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Abstract
Polypharmacy
contributes to medication errors, non-compliance
and increased risk of hospitalization leading
to poor quality of life. Financial burden on patients
and the economy may also occur.
Aim: Studying the prevalence of polypharmacy
and inappropriate medication use among elderly
persons in an Egyptian rural area.
Methods: a cross sectional design, at Dar-Alsalam
village, Mansoura city, Dakhlia governate, Egypt.
Subjects included all individuals aged 60 years
and over living in the village during the time
of the study (395 elderly individual). Measurements
included detailed interview including medical
history, previous hospital reports, available
investigations and medication review. Screening
for polypharmacy, as the use of five or more drugs,
is an inappropriate prescription according to
Beers criteria 2003.
Results: The percentage of polypharmacy
was 56%. There is a high significant association
between the number of physicians and Polypharmacy
(p < 0.01). Inappropriate medication use was
reported in 41% of the participating elderly;
32% of these medications are present in Table
1with high severity, while 2.9 % are present in
Table two. There was a significant relation between
polypharmacy and inappropriate medication use
p <0.01.
Conclusion: Polypharmacy is an important
problem in the elderly population. There is a
high significant association between the number
of physicians' consultations and polypharmacy.
There is a significant relation between polypharmacy
and inappropriate medication use.
Keywords: polypharmacy, elderly, inappropriate
medication, rural area
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INTRODUCTION
Polypharmacy refers to
the use of multiple medications by the patient and is
commonly defined as using more than a certain number
of drugs [1, 2]. Many use a cut point of three to five
drugs per patient [3].The most common definition is
the concurrent use of five or more drugs [4,5] and screening
for inappropriate drug prescription was done by using
Beers criteria 2003. 49% of elderly women and 45% of
elderly men take five or more drugs [6]. Polypharmacy
is regarded also as an important risk factor for falling
in the elderly population [7-11]. Polypharmacy contributes
to medication errors, drug interactions, non-compliance,
and increased risk of hospitalization. They all lead
to poor quality of life, increases morbidity, mortality,
geriatric syndromes, decline of functional status and
complexity of care. They also impose a huge financial
burden on both the patient and the economy either directly
due to medications or indirectly due to treating adverse
events [12-15].
Inappropriate medication use was defined as prescribing
medication that does not agree with accepted medical
standards, has greater potential to harm than to benefit
the patient in regular doses regardless of patient diagnoses
or conditions, has contraindication for specific conditions,
has potentially harmful drug-drug interactions, or is
therapeutically duplicative to other medications [13,
15-16].
Several studies have examined the prevalence of inappropriate
medication use in the elderly (older patients take at
least 1 inappropriate drug); it ranged from 14% to 44%
[17-18].
This study aimed at studying the prevalence of Polypharmacy
and inappropriate medication use among elderly persons
in an Egyptian rural area.
MATERIALS AND METHODS
-Study locality:
The study was carried out in Dar-Alsalam village, which
is 15 kilometers from Mansora city, the capital of Dakhlia
governate, Egypt.
- All individuals aged 60 years and over living in the
village during the time of the study were considered
subjects. The number of elderly living in Dar El-Salam
village, Dakhlia, governate was estimated to be 418
elderly [19]. Most of the subjects' localization (395)
was done with the help of nursing and social workers
of the village primary health care unit. Eighteen of
them were not included (11 subjects were not present
at the time of the study while 7 subjects refused to
participate) and the rest of the subjects (377) were
included. Almost 6 % (n=23) of the subjects' addresses
could not be recognized.
All participants underwent a home interview and
we reviewed the following:
- Medical history including lists of active medical
conditions. Reviewing the available outpatient notes,
emergency department notes, hospital discharge summaries
and recent laboratory or diagnostic test results from
the year before inclusion in the study.
- Number of managing physicians and hospital admissions
in the last year.
- Medication review to determine current actually used
medications
- Matching the complete list of chronic medical conditions
to the prescribed medications.
