Pharmacological treatment optimization in older patients
- Autores: Marta Gutiérrez Valencia
- Directores de la Tesis: Nicolás Ignacio Martínez Velilla (dir. tes.)
- Lectura: En la Universidad Pública de Navarra ( España ) en 2019
- Idioma: inglés
- Tribunal Calificador de la Tesis: Amaia Calderón Larrañaga (presid.), Tomás Belzunegui Otano (secret.), Juan Erviti López (voc.)
- Programa de doctorado: Programa de Doctorado en Ciencias de la Salud por la Universidad Pública de Navarra
- Materias:
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- Resumen
The use of medications in the elderly is a complex issue influenced by many health and non-health related factors. Drug therapy is one of the most important tools available for preserving and improving health. However, polypharmacy and the inappropriate use of medications can imply adverse effects and situations of vulnerability that condition negative health outcomes. The following work intends to study this phenomenon in different areas ―at population or community level, in institutionalized and hospitalized patients―, analyzing its relationship with different factors that may be of interest in the elderly patient, and especially with frailty. Finally, it focuses on the hospitalized elderly, one of the most vulnerable sectors to pharmacological iatrogenesis, investigating the impact of hospitalization on pharmacological therapy, reviewing the different strategies that have been proposed for pharmacological optimization in these patients and exploring the usefulness of an intervention specifically adapted to these patients in our environment.
The most relevant methodology and results are summarized below:
Chapter 1: Prevalence of polypharmacy and associated factors in older adults in Spain: Data from the National Health Survey 2017 Background and objective: to estimate the prevalence of polypharmacy and hyperpolypharmacy in non-institutionalized older adults in Spain and assess the associated factors.
Material and methods: a cross-sectional study based on data from the National Health Survey of Spain 2017, with participants over 65 years old. The prevalence of polypharmacy (≥5 medications) and hyperpolypharmacy (≥10) was estimated, as well as the association with several factors through multivariate logistic regression. A sensitivity analysis was also carried out considering the possible consumption of more than one drug for the same indication (polytherapy).
Results: 7023 participants were included, with a mean age of 76.0 (SD 7.6) years, 59.4% women and an average consumption of 3.3 (SD 2.2) drugs per person. The prevalence of polypharmacy was 27.3% (95% CI 26.2-28.3), being 0.9% (95% CI 0.7-1.1) in the case of hyperpolypharmacy. The sensitivity analysis showed that the prevalence could be at least 37.5% and the average number of drugs 3.9 (SD 2.5) when considering polytherapy. The number of chronic diseases, the degree of dependence for the basic activities of daily living, the self-perceived health and contacts with the health system were the factors most associated with polypharmacy. Sensory deficits and incontinence were negatively associated.
Conclusions: the prevalence of polypharmacy in the elderly in primary care continues to increase, and could be widely underestimated. In addition to the multimorbidity, factors such as functional capacity or geriatric syndromes, which are essential in elderly people, modulate the habits of consumption and prescription of drugs in this population.
Chapter 2: The relationship between Frailty and Polypharmacy in older people: a Systematic Review Aims: Frailty is a complex geriatric syndrome resulting in decreased physiological reserves. Frailty and polypharmacy are common in older adults and the focus of extensive studies, although little is known about the impact they may have on each other. This is the first systematic review analysing the available evidence on the relationship between frailty and polypharmacy in older adults.
Methods: Systematic review of quantitative studies. A comprehensive literature search for publications in English or Spanish was performed on MEDLINE, CINAHL, the Cohrane Database and PsycINFO in September 2017 without applying restrictions on the date of publication. Studies reporting any relationship between frailty and polypharmacy in older adults were considered.
Results: A total of 25 publications were included, all of them observational studies. Evaluation of Fried’s frailty criteria was the most common approach, followed by the Edmonton Frail Scale and FRAIL scale. Sixteen of 18 cross-sectional analyses and five of seven longitudinal analyses demonstrated a significant association between an increased number of medications and frailty. The causal relationship is unclear and appears to be bidirectional. Our analysis of published data suggests that polypharmacy could be a major contributor to the development of frailty.
Conclusions: A reduction of polypharmacy could be a cautious strategy to prevent and manage frailty. Further research is needed to confirm the possible benefits of reducing polypharmacy in the development, reversion or delay of frailty.
Chapter 3: The Relationship between frailty, polypharmacy, and underprescription in older adults living in nursing homes Purpose: Frailty, polypharmacy, and underprescription are considered a major matter of concern in nursing homes, but the possible relationships between them are not well known. The aim is to examine the possible association between medication underprescription, polypharmacy, and frailty in older people living in nursing homes.
Methods: A cross-sectional analysis from a concurrent cohort study, including 110 subjects ≥ 65 years living in two nursing homes. Four frailty scales were applied; polypharmacy was defined as ≥ 5 medications and underprescription was measured with Screening Tool to Alert to Right Treatment (START) criteria. Logistic regression models were performed to assess the associations.
Results: The mean age was 86.3 years (SD 7.3) and 71.8% were female. 73.6% of subjects took ≥ 5 chronic medications and 60.9% met one or more START criteria. The non-frail participants took more medications than the frail subjects according to the imputated frailty Fried criteria (8.1 vs 6.7, p = 0.042) and the FRAIL-NH scale (7.8 vs 6.8, p=0.026). Multivariate analyses did not find an association between frailty and polypharmacy. Frail participants according to the Fried criteria met a higher number of START criteria (1.9 vs 1.0, p = 0.017), and had a higher prevalence of underprescription (87.5 vs 50.0%), reaching the limit of statistical significance in multivariate analysis.
