Polypharmacy, comorbidity and frailty: a complex interplay in older patients at the emergency department

Abstract

Purpose Older adults at the emergency department (ED) with polypharmacy, comorbidity, and frailty are at risk of adverse health outcomes. We investigated the association of polypharmacy with adverse health outcomes, in relation to comorbidity and frailty. Methods This is a prospective cohort study in ED patients ≥ 70 years. Non-polypharmacy was defined as 0–4 medications, polypharmacy 5–9 and excessive polypharmacy ≥ 10. Comorbidity was classified by the Charlson comorbidity index (CCI). Frailty was defined by the Identification of Seniors At Risk—Hospitalized Patients (ISAR-HP) score. The primary outcome was 3-month mortality. Secondary outcomes were readmission to an ED/hospital ward and a self-reported fall < 3 months. The association between polypharmacy, comorbidity and frailty was analyzed by logistic regression. Results 881 patients were included. 43% had polypharmacy and 18% had excessive polypharmacy. After 3 months, 9% died, 30% were readmitted, and 21% reported a fall. Compared with non-polypharmacy, the odds ratio (OR) for mortality ranged from 2.62 (95% CI 1.39–4.93) in patients with polypharmacy to 3.92 (95% CI 1.95–7.90) in excessive polypharmacy. The OR weakened after adjustment for comorbidity: 1.80 (95% CI 0.92–3.52) and 2.32 (95% CI 1.10–4.90). After adjusting for frailty, the OR weakened to 2.10 (95% CI 1.10–4.00) and OR 2.40 (95% CI 1.15–5.02). No significant association was found for readmission or self-reported fall. Conclusions Polypharmacy is common in older patients at the ED. Polypharmacy, and especially excessive polypharmacy, is associated with an increased risk of mortality. The observed association is complex given the confounding effect of comorbidity and frailty.

Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project

“…The high percentage of patients with polypharmacy observed in the EDEN-32 study (63.4%) study is comparable to the percentages found in other studies in the field of emergency care. 7 , 18 – 20 It is noteworthy that, as in the previous studies mentioned, drugs for the prevention of cardiovascular events, including RAASi, statins, and diuretics, have been the most frequently prescribed in this population. Diuretics were the most common medications prescribed among the severe polypharmacy patients.…”

“…Our study did not find an association between polypharmacy and 30-day mortality. van Dam et al 18 reported an increase in the risk of 90-day mortality but did not find an association with the risk of readmission. Other authors also have reported this association between mortality in patients with polypharmacy after ED discharge.…”

The Effect of Frailty on the Efficacy and Safety of Intensive Blood Pressure Control: A Post Hoc Analysis of the SPRINT Trial

“…14 Polypharmacy is also common in patients with frailty. 15 Severe frailty with excess polypharmacy was associated with higher risks of adverse events, especially unplanned hospitalization. 16 As populations continue to age, the prevalence of the oldest and most frail increase.…”

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

“…Notably, polypharmacy, particularly severe polypharmacy (defined as more than 10 medications), was associated with a higher 30-day mortality rate. However, no significant relationship was demonstrated between polypharmacy and self-reported falls in the three months following discharge or with readmissions [ 24 ].…”