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PubMed2003

Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist.

Polypharmacy in the elderly complicates therapy, increases cost, and is a challenge for healthcare agencies. In the context of the evolving role of the pharmacist, this systematic review examines the effectiveness of interventions led by pharmacists in reducing polypharmacy. A computerised search was conducted using Medline, Embase geriatrics and gerontology (2001 edition), the Cochrane Library and International Pharmaceutical Abstracts (IPA) databases. A manual search of articles on polypharmacy and the role of pharmacists in the therapy of the elderly and of the reference sections of all retrieved articles was also carried out. Search terms used were 'polypharmacy', 'elderly', 'aged', 'intervention' and 'pharmacist(s)'. Articles that fulfilled the following criteria were included: only elderly people were included in the study, or all ages were included but the study gave separate results for the elderly; the outcome was expressed as a reduction in the number of medications; a pharmacist participated in the study; and the study was a controlled or a randomised controlled study. We initially identified 106 articles, but only 14 studies met our four inclusion criteria. Reduction in the number of medications was not the major purpose of most selected studies but often a secondary outcome. Objectives differed, the general aim being to enhance the quality of prescribing in elderly patients. These controlled studies argued in favour of the effectiveness of pharmacists' interventions, even though the number of medications eliminated was small. Most studies were not designed to demonstrate the impact of reducing the number of drugs on the clinical consequences of polypharmacy (nonadherence, adverse drug reactions, drug-drug interactions, increased risk of hospitalisation, and medication errors). The most frequently reported outcome related to cost savings. It was therefore difficult to assess whether the interventions benefited the patient. The methodological quality of many identified studies was poor. In particular, the study objectives were often very broad and ill-defined. Polypharmacy itself has been defined in different ways and the appropriate definition may differ according to the patient population and the study setting. Further studies are needed to find the most effective way to reduce polypharmacy, especially in the frail elderly population, and to quantify the real advantages of simplifying their drug regimens in terms of improved quality of life.

Age Factors↗

PubMed1999

Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication reviews.

OBJECTIVE: To examine the effects of medication reviews by primary care physicians on prescriptions written for elderly members of a Medicare managed care organization who were at risk for polypharmacy. STUDY DESIGN: Prospective study with follow-up survey. PATIENTS AND METHODS: We conducted a study in 1995 to demonstrate the prevalence of polypharmacy (defined as receiving 5 or more prescription medications during the 3-month study period) among elderly members of our managed care organization. Two years later, elderly members identified as being at risk for polypharmacy were sent a letter encouraging them to schedule a medication review with their primary care physician. Each primary care physician was provided with clinical practice guidelines on polypharmacy and patient-specific medication management reports. Patients and physicians were subsequently mailed a survey to assess the impact of the medication review program on prescribing practices. RESULTS: Of 37,372 elderly members screened, 5737 (15%) were at risk for polypharmacy. Of these, 2615 (46%) responded to the follow-up survey. Of the survey respondents, 1087 (42%) had gone to their primary care physician for a medication review. During the review, 96% of patients discussed their prescription medications and 72% discussed nonprescription medications they were taking. Twenty percent reported that their physician discontinued medications, 29% reported that the physician changed the dose of a medication, and 17% informed their physician about a new prescription or nonprescription medication they were taking. Of the 275 primary care physicians surveyed, 56 (20%) returned the questionnaire. Of these, 61% reported that the medication review program was "very" or "somewhat useful." Thirty-five percent reported discontinuing unnecessary medications, and 23% reported decreasing the frequency of dosing. Overall, 45% of physicians reported making at least one change in their prescribing to a member at risk for polypharmacy. CONCLUSIONS: Our program promoting medication reviews between primary care physicians and their elderly patients resulted in significant changes in prescribing by physicians. This type of program is likely to decrease the risk of polypharmacy among older members of a Medicare managed care organization.

Aged↗

PubMed1999

[Polypharmacy in the ambulatory care of aged patients].

