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Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study

European Journal of Clinical Pharmacology volume 67, pages 507–519 (2011)Cite this article

Abstract

Purposes

We evaluated the prevalence and factors associated with polypharmacy and investigated the role of polypharmacy as a predictor of length of hospital stay and in-hospital mortality.

Methods

Thirty-eight internal medicine wards in Italy participated in the Registro Politerapie SIMI (REPOSI) study during 2008. One thousand three hundred and thirty-two in-patients aged ≥65 years were enrolled. Polypharmacy was defined as the concomitant use of five or more medications. Linear regression analyses were used to evaluate predictors of length of hospital stay and logistic regression models for predictors of in-hospital mortality. Age, sex, Charlson comorbidity index, polypharmacy, and number of in-hospital clinical adverse events (AEs) were used as possible confounders.

Results

The prevalence of polypharmacy was 51.9% at hospital admission and 67.0% at discharge. Age, number of drugs at admission, hypertension, ischemic heart disease, heart failure, and chronic obstructive pulmonary disease were independently associated with polypharmacy at discharge. In multivariate analysis, the occurrence of at least one AE while in hospital was the only predictor of prolonged hospitalization (each new AE prolonged hospital stay by 3.57 days, p < 0.0001). Age [odds ratio (OR) 1.04; 95% confidence interval (CI) 1.01–1.08; p = 0.02), comorbidities (OR 1.18; 95% CI 1.12–1.24; p < 0.0001), and AEs (OR 6.80; 95% CI 3.58–12.9; p < 0.0001) were significantly associated with in-hospital mortality.

Conclusions

Although most elderly in-patients receive polypharmacy, in this study, it was not associated with any hospital outcome. However, AEs were strongly correlated with a longer hospital stay and higher mortality risk.

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References

  1. Gurwitz JH (2004) Polypharmacy. A new paradigm for quality drug therapy in the elderly? Arch Intern Med 164:1957–1959

    PubMed  Article  Google Scholar 

  2. Hajjar ER, Cafiero AC, Hanlon JT (2007) Polypharmacy in elderly patients. Am J Geriatr Pharmacother 5:345–351

    PubMed  Article  Google Scholar 

  3. Hilmer SN, Gnjidic D (2009) The effects of polypharmacy in older adults. Clin Pharmacol Therapeutics 85:86–98

    Article  CAS  Google Scholar 

  4. Steinman MA, Landefeld CS, Rosenthal GE et al (2006) Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 54:1516–1523

    PubMed  Article  Google Scholar 

  5. Kaufman DW, Kelly JP, Rosemberg L, Anderson TE, Mitchell AA (2002) Recent patterns of medication use in the ambulatory adult population of the united State: the Slone survey. JAMA 287:337–344

    PubMed  Article  Google Scholar 

  6. Corsonello A, Pedone C, Corica F, Antonelli Incalzi R, on behalf of the Gruppo Italiano di Farmacovigilanza (GIFA) investigators (2007) Polypharmacy in the elderly patients at discharge from the acute care hospital. Therapeutics and Clinical Risk Management 3:197–203

    PubMed  Article  Google Scholar 

  7. Wawruch M, Zikavska M, Wsolova L, Kuzelova M, Tisonova J, Gajdosik J et al (2008) Polyphramacy in elderly hospitalised patients in Slovakia. Pharm World Sci 30:235–242

    PubMed  Article  Google Scholar 

  8. Schuler J, Duckelmann C, Beindl W, Prinz E, Michalski T, Pichelr M (2008) Polypharmacy and inappropriate prescribing in elderly internal medicine patients in Austria. Wien Klin Wochenschr 120:733–741

    PubMed  Article  Google Scholar 

  9. Viktil KK, Blix HS, Moger TA, Reikvam A (2006) Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol 63:187–195

    PubMed  Article  Google Scholar 

  10. Milton JC, Hill-Smith I, Jackson SHD (2008) Prescribing for older people. BMJ 336:606–609

    PubMed  Article  Google Scholar 

  11. Simonson W, Feinberg JL (2005) Medication-related problems in the elderly. Defining the issues and identifying solutions. Drug Aging 22:559–569

    Article  Google Scholar 

  12. Veehof LJG, Stewart RE, Haaijer-Raskamp FM, Meyboom-de Jong B (2000) The development of polypharmacy. A longitudinal study. Fam Pract 17:261–267

    PubMed  Article  CAS  Google Scholar 

  13. Linjakumpu T, Hartkainen S, Klaukka T, Veijola J, Kivela SL, Isoaho R (2002) Use of medications and polypharmacy are increasing among elderly. J Clin Epidemiol 55:809–817

