, hypertension, dependency on instrumental activities of daily living, low subjective health and medication disagreement between doctors and patients. Conclusion This older general practice population in Germany is among the top pharmaceutical user group of European study samples. Apart from disease-specific determinants, GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy.
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TL;DR: To determine the association of polypharmacy with nutritional status, functional ability and cognitive capacity among elderly persons, a large number of elderly persons are surveyed.
Abstract: Purpose
To determine the association of polypharmacy with nutritional status, functional ability and cognitive capacity among elderly persons.
Methods
This was a prospective cohort study of 294 survivors from the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) Study, with yearly follow-ups during 2004 to 2007. Participants were the citizens of Kuopio, Finland, aged 75 years and older at baseline. Polypharmacy status was categorized as non-polypharmacy (0–5 drugs), polypharmacy (6–9 drugs) and excessive polypharmacy (10+ drugs). A linear mixed model approach was used for analysis the impact of polypharmacy on short form of mini nutritional assessment (MNA-SF), instrumental activities of daily living (IADL) and mini-mental status examination (MMSE) scores.
Results
Excessive polypharmacy was associated with declined nutritional status (p = 0.001), functional ability (p < 0.001) and cognitive capacity (p < 0.001) when compared to non-polypharmacy group. Age, institutional living, poor self-reported health and time of measuring were also associated with the three outcome measures. In the excessive polypharmacy group, the proportion of malnourished or at risk of it increased from 31% to 50%, having difficulties in daily tasks from 48% to 74% and impaired cognition from 36% to 54% during the follow-up. The mixed model analysis revealed that polypharmacy status was not able to predict the progress of MNA-SF, IADL and MMSE scores over a three-year time.
Conclusions
Excessive polypharmacy is associated with decline in nutritional status, functional ability and cognitive capacity in elderly persons. However, the changes in nutrition, physical functionality and cognition over a three-year period cannot be predicted by polypharmacy status. Copyright © 2011 John Wiley & Sons, Ltd.
315 citations
TL;DR: This study points to the importance of excessive polypharmacy as an indicator for mortality in elderly persons following adjustment for co-morbidities.
Abstract: Increased use of drugs has raised concern about the risks of polypharmacy in elderly populations. Adverse outcomes, such as hospitalizations and falls, have been shown to be associated with polypharmacy. So far, little information is available on the association between polypharmacy status and mortality. To assess whether polypharmacy (six to nine drugs) or excessive polypharmacy (ten or more drugs) could be indicators of mortality in elderly persons. This was a population-based cohort study conducted between 1998 and 2003 with mortality follow-up through to 2007. The data in this study were derived from the population-based Kuopio 75+ Study, which involved elderly persons aged ≥75 years living in the city of Kuopio, Finland. The initial sample (sample frame n=4518, random sample n=700) was drawn from the population register. For the purpose of this study, two separate analyses were carried out. In the first phase, participants (aged ≥75 years, n=601) were followed from 1998 (baseline) to 2002. In the second phase, survivors (aged ≥80 years, n=339) were followed from 2003 to 2007. Current medications were determined from drug containers and prescriptions during interviews conducted by a trained nurse. The Kaplan-Meier method and Cox proportional hazards regression were used to examine the association between polypharmacy status and mortality. In the first phase, 28% (n=167) belonged to the excessive polypharmacy group, 33% (n=200) to the polypharmacy group, and the remaining 39% (n=234) to the non-polypharmacy (0–5 drugs) group. The corresponding figures in the second phase were 28% (n=95), 39% (n=132) and 33% (n=112), respectively. The mortality rate was 37% in the first phase and 40% in the second phase. In both phases, the survival curves showed a significant difference in all-cause mortality between the three polypharmacy groups. In the first phase, the univariate model showed an association between excessive polypharmacy and mortality (hazard ratio [HR] 2.53, 95% CI 1.83, 3.48); however, after adjustment for demographics and other variables measuring functional and cognitive status, this association did not remain statistically significant (HR 1.28, 95% CI 0.86, 1.91). In the second phase, the association between excessive polypharmacy and mortality (HR 2.23, 95% CI 1.21, 4.12) remained significant after adjustments. Age, male sex and dependency according to the Instrumental Activities of Daily Living screening instrument were associated with mortality in both phases. This study points to the importance of excessive polypharmacy as an indicator for mortality in elderly persons. This association needs to be confirmed following adjustment for co-morbidities.
280 citations
TL;DR: The study indicates that the factors associated with PP and EPP are not uniform, while poor self-reported health and several specific disease states were associated with both PP andEPP.