The aim of this study was to assess the prevalence and possible predictors of polypharmacy in a sample of the general population. The sample consisted of 638 subjects (267 males, mean age 54.7, and 371 females, mean age 55) taken from the records of three general practitioners in the city of Turin, Italy. The prevalence of polypharmacy, for prescription drugs, was 12.5% (80 subjects). The prevalence of polypharmacy, for non prescription drugs, was 17.4% (111 subjects). The number of prescription drugs per patient rises progressively with age, averaging 2.28 and 2.5 respectively in males and in female aged older than 80 years. The number of non prescription drugs was observed to decrease with age: in women, subjects that used two or more non prescription drugs were 35% in those aged under 50 years, 20% in subjects aged from 65 to 80 years and 12.5% in those aged older than 80 years. Subjects aged older than 65 years, an IADL score < 10, more than 20 physical exams performed by practitioner in the last year, a recent hospitalisation, presence of cardiovascular disease, and presence of genito-urinary disease, were significantly and independently associated to polypharmacy for prescription drugs. Only female sex was significantly associated to polypharmacy for non prescription drugs. Our conclusion is that although age should not be involved in polypharmacy as a variable, several phenomena that influence medical treatment goals become more prevalent with increasing age and explain the high drugs consumption in the elderly. A rational, essential therapy, helped by guidelines could reduce potential problems associated with polypharmacy in the elderly.

Activities of Daily Living↗

PubMed2000

[Big differences in the frequency of polypharmacy between physicians].

Polypharmacy, the simultaneous use of multiple drugs, is associated with adverse drug reactions, medication errors, and increased risk of hospitalisation. When the number of drugs is five or more (major polypharmacy), a significant risk may be present. We analysed the prevalence of major polypharmacy among listed patients, and identified possible predictors of major polypharmacy related to the practice. Prescription data were retrieved from the Odense Pharmaco-epidemiological Database and the age and sex standardised prevalence rate of major polypharmacy was calculated for each practice (n = 173). Possible predictors of major polypharmacy related to the GPs were analysed by backward stepwise linear multiple regression. A six-fold variation between practices in the prevalence of major polypharmacy was found, i.e. from 16 to 96 per 1000 listed patients (median: 42). Predictors related to the practice structure, workload, clinical work profile, and prescribing profile could explain 56% of the variation.

Adult↗

PubMed2004

Polypharmacy and inappropriate medication use in Singapore nursing homes.

INTRODUCTION: At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. MATERIALS AND METHODS: A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria). RESULTS: Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P < 0.001, chi2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141). CONCLUSION: The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.

Aged↗

PubMedDate not supplied

[Polypharmacy in psychiatric patients as an alternative to limited mental health resources].

INTRODUCTION: Polypharmacy with psychoactive drugs is an increasingly common and debatable contemporary practice in clinical psychiatry more probably based on experience than evidence. The objective of this study was to evaluate the prevalence and estimators of polypharmacy in psychiatric patients living in an area with very limited mental health resources. METHOD: All patients (n = 352) with mental disorders receiving psychotropic medication living in La Gomera were studied through an audit of case records and a second phase confirmation strategy through personal interviews. RESULTS: The mean number of psychoactive drugs prescribed was 2.22 +/- 0.70 (range: 1-6). The rate of polypharmacy was 67 %, with 34.1 % of patients receiving two drugs, 20.5 % receiving three drugs and 12.5 % of the patients receiving four or more psychotropic drugs at the same time. Multiple regression analysis shows that none of the variables considered (age, sex, marital status, educational level, work activity and diagnosis) had predictive value in regards to the number of psychotropic drug used. Benzodiazepines were the most prevalent drugs in single drug therapy, while antidepressants and antipsychotics were the most used in combination with other treatment. A questionably very high degree of same-class polypharmacy was observed, while multiclass, adjunctive and augmentation polypharmacy seems to be more appropriate. CONCLUSION: The psychiatric clinical practice needs to develop indicators for an appropriate polypharmacy of mental disorders. More research is still needed to identify patients at risk of polypharmacy in order to develop interventions that minimize the risks associated to this treatment alternative.

Adult↗

PubMed2004

Validation of polypharmacy process measures in inpatient schizophrenia care.

The influence of combining antipsychotics and different classes of psychotropic drugs on treatment outcome in schizophrenia remains unclear. As part of a comprehensive quality management program, we prospectively evaluated two schizophrenia polypharmacy performance measures in a cohort of 1,075 consecutively recruited individuals with schizophrenia in seven psychiatric hospitals. Multiple concurrent antipsychotic and overall psychotropic polypharmacy rates were noticeably high. In case-mix-adjustment models controlling for a variety of confounding baseline parameters, patients discharged with more than one antipsychotic had significantly poorer outcomes with respect to both mental state and social functioning. Prescription of more than three psychotropic agents did not adversely affect social functioning when patients taking more than three were compared to patients given fewer medications. Case-mix models suggest that antipsychotic polypharmacy, while used more often for individuals with chronic disease and more thought disturbance, is only partly a reaction to disease severity. The antipsychotic polypharmacy process measure may be used to identify treatment problems in order to find alternatives to polypharmacy. The measure can be easily assessed in a variety of settings and does not depend on the availability of case-mix data. The rising trend toward polypharmacy in schizophrenia care, which is not supported by current guideline recommendations, warrants critical appraisal.