    PubMed  Article  Google Scholar 

  14. Koh Y, Kutty FBM, Li SC (2005) Drug-related problems in hospitalized patients on polypharmacy: the influence of age and gender. Therapeutics and Clinical Risk Management 1:39–48

    PubMed  Article  Google Scholar 

  15. Lund BC, Camahan RM, Egge JA, Chrischilles EA, Kaboli PJ 2010 Inappropriate prescribing predicts adverse drug events in older adults. Ann Pharmacother. doi:10.1345/aph.1M657

  16. Spinewine A, Schmader KE, Barber N et al (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370:173–184

    PubMed  Article  Google Scholar 

  17. Veehof LJG, Meyboom-de Jong B, Haaijer-Raskamp FM (2000) Polypharmacy in the elderly-a literature review. Eur J Gen Pract 6:98–106

    Article  Google Scholar 

  18. Jyrkka J, Enlund H, Korhonen MJ, Sulkava R, Hartikainen S (2009) Polypharmacy stauts as an indicator of mortality in an elderly population. Drugs Aging 26:1039–1048

    PubMed  Article  Google Scholar 

  19. Onder G, Pedone C, Landi F, Cesari M, Vedova C, Bernabei R et al (2002) Adverse drug reactions as cause of hospital admission: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc 50:1962–1968

    PubMed  Article  Google Scholar 

  20. Onder G, Landi F, Liperoti R, Fialova D, Gambassi G, Bernabei R (2005) Impact of inappropriate drug use among hospitalized older adults. Eur J Clin Pharmacol 61:1453–1459

    Article  Google Scholar 

  21. Bressler R, Bahl JJ (2003) Principles of drug therapy for the elderly patients. Mayo Clin Proc 78:1564–1577

    PubMed  Article  CAS  Google Scholar 

  22. van den Akker M, Buntinx F, Knottnerus JA (1996) Comorbidity or multimorbidity: what’s in a name? A review of literature. Eur J Gen Pract 2:65–70

    Article  Google Scholar 

  23. van den Akker M, Buntinx F, Metsemakers JF et al (1998) Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 51:367–375

    PubMed  Article  Google Scholar 

  24. Verbrugge LM, Lepkowski JM, Imanaka Y (1989) Comorbidity and its impact on disability. Milbank Q 67:450–484

    PubMed  Article  CAS  Google Scholar 

  25. Gijsen R, Hoeymans N, Schellevis FG, Ruwaard D, Satariano WA, van den Bos GA (2001) Causes and consequences of comorbidity: a review. J Clin Epidemiol 54:661–674

    PubMed  Article  CAS  Google Scholar 

  26. Wolff JL, Starfield B, Anderson G (2002) Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 162:2269–2276

    PubMed  Article  Google Scholar 

  27. Boyd CM, Ritchie CS, Tipton EF, Studenski SA, Wieland D (2008) From bedside to bench: summary from the American Geriatrics Society/National Institute on Aging Research conference on comorbidity and multiple morbidity in older adults. Aging Clin Exp Res 20:181–188

    PubMed  Google Scholar 

  28. Tinetti ME, Bogardus ST, Agostini JV (2004) Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 351:2870–2874

    PubMed  Article  CAS  Google Scholar 

  29. Boyd CM, Darer J, Boult C et al (2005) Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 294:716

    PubMed  Article  CAS  Google Scholar 

  30. Creditor MC (1993) Hazard of hospitalization of the elderly. Ann Intern Med 118:219–223

    PubMed  CAS  Google Scholar 

  31. World Health Organization (1987) International Classification of Diseases, Injuries, and Causes of Death. Ninth Revision (ICD-9). Geneva: World Health Organization. http://icd9cm.chrisendres.com/. Accessed 12 July 2010

  32. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    PubMed  Article  CAS  Google Scholar 

  33. World Health Organization. Guidelines for ATC Classification. Sweden, WHO Collaborating Centre for Drug Statistics Methodology, Norway and Nordic Councils on Medicines, 1990

  34. Bernardini B, Meinecke C, Zaccarini C, Bongiorni N, Fabbrini S, Gilardi C, Bonaccorso O, Guaita A (1993) Adverse clinical events in dependent long-term nursing home residents. J Am Geriatr Soc 41:105–111

    PubMed  CAS  Google Scholar 

  35. Bellelli G, Frisoni GB, Barbisoni P, Beffelli S, Rozzini R, Trabucchi M (2001) The management of adverse clinical events in nursing homes: a 1-years survey study. J Am Geriatr Soc 49:915–925

