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Open Access 01-12-2018 | Research article

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

Authors: Anja Rieckert, Ulrike S. Trampisch, Renate Klaaßen-Mielke, Eva Drewelow, Aneez Esmail, Tim Johansson, Sophie Keller, Ilkka Kunnamo, Christin Löffler, Joonas Mäkinen, Giuliano Piccoliori, Anna Vögele, Andreas Sönnichsen

Published in: BMC Primary Care | Issue 1/2018

Abstract

Background

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.

Methods

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).

Results

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).

Conclusions

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.

Trial registration

This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559).

Available only for authorised users

Eurostat. Population structure and ageing. 2016. http://ec.europa.eu/eurostat/statistics-explained/index.php/Population_structure_and_ageing#Further_Eurostat_information.

Halvorsen KH, Selbaek G, Ruths S. Trends in potentially inappropriate medication prescribing to nursing home patients: comparison of three cross-sectional studies. Pharmacoepidemiol Drug Saf. 2017;26:192–200. https://doi.org/10.1002/pds.4142 .CrossRefPubMed

Tsoi CS, Chow JY, Choi KS, Li H-W, Nie JX, Tracy CS, et al. Medical characteristics of the oldest old: retrospective chart review of patients aged 85+ in an academic primary care Centre. BMC Res Notes. 2014;7:340. https://doi.org/10.1186/1756-0500-7-340 .CrossRefPubMedPubMedCentral

Wauters M, Elseviers M, Vaes B, Degryse J, Dalleur O, Vander Stichele R, et al. Polypharmacy in a Belgian cohort of community-dwelling oldest old (80+). Acta Clin Belg. 2016;71:158–66. https://doi.org/10.1080/17843286.2016.1148298 .CrossRefPubMed

Junius-Walker U, Theile G, Hummers-Pradier E. Prevalence and predictors of polypharmacy among older primary care patients in Germany. Fam Pract. 2007;24:14–9. https://doi.org/10.1093/fampra/cml067.

Herr M, Robine J-M, Pinot J, Arvieu J-J, Ankri J. Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people. Pharmacoepidemiol Drug Saf. 2015;24:637–46. https://doi.org/10.1002/pds.3772 .CrossRefPubMed

Hovstadius B, Petersson G, Hellström L, Ericson L. Trends in inappropriate drug therapy prescription in the elderly in Sweden from 2006 to 2013: assessment using national indicators. Drugs Aging. 2014;31:379–86. https://doi.org/10.1007/s40266-014-0165-5 .CrossRefPubMedPubMedCentral

Guerriero F, Orlando V, Tari DU, Di Giorgio A, Cittadini A, Trifiro G, Menditto E. How healthy is community-dwelling elderly population? Results from Southern Italy Transl Med UniSa. 2015;13:59–64.PubMed

Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3:383–9.CrossRefPubMedPubMedCentral

10.

Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17:230. https://doi.org/10.1186/s12877-017-0621-2 .CrossRefPubMedPubMedCentral

11.

Guthrie B, Makubate B, Hernandez-Santiago V, Dreischulte T. The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995-2010. BMC Med. 2015;13:74. https://doi.org/10.1186/s12916-015-0322-7 .CrossRefPubMedPubMedCentral

12.

Corsonello A, Pedone C, Incalzi RA. Age-related pharmacokinetic and pharmacodynamic changes and related risk of adverse drug reactions. Curr Med Chem. 2010;17:571–84.CrossRefPubMed

13.

Fried TR, O'Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatr Soc. 2014;62:2261–72. https://doi.org/10.1111/jgs.13153 .CrossRefPubMedPubMedCentral

14.

Agostini JV, Han L, Tinetti ME. The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc. 2004;52:1719–23. https://doi.org/10.1111/j.1532-5415.2004.52467.x .CrossRefPubMed

15.

Wimmer BC, Cross AJ, Jokanovic N, Wiese MD, George J, Johnell K, et al. Clinical outcomes associated with medication regimen complexity in older people: a systematic review. J Am Geriatr Soc. 2017;65:747–53. https://doi.org/10.1111/jgs.14682 .CrossRefPubMed

16.

Payne RA, Abel GA, Avery AJ, Mercer SW, Roland MO. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Br J Clin Pharmacol. 2014;77:1073–82. https://doi.org/10.1111/bcp.12292 .CrossRefPubMedPubMedCentral

17.

The King's Fund. Polypharmacy and medicines optimisation: Making it safe and sound. 2013.

18.