Adolescent↗

PubMed2004

Antipsychotic polypharmacy in patients with schizophrenia: a multicentre comparative study in East Asia.

AIMS: Previous studies of the prescription patterns of psychotropic medications in patients with schizophrenia have highlighted a high rate of antipsychotic polypharmacy, but data in Asia are sparse. This study seeks to examine the prevalence of antipsychotic polypharmacy in patients with schizophrenia and compare the differences between patients receiving one vs. those receiving more than one antipsychotic. METHODS: Antipsychotic prescription for a sample of 2399 patients with schizophrenia from six countries and territories was evaluated. Daily doses of antipsychotic medications were converted to standard chlorpromazine equivalents (CPZ). RESULTS: Antipsychotic polypharmacy was found in 45.7% (n = 1097) of the patients with wide intercountry variations. Polypharmacy was associated with male gender [odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06, 1.46, P < 0.01], advanced age (t = -7.81, d.f. = 2396, P < 0.001), psychiatric hospital setting (OR 1.34, 95% CI 1.11, 1.62) as well as higher daily CPZeq doses (411.47 vs. 983.10 CPZeq day(-1), z = -25.94, P < 0.001), anticholinergic use (OR 3.17, 95% CI 2.65, 3.79, P < 0.001) and less use of an atypical antipsychotic drug (OR 0.83, 95% CI 0.71, 0.98, P < 0.05). On multivariate analysis, country, age and duration of illness were significantly associated with antipsychotic polypharmacy. CONCLUSION: This study highlighted the wide intercountry variations of antipsychotic polypharmacy which are likely to be influenced by a complex combination of clinical, setting, cultural and personal practice factors, requiring more research.

Antipsychotic Agents↗

PubMed2006

Polypharmacy and falls in the middle age and elderly population.

AIM: Falls in the elderly are common and often serious. We studied the association between multiple drug use (polypharmacy) and falls in the elderly. METHODS: This was a population-based cross-sectional study, part of the Rotterdam Study. The participants were 6928 individuals aged > or = 55 years. The prevalence of falls in the previous year was assessed. Medication use was determined with an interviewer-administered questionnaire with verification of use. Polypharmacy was defined as the use of four or more drugs per day. RESULTS: The prevalence of falls strongly increased with age. Falls were more common in women than in men. Fall risk increased with increasing disability, presence of joint complaints, use of a walking aid and fracture history. The risk of falling increased significantly with the number of drugs used per day (P for trend < 0.0001). After adjustment for a large number of comorbid conditions and disability, polypharmacy remained a significant risk factor for falling. Stratification for polypharmacy with or without at least one drug which is known to increase fall risk (notably CNS drugs and diuretics) disclosed that only polypharmacy with at least one risk drug was associated with an increased risk of falling. CONCLUSIONS: Fall risk is associated with the use of polypharmacy, but only when at least one established fall risk-increasing drug was part of the daily regimen.

Accidental Falls↗

PubMed2005

Determinants of antipsychotic polypharmacy in psychiatric inpatients: a prospective study.

A recent survey of clinicians' opinions suggested that antipsychotic polypharmacy is reserved for particularly severe cases, and that it is intended to avoid high doses of a single drug. In the present study, we tested these clinicians' reasons for antipsychotic polypharmacy in a sample of Italian psychiatric inpatients. During a 6-year recruitment period, all psychiatric patients receiving antipsychotic therapy at discharge from an inpatient facility were included. Sociodemographic and clinical data were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered on admission and before discharge. At discharge, data on length of inpatient stay, psychotropic drug therapy and treatment adherence were collected. Prescribed daily doses were converted into multiples of the defined daily doses. A total of 354 inpatients receiving antipsychotic treatment at discharge were included. Of these, 100 (28%) were discharged with two or more antipsychotic drugs. After background group differences were controlled for, positive symptoms, manic/hostility symptoms and polypharmacy on admission were predictors of polypharmacy at discharge. The risk of high-dose antipsychotics in patients receiving polypharmacy at discharge was 10-fold higher than that in patients receiving one antipsychotic (odds ratio 10.70, 95% confidence interval 4.78-23.97, P<0.001). The perception of clinicians is to reserve antipsychotic polypharmacy for severe, persistent and difficult-to-treat cases, and this was confirmed by the finding that patients discharged on two or more antipsychotic agents were more severely ill on admission. Conversely, the theoretical advantage of avoiding a high dose of a single drug is counterbalanced by the documented disadvantage of administering high total doses.