- Screening for Polypharmacy as the use of five or more
drugs
-Screening for inappropriate prescription according
to Beers criteria 2003[20]. This criteria classifies
inappropriate drug use in elderly persons into 2 tables;
Table 1 describes 48 drugs or drug classes to be avoided
in older adults, while Table 2 describes 20 diseases/conditions
and medications to be avoided in older adults with these
conditions.
Statistical Analysis
The statistical analysis of data was done by using Excel
program and SPSS program (Statistical Package for Social
Science) version 10. One way ANOVA test was done to
compare more than two groups, followed by Post Hoc test
LSD (least significant difference) for inter group comparisons.
For quantitative data, student t-test was used to compare
between the two groups. Paired sample t-test was done
to compare one group at different times. Chi square
test was used for qualitative data. Correlation co efficiency
was done to detect association between variables.
N.B: P is significant if < 0.05 at
confidence interval 95%.
Ethical issues:
1- This study was approved by Ain Shams University ethical
committee
2- Informed oral consent was taken from the subjects
RESULTS
The
participants were divided into four groups according
to age: group A; 60-64years, group B 65-70 years, group
C 71-74 years and group D > 75years. Nearly
50% of subjects' previous occupation was as farmers
while the rest were working as: employees 21%, manual
workers 17% and 21% were housewives (Table 1).
Table 1: Personal characteristics of the participants
Studying
the distribution of the chronic medical diseases revealed
that there is no significant difference between groups
as regards the presence of chronic medical illnesses.
The most common disease was hypertension 32% (n =122)
then diabetes mellitus, chronic liver disease each representing
28% (n =104), and lung diseases 12% (n= 48).
There is no significant difference between groups as regards
the number of total medications (p=.525). The average
number of medications was 4.9 3.1 per person. The percentage
of polypharmacy (> 5 medications) was 56 % (Table
2).
Table 2: Number of medications taken by elderly
There is no significant difference between groups as regards
the number of over the counter drugs OTC (p=.234). In
all of the participants; the average number of Over The
Counter (OTC) medications per patient was 0.351 0.68 and
maximum number per patient was 5 OTC medications. The
percent of elderly taking OTC was 30 % (n=114). The most
common OTC was NSAIDS which represented 43.7% of the total
OTC medications followed by antacid and H2 blockers which
represents16.9%.
There is a high significant association between the number
of physicians consulted per person and Polypharmacy (p
= .000). Polypharmacy was associated with general practitioner,
internal medicine, cardiologist, and rheumatologist consultation
but not with chest medicine, and orthopedic physician's
consultation (Table 3).
Table 3: Relation between type and number of managing
physicians in the last year and polypharmacy
Patients with musculoskeletal diseases are 15 times more
liable to polypharmacy than those without. While Patients
with chronic liver diseases are 7.9 times more liable
to polypharmacy than those without (Table 4).
Table 4: Risk estimate for different disease states
Inappropriate medication use was reported in 41% (n= 155)
of the participating elderly, 32% (n=120) of these medications
present in Table one with high severity, while 2.9% (n=12)
present in Table two. There is no significant difference
between groups (p=.360). (Table 5).
Table 5: Inappropriate medication use among elderly
age groups according to Beers
40% of the reported inappropriate medications are OTC.
There is significant relation between Polypharmacy and
inappropriate medication use. 71% (n=110) of elderly take
inappropriate medication and have Polypharmacy and so,
51.9 % (n= 110) of elderly with polypharmacy (n= 212)
have inappropriate medication use P =0.000.
DISCUSSION
Very few interventions in medicine are completely without
the potential for harm thus quality depends on whether
the benefits of an intervention outweighs the harm, and
whether this benefit harm balance compares favorably to
the balance associated with alternative treatments [21].