Corsonello A, Pedone C, Corica F, Incalzi RA. On behalf of the Gruppo Italiano di. Polypharmacy in elderly patients at discharge from the acute care hospital. Ther Clin Risk Manag. 2007;3:197–203. https://doi.org/10.2147/tcrm.2007.3.1.197.

19.

Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J. The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people. J Am Geriatr Soc. 2009;57:62–9. https://doi.org/10.1111/j.1532-5415.2008.02040.x .CrossRefPubMed

20.

Jyrkka J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S. Patterns of drug use and factors associated with polypharmacy and excessive polypharmacy in elderly persons: results of the Kuopio 75+ study: a cross-sectional analysis. Drugs Aging. 2009;26:493–503. https://doi.org/10.2165/00002512-200926060-00006 .CrossRefPubMed

21.

Kim H-A, Shin J-Y, Kim M-H, Park B-J. Prevalence and predictors of polypharmacy among Korean elderly. PLoS One. 2014;9:e98043. https://doi.org/10.1371/journal.pone.0098043 .CrossRefPubMedPubMedCentral

22.

Mayer S, Osterle A. Socioeconomic determinants of prescribed and non-prescribed medicine consumption in Austria. Eur J Pub Health. 2015;25:597–603. https://doi.org/10.1093/eurpub/cku179 .CrossRef

23.

O’Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ Open. 2016;6:e010505. https://doi.org/10.1136/bmjopen-2015-010505 .CrossRefPubMedPubMedCentral

24.

Onder G, Liperoti R, Fialova D, Topinkova E, Tosato M, Danese P, et al. Polypharmacy in nursing home in Europe: results from the SHELTER study. J Gerontol A Biol Sci Med Sci. 2012;67:698–704. https://doi.org/10.1093/gerona/glr233 .CrossRefPubMed

25.

Walckiers D, van der Heyden J, Tafforeau J. Factors associated with excessive polypharmacy in older people. Arch Public Health. 2015;73:50. https://doi.org/10.1186/s13690-015-0095-7 .CrossRefPubMedPubMedCentral

26.

Sonnichsen A, Trampisch US, Rieckert A, Piccoliori G, Vogele A, Flamm M, et al. Polypharmacy in chronic diseases-reduction of inappropriate medication and adverse drug events in older populations by electronic decision support (PRIMA-eDS): study protocol for a randomized controlled trial. Trials. 2016;17:57. https://doi.org/10.1186/s13063-016-1177-8 .CrossRefPubMedPubMedCentral

27.

Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489–95. https://doi.org/10.1503/cmaj.050051 .CrossRefPubMedPubMedCentral

28.

Maruish MEE. User’s manual for the SF-12v2 health survey. 3rd ed. Lincoln, RI: QualityMetric Incorporated; 2012.

29.

OECD. Classifying Educational Programmes – Manual for ISCED-97 Implementation in OECD Countries – 1999 Edition. OECD. 1999.

30.

World Health Organization. The Anatomical Therapeutic Chemical Classification System with Defined Daily Doses (ATC/DDD). http://www.who.int/classifications/atcddd/en/. Accessed 14 Feb 2018.

31.

World Health Organization. Classification of Diseases (ICD). http://www.who.int/classifications/icd/en/. Accessed 14 Feb 2018.

32.

Renom-Guiteras A, Meyer G, Thürmann PA. The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries. Eur J Clin Pharmacol. 2015;71:861–75. https://doi.org/10.1007/s00228-015-1860-9 .CrossRefPubMedPubMedCentral

33.

Herr M, Sirven N, Grondin H, Pichetti S, Sermet C. Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population. Eur J Clin Pharmacol. 2017; https://doi.org/10.1007/s00228-017-2276-5 .

34.

Saum K-U, Schöttker B, Meid AD, Holleczek B, Haefeli WE, Hauer K, Brenner HI. Polypharmacy associated with frailty in older people? Results from the ESTHER cohort study. J Am Geriatr Soc. 2017;65:e27–32. https://doi.org/10.1111/jgs.14718.

35.

Morley JE. Inappropriate drug prescribing and polypharmacy are major causes of poor outcomes in long-term care. J Am Med Dir Assoc. 2014;15:780–2. https://doi.org/10.1016/j.jamda.2014.09.003 .CrossRefPubMed

36.

Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14:392–7. https://doi.org/10.1016/j.jamda.2013.03.022 .CrossRefPubMedPubMedCentral

37.

Veronese N, Stubbs B, Noale M, Solmi M, Pilotto A, Vaona A, et al. Polypharmacy is associated with higher frailty risk in older people: an 8-year longitudinal cohort study. J Am Med Dir Assoc. 2017;18:624–8. https://doi.org/10.1016/j.jamda.2017.02.009 .CrossRefPubMedPubMedCentral

38.

