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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 4  |  Page : 165-168

A cross-sectional study to assess prevalence of polypharmacy and potentially inappropriate medicines in geriatric population of western Maharashtra


1 Department of Geriatrics, AFMC, Pune, Maharashtra, India
2 Commandant, Air Force Hospital, Kanpur, Allahabad, Uttar Pradesh, India

Date of Submission21-Oct-2020
Date of Decision09-Jan-2021
Date of Acceptance19-Jan-2021
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Vivek Aggarwal
Department of Geriatrics, AFMC, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_17_20

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  Abstract 


Introduction: With advancing age, polypharmacy is increasing due to multiple diseases, multiple doctors and symptoms specific over the counter self medication. This leads to adverse drug reactions and increase in potentially in appropriate medicines (PIMs). This study was undertaken to assess the prevalence of poly -pharmacy in elderly. The secondary objectives were to look for an association between common geriatric symptoms and polypharmacy and estimate prevalence of PIMs. Methodology: Analytical observational cross-sectional study conducted in a tertiary care hospital in Western Maharashtra over a period of 6 months between Aug 2016 to Dec 2016. PIMs were estimated base on BEERS criteria. Results: A total of 168 participants were interviewed. They were selected sequentially from a polyclinic with high geriatric load. Among the participants, there were 120 (71.43%) males and 48 (28.57%) females. The mean age was 70.25 years ± 6.25 years (range 51 to 90 years). Most (77.98%) of the elderly suffered from 2 or more diseases. The average number of drugs taken was 6.85 ± 3.42. Numerical polypharmacy (> 5 drugs) was present in 124 (73.81 %) elderly, with micro-polypharmacy (> 5 drugs) in 83 (49.40 %) and macro-polypharmacy (> 10 rugs) in 41 (24.41 %). According to Beers' criteria, 87 (37.8 %) participants had been prescribed at least one PIM Conclusion: Polypharmacy is widely prevalent in the geriatric age group and has a significant association with PIMs. It is important to evaluate the patient comprehensively and deprescribe unnecessary medicines to reduce PIMs, adverse drug reactions and drug drug interactions.

Keywords: Polypharmacy, geriatric, potentially inappropriate medication


How to cite this article:
Aggarwal V, Sashindran V K, Rai AK, Vasdev V. A cross-sectional study to assess prevalence of polypharmacy and potentially inappropriate medicines in geriatric population of western Maharashtra. J Indian Acad Geriatr 2020;16:165-8

How to cite this URL:
Aggarwal V, Sashindran V K, Rai AK, Vasdev V. A cross-sectional study to assess prevalence of polypharmacy and potentially inappropriate medicines in geriatric population of western Maharashtra. J Indian Acad Geriatr [serial online] 2020 [cited 2021 Apr 20];16:165-8. Available from: http://www.jiag.com/text.asp?2020/16/4/165/310001




  Introduction Top


The World Health Organization defines polypharmacy as “the administration of many drugs simultaneously or the administration of an excessive number of drugs than required.”[1] However, this definition does not specify the number of drugs that qualifies for polypharmacy.[2] Various studies define polypharmacy either as a numerical number or as descriptive polypharmacy. Numerically, polypharmacy is defined as the consumption of five or more drugs.[3],[4]

The elderly accounts for approximately one-tenth of the population in India.[5] With advancing age, they acquire several diseases, thereby necessitating the concurrent use of multiple medications. Easy availability of over-the-counter symptom-specific drugs leads to self-medication by many patients, who find hospital visits for trivial ailments unnecessary. The elderly may also self-prescribe certain medicines, dietary, and herbal supplements for common problems such as pain, weakness, and constipation.[6] To increase patient's satisfaction, there is a culture of prescribing more drugs than actually necessary. Hence, elderly patients usually fit the bill of polypharmacy. The chance of adverse drug events (ADE) increases with the number of medicines consumed.[7] Often concurrent prescriptions by specialists treating different diseases are not reviewed for dangerous drug interaction(s) or inappropriate prescription.

In routine practice, an ADE occurrence might be misdiagnosed as a particular medical condition, leading to the addition of yet another drug to treat it. It leads to a spiral of further ADE and further medications. Another factor leading to this type of prescription cascade in the elderly is atypical presentations of common illnesses. Furthermore, common geriatric presentations, such as falls, urinary incontinence, and fractures, may mask drug interactions. They may thus prevent early detection of the ADE.

There are many drugs which should be avoided in the elderly or should be prescribed with caution. These are called “potentially inappropriate medications (PIMs).”[8] The American Geriatric Society (AGS) uses the Beers criteria (2012) to identify PIMS. These prescriptions can contribute to treatment-related morbidity in the elderly.

This study was undertaken to assess the prevalence of polypharmacy in the elderly. The secondary objectives were to look for an association between common geriatric symptoms and polypharmacy and estimate prevalence of PIMs.