It is not surprising that patients taking multiple medications
are more likely to experience medication-related adverse
events. As described, bad things happen to people taking
multiple medications [17]. However, the totality of a
patient's medication regimen can have important effects
beyond the sum of risks associated with the individual
drugs and include problems of medication costs and adherence
to complex medication regimens. In contrast, Polypharmacy
can be appropriate when multiple drug regimens are necessary
for the treatment of conditions and are carefully monitored
by clinicians for achieving a therapeutic goal and for
drug-related problems [22]. These considerations increase
the need to prove that the potential benefits of therapy
outweigh the adverse effects.
We performed the current study in a rural area which was
known to have marked different demographic, cultural and
medical criteria than those living in the big cities.
The response proportion (96%) is considered high compared
to the usual response proportion in population-based studies
[23].
It is worth mentioning that of the remaining 4% (n=18),
seven subjects refused to participate in the study and
the remaining (11 subjects) were not present during neither
the 1st nor a 2nd visit trial which was conducted one
month after the first visit.
In the current study the average number of medications
was 4.9 3.1 per person which is comparable to other studies
with an average number ranging from 3-8 [24-25].
In the current study the percentage of polypharmacy (>
5 medications) was 56%.
There is a variable estimate of polypharmacy prevalence
among different studies ranging from 19% to 64 %. The
variation between different studies can be explained by;
difference in the population characteristics (urban or
rural citizens, community dwelling or hospitalized), differences
in polypharmacy definition [5, 27-30].
The relatively high percentage of polypharmacy may be
referred to, population characteristics, high prevalence
of OTC medications, more visits to general practitioner
(56% of elderly visit general practitioners with a tendency
to prescribe more drugs per illness) more frequently than
other specialists and the high prevalence of diseases
as those with > one medical condition represent
88% of the population.
In the current study, the percent of elderly taking OTC
was 30 %. Generally the use of OTC is increasing [30]
especially among elderly [26, 32].
The current study supported the previous findings that
NSAIDS are considered the commonly used drugs without
prescription [33] which spots light on the importance
of health education about the indications and the side
effects of NSAIDS in geriatric practice.
The current study found that; chronic liver disease, hypertension,
and stroke, heart failure, and dementia increased the
risk of the presence of polypharmacy. Higher values in
the current study may be because these diseases are managed
mostly by general practitioners who usually prescribe
more drugs than specialists, and patients are also managed
by multiple physicians without coordination in between
leading to multiple prescriptions. On the other hand there
is an insignificant association between Polypharmacy and
diabetes mellitus, Parkinsonism, depression, COPD, urinary
incontinence, and benign prostatic hyperplasia.
Using Beers' criteria to determine inappropriate medication
prescribing is useful. Beers' criteria helps the clinician
identify adverse reactions and medications that should
be avoided or used with caution in the older population.
Beers' criteria were utilized in several research studies
addressing inappropriate prescribing [28, 34-36]
In the current study the prevalence of inappropriate medications
in older people was 41% of the participating elderly,
which is comparable to other studies using the same method
(Beers' criteria) to assess drug inappropriateness and
reported percentages were very close to ours [37-38].
On the contrary, utilizing the Medication Appropriateness
Index showed that 58.6% of patients had > 1
unnecessary prescribed drug [39]. It is also worth mentioning
that evaluation of inappropriate medications in different
settings like outpatient clinics or long term care facilities
reported lower percentages [40-42]
A high percentage of inappropriate medications, 41% in
the current study, may be referred to a high prevalence
of polypharmacy [26, 38-39], OTC medications and visiting
general practitioners prescribing more frequently than
other specialists.
In conclusion: polypharmacy is an important problem in
the elderly population. The percentage of polypharmacy
was 56%. There is a high significant association between
the number of physicians and polypharmacy. There is a
significant relation between polypharmacy and inappropriate
medication use.
REFERENCES
1-Koh Y, Fatimah BM, Li
SC. Therapy related hospital admission in patients on
Polypharmacy in Singapore, a pilot study: Pharmacy World
and Science 2003; 25, 135-37.