Counterweight Project Team. The impact of obesity on drug prescribing in primary care. Br J Gen Pract. 2005;55:743–9.PubMedCentral

39.

Amarya S, Singh K, Sabharwal M. Health consequences of obesity in the elderly. J Clinical Gerontology Geriatrics. 2014;5:63–7. https://doi.org/10.1016/j.jcgg.2014.01.004 .CrossRef

40.

Lee SJ, Leipzig RM, Walter LC. Incorporating lag time to benefit into prevention decisions for older adults. JAMA. 2013;310:2609–10. https://doi.org/10.1001/jama.2013.282612 .CrossRefPubMedPubMedCentral

41.

Tinetti ME, McAvay GJ, Fried TR, Allore HG, Salmon JC, Foody JM, et al. Health outcome priorities among competing cardiovascular, fall injury, and medication-related symptom outcomes. J Am Geriatr Soc. 2008;56:1409–16. https://doi.org/10.1111/j.1532-5415.2008.01815.x .CrossRefPubMedPubMedCentral

42.

Schuling J, Gebben H, Veehof LJG, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56. https://doi.org/10.1186/1471-2296-13-56 .CrossRefPubMedPubMedCentral

43.

Baker DP, Leon J, Smith Greenaway EG, Collins J, Movit M. The education effect on population health: a reassessment. Popul Dev Rev. 2011;37:307–32. https://doi.org/10.1111/j.1728-4457.2011.00412.x .CrossRefPubMedPubMedCentral

44.

Roland M. Linking physicians' pay to the quality of care--a major experiment in the United Kingdom. N Engl J Med. 2004;351:1448–54. https://doi.org/10.1056/NEJMhpr041294 .CrossRefPubMed

45.

MacBride-Stewart SP, Elton R, Walley T. Do quality incentives change prescribing patterns in primary care? An observational study in Scotland. Fam Pract. 2008;25:27–32. https://doi.org/10.1093/fampra/cmm074 .CrossRefPubMed

46.

McGovern MP, Boroujerdi MA, Taylor MW, Williams DJ, Hannaford PC, Lefevre KE, Simpson CR. The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care. Fam Pract. 2008;25:33–9. https://doi.org/10.1093/fampra/cmm073.

47.

Kojima G, Iliffe S, Jivraj S, Walters K. Association between frailty and quality of life among community-dwelling older people: a systematic review and meta-analysis. J Epidemiol Community Health. 2016;70:716–21. https://doi.org/10.1136/jech-2015-206717 .CrossRefPubMed

48.

Frailty, polypharmacy and deprescribing. Drug Ther Bull 2016;54:69–72. doi:https://doi.org/10.1136/dtb.2016.6.0408 .

49.

Eisele M, Kaduszkiewicz H, König H-H, Lange C, Wiese B, Prokein J, et al. Determinants of health-related quality of life in older primary care patients: results of the longitudinal observational AgeCoDe study. Br J Gen Pract. 2015;65:e716–23. https://doi.org/10.3399/bjgp15X687337 .CrossRefPubMedPubMedCentral

50.

Puth M-T, Weckbecker K, Schmid M, Münster E. Prevalence of multimorbidity in Germany: impact of age and educational level in a cross-sectional study on 19,294 adults. BMC Public Health. 2017;17:826. https://doi.org/10.1186/s12889-017-4833-3 .CrossRefPubMedPubMedCentral

51.

Montiel-Luque A, Núñez-Montenegro AJ, Martín-Aurioles E, Canca-Sánchez JC, Toro-Toro MC, González-Correa JA. Medication-related factors associated with health-related quality of life in patients older than 65 years with polypharmacy. PLoS One. 2017; https://doi.org/10.1371/journal.pone.0171320 .

Title: Polypharmacy in older patients with chronic diseases: a cross-sectional analysis of factors associated with excessive polypharmacy
Authors: Anja Rieckert
Ulrike S. Trampisch
Renate Klaaßen-Mielke
Eva Drewelow
Aneez Esmail
Tim Johansson
Sophie Keller
Ilkka Kunnamo
Christin Löffler
Joonas Mäkinen
Giuliano Piccoliori
Anna Vögele
Andreas Sönnichsen
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: BMC Primary Care / Issue 1/2018
Electronic ISSN: 2731-4553
DOI: https://doi.org/10.1186/s12875-018-0795-5

At a glance: The STEP trials

Springer Medicine

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

Abstract

Background

Methods

Results

Conclusions

Trial registration

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Trial registration

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