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Drugs & Aging

, Volume 27, Issue 12, pp 1019–1028 | Cite as

Prevalence and Risk of Polypharmacy among the Elderly in an Outpatient Setting

A Retrospective Cohort Study in the Emilia-Romagna Region, Italy
  • S. Lane Slabaugh
  • Vittorio MaioEmail author
  • Megan Templin
  • Safiya Abouzaid
Original Research Article

Abstract

Background: Polypharmacy, the simultaneous taking of many medications, has been well documented and is a topic of much concern for those looking to improve the quality of care for the elderly. Elderly patients often develop complicated and multifactorial health states that require extensive pharmacotherapy, leaving this population at risk for exposure to drug-drug interactions and other adverse events. Previous literature supports an association between an increase in the rate of adverse events as the number of drugs taken by a patient increases.

Objective: We sought to evaluate the prevalence of polypharmacy, and to determine patient characteristics that are predictive of exposure to polypharmacy, in the elderly population of the Emilia-Romagna region in Italy.

Methods: We conducted a retrospective cohort study of the 2007 Emilia-Romagna outpatient pharmacy database linked with patient information available from a demographic file of approximately 1 million Emilia-Romagna residents aged ≥65 years. The cohort comprised 887 165 elderly subjects who had at least one prescription filled during the study year. Using the WHO’s defined daily dose (DDD) to determine the duration of treatment for a given drug, we defined a polypharmacy episode as overlapping treatment with five or more medications occurring for at least 1 day. The prevalence of polypharmacy was measured together with subject characteristics found to be predictive of polypharmacy exposure.

Results: A total of 349 689 elderly people in the population (39.4%) were exposed to at least one episode of polypharmacy during the study period. The prevalence of polypharmacy substantially increased with age and with a higher number of chronic conditions. Over 35% of those exposed to polypharmacy were exposed for 101 or more days of the year. The top three classes of medications involved in polypharmacy were antithrombotics, peptic ulcer disease and gastro-oesophageal reflux disease agents, and ACE inhibitors. The odds of exposure to polypharmacy were higher for older subjects, males and subjects living in urban areas.

Conclusions: This study provides evidence that the prevalence of polypharmacy in the elderly in Emilia-Romagna is substantial. Educational programmes should be developed to inform clinicians about the magnitude of the polypharmacy phenomenon and the patient characteristics associated with polypharmacy. Raising physicians’ awareness of polypharmacy may help to ensure safe, effective and appropriate use of medication in the elderly.

Keywords

Elderly Subject Peptic Ulcer Disease Anatomical Therapeutic Chemical Define Daily Dose Elderly Drug User 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

This research was supported through a collaborative agreement between the Regional Health Care Agency, Assessorato alla Sanita’, Emilia-Romagna, Italy and Thomas Jefferson University, Philadelphia, PA, USA. Dr Slabaugh and Dr Abouzaid are enrolled in a fellowship in pharmacoeconomics and outcomes research sponsored by Ortho-McNeil-Janssen Scientific Affairs, LLC, Titusville, NJ, USA. Dr Maio had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of data analysis. The authors have no conflicts of interests relevant to this research. The authors thank Roberto Grilli, MD, and Rossana De Palma, MD, from the Regional Health Care Agency, Emilia-Romagna, Italy, for providing the data and guidance.