Adolescent↗

PubMed2001

Antipsychotic polypharmacy: a survey of discharge prescriptions from a tertiary care psychiatric institution.

OBJECTIVE: To perform a retrospective survey of discharge medications at a tertiary care psychiatric facility and to assess the incidence of antipsychotic polypharmacy. METHOD: This is a retrospective survey that used the Department of Pharmacy's computer database to obtain relevant discharge information on all nongeriatric patients with schizophrenia discharged from Riverview Hospital between November 1, 1996 and October 31, 1998. From a total of 492 eligible patients, 229 met the inclusion criteria and formed the database for the survey. RESULTS: The main finding of the survey was that 27.5% of our discharged patients diagnosed with schizophrenia left our facility on an antipsychotic polypharmacy regimen. Compared with patients discharged on a single antipsychotic, the pooled data revealed a significantly greater use of anticholinergic agents in those patients prescribed an antipsychotic polypharmacy regimen. Further, of the atypical agents, only risperidone showed a statistically significant reduction in dosage when coprescribed with a second antipsychotic. CONCLUSION: Although antipsychotic polypharmacy persists today, as it has over the past 30 years, evidence-based data to support this controversial treatment strategy is lacking. As a result clinicians are relying on their clinical experience, and perhaps intuition, to design antipsychotic polypharmacy treatment protocols. Efforts should be made to replace subjective clinical impression with a more rational approach to antipsychotic polypharmacy--one that is based on pharmacodynamic and pharmacokinetic understanding of drug action.

Adult↗

PubMed1992

Polypharmacy in psychiatry: three case studies and methods for prevention.

OBJECTIVE: To illustrate problems of overprescribing in the elderly and to make practical suggestions for prevention of polypharmacy. DESIGN: Three cases of polypharmacy in psychiatric patients admitted to the hospital between January and March 1990 are described. Intervention to correct drug-related problems in these patients is described and methods of preventing polypharmacy are discussed. SETTING: Inpatient psychiatry service in a tertiary-care center. PATIENTS: Elderly psychiatry patients (n = 3) taking an excessive number of medications. This polypharmacy was believed to contribute to decreased cognitive and/or physical function. INTERVENTIONS: Medication regimens were reviewed by the physician and pharmacist. Those considered unnecessary or believed to be adversely affecting the patient were discontinued. RESULTS: All patients were discharged on a reduced number of medications, with improvement in cognitive and/or physical function. CONCLUSIONS: Polypharmacy contributes to an increased incidence of adverse reactions in the elderly. Implementation of practical methods for reducing polypharmacy can lead to a reduction in the number of drug-related adverse effects and improved care of the elderly patient.

Aged↗

PubMed1992

Overcoming problems with polypharmacy and drug misuse in the elderly.

Polypharmacy, the inappropriate use of multiple drug regimens, has a significant impact on the health of elderly individuals. Drug use increases with age, but suitability of therapy is sometimes difficult to define. In ambulatory and hospital care, there is some documentation of poor prescribing practices by physicians and drug misuse by patients. Sound data suggest that polypharmacy and drug misuse are highly prevalent in long-term care facilities. Psychotherapeutic agents are the most commonly misused drugs by physicians in this setting. Polypharmacy is associated with factors such as the number and severity of illnesses, hospitalization, number of physicians seen, number of pharmacies used, and possibly increased patient age. Methods to prevent polypharmacy and drug misuse have not been well studied. There is a need for intensive research to define effective methods to strengthen prescribing practice of physicians for elderly patients, to promote cooperation among health care personnel in ensuring optimal drug use by patients, and to enhance the role of patients as responsible partners in drug therapy. The authors are confident, however, that drug misuse and polypharmacy can be reduced in older persons by the use of current knowledge of risk factors associated with polypharmacy and by improved communication between the physician and patient.

