Advertisement

Benefits, risks and impacts on quality of life of medications used in multimorbid older adults: a Delphi study

  • Caroline SiroisEmail author
  • Carlotta Lunghi
  • William Berthelot
  • Marie-Laure Laroche
  • Anissa Frini
Research Article
  • 65 Downloads

Abstract

Background Multimorbidity and polypharmacy are common in older people. Despite the existence of quality criteria for medication use among this population, there is little guidance for managing the complex pharmacological arsenal in a multimorbidity context. Objective To establish consensus on benefits, risks and impacts on quality of life of medications used in an older adult with three chronic diseases that require complex pharmacotherapy. Setting International experts in pharmacology. Method A panel of experts responded to three rounds of a Delphi survey. They assessed the benefits, risks and positive impacts on quality of life of 50 different medications or medication classes that could be used by a hypothetical multimorbid older patient aged 65–75 years, with type 2 diabetes, heart failure and chronic obstructive pulmonary disease. Each aspect was evaluated on a 5-level Likert scale. Main outcome measure Percentage of agreement on each of the three aspects for all medication. Results Consensus was reached on 95% of items (166/174). Only two medication classes were associated with both the highest category of benefits and positive impacts on quality of life, and the lowest risk category: long-acting anticholinergics and long-acting beta-2-agonists. Nine other medications/classes of medications were categorized within the highest benefits level (metformin, DPP-4-inhibitors, short-acting beta-2-agonists, ACE inhibitors, beta-blockers, warfarin, non-vitamin K oral anticoagulants, nitrates and acetaminophen). Fifteen medications were included in the highest level of risks, among which warfarin and Non-vitamin K oral anticoagulants. Conclusions Medications recommended in clinical guidelines for individual diseases are generally considered positive for multimorbid older patients. Nevertheless, a non-negligible number of medications was deemed negative or very negative by our panelists. For multimorbid patients, individualizing treatment according to their preferences seems of utmost importance.

Keywords

Benefits Multimorbidity Polypharmacy Quality of life Risks 

Notes

Acknowledgements

We sincerely thank all the participants who generously responded to our lengthy Delphi survey and provided valuable comments. We also thank Myles Gaulin who edited our document.

Funding

The study was supported by a Grant from the Université du Québec à Rimouski and a grant by the Research Centre in Patient Care and Front Line Services at Laval University (Centre de recherche sur les soins et les services de première ligne de l’Université Laval). Caroline Sirois is a recipient of a Junior 1 Research Scholar from the Quebec Research Funds in Health (Fonds de recherche du QuébecSanté, FRQS).

Conflicts of interest

The authors declare no conflict of interest.