References

  1. 1.
    Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract 2005 Apr; 17(4): 123–32PubMedCrossRefGoogle Scholar
  2. 2.
    Jyrkka J, Vartiainen L, Hartikainen S, et al. Increasing use of medicines in elderly persons: a five-year follow-up of the Kuopio 75+ study. Eur J Clin Pharmacol 2006 Feb; 62(2): 151–8PubMedCrossRefGoogle Scholar
  3. 3.
    Junius-Walker U, Theile G, Hummers-Pradier E. Prevalence and predictors of polypharmacy among older primary care patients in Germany. Fam Pract 2007 Feb; 24(1): 14–9PubMedCrossRefGoogle Scholar
  4. 4.
    Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA 2002 Jan 16; 287(3): 337–44PubMedCrossRefGoogle Scholar
  5. 5.
    Linjakumpu T, Hartikainen S, Klaukka T, et al. Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol 2002 Aug; 55(8): 809–17PubMedCrossRefGoogle Scholar
  6. 6.
    Bjerrum L, Sogaard J, Hallas J, et al. Polypharmacy: correlations with sex, age and drug regimen. A prescription database study. Eur J Clin Pharmacol 1998 May; 54(3): 197–202PubMedCrossRefGoogle Scholar
  7. 7.
    Onder G, Pedone C, Landi F, et al. Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc 2002 Dec; 50(12): 1962–8PubMedCrossRefGoogle Scholar
  8. 8.
    Flaherty JH, Perry 3rd HM, Lynchard GS, et al. Polypharmacy and hospitalization among older home care patients. J Gerontol A Biol Sci Med Sci 2000 Oct; 55(10): M554–9PubMedCrossRefGoogle Scholar
  9. 9.
    Field TS, Gurwitz JH, Harrold LR, et al. Risk factors for adverse drug events among older adults in the ambulatory setting. J Am Geriatr Soc 2004 Aug; 52(8): 1349–54PubMedCrossRefGoogle Scholar
  10. 10.
    Alarcon T, Barcena A, Gonzalez-Montalvo JI, et al. Factors predictive of outcome on admission to an acute geriatric ward. Age Ageing 1999 Sep; 28(5): 429–32PubMedCrossRefGoogle Scholar
  11. 11.
    Mannesse CK, Derkx FH, de Ridder MA, et al. Contribution of adverse drug reactions to hospital admission of older patients. Age Ageing 2000 Jan; 29(1): 35–9PubMedCrossRefGoogle Scholar
  12. 12.
    Viktil KK, Blix HS, Moger TA, et al. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol 2007 Feb; 63(2): 187–95PubMedCrossRefGoogle Scholar
  13. 13.
    Bjerrum L, Rosholm JU, Hallas J, et al. Methods for estimating the occurrence of polypharmacy by means of a prescription database. Eur J Clin Pharmacol 1997; 53(1): 7–11PubMedCrossRefGoogle Scholar
  14. 14.
    Jyrkka J, Enlund H, Korhonen MJ, et al. 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(6): 493–503PubMedCrossRefGoogle Scholar
  15. 15.
    Haider SI, Johnell K, Weitoft GR, et al. 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 Jan; 57(1): 62–9PubMedCrossRefGoogle Scholar
  16. 16.
    Haider SI, Johnell K, Thorslund M, et al. Analysis of the association between polypharmacy and socioeconomic position among elderly aged > or =77 years in Sweden. Clin Ther 2008 Feb; 30(2): 419–27PubMedCrossRefGoogle Scholar
  17. 17.
    Thomas HF, Sweetnam PM, Janchawee B, et al. Polypharmacy among older men in South Wales. Eur J Clin Pharmacol 1999 Jul; 55(5): 411–5PubMedCrossRefGoogle Scholar
  18. 18.
    Kennerfalk A, Ruigomez A, Wallander MA, et al. Geriatric drug therapy and healthcare utilization in the United Kingdom. Ann Pharmacother 2002 May; 36(5): 797–803PubMedCrossRefGoogle Scholar
  19. 19.
    Chen YF, Dewey ME, Avery AJ. Self-reported medication use for older people in England and Wales. J Clin Pharm Ther 2001 Apr; 26(2): 129–40PubMedCrossRefGoogle Scholar
  20. 20.
    Veehof LJG, Stewart RE, Haaijer-Ruskamp FM, et al. The development of polypharmacy: a longitudinal study. Fam Pract 2000; 17(3): 261–7PubMedCrossRefGoogle Scholar
  21. 21.
    Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother 2007 Mar; 5(1): 31–9PubMedCrossRefGoogle Scholar
  22. 22.
    Jörgensen T, Johansson S, Kennerfalk A, et al. Prescription drug use, diagnoses, and healthcare utilization among the elderly. Ann Pharmacother 2001; 35(9): 1004–9PubMedCrossRefGoogle Scholar
  23. 23.
    Grimmsmann T, Himmel W. Polypharmacy in primary care practices: an analysis using a large health insurance database. Pharmacoepidemiol Drug Saf 2009 Dec; 18(12): 1206–13PubMedCrossRefGoogle Scholar
  24. 24.
    Louis DS, Yuen EJ, Maio V, et al. A population-based longitudinal healthcare database in the Emilia-Romagna region, Italy: a resource for planning and research. Health Policy Newsl 2005 June; 18(2): 6Google Scholar
  25. 25.
