Epidemiology and associated factors of polypharmacy in older patients in primary care: a northern Italian cross-sectional study

Abstract

Background A precondition for developing strategies to reduce polypharmacy and its well-known harmful consequences is to study its epidemiology and associated factors. The objective of this study was to analyse the prevalence of polypharmacy (defined as ≥8 prescribed drugs), of potentially inappropriate medications (PIMs) and major drug-drug interactions (DDIs) among community-dwelling general practice patients aged ≥75 years and to identify characteristics being associated with polypharmacy. Methods This cross-sectional study is derived from baseline data (patients’ demographic/biometric characteristics, diagnoses, medication-related data, cognitive/affective status, quality of life) of a northern-Italian cluster-RCT. PIMs and DDIs were assessed using the 2012 Beers criteria and the Lexi-Interact® database. Data were analysed using descriptive methods, Wilcoxon rank-sum tests, Fisher’s exact tests and Spearman correlations. Results Of the eligible patients aged 75+, 13.4% were on therapy with ≥8 drugs. Forty-three general practitioners and 579 patients participated in the study. Forty five point nine percent of patients were treated with ≥1 Beers-listed drugs. The most frequent PIMs were benzodiazepines/hypnotics (19.7% of patients) and NSAIDs (6.6%). Sixty seven point five percent of patients were exposed to ≥1 major DDI, 35.2% to ≥2 major DDIs. Antithrombotic/anticoagulant medications (30.4%) and antidepressants/antipsychotics (23.1%) were the most frequently interacting drugs. Polypharmacy was significantly associated with a higher number of major DDIs (Spearman’s rho 0.33, p < 0.001) and chronic conditions (Spearman’s rho 0.20, p < 0.001), higher 5-GDS scores (thus, lower affective status) (Spearman’s rho 0.12, p = 0.003) and lower EQ-5D-5L scores (thus, lower quality of life) (Spearman’s rho − 0.14, p = 0.001). Patients’ age/sex, 6-CIT scores (cognitive status), BMI or PIM use were not correlated with the number of drugs. Conclusions The prevalence of polypharmacy, PIMs and major DDIs was considerable. Results indicate that physicians should particularly observe their patients with multiple conditions, reduced health and affective status, independently from other patients’ characteristics. Careful attention about indication, benefit and potential risk should be paid especially to patients on therapy with specific drug classes identified as potentially inappropriate or prone to major DDIs in older persons (e.g., benzodiazepines, NSAIDs, protonic pump inhibitors, antithrombotics/anticoagulants, antidepressants/antipsychotics). Trial registration The cluster-RCT on which this cross-sectional analysis is based was registered with Current Controlled Trials Ltd. (ID ISRCTN: 38449870) on 2013-09-11.

Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial

“…In both treatment groups, quality of life and affective status showed a tendency to decrease over time, most probably due to the natural functional decline in older-aged patients. Interestingly, the cognitive function of the assessed participants remained stable throughout the observation period which concords to the fact that only few patients with diagnosticated dementia participated in the study [ 31 ] and severe cognitive impairment was an exclusion criterium.…”

“…This northern-Italian RCT investigated the effect of medication reviews and recommendations provided by three experts with different professional background on patient-relevant outcomes in older-aged general practice patients on polypharmacy. The study found a high prevalence of polypharmacy, PIMs and DDIs, as described in the publication of epidemiological baseline data [ 31 ]. The composite primary outcome of non-elective hospital admissions or death was experienced significantly more often in the IG in the unadjusted analysis; yet, as significance disappeared after adjustment, which was also noted for hospitalisations as single secondary endpoint, this phenomenon seems to be strongly related to the higher occurrence of hospital admissions in the IG within the pre-interventional period.…”

“…The pre-review was carried out (a) to describe the whole study sample in terms of prevalence of PIMs, DDIs and associated factors [ 31 ], and (b) for the intervention group to provide the experts with information serving as a basis for the elaboration of the deprescribing recommendations (see below). The results of the pre-review were not communicated to the participating GPs at any time.…”

“…Therefore, the present cluster-randomised controlled trial (RCT) ‘PRIMA’ ( P olypharmacy in chronic diseases- R eduction of I nappropriate M edication and A dverse drug events in older populations) [ 31 ] was initiated with the aim to study if the prudent, evidence-based intervention to reduce polypharmacy leads to benefits for multimorbid older patients in the primary care setting.…”

Suicidal and accidental drug poisoning mortality among older adults and working-age individuals in Spain between 2000 and 2018

“…Notably, depression may have played a crucial role as it is considered one of the most important risk factors for suicide, especially in older adults [ 28 ], and is also an independent risk factor for excessive polypharmacy [ 29 ]. Furthermore, antidepressants are one of the most common contributors of polypharmacy and, when present, they are the second most frequently interacting drug [ 30 ]. We detected higher poisoning suicide mortality among older adults living in urban rather than rural areas, a finding that could be linked to the overall higher prevalence of depression in urban environments [ 31 ].…”