Conclusion: The positive association found in previous studies between frailty and polypharmacy cannot be extrapolated to institutionalized populations. There is a trend towards higher rates of underprescription in frail subjects. Underprescription in frail older adults should be redefined and new strategies to measure it should be developed.
Chapter 4: Impact of hospitalization in an acute geriatric unit on polypharmacy and potentially inappropriate prescriptions: A retrospective study Aim: Polypharmacy is a highly prevalent geriatric syndrome, and hospitalizations can worsen it. The aim of the present study was to analyze the influence of hospitalization on polypharmacy and indicators of quality of prescribing, and their possible association with health outcomes. Methods: A retrospective study of 200 patients discharged from an acute geriatric unit was carried out. Indicators of quality of prescription were registered at admission and discharge: polypharmacy defined as ≥5 medications, hyperpolypharmacy (≥10), potentially inappropriate prescribing by Beers and Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, potentially prescribing omissions by Screening Tool to Alert doctors to the Right Treatment (START) criteria, drug interactions and anticholinergic burden measured with the Anticholinergic Risk Scale. Mortality, emergency room visits and hospital admissions occurring during 6 months after discharge were also registered. Results: The total number of drugs increased at discharge (9.1 vs 10.1, P < 0.001), without increasing chronic medications (8.5 vs 8.3, P = 0.699). No significant variations were observed in the prevalence of polypharmacy (86.5% vs 82.2%), potentially inappropriate prescribing (68.5%vs 71.5%), potential prescribing omissions (58%vs 58%) or drug interactions (82.5%vs 83.5%). Patients with anticholinergic drugs tended to increase, not reaching statistical significance (39.5% vs 44.5%; P = 0.064). Polypharmacy was associated with emergency room visits (OR 2.62, 95% CI 1.07–6.40; P = 0.034), and hyperpolypharmacy with hospitalizations (OR 2.49, 95% CI 1.25–4.93; P = 0.009). Conclusions: After hospitalization in an acute geriatric unit, the prevalence of polypharmacy, potentially inappropriate prescribing, potential prescribing omissions, interactions or anticholinergic drugs is still very high. Polypharmacy is a risk factor for hospitalization and emergency room visits. Measuring indicators of quality of prescription might be useful to design interventions to optimize pharmacotherapy and improve health outcomes in elderly acute patients.
Chapter 5: Interventions to optimize pharmacologic treatment in hospitalized older adults: a systematic review Objective: To summarise the evidence on interventions aimed at optimising the drug treatment of hospitalised elderly patients.
Material and methods: We conducted a search in the main medical literature databases, selecting prospective studies of hospitalised patients older than 65 years who underwent interventions aimed at optimising drug treatment, decreasing polypharmacy and improving the medication appropriateness, health outcomes and exploitation of the healthcare system.
Results: We selected 18 studies whose interventions consisted of medication reviews, detection of predefined drugs as potentially inappropriate for the elderly, counselling from a specialised geriatric team, the use of a computer support system for prescriptions and specific training for the nursing team. Up to 14 studies assessed the medication appropriateness, 13 of which showed an improvement in one or more of the parameters. Seven studies measured the impact of the intervention on polypharmacy, but only one improved the outcomes compared with the control. Seven other studies analysed mortality, but none of them showed a reduction in that rate. Only 1 of 6 studies showed a reduction in the number of hospital readmissions, and 1 of 4 studies showed a reduction in the number of emergency department visits.
Conclusions: Despite the heterogeneity of the analysed interventions and variables, we obtained better results in the process variables (especially in medication appropriateness) than in those that measured health outcomes, which had greater variability.
Chapter 6: A medicine optimization strategy in an acute geriatric unit: the pharmacist in the geriatric team Aim: Older patients admitted to acute geriatric units (AGU) use frequently many medications and are particularly vulnerable to adverse drug events, so specific interventions in this setting are needed. In this study, we describe a new medicine optimization strategy in an AGU and explore its potential in reducing polypharmacy and improving medication appropriateness.
Methods: Prospective study with patients aged ≥ 75 years who were admitted to an AGU in a tertiary hospital. An intervention based on a pharmacist clinical interview, medication history, and a structured medication review within a comprehensive geriatric assessment (CGA) was proposed. The differences regarding polypharmacy as the primary outcome (≥5 chronic drugs), hyperpolypharmacy (≥10), number of drugs, drug-related problems (DRP) and Screening Tool of Older Person’s Prescription (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START) criteria between admission and discharge were evaluated.
Results: From October 2016 to April 2017, 234 patients were enrolled, aged 87.6 years (SD = 4.6); 143 (61.1%) were female. The intervention resulted in a statistically significant improvement in polypharmacy (-10.2%, 95%CI,-15.3,-5.2), hyperpolypharmacy (-16.6%, 95%CI,-22.3,-11.0), number of medications (-1.4, 95%CI,-1.8,-1.0), STOPP criteria (-19.2%, 95%CI,-24.9,-13.6), START criteria (-6.8%, 95%CI,-10.1,-3.5) and DRP (-2.7, 95%CI,-2.9,-2.4) (p<0.001 for all).
Conclusions: A systematic pharmacist-led intervention at hospital admission to an AGU within a CGA was associated to a decrease in polypharmacy, drug related problems and potentially inappropriate prescribing.