    PubMed  Article  CAS  Google Scholar 

  36. Pasina L, Nobili A, Tettamanti M, Salerno F, Corrao S, Bonazzi J, Vicidomini R, Mannucci PM (2009) A nome del partecipanti al Progetto Registro Politerapie SIMI. Utilizzo e appropriatezza d’uso dei farmaci anti-ulcera peptica/reflusso gastroesofageo in una coorte di anziani ricoverati in reparti di medicina interna. Intern Emerg Med 4:S69

    Article  Google Scholar 

  37. Redelmeier DA, Tan SH, Booth GL (1998) The treatment of unrelated disorders in patients with chronic medical diseases. N Eng J Med 338:1516–1520

    Article  CAS  Google Scholar 

  38. Holmes HM (2009) Rational prescribing for patients with a reduced life expectancy. Clin Pharmacol Therapeutics 85:103–107

    Article  CAS  Google Scholar 

  39. Knight EL, Avorn J (2001) Quality indicators for appropriate medication use in vulnerable elders. Intern Med 135:703–710

    CAS  Google Scholar 

Download references

Acknowledgments

We thank Professor Farncesco Violi, President of the Italian Society of Internal Medicine, for his help and encouragement. We are grateful to Judith Baggott for editorial assistance.

Financial disclosure

Carlotta Franchi holds a fellowship granted by Rotary Clubs Milano Naviglio Grande San Carlo, Milano Scala and Inner Wheel Milano San Carlo.

Conflict of interest

All the authors declare that no conflict of interest exist. All the authors state that they have a full control of data and that they agree to allow the journal to review their data if requested.

Funding sources

Nothing.

Author information

Affiliations

  1. Laboratory for Quality Assessment of Geriatric Therapies and Services, “Mario Negri” Institute for Pharmacological Research, via Giuseppe La Masa, 19, 20156, Milan, Italy

    Alessandro Nobili, Luca Pasina, Carlotta Franchi & Luigi De Vittorio

  2. Laboratory of Geriatric Neuropsychiatry, “Mario Negri” Institute for Pharmacological Research, via Giuseppe La Masa, 19, 20156, Milan, Italy

    Mauro Tettamanti

  3. Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy

    Giuseppe Licata & Salvatore Corrao

  4. Medicina Interna, IRCCS Policlinico San Donato, University of Milano, Milan, Italy

    Francesco Salerno

  5. Department of Medical and Surgery Sciences, University of Brescia Geriatric Ward, Spedali Civili, Brescia, Italy

    Alessandra Marengoni

  6. Department of Internal Medicine, University of Perugia, Perugia, Italy

    Alfonso Iorio & Maura Marcucci

  7. Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Milan, Italy

    Pier Mannuccio Mannucci

Authors
  1. Alessandro Nobili
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  2. Giuseppe Licata
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  3. Francesco Salerno
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  4. Luca Pasina
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  5. Mauro Tettamanti
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  6. Carlotta Franchi
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  7. Luigi De Vittorio
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  8. Alessandra Marengoni
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  9. Salvatore Corrao
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  10. Alfonso Iorio
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  11. Maura Marcucci
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  12. Pier Mannuccio Mannucci
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Consortia

On behalf of SIMI Investigators

Corresponding author

Correspondence to Alessandro Nobili.

Additional information

SIMI, Italian Society of Internal Medicine. Participating hospitals and coauthors are listed in the Acknowledgements.