  Materials and Methods Top


This was an observational cross-sectional study conducted in a tertiary care hospital in Western Maharashtra over 6 months. Using the prevalence of polypharmacy as 88% from a previous study,[9] a confidence interval of 95%, and Type 1 α-error of 5%, the sample size was calculated to be 163. Participation in this study was voluntary. The study was initiated after taking permission from the Institutional Ethics Committee and took the informed consent was taken from the participants. An elderly subject was defined as any participant of age >60 years.[10],[11] Participants were selected randomly from all elderly patients more than 60 years attending outpatient polyclinic. Polypharmacy was classified as micropolypharmacy (5–9 drugs) and macropolypharmacy as ten or more drugs.[12] Data were recorded data on a predesigned, pilot-tested questionnaire which was mostly self-administered. For participants who could not read or write, the interview method was used to administer the questionnaire. All data collected were kept confidential. The data collected were entered into Microsoft Excel and analyzed using SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA). using Chi-square test and descriptive statistics. Potentially inappropriate medicines were identified using AGS BEERS criteria 2015. Association between polypharmacy and PIMs was estimated using the Chi-square test. Association of polypharmacy and PIMs with age, gender, depression, and geriatric syndromes was also calculated using Chi-square test. Postprescription analysis, all the patients' prescriptions were rationalized in consultation with a geriatrician, and then all participants were educated about the hazards of polypharmacy.


  Results Top


After initial screening and consent, a total of 168 geriatric patients more than 60 years were interviewed. They were selected sequentially from a veteran's polyclinic. There were 120 (71.43%) males and 48 (28.57%) females among the participants. The mean age was 70.25 years ± 6.25 years (range 51–90 years). Most (77.98%) of the elderly suffered from two or more diseases. The average number of drugs taken was 6.85 ± 3.42. Polypharmacy was present in 124 (73.81%) elderly, with micropolypharmacy in 83 (49.40%) and macropolypharmacy in 41 (24.41%). There was no significant difference in polypharmacy among males and females (P > 0.05) [Table 1]. There was a significant association between polypharmacy and the presence of depression [Table 2]. A Chi-square test for trend revealed no association (P > 0.05) between increasing age and polypharmacy [Table 3].
Table 1: Distribution of (i) polypharmacy and (ii) potentially inappropriate medication in males and females

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Table 2: Distribution of polypharmacy in the elderly with specific symptoms

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Table 3: Distribution of polypharmacy with age

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According to Beers criteria, 87 (37.8%) participants were prescribed at least one PIM. There was no significant difference in PIM among males and females (P > 0.05) [Table 1]. There was a significant association between the presence of polypharmacy and prescription of PIMs [Table 4].
Table 4: Distribution of polypharmacy with potentially inappropriate medications

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  Discussion Top


Increasing life expectancy has led to an increase in the proportion of geriatric clientele in health-care facilities worldwide. Aging is associated with a rise in morbidities and hence multiple medications for its treatment. This has led to increasing in the prevalence of polypharmacy in recent years.[12],[13] This study shows a high prevalence of polypharmacy among the population studied. This could be due to many reasons. The participants were drawn from government polyclinic with the increased workload of retired government employees. Since all of them were pensioners and had access to the free health-care facility, the awareness about their health was very high in the study population. The high prevalence of PIMs can be due to polyconsultation in over-subscribed subspecialty outpatient departments and the absence of family physicians or general practitioners who would have otherwise scanned prescriptions for PIMs and medications. Thus, PIMs were associated with polypharmacy. This is consistent with other published studies.[14],[15]

Others have also reported the association between depression and polypharmacy.[16],[17] Depression and dementia both increase with age. Very often, dementia is mistakenly diagnosed as depression. Many patients with depression present with vague somatic complaints, and this can lead to a prescription spiral. Aging is also associated with cognitive decline. Many elderly are, therefore, not able to recall the medications they are on. This assumes great importance when they come to clinics without their old records. Blind prescribing puts them at a higher risk for PIMs. Digitalization of patient health records and unique identification numbers for each patient can go a long way in remedying this problem. Another practical solution in this scenario could be carrying all the prescribed medications in a single bag and carrying it each time a prescription is sought from any doctor. Other causes for ADEs in the elderly could be forgetting to take medicines as scheduled or getting confused and overdosing themselves. Mobile phone-based reminders can be a low-cost solution.

The menace of PIMs is avoidable by taking simple steps that focus on the treatment of the person as a whole and not as multiple organ systems. It can be done by scrutinizing the patient's prescriptions eliminating drugs with overlapping actions, and checking potential interactions that could result in ADEs. Predesigned tools such as the Beers criteria, STOPP-START toolkit, and Medication Appropriateness Index are already available to identify such interactions. Their integration with electronic patient prescriptions will provide a dual solution: real-time detection of PIMs and correction of prescriptions by the doctor. Including geriatric medicine in the undergraduate curriculum and increasing postgraduate training in geriatrics will go a long way in educating about polypharmacy and PIMs. Including a clinical pharmacologist in a geriatric team will help identify the drug interactions and PIMs in more accurately. Increasing awareness about geriatric practice among general practitioners and doctors in government hospitals is also required to improve geriatric patients' prescribing practices.