Abstract: Although the increasing use of drugs in elderly persons has raised many concerns in recent years, the process leading to polypharmacy (PP) and excessive polypharmacy (EPP) remains largely unknown. To describe the number and type of drugs used and to evaluate the role of different factors associated with PP (i.e. 6–9 drugs) and EPP (i.e. ≥10 drugs), with special reference to the number and type of medical diagnoses and symptoms, in a population of home-dwelling elderly persons aged ≥75 years. The study was a cross-sectional analysis of a population-based cohort in 1998. The population consisted of home-dwelling elderly persons aged ≥75 years in the city of Kuopio, Finland. The data for the analysis were obtained from the Kuopio 75+ Study, which drew a random sample of 700 elderly residents aged ≥75 years living in the city of Kuopio from the population register. Of these, 601 attended a structured clinical examination and an interview carried out by a geriatrician and a trained nurse in 1998. For this analysis, all home-dwelling elderly participants (n = 523) were included. Study data were expressed as proportions and means with standard deviations. The factors associated with PP and EPP were examined by multinomial logistic regression. The most commonly used drugs were cardiovascular drugs (97% in EPP, 94% in PP and 59% in non-PP group) and analgesics (89%, 76% and 54%), respectively. Use of psychotropics was markedly higher in the EPP group (77%) than in the PP (42%) and non-PP groups (20%). The mean number of drugs per diagnosis was 3.6 in the EPP group, 2.6 in the PP group and 1.6 in the non-PP group. Factors associated only with EPP were moderate self-reported health (odds ratio [OR] 2.05; 95% CI 1.08, 3.89), female gender (OR 2.43; 95% CI 1.27, 4.65) and age ≥85 years (OR 2.84; 95% CI 1.41, 5.72). Factors that were associated with both PP and EPP included poor self-reported health (PP: OR 2.15; 95% CI 1.01, 4.59 and EPP: OR 6.02; 95% CI 2.55, 14.20), diabetes mellitus (PP: OR 2.28; 95% CI 1.26, 4.15 and EPP: OR 2.07; 95% CI 1.03, 4.18), depression (PP: OR 2.13; 95% CI 1.16, 3.90 and EPP: OR 2.93; 95% CI 1.51, 5.66), pain (PP: OR 2.69; 95% CI 1.68, 4.30 and EPP: OR 2.74; 95% CI 1.56, 4.82), heart disease (PP: OR 2.51; 95% CI 1.54, 4.08 and EPP: OR 4.63; 95% CI 2.45, 8.74) and obstructive pulmonary disease (including asthma or chronic obstructive pulmonary disease) [PP: OR 2.79; 95% CI 1.24, 6.25 and EPP: OR 6.82; 95% CI 2.87, 16.20]. The study indicates that the factors associated with PP and EPP are not uniform. Age ≥85 years, female gender and moderate self-reported health were factors associated only with EPP, while poor self-reported health and several specific disease states were associated with both PP and EPP. The high number of drugs per diagnosis observed in this study calls for a thorough assessment of the need for and outcomes associated with use of these drugs.
210 citations
TL;DR: Age, gender, number of limitations with activities of daily living, numberof chronic diseases, quality of life, depression, physical inactivity, network satisfaction, difficulty in taking medications, years of education and shortage of money were significant variables associated with polypharmacy.
183 citations
TL;DR: It was showed that the prevalence of polypharmacy varied between 10% to as high as around 90% in different populations, and chronic conditions, demographics, socioeconomics and self-assessed health factors were independent predictors of polyPharmacy.
Abstract: A high rate of polypharmacy is, in part, a consequence of the increasing proportion of multimorbidity in the ageing population worldwide. Our understanding of the potential harm of taking multiple medications in an older, multi-morbid population, who are likely to be on a polypharmacy regime, is limited. This is a narrative literature review that aims to appraise and summarise recent studies published about polypharmacy. We searched MEDLINE using the search terms polypharmacy (and its variations, e.g. multiple prescriptions, inappropriate drug use, etc.) in titles. Systematic reviews and original studies in English published between 2003 and 2018 were included. In this review, we provide current definitions of polypharmacy. We identify the determinants and prevalence of polypharmacy reported in different studies. Finally, we summarise some of the findings regarding the association between polypharmacy and health outcomes in older adults, with a focus on frailty, hospitalisation and mortality. Polypharmacy was most often defined in terms of the number of medications that are being taken by an individual at any given time. Our review showed that the prevalence of polypharmacy varied between 10% to as high as around 90% in different populations. Chronic conditions, demographics, socioeconomics and self-assessed health factors were independent predictors of polypharmacy. Polypharmacy was reported to be associated with various adverse outcomes after adjusting for health conditions. Optimising care for polypharmacy with valid, reliable measures, relevant to all patients, will improve the health outcomes of older adult population.