    Haider SI, Johnell K, Thorslund M, et al. Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992–2002. Int J Clin Pharmacol Ther 2007 Dec; 45(12): 643–53PubMedGoogle Scholar
  26. 26.
    WHO Collaborating Centre for Drug Statistics Methodology. ATC/DDD index 2009 [online]. Available from URL: http://www.whocc.no/atcddd/ [Accessed 2009 Sep 28]
  27. 27.
    Maio V, Yuen E, Rabinowitz C, et al. Using pharmacy data to identify those with chronic conditions in Emilia Romagna, Italy. J Health Serv Res Policy 2005 Oct; 10(4): 232–8PubMedCrossRefGoogle Scholar
  28. 28.
    Maio V, Yuen EJ, Novielli K, et al. Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study. Drugs Aging 2006; 23(11): 915–24PubMedCrossRefGoogle Scholar
  29. 29.
    Corsonello A, Pedone C, Corica F, et al. Polypharmacy in elderly patients at discharge from the acute care hospital. Ther Clin Risk Manag 2007; 3(1): 197–203PubMedCrossRefGoogle Scholar
  30. 30.
    Rozenfeld S, Fonseca MJ, Acurcio FA. Drug utilization and polypharmacy among the elderly: a survey in Rio de Janeiro City, Brazil. Rev Panam Salud Publica 2008 Jan; 23(1): 34–43PubMedCrossRefGoogle Scholar
  31. 31.
    Steinman MA, Seth Landefeld C, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006; 54(10): 1516–23PubMedCrossRefGoogle Scholar
  32. 32.
    Ziere G, Dieleman JP, Hofman A, et al. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol 2006 Feb; 61(2): 218–23PubMedCrossRefGoogle Scholar
  33. 33.
    Rowe JW, Andres R, Tobin JD, et al. The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. J Gerontol 1976 Mar; 31(2): 155–63PubMedCrossRefGoogle Scholar
  34. 34.
    Chan DC, Hao YT, Wu SC. Polypharmacy among disabled Taiwanese elderly: a longitudinal observational study. Drugs Aging 2009; 26(4): 345–54PubMedCrossRefGoogle Scholar
  35. 35.
    Bierman AS, Pugh MJ, Dhalla I, et al. Sex differences in inappropriate prescribing among elderly veterans. Am J Geriatr Pharmacother 2007 Jun; 5(2): 147–61PubMedCrossRefGoogle Scholar
  36. 36.
    Bjerrum L, Sogaard J, Hallas J, et al. Polypharmacy in general practice: differences between practitioners. Br J Gen Pract 1999 Mar; 49(440): 195–8PubMedGoogle Scholar
  37. 37.
    Jonsson AK, Spigset O, Jacobsson I, et al. Cerebral haemorrhage induced by warfarin: the influence of drug-drug interactions. Pharmacoepidemiol Drug Saf 2007 Mar; 16(3): 309–15PubMedCrossRefGoogle Scholar
  38. 38.
    Gagne JJ, Maio V, Rabinowitz C. Prevalence and predictors of potential drug-drug interactions in Regione Emilia-Romagna, Italy. J Clin Pharm Ther 2008 Apr; 33(2): 141–51PubMedCrossRefGoogle Scholar
  39. 39.
    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): 2716–24PubMedCrossRefGoogle Scholar
  40. 40.
    Maio V, Del Canale S, Abouzaid S. Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther 2010; 35(2): 219–29PubMedCrossRefGoogle Scholar
  41. 41.
    WHO Collaborating Centre for Drug Statistics Methodology. DDD definition and general considerations [online]. Available from URL: http://www.whocc.no/ddd/definition_and_general_considera/ [Accessed 2010 Aug 2]
  42. 42.
    Merlo J, Wessling A, Melander A. Comparison of dose standard units for drug utilisation studies. Eur J Clin Pharmacol 1996; 50(1–2): 27–30PubMedCrossRefGoogle Scholar
  43. 43.
    Abebe W. Herbal medication: potential for adverse interactions with analgesic drugs. J Clin Pharm Ther 2002 Dec; 27(6): 391–401PubMedCrossRefGoogle Scholar
  44. 44.
    Bush TM, Rayburn KS, Holloway SW, et al. Adverse interactions between herbal and dietary substances and prescription medications: a clinical survey. Altern Ther Health Med 2007 Mar-Apr; 13(2): 30–5PubMedGoogle Scholar
  45. 45.
    Hoblyn JC, Brooks 3rd JO. Herbal supplements in older adults: consider interactions and adverse events that may result from supplement use. Geriatrics 2005 Feb 22–3; 60(2): 18–3PubMedGoogle Scholar
  46. 46.
    Shaw D, Murray V, Volans G. Adverse effects of herbal remedies and OTC medicines. Br J Clin Pharmacol 1999 Feb; 47(2): 227–8; author reply 229–30PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  • S. Lane Slabaugh
    • 1
  • Vittorio Maio
    • 1
    Email author
  • Megan Templin
    • 2
  • Safiya Abouzaid
    • 1
  1. 1.Jefferson School of Population HealthThomas Jefferson UniversityPhiladelphiaUSA
  2. 2.Center for Research in Medical Education and Health CareJefferson Medical CollegePhiladelphiaUSA

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