The study's limitations are a unique patient subset (retired government employees) and a single medical facility restriction. There is a need for more extensive studies in various health-care facilities and different parts of the country. This will reveal the true magnitude of the problem and go a long way in educating doctors about prescribing norms for the elderly. The ever-increasing adverse outcomes of polypharmacy[18] and PIMs[19] call for a balanced approach toward geriatric prescribing. In geriatric practice, polypharmacy may be unavoidable, and a necessary evil but awareness of its dangers can go a long way in mitigation patient harm.


  Conclusion Top


With the advancing age, polypharmacy is on the rise in the geriatric population. In our study, polypharmacy was seen in 73% of the geriatric patients. Almost one-third of them were on more than ten drugs. PIMs were also seen in 37.8% of the elderly patients and had a statistically significant relationship with polypharmacy. Polypharmacy can be effectively tackled by a comprehensive assessment of the patient with regular drug review and deprescribing unnecessary and potentially inappropriate drugs. Tackling polypharmacy effectively will lead to cost reduction in health care and reduce adverse drug reactions and drug–drug interaction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. A Glossary of Terms for Community Health Care and Services for Older Persons. WHO; 2004. Available from: http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf.  Back to cited text no. 1
    
2.
Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol 2007;63:187-95.  Back to cited text no. 2
    
3.
Fulton MM, Allen ER. Polypharmacy in the elderly: A literature review. J Am Acad Nurse Pract 2005;17:123-32.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Census of India website. India: Office of the Registrar General & Census Commissioner, India; 2011. Available from: http://www.censusindia.gov.in/vital_statistics/srs_report/9chap%202%20-%202011.pdf.[Last accessed on 2020 Oct 10].  Back to cited text no. 5
    
6.
John NN, Kumar AN. A study on polypharmacy in senior Indian population. Int J Pharm Chem Biol Sci 2013;3:168-71.  Back to cited text no. 6
    
7.
Field TS, Gurwitz JH, Harrold LR, Rothschild J, DeBellis KR, Seger AC, et al. Risk factors for adverse drug events among older adults in the ambulatory setting. J Am Geriatr Soc 2004;52:1349-54.  Back to cited text no. 7
    
8.
American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616-31.  Back to cited text no. 8
    
9.
Veena DR, Padma L, Sapna P. Drug prescribing pattern in elderly patients in a teaching hospital. IOSR J Dent Med Sci 2012;1:39-42.  Back to cited text no. 9
    
10.
Ministry of Statistics and Programme Implementation Website. India; 2016. Available from: http://mospi.nic.in/sites/default/files/publication_ reports/ElderlyinIndia_2016.pdf. [Last accessed on 2020 Oct 10].  Back to cited text no. 10
    
11.
Lindesay J, Thompson C. Housebound elderly people: Definition, prevalence and characteristics. Int J Geriatr Psychiatry 1993;8:231-7.  Back to cited text no. 11
    
12.
Hovstadius B, Hovstadius K, Astrand B, Petersson G. Increasing polypharmacy-an individual-based study of the Swedish population 2005-2008. BMC Clin Pharmacol 2010;10:16.  Back to cited text no. 12
    
13.
Veehof L, Stewart R, Haaijer-Ruskamp F, Jong BM. The development of polypharmacy. A longitudinal study. Fam Pract 2000;17:261-7.  Back to cited text no. 13
    
14.
Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K. Potentially inappropriate prescribing and cost outcomes for older people: A national population study. Br J Clin Pharmacol 2010;69:543-52.  Back to cited text no. 14
    
15.
O'Mahony D, Gallagher PF. Inappropriate prescribing in the older population: Need for new criteria. Age Ageing 2008;37:138-41.  Back to cited text no. 15
    
16.
Antonelli Incalzi R, Corsonello A, Pedone C, Corica F, Carbonin P. Depression and drug utilization in an elderly population. Ther Clin Risk Manag 2005;1:55-60.  Back to cited text no. 16
    
17.
Srivatsa S, Bose D, Sushma M, Jayanthi CR. A prospective cohort study to evaluate the correlates of polypharmacy and its association with depression among elderly patients. Int J Basic Clin Pharmacol 2017;5:1984-90.  Back to cited text no. 17
    
18.
Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 2014;13:57-65.  Back to cited text no. 18
    
19.
Lin HY, Liao CC, Cheng SH, Wang PC, Hsueh YS. Association of potentially inappropriate medication use with adverse outcomes in ambulatory elderly patients with chronic diseases: Experience in a Taiwanese medical setting. Drugs Aging 2008;25:49-59.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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