159 citations
References
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01 Jan 1987
TL;DR: A longitudinal study of service delivery within MRI services at Auckland University for patients, researchers and referring practitioners has been carried out since 2006 as mentioned in this paper, with a focus on the effects of service provision on patient satisfaction.
Abstract: A longitudinal study (since 2006) looking at the effects of service delivery within MRI services at Auckland University for patients, researchers and referring practitioners
2,922 citations
TL;DR: Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background.
Abstract: ContextCriteria for potentially inappropriate medication use among elderly
patients have been used in the past decade in large US epidemiological surveys
to identify populations at risk and specifically target risk-management strategies.
In contrast, in Europe little information is available about potentially inappropriate
medication use and is based on small studies with uncertain generalizability.ObjectiveTo estimate the prevalence and associated factors of potentially inappropriate
medication use among elderly home care patients in European countries.Design, Setting, and ParticipantsRetrospective cross-sectional study of 2707 elderly patients receiving
home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled
in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy,
the Netherlands, Norway, and the United Kingdom. Patients were prospectively
assessed between September 2001 and January 2002 using the Minimum Data Set
in Home Care instrument.Main Outcome MeasuresPrevalence of potentially inappropriate medication use was documented
using all expert panels criteria for community-living elderly persons (Beers
and McLeod). Patient-related characteristics independently associated with
inappropriate medication use were identified with a multiple logistic regression
model.ResultsCombining all 3 sets of criteria, we found that 19.8% of patients in
the total sample used at least 1 inappropriate medication; using older 1997
criteria it was 9.8% to 10.9%. Substantial differences were documented between
Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%,
ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate
medication use was associated with patient’s poor economic situation
(adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36),
polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82;
95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively
associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92)
and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate
medication use significantly increased with the number of associated factors
(P<.001).ConclusionsSubstantial differences in potentially inappropriate medication use
exist between European countries and might be a consequence of different regulatory
measures, clinical practices, or inequalities in socioeconomic background.
Since financial resources and selected patient-related characteristics are
associated with such prescribing, specific educational strategies and regulations
should reflect these factors to improve prescribing quality in elderly individuals
in Europe.
682 citations
TL;DR: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients found that consultation length is determined by variables related to the doctor and the doctor's country as well as by those related to patients.
Abstract: Objectives: To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors9 and patients9 perceptions of psychosocial aspects. Design: Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients. Setting: General practices in six European countries. Participants: 190 general practitioners and 3674 patients. Results: In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors9 variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor9s perception had more influence in this situation than the patient9s. Consultation length is influenced by the patients9 sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient9s age (the older the patient the longer the consultation). As a doctor9s workload increased, the length of consultations decreased. The general practitioner9s sex or age and patient9s level of education were not related to the length of consultation. Conclusion: Consultation length is determined by variables related to the doctor and the doctor9s country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.
487 citations
TL;DR: Significant changes in medicine use and polypharmacy were carried out among community-dwelling persons aged 64 years or over in 1990-91 and 1998-99 in the municipality of Lieto in southwestern Finland.
467 citations
TL;DR: Factors affecting outcome in older medical patients are complex and it is important not just to look at routinely available statistics such as age, gender and diagnosis but also to take into account multifaceted aspects such as functional status and cognitive function.
Abstract: Introduction: the ACMEplus project aims to devise a standardised system for measuring case-mix and outcome in older patients admitted to hospitals in different parts of Europe for primarily ‘medical’ (i.e. not surgical or psychiatric) reasons. As a Wrst step in this project, a systematic review was carried out to identify factors which had a signiWcant inXuence on outcome in such patients. Methods: the systematic search used Medline 1966–2000, Cinahl 1982–2000, Web of Science 1981–2000, reference lists of relevant papers and a hand search of Age and Ageing 1974–2000. A six-category grading system was devised to classify the 313 identiWed papers with regard to their relevance to the ACMEplus project, study design and power. The analysis of the 14 ‘category 1’ papers is presented. Results: the main areas of assessment of case-mix were function, cognition, depression, illness severity, nutrition, social elements, aspects of diagnosis and demographic details. Statistically signiWcant predictors, for the four outcome measures, listed below were:
365 citations