References

  1. 1.
    Salive ME. Multimorbidity in older adults. Epidemiol Rev. 2013;35:75–83.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012;380(9836):37–43.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity’s many challenges. BMJ. 2007;334(7602):1016–7.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Buffel du Vaure C, Ravaud P, Baron G, Barnes C, Gilberg S, Boutron I. Potential workload in applying clinical practice guidelines for patients with chronic conditions and multimorbidity: a systematic analysis. BMJ Open. 2016;6(9):e012265.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Zhou L, Rupa AP. Categorization and association analysis of risk factors for adverse drug events. Eur J Clin Pharmacol. 2018;74(4):389–404.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Rodrigues MC, Oliveria CD. Drug-drug interactions and adverse drug reactions in polypharmacy among older adults: an integrative review. Rev Lat Am Enferm. 2016;24:e2800.Google Scholar
  7. 7.
    Miller GE, Sarpong EM, Davidoff AJ, Yang EY, Brandt NJ, Fick DM. Determinants of potentially inappropriate medication use among community-dwelling older adults. Health Serv Res. 2017;52(4):1534–49.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Gutiérrez-Valencia M, Izquierdo M, Cesari M, Casas-Herrero A, Inzitari M, Martinez-Velilla N. The relationship between frailty and polypharmacy in older people: a systematic review. Br J Clin Pharmacol. 2018;84(7):1432–44.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Wallace E, Stuart E, Vaughan N, Bennett K, Fahey T, Smith SM. Risk prediction models to predict hospital admission in community-dwelling adults: a systematic review. Med Care. 2014;52(8):751–65.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Leelakanok N, Holcombe AL, Bund BC, Gu X, Schweizer ML. Association between polypharmacy and death: a systematic review and meta-analysis. J Am Pharm Assoc. 2017;57(6):729–38.CrossRefGoogle Scholar
  11. 11.
    Sirois C, Simard M, Gosselin E, Gagnon ME, Roux B, Laroche ML. Mixed bag “polypharmacy”: methodological pitfalls and challenges of this exposure definition. Curr Epidemiol Rep. 2019;6:390–401.CrossRefGoogle Scholar
  12. 12.
    Tseng HM, Lee CH, Chen YJ, Hsu HH, Huang LY, Huang JL. Developing a measure of medication-related quality of life for people with polypharmacy. Qual Life Res. 2016;25(5):1295–302.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Mohammed MA, Moles RJ, Hilmer SN, Kouladjian O’Donnel L, Chen TF. Development and validation of an instrument for measuring the burden of medicine on functioning and well-being: the medication-related burden quality of life (MRB-QoL) tool. BMJ Open. 2018;8(1):e018880.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Montiel-Luque A, Nunez-Montenegro AJ, Martin-Aurioles E, Canca-Sanchez JC, Toro-Toro MC, Ganzalez-Correa JA, et al. Medication-related factors associated with health-related quality of life in patients older than 65 years with polypharmacy. PLoS One. 2017;12(2):e0171320.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Tegegn HG, Erku DA, Sebsibe G, Gizaw B, Seifu D, Tigabe M, et al. Medication-related quality of life among Ethiopian elderly patients with polypharmacy: a cross-sectional study in an Ethiopia university hospital. PLoS One. 2019;14(3):e0214191.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Schenker Y, Park SY, Jeong K, Pruskowski J, Kavalieratos D, Resick J, et al. Associations between polypharmacy, symptom burden, and quality of life in patients with advanced, life-limiting illness. J Gen Intern Med. 2019;34(4):559–66.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Noale M, Veronese N, Cavallo Perin P, Pilotto A, Tiengo A, Crepaldi G, et al. Polypharmacy in elderly patients with type 2 diabetes receiving oral antidiabetic treatment. Acta Diabetol. 2016;53(2):323–30.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Sirois C, Ouali A, Simard M. Polypharmacy among older individuals with COPD: trends between 2000 and 2015 in Quebec, Canada. COPD. 2019;12:1–6.  https://doi.org/10.1080/15412555.2019.1646716.CrossRefGoogle Scholar
  19. 19.
    Kennel PJ, Kneifati-Hayek J, Bryan J, Banerjee S, Sobol I, Lachs MS, et al. Prevalence and determinants of hyperpolypharmacy in adults with heart failure: an observational study from the national health and nutrition examination survey (NHANES). BMC Cardiovasc Disord. 2019;19(1):76.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Sirois C, Lunghi C, Laroche ML, Maheux A, Frini A. The delicate choice of optimal basic therapy for multimorbid older adults: a cross-sectional survey. Res Soc Adm Pharm. 2019;15(6):761–6.CrossRefGoogle Scholar
  21. 21.
    Pirina P, Martinetti M, Spada C, Zinellu E, Pes R, Chessa E, et al. Prevalence and management of COPD and heart failure comorbidity in the general practitioner setting. Respir Med. 2017;131:1–5.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Dauriz M, Targher G, Laroche C, Temporelli PL, Ferrari R, Anker S, et al. Association between diabetes and 1-year adverse clinical outcomes in a multinational cohort of ambulatory patients with chronic heart failure: results from the ESC-HFA heart failure long-term registry. Diabetes Care. 2017;40(5):671–8.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Doos L, Bradley E, Rushton CA, Satchithananda D, Davies SJ, Kadam UT. Heart failure and chronic obstructive pulmonary disease multimorbidity at hospital discharge transition: a study of patient and carer experience. Health Expect. 2015;18(6):2401–12.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Aronow WS. Treatment of heart failure in older persons. Dilemmas with coexisting conditions: diabetes mellitus, chronic obstructive pulmonary disease, and arthritis. Congest Heart Fail. 2003;9(3):142–7.