2-Nguyen JK, Fouts MM, Kotabe SE (2006): Polypharmacy
as a risk factor for adverse drug reactions in geriatric
nursing home residents: The American Journal of Geriatric
Pharmacotherapy 2006; 4, 36-41.
3-Meyer TJ, Koote DV, Marsh S et al. Reduction of polypharmacy
by feedback to clinicians: J Gen Intern Med 1991; 6:133-6.
4-Johansson S, Kennerfalk A, Wallander M, et al. Prescription
drug use, diagnoses, and healthcare utilization among
the elderly. The Annals of Pharmacotherapy 2001; 35(9),
1004-1009
5-Haider SI, Johnell K. Mats Thorslund; and Johan Fastbom.
Analysis of the Association between Polypharmacy and
Socioeconomic Position among Elderly Aged >77 Years
in Sweden. Clinical Therapeutics 2008; 30 (2).
6-Rollason V, Vogt N. Reduction of Polypharmacy in the
elderly. A systematic review of the pharmacist: Drugs
Aging 2003; 817-32.
7- Robbins AS, Rubenstein LZ, Josephson KR, et al. Predictors
of falls among elderly people. Results of two population-based
studies: Arch Intern Med 1989; 149: 1628-33.
8- Evans JG. Drugs and falls in later life: Lancet 2003;
361 (9356): 448
9- Cumming RG, Miller JP, Kelsey JL, et al. Medications
and multiple falls in elderly people. The St Louis OASIS
study: Age Ageing 1991; 20: 455-61.
10-Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls
in older people: a systematic review and meta-analysis
I. Psychotropic drugs: J Am Geriatr Soc 1999; 47: 30-9.
11- Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls
in older people. A systematic review and meta-analysis.
II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999;
47: 40-50.
12-Monane M, Monane S, Semla T. Optimal medication use
in elders. Key to successful aging: West J Med 1997;
167:233-237.
13-HanlonJT, Kenneth E. Schmader, et al. Suboptimal
Prescribing in Older Inpatients and Outpatients: Drugs
and pharmacology 2001; 49 (2).JAGS 49:200-209
15-Suzanne VF, Linda RT, Cornelis HW. (2006): Evaluation
of Pharmacotherapy in Geriatric Patients after Performing
Complete Geriatric Assessment at a Diagnostic Day Clinic:
Clin Drug Invest 2006: 169-74
16-Midlöv P and Gallagher. Inappropriate Drug in
the Elderly. Drug-Related Problems in the Elderly 2009;
10:2446-6
17-Zhan HJ: Aging, health care, and elder care: perpetuation
of gender inequalities in China: Health Care Women Int.
2005 Sep; 26(8):693-712.
18-Stuck AE, Beers MH, Steiner A, et al. Inappropriate
medication use in community-residing older persons:
Arch Intern Med 1994; 154:2195-200
19-Hajjar ER, Hanlon JT, Sloane RJ et al. (2005): Unnecessary
drug use in frail older people at hospital discharge:
J Am Geriatr Soc. 2005; 53:1518-23.
20-The central agency for public mobilization and statistics
(CAPMS, 2008)
21- Fick DM, Cooper JW, Wade WE et al. Updating the
Beers criteria for potentially inappropriate medication
use in older adults. Results of a US consensus panel
of experts: Arch Intern Med. 2003; Dec 8-22; 163(22):2716-24.
22- Steinman MA. Polypharmacy and the balance of medication
benefits and risks: Am J Geriatr Pharmacotherap. 2007;
Dec; 5(4):314-6.
23- Gray CL, Gardner C. Adverse Drug Events in the Elderly.
An Ongoing Problem. Journal of Managed Care Pharmacy
JMCP 2009; September 15 (7). www.amcp.org
24-Stang A.Nonresponse research - an underdeveloped
field in epidemiology: European Journal of Epidemiology
2003; 18: 929-931
25- Rajska-Neumann A, Wieczorowska-Tobis K. Polypharmacy
and potential inappropriateness of pharmacological treatment
among community-dwelling elderly patients: Arch. Grantol.Geriatr
2007; Suppl.1 303-9.