Appendix

Appendix

REPOSI collaborators and participating units

The following hospital and investigators contributed to this study: Pier Mannuccio Mannucci, Alberto Tedeschi, Raffaella Rossio (Medicina Interna 2, Fondazione IRCCS Ospedale Maggiore, Milano); Guido Moreo, Barbara Ferrari (Medicina Interna 3, Fondazione IRCCS Ospedale Maggiore, Milano); Cesare Masala, Antonio Mammarella, Valeria Raparelli (Medicina Interna, Università La Sapienza, Roma); Nicola Carulli, Stefania Rondinella, Iolanda Giannico (Medicina Metabolica, Università di Modena e Reggio Emilia); Leonardo Rasciti, Silvia Gualandi (Medicina Interna, Policlinico S. Orsola Malpighi, Bologna); Valter Monzani, Valeria Savojardo (Medicina d’Urgenza, IRCCS Fondazione Ospedale Maggiore, Milano); Maria Domenica Cappellini, Giovanna Fabio, Flavio Cantoni (Medicina Interna 1A, Fondazione IRCCS Ospedale Maggiore, Milano); Franco Dallegri, Luciano Ottonello, Alessandra Quercioli, Alessandra Barreca (Medicina Interna 1, Università di Genova); Riccardo Utili, Emanuele Durante-Mangoni, Daniela Pinto (Medicina Interna, Seconda Università di Napoli); Roberto Manfredini, Elena Incasa, Emanuela Rizzioli (Medicina Interna, Azienda USL, Ferrara); Massimo Vanoli, Gianluca Casella (Medicina Interna, Ospedale di Lecco, Merate); Giuseppe Musca, Olga Cuccurullo (Medicina Interna, P.O. Cetraro, ASP Cosenza); Laura Gasbarrone, Giuseppe Famularo, Maria Rosaria Sajeva (Medicina Interna, Ospedale San Camillo Forlanini, Roma); Antonio Picardi, Dritan Hila (Medicina Clinica-Epatologia, Università Campus Bio-Medico, Roma); Renzo Rozzini, Alessandro Giordano (Fondazione Poliambulanza, Brescia); Andrea Sacco, Antonio Bonelli, Gaetano Dentamaro (Medicina, Ospedale Madonna delle Grazie, Matera); Francesco Salerno, Valentina Monti, Massimo Cazzaniga (Medicina Interna, IRCCS Policlinico San Donato, Università di Milano); Ingrid Nielsen, Piergiorgio Gaudenzi, Lisa Giusto (Medicina ad Alta Rotazione, Azienda Ospedaliera Universitaria, Ferrara); Enrico Agabiti Rosei, Damiano Rizzoni, Luana Castoldi (Clinica Medica, Università di Brescia); Daniela Mari, Giuliana Micale (Medicina Generale ad indirizzo Geriatrico, IRCCS Istituto Auxologico Italiano, Milano); Emanuele Altomare, Gaetano Serviddio, Santina Salvatore (Medicina Interna, Università di Foggia); Carlo Longhini, Cristian Molino (Clinica Medica, Azienda Mista Ospedaliera Universitaria Sant’Anna, Ferrara); Giuseppe Delitalia, Silvia Deidda, Luciana Maria Cuccuru (Clinica Medica, Azienda Mista Ospedaliera Universitaria, Sassari); Giampiero Benetti, Michela Quagliolo, Giuseppe Riccardo Centenaro (Medicina 1, Ospedale di Melegnano, Vizzolo Predabissi, Milano); Alberto Auteri, Anna Laura Pasqui, Luca Puccetti (Medicina Interna, Azienda Ospedaliera Universitaria Le Scotte, Siena); Carlo Balduini, Giampiera Bertolino, Piergiorgio Cavallo (Dipartimento di Medicina Interna, Fondazione IRCCS Policlinico San Matteo, Università degli Studi di Pavia); Esio Ronchi, Daniele Bertolini, Nicola Lucio Liberato (Medicina Interna, Ospedale Carlo Mira, Casorate Primo, Pavia); Antonio Perciccante, Alessia Coralli (Medicina, Ospedale San Giovanni-Decollato-Andisilla, Civita Castellana); Luigi Anastasio, Leonardo Bertucci (Medicina Generale, Ospedale Civile Serra San Bruno); Giancarlo Agnelli, Ana Macura, Alfonso Iorio, Maura Marcucci (Medicina Interna e Cardiovascolare, Ospedale Santa Maria della Misericordia, Università di Perugia); Cosimo Morabito, Roberto Fava (Medicina, Ospedale Scillesi d’America, Scilla); Giuseppe Licata, Antonino Tuttolomondo, Riccardo Di Sciacca (Medicina Interna e Cardioangiologia, Università degli Studi di Palermo); Luisa Macchini, Anna Realdi (Clinica Medica 4, Università di Padova); Luigi Cricco, Alessandra Fiorentini, Cristina Tofi (Geriatria, Ospedale di Montefiascone); Carlo Cagnoni, Antonio Manucra (UO Medicina e Primo Soccorso, Ospedale di Bobbio, Azienda USL di Piacenza); Giuseppe Romanelli, Alessandra Marengoni, Francesca Bonometti (UO Geriatria, Spedali Civili di Brescia); Michele Cortellaro, Maria Rachele Meroni, Marina Magenta (Medicina 3, Ospedale Luigi Sacco, Università di Milano); Carlo Vergani, Dionigi Paolo Rossi (Geriatria, Fondazione IRCCS Ospedale Maggiore e Università di Milano).

Clincal data monitoring and revision: Valentina Spirito, Damia Noce, Jacopo Bonazzi, Rossana Lombardo, Luigi De Vittorio (Istituto di Ricerche Farmacologiche “Mario Negri”, Milano).

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Nobili, A., Licata, G., Salerno, F. et al. Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study. Eur J Clin Pharmacol 67, 507–519 (2011). https://doi.org/10.1007/s00228-010-0977-0

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  • DOI: https://doi.org/10.1007/s00228-010-0977-0

Keywords

  • Elderly
  • Polypharmacy
  • Hospital stay
  • In-hospital mortality