Polypharmacy research paper

Polypharmacy as a risk factor for clinically relevant sarcopenia: results from the berlin aging study II. Furthermore, two small cross-sectional studies investigating the association between multiple medications and health-related quality of life found no statistically significant effect of polypharmacy on quality of life [ 68 Lalic S , Jamsen KM , Wimmer BC , et al. Polypharmacy and medication regimen complexity as factors associated with staff informant rated quality of life in residents of aged care facilities: a cross-sectional study.

An update on the clinical consequences of polypharmacy in older adults: a narrative review

Medication-related factors associated with health-related quality of life in patients older than 65 years with polypharmacy. Polypharmacy has been linked to lowered cognitive functions and dementia. Some of these studies have analyzed cognitive status at one time point, and others have analyzed if polypharmacy is associated with a decline in cognitive status.

In a cross-sectional study of community-living Japanese older adults, polypharmacy was associated with lower cognitive status [ 70 Niikawa H , Okamura T , Ito K , et al. Association between polypharmacy and cognitive impairment in an elderly Japanese population residing in an urban community. Geriatr Gerontol Int.

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A longitudinal register-based nested case-control study matching incident dementia cases with dementia-free cases found that polypharmacy was associated with receiving a dementia diagnosis. The association between polypharmacy and dementia: a nested case-control study based on a year longitudinal cohort database in South Korea. Being exposed to polypharmacy at two time points, compared to one time point, was found to be associated with a stronger negative association between polypharmacy and cognitive function in an aforementioned British study, suggesting a cumulative negative effect of polypharmacy [ 60 Rawle MJ , Cooper R , Kuh D , et al.

Two studies have investigated if polypharmacy is associated with a faster decline in cognition. Cognitive decline and polypharmacy in an elderly population. In the context of polypharmacy and cognition, it is of great importance to also consider specific drug types; for example, psychotropics and drugs with anticholinergic properties are known to have negative effects on cognition [ 62 Vetrano DL , Villani ER , Grande G , et al.

Background

Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. Polypharmacy in people with dementia: associations with adverse health outcomes. Exp Gerontol. Polypharmacy and medication regimen complexity as risk factors for hospitalization among residents of long-term care facilities: a prospective cohort study.

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Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. Polypharmacy and health outcomes among older adults discharged from hospital: results from the CRIME study. The study found an independent association between the exposure to polypharmacy and subsequent all-cause and fall-related hospitalization while adjusting for the use of potentially inappropriate medications and anticholinergic burden. Another interesting finding is that Payne et al.

Future studies should also include measures of the length of hospital stay. This would provide a more detailed picture of health-care consumption and is easily compared across studies and health-care systems [ 78 Formica D , Sultana J , Cutroneo P , et al. The economic burden of preventable adverse drug reactions: a systematic review of observational studies.

In , a systematic review withmeta-analysis was published investigating the association between polypharmacy and mortality [ 16 Leelakanok N , Holcombe AL , Lund BC , et al. In all, 47 articles were included in the meta-analysis. Pooled estimates were presented for papers using the number of drugs as a continuous variable, and the odds ratio for mortality was 1.

In addition, pooled estimates from papers using different categorical cut-offs for the number of drugs were also presented; these analyses suggested a potential dose—response relationship, where a higher cut-off yielded a higher estimate for the association between polypharmacy and death. For the cut-off of five or more drugs, the pooled estimate was 1.

The authors noted a large variety in how the included studies addressed confounding by indication e. Hence, the authors did not rule out the possibility of residual confounding affecting the pooled estimates. A notable example of a study addressing the issue of confounding by indication was published after this systematic review.

Polypharmacy and mortality: new insights from a large cohort of older adults by detection of effect modification by multi-morbidity and comprehensive correction of confounding by indication. Interestingly, they observed that the association between polypharmacy and non-cancer mortality was found when adjusting for chronic conditions hazard ratio HR 2.

The authors thus suggest that solely adjusting for chronic condition is insufficient to avoid confounding by indication when relating polypharmacy to subsequent clinical consequences.

Three major challenges for extending the research on polypharmacy and potential negative outcomes have been identified in this review. First, there is a need to further refine the definition of polypharmacy.