26-Hogan DB, Maxwell CJ, Fung TS, et al. "Prevalence
and Potential Consequences of Benzodiazepine Use in
Senior Citizens. Results from the Canadian Study of
Health and Aging": Canadian Journal of Clinical
Pharmacology 2003; 10(2), 72-7.
27-Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy
and prescribing quality in older people: JAm Geriatr
Soc.2003; 54:1516-23
28-Linjakumpu T, Hartikainen S, Klaukka T, et al. Use
of medications and Polypharmacy are increasing among
the elderly: Journal of Clinical Epidemiology 2002;55:
809-17.
29-Rozenfeld S, Fonseca MJ, Francisco A (2008): Drug
utilization and polypharmacy among the elderly in Brazil
elderly: a survey in Rio de Janeiro City, Brazil: Rev
Panam Salud Publica 2008; 23(1):34-43
30-Tulner LR, Frankfort SV, Gijsen G,et al., (2008).
Drug-Drug Interactions in a Geriatric Outpatient Cohort.
Drugs Aging 2008; 25 (4)
31-Wawruch M, Zikavska M, Wsolova L. Polypharmacy in
elderly hospitalised patients in Slovakia: Pharm World
Sci 2008; 30:235-42.
32-Goh LY, Vitry AI, Semple SJ, et al. Self-medication
with over the counter drugs and complementary medications
in South Australia's elderly population: BMC Complement
Arch. Itern. Med 2009; 11; 9:42.
33-Beyth R, Shorr R. Epidemiology of Adverse Drug Reactions
in the Elderly by Drug Class: Drugs & Aging 1999;
14 (3): 231-9
34-Wilcox C, Cryer B, and Triadafilopoulos G . Patterns
of Use and Public Perception of Over-the-Counter Pain
Relievers: Focus on Nonsteroidal Anti-inflammatory Drugs:
J Rheumatol 2005; 32:2218-24
35- Hanlon JT, Schmader KE, Boult C. Use of inappropriate
prescription drugs by older adult. J Am Geriatr Soc.
2002 Jan; 50(1):26-34
36-Raji MA, Ostir GV, and Goodwin JS. "Potentially
Inappropriate Medication Use by Elderly Mexican Americans."
The Annals of Pharmacotherapy2003; 37, 1197-202.
37-Goulding, M.R. "Inappropriate Medication Prescribing
for Elderly Ambulatory Care Patients." Arch. Intern.
Med 2004; 164:305-12.
38-Fulton MM, Allen ER. Polypharmacy in the elderly:
a literature review. Journal of the American Academy
of Nurse Practitioners 2005; 17, 123-32
39-Golden AG, Preston RA, Barnett SD . Inappropriate
medication prescribing in homebound older adults. J
Am Geriatr Soc. 1999 Aug; 47(8):948-53.
40-Rossi MI, Hajjar ER, Hanlon JT. Polypharmacy and
Health Beliefs in Older Outpatients. The American Journal
of Geriatric Pharmacotherapy 2007; 12,001
41- Curtis LH, Sendersky V, Schulman KA, et al. "Inappropriate
Prescribing for Elderly Americans in a Large Outpatient
Population." Arch. Intern. Med 2004; 164:1621-25.
42- Chou HJ, Huang CM, Tarn YH, et al. (2004). Drug
regimen review in a nursing home in Taiwan. 64th Congress
of FIP World Congress of Pharmacy and Pharmaceutical
Sciences 2004; New Orleans (LA), 70.
43- Spore DL, Mor V, Larrat P, et al. Inappropriate
drug prescriptions for elderly residents of board and
care facilities. Am J Public Health. 1997 Mar; 87(3):404-9.
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