Old age, high risk medication, polypharmacy: a trilogy of risks in older patients with atrial fibrillation

Abstract

Background:The safety of pharmacotherapy in atrial fibrillation (AF) is compounded by a trilogy of risks old age, high-risk medications (e.g., antithrombotics, antiarrhythmics), polypharmacy due to multiple patient comorbidities. However, to date, scarce study has investigated the use of polypharmacy (including potentially inappropriate medication (PIM)) in AF patients, and how this may contribute to their overall risk of medication misadventure.Objectives:To review the extent of polypharmacy and PIM use in older patients (65 years or older) with AF.Methods:Information was extracted from a database characterising a cohort of older AF patients treated in general practice in New South Wales, Australia. Patient characteristics, number and types of drugs, the degree of PIM use were recorded. The predictors for the use of polypharmacy in older AF patients were identified.Results:Overall, 367 patients (mean age 77.8 years) were reviewed, among which 94.8% used 5 medications or more and over half used 10 medications or more. Cardiovascular agents were most commonly used (98.9%), followed by antithrombotics (90.7%). Among agents deemed PIMs, digoxin (30.2%) was the most frequently used, followed by benzodiazepines (19.6%), and sotalol (9.8%). AF patients using polypharmacy were more likely to have low bleeding risk (OR=10.97), representing those patients in whom high-risk antithrombotics are mostly indicated. Patients with major-polypharmacy (5-9 medications) are more likely to have obstructive pulmonary diseases (OR=2.32), upper gastrointestinal diseases (OR=2.02) and poor physical function (OR=1.04), but less likely to have cognitive impairment (OR=0.27).Conclusion:Polypharmacy affects oldest AF patients, comprising medications that are indicated for AF, yet regarded as PIMs. Patients with lower risk of bleeding, obstructive pulmonary diseases, upper gastrointestinal diseases and poor physical function are also at higher risk of using higher number of medications. This may lead to an increased risk for medication misadventure due to the concomitant use of polypharmacy and medications for AF.

Polypharmacy and health outcomes in atrial fibrillation: a systematic review and meta-analysis

“…The other study identified in our systematic review also describes poorer physical functioning, based on an individual’s ability to undertake five predetermined activities, with incremental declines observed for moderate and severe polypharmacy 39. This is consistent with Australian data which demonstrated an incremental association between poorer physical functioning, as determined by the SF-36, with moderate and severe polypharmacy, respectively 29. Together, these studies provide a strong signal of the association between poorer physical functioning and polypharmacy.…”

“…Comparatively little research has been done on the prevalence of polypharmacy in patients with AF and possible associated adverse health outcomes. Polypharmacy prevalence in AF has ranged from 40% to 95% depending on the setting, study population, ascertainment criteria and methods 28 29. Some medications commonly used by patients with AF, including antihypertensive agents and anticoagulation agents, are leading causes of adverse drug events in the elderly 19.…”

Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges

“… 99) Rates of polypharmacy among AF patients may be even higher, ranging from 40% to 95%. 100) 101) Polypharmacy is associated with an increased risk of mortality, adverse drug reactions, longer hospitalizations, higher re-hospitalization rates and higher risk for both thromboembolism and major bleeding. 102) 103) 104) 105) …”

Defining an ‘older’ patient in the context of therapeutic decision making: perspectives of Australian pharmacists and nurses

“…5 Furthermore, several studies highlight the risks of polypharmacy in older patients, including drug-drug interactions, anticholinergic burden as well as the use of potentially inappropriate medications (PIMs), which may result in hospitalisation and harm to patients including falls etc. [9][10][11][12] The inappropriate use of medicines in this patient group may be attributed to the lack of a standard definition that appropriately characterises an older adult patient. Often, chronological age is used as a basis for making pharmacotherapeutic decisions, i.e.…”