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Timbie JW, Hayward RA, Vijan S. Variation in the net benefit of aggressive cardiovascular risk factor control across the US population of patients with diabetes mellitus. Arch Intern Med. 2010;170(12):1037–44.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Kim DH, Rich MW. Patient-centred care of older adults with cardiovascular disease and multiple chronic conditions. Can J Cardiol. 2016;32(9):1097–107.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Boulkedid R, Abdoul H, Loustau M, Sibony O, Alberti C. Using and reporting the Delphi method for selecting healthcare quality indicators: a systematic review. PLoS One. 2011;6(6):e20476.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38(3):655–62.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Harper W, Clement M, Goldenberg R, Hanna A, Main A, Retnakaran R, et al. Canadian diabetes association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada: pharmacologic management of type 2 diabetes. Can J Diabetes. 2013;37(1):S61–8.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. Respirology. 2017;22:575–601.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Canadian Diabetes Association Clinical Practice Guidelines Expert Comittee, Howlett JG, MacFadyen JC. Treatment of diabetes in people with heart failure. Can J Diabetes. 2013;37(1):S126–8.Google Scholar
  33. 33.
    Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. J Am Coll Cardiol. 2013;62:e147–239.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: systematic review and meta-analysis. Circulation. 2015;132:194–204.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Opstelten W, van den Donk M, Kuijpers T, Burgers J. New oral anticoagulants for nonvalvular atrial fibrillation in the elderly: limited applicability in primary care. Eur J Gen Pract. 2015;21:145–9.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Bereznicki LR, Peterson GM, Jackson SL, Jeffrey EC. The risks of warfarin use in the elderly. Expert Opin Drug Saf. 2006;5:417–31.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the national registry of atrial fibrillation. JAMA. 2001;285:2864–70.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro heart survey. Chest. 2010;138:1093–100.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Singh S, Zieman S, Go AS, Fortmann SP, Wenger NK, Fleg JL, et al. Statins for primary prevention in older adults—moving toward evidence-based decision-making. J Am Geriatr Soc. 2018;66(11):2188–96.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    American Geriatrics Society. American geriatrics society 2015 updated Beers critera for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227–46.CrossRefGoogle Scholar
  41. 41.
    O’Connor N, Gallagher P, O’Mahony D. Inappropriate prescribing. Criteria, detection and prevention. Drugs Aging. 2012;29:437–52.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Molokhia M, Majeed A. Current and future perspectives on the management of polypharmacy. BMC Fam Pract. 2017;18(1):70.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Mangin D, Bahat G, Golomb BA, Mallery LH, Moorhouse P, Onder G, et al. International group for reducing inappropriate medication use & polypharmacy (IGRIMUP): position statement and 10 recommendations for actions. Drugs Aging. 2018;35(7):575–87.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Mantelli S, Jungo KT, Rozsnyai Z, Reeve E, Luymes CH, Poortvliet RKE, et al. How general practitioners would deprescribe in frail oldest-old with polypharmacy—the LESS study. BMC Fam Pract. 2018;19(1):169.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Jungo KT, Rozsnyai Z, Mantelli S, Floriani C, Löwe AL, Lindemann F, et al. “Optimising parmacotherapy in the multimorbid elderly in primary care” (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial. BMJ Open. 2019;9(9):e031090.CrossRefGoogle Scholar
  46. 46.
    Adam L, Moutzouri E, Baumgartner C, Loewe AL, Feller M, M’Rabet-Bensalah K, et al. Rationale and design of optimizing therapy to prevent avoidable hospital admissions in multimorbid older people (OPERAM): a cluster randomized controlled trial. BMJ Open. 2019;9(6):e026769.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Pittet VEH, Maillard MH, Simonson T, Fournier N, Rogler G, Michetti P, et al. Differences in outcomes reported by patients with inflammatory bowel diseases vs their health care professionals. Clin Gastroenterol Hepatol. 2019;17(10):2050–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Bertocchio JP, Baranger T, Isnard-Rouchon M, Zaoui P, Mousson C, Deray G. Discrepancies (and confluences) in perception between patients and nephrologists of chronic kidney disease impact on vital impetus in adults not undergoing hemodialysis: results of the French MAEVA study. Nephrol Ther. 2018;14(4):222–30.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Sackett DL, Straus SE, Richardson S, Rosenberg W, Haynes B. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone; 2000.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Social and Preventive MedicineLaval UniversityQuebecCanada
  2. 2.Centre d’excellence sur le vieillissement de Québec, CIUSSS-CNHôpital St-SacrementQuebecCanada
  3. 3.Centre de recherche sur les soins et les services de première ligne de l’Université LavalQuebecCanada
  4. 4.Department of NursingUQARLévisCanada
  5. 5.Faculty of MedicineLaval UniversityQuebecCanada
  6. 6.Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Régional de Pharmacovigilance, de Pharmacoépidémiologie et d’information sur les médicamentsCentre Hospitalier Universitaire de LimogesLimogesFrance
  7. 7.Faculty of MedicineLimoges UniversityLimogesFrance
  8. 8.INSERM 1248Limoges UniversityLimogesFrance
  9. 9.Department of ManagementUQARLévisCanada

Personalised recommendations