Aged↗

PubMed2006

Prevalence and predictors of polypharmacy among older primary care patients in Germany.

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.

Aged↗

PubMed1997

Decreasing polypharmacy in clients most at risk.

Approximately one third of all drugs prescribed in the United States are considered unnecessary. Polypharmacy, the unnecessary, excessive use of prescription and over-the-counter medications, increases clients' risk for adverse drug reactions and drug-drug interactions. Reducing the incidence of polypharmacy is a health protection goal of Healthy People 2000. Older clients, particularly older women living independently in the community, are at highest risk for polypharmacy caused by age-related changes in pharmacokinetics and pharmacodynamics, the presence of comorbidities requiring pharmacologic management, and high rates of unintentional noncompliance with their therapeutic regimen. Health providers may contribute to polypharmacy directly by excessive or inappropriate prescribing practices or indirectly through their inability to resist client's demands for pharmacologic interventions. Strategies to prevent and detect polypharmacy are suggested to reduce its incidence and the severity of its consequences.

Aged↗

PubMed2006

Best practices: An initiative to curtail the use of antipsychotic polypharmacy in a state psychiatric hospital.

A performance improvement initiative was undertaken at a state psychiatric hospital to reduce antipsychotic polypharmacy. Data from physicians' order forms were used to document the prescribing practices of 14 psychiatrists in November 2001 and in August 2002. After baseline data were collected, the chief of psychiatry met with each psychiatrist to compare his or her prescribing data with data of anonymous peers. The chief also asked all psychiatrists to decrease antipsychotic polypharmacy by at least 10 percent. Antipsychotic polypharmacy fell significantly--from 42 percent of patients treated with antipsychotics in November 2001 to 31 percent in August 2002. Higher utilizers of polypharmacy at baseline continued to be high utilizers at follow-up. Less antipsychotic polypharmacy was not associated with more use of other psychotropic medications. The findings suggest that initiatives that involve the focused attention of leadership and only a modest investment of effort can result in significant change in prescribing practices in a state hospital.

Antipsychotic Agents↗

PubMed2005

Health outcomes and polypharmacy in elderly individuals: an integrated literature review.

The purpose of this integrated literature review was to determine the extent of research available related to polypharmacy and its effect on the health outcomes of the elderly population. A search of the Cumulative Index of Nursing and Allied Health Literature and Medline was conducted for studies published between 1995 and 2003 that linked polypharmacy and outcomes in the elderly population. The 16 studies in this integrative literature review were conducted in the United States, Canada, Australia, and Europe. Polypharmacy was shown to be a statistically significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition. The effect of polypharmacy on elderly individuals is significant as demonstrated by this literature review. Nurses are in a unique position to monitor and potentially eliminate adverse effects of a complex medication regimen. Nursing research on polypharmacy and its effects on nursing-sensitive outcomes will help define guidelines for prevention and intervention.

Activities of Daily Living↗

PubMed2000

Polypharmacy (or polytherapy) in the treatment of heart failure.

There is now conclusive evidence that most patients with heart failure due to left ventricular systolic dysfunction should be treated with angiotensin converting enzyme (ACE) inhibitors and beta-blockers. They will also need diuretics for the control of fluid retention. There is also a powerful case for adding spironolactone to the treatment of patients with more severe symptoms. Many doctors would also use digoxin and, especially if coronary disease is present, aspirin or warfarin. Most patients also have other chronic diseases, such as diabetes, arthritis, depression and dyspepsia, and each of these may provoke the prescription of yet another agent. Many patients will receive prescriptions to treat the side-effects of their therapy. Finding a sure path through the morass of pharmacotherapy is a daunting task. Polypharmacy is having a negative impact on new drug research in an area where there are in fact remarkably few really effective treatments and the therapeutic problem is only partially solved. This paper discusses some of the issues surrounding polypharmacy in heart failure and how to resolve them, using an illustrative case history. It highlights the potential benefits of polypharmacy with effective drugs and the gross over-use of ineffective treatments in heart failure. The major problem with polypharmacy in heart failure is not the heart failure treatment itself, but the drugs for other concomitant conditions, the effectiveness of which is often not supported by an appropriate evidence base and for which alternative, less noxious management strategies often exist. Polypharmacy may be deleterious not only because of the increased potential for side-effects and drug interactions but also because taking unnecessary therapy reduces compliance with effective drugs.

Cardiovascular Agents↗