Polypharmacy - Wikipedia

Second, the methodological challenges in assessing the association between polypharmacy and negative outcomes should be better acknowledged in future studies. Third, we need to further develop interventions to reduce polypharmacy in order to produce successful and scalable strategies. These issues are further discussed in the following sections. No standard definition exists for what constitutes polypharmacy. When polypharmacy is defined as a count of the number of drugs, a cut-off of five or more concurrently is most frequently used [ 6 Masnoon N , Shakib S , Kalisch-Ellett L , et al.

Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol.

Pharmacists must work with others to roll back polypharmacy culture

Polypharmacy cut-off for gait and cognitive impairments. Front Pharmacol. Defining polypharmacy as a specific number of drugs is useful for monitoring drug use in large populations and as a crude marker of polypharmacy in epidemiological studies of the harms of polypharmacy when it might not be practically feasible to make a more detailed assessment of the appropriateness of polypharmacy.

In these situations, considering the composition of drugs in the regimen in relation to the needs of the patient is crucial to make a personalized optimization of the current drug regimen. There are promising initiatives to combine the cut-off approaches and the clinical judgment approach in a meaningful way. Burt et al. It is inherently difficult to correctly estimate the negative health outcomes related to polypharmacy given that polypharmacy itself is most often a consequence of poor health.

The challenge is to prove a negative effect of polypharmacy beyond the already existing health problems that the polypharmacy drug regimen is intended to treat.

Confounding by indication in clinical research. Common strategies to reduce the risk of this bias are to adjust for general health status or some composite score of general health status for example, Charlson Comorbidity Index [ 84 Charlson M , Szatrowski TP , Peterson J , et al. Validation of a combined comorbidity index. Assessing and measuring chronic multimorbidity in the older population: a proposal for its operationalization.

The strong correlation between number of drugs and number of health problems may not only be solved by solely adjusting for health status. Study designs mimicking randomized control trials can strengthen the evidence as a classical trial randomizing polypharmacy to patients would not be ethically feasible. Adverse geriatric outcomes secondary to polypharmacy in a mouse model: the influence of aging.

The polypharmacy mouse model: novel findings and new opportunities. To increase the potential of making causal claims about the association between polypharmacy and clinical outcomes, temporality is a key issue. The consequences of polypharmacy ought to be studied at a time point later than when polypharmacy status is assessed, and more efforts should be directed to accounting for intra-individual changes in polypharmacy status over time; for example, by using polypharmacy as a time-varying exposure [ 73 Lu W-H , Wen Y-W , Chen L-K , et al.

Changes in drug use and polypharmacy after the age of a longitudinal study of the danish cohort. This could provide important insights into whether a persistent exposure to polypharmacy may lead to a cumulative risk of negative outcomes as suggested in a recent study [ 60 Rawle MJ , Cooper R , Kuh D , et al. Furthermore, many of these interventions are complex and might therefore have limited scalability [ 39 Johansson T , Abuzahra ME , Keller S , et al.

References

In a large cluster-randomized trial of 1, multimorbid patients in the UK allocated to usual care or patient-centered care optimized for management of multimorbidity , the authors found that the intervention did not reduce the number of drugs Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Furthermore, the increasing sophistication of computerized decision support systems for the optimization of drug therapy for older adults will likely lead to a larger uptake of these important tools.

Decision support systems have been found to reduce the risk of potential inappropriate medication use [ 91 Clyne B , Bradley MC , Hughes C , et al. Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence. Clin Geriatr Med. Computerised interventions designed to reduce potentially inappropriate prescribing in hospitalised older adults: a systematic review and meta-analysis. By combining decision support tools with relevant patient data regarding, for example, kidney function creatinine clearance rate and genetic ability to metabolize drugs e.

CYP enzymes , there is a great potential to provide more tailored prescribing — moving closer to the concept of personalized medicine [ 93 Brixner D , Biltaji E , Bress A , et al. The effect of pharmacogenetic profiling with a clinical decision support tool on healthcare resource utilization and estimated costs in the elderly exposed to polypharmacy.

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