Abstract: Introduction: Polypharmacy, the use of multiple medications by one individual, is increasingly common among older adults. Caring for the growing number of older people with complex drug regimens an ...

Abstract: 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 Cochrane 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.

Abstract: Objective Polypharmacy is the concomitant use of several drugs by a single person, and it increases the risk of adverse drug-related events in older adults. Little is known about the epidemiology of polypharmacy at the population level. We aimed to measure the prevalence and incidence of polypharmacy and to investigate the associated factors. Methods A prospective cohort study was conducted using register data with national coverage in Sweden. A total of 1,742,336 individuals aged ≥65 years at baseline (November 1, 2010) were included and followed until death or the end of the study (December 20, 2013). Results On average, individuals were exposed to 4.6 (SD =4.0) drugs at baseline. The prevalence of polypharmacy (5+ drugs) was 44.0%, and the prevalence of excessive polypharmacy (10+ drugs) was 11.7%. The incidence rate of polypharmacy among individuals without polypharmacy at baseline was 19.9 per 100 person-years, ranging from 16.8% in individuals aged 65-74 years to 33.2% in those aged ≥95 years (adjusted hazard ratio [HR] =1.49, 95% confidence interval [CI] 1.42-1.56). The incidence rate of excessive polypharmacy was 8.0 per 100 person-years. Older adults using multi-dose dispensing were at significantly higher risk of developing incident polypharmacy compared with those receiving ordinary prescriptions (HR =1.51, 95% CI 1.47-1.55). When adjusting for confounders, living in nursing home was found to be associated with lower risks of incident polypharmacy and incident excessive polypharmacy (HR =0.79 and HR =0.86, p<0.001, respectively). Conclusion The prevalence and incidence of polypharmacy are high among older adults in Sweden. Interventions aimed at reducing the prevalence of polypharmacy should also target potential incident polypharmacy users as they are the ones who fuel future polypharmacy.

Abstract: The prevalence of pressure ulcers particularly in the frail older adult population continues to be high and very costly especially in those suffering from chronic diseases and has brought a higher awareness to comprehensive, preventive and therapeutic measures for treatment of pressure ulcers. Internal risk factors highlighted by comorbidities play a crucial role in the pathogenesis of pressure ulcers. Focusing on the impact of common chronic diseases (comorbidities) in aging on pressure ulcers (e.g., cardiovascular diseases, diabetes, chronic pulmonary diseases, renal diseases and neurodegenerative disorders) and the significant complicating conditions e.g., anemia, infectious diseases, malnutrition, hospitalization, incontinence and polypharmacy, frailty and disability becomes important in developing a more complete, inclusive and multidisciplinary approach to prevention of PU in older patients. To describe chronic and acute conditions which are risk factors in elderly patients for developing PU. We present an overview of comorbidities seen with PU in three diverse patient locations. The inclusion criteria are sites (community, acute hospital and long term facilities), older patients, chronic diseases and pressure ulcers grade 2 and over. Using a recently developed conceptual framework accepted by European and National Pressure Ulcer Advisory Panels, we examined chronic diseases to identify the risk factors of chronic conditions and complicating conditions which potentially influence risk for PU development. Multiple chronic diseases and complicating factors which associated with immobility, tissue ischemia, and undernutrition are caused to PU in community settings, hospitals, and nursing facilities.

Abstract: The complexity and heterogeneity of patients with multimorbidity and polypharmacy renders traditional disease-oriented guidelines often inadequate and complicates clinical decision making. To address this challenge, guidelines have been developed on multimorbidity or polypharmacy. To systematically analyse their recommendations, we conducted a systematic guideline review using the Ariadne principles for managing multimorbidity as analytical framework. The information synthesis included a multistep consensus process involving 18 multidisciplinary experts from seven countries. We included eight guidelines (four each on multimorbidity and polypharmacy) and extracted about 250 recommendations. The guideline addressed (i) the identification of the target population (risk factors); (ii) the assessment of interacting conditions and treatments: medical history, clinical and psychosocial assessment including physiological status and frailty, reviews of medication and encounters with healthcare providers highlighting informational continuity; (iii) the need to incorporate patient preferences and goal setting: eliciting preferences and expectations, the process of shared decision making in relation to treatment options and the level of involvement of patients and carers; (iv) individualized management: guiding principles on optimization of treatment benefits over possible harms, treatment communication and the information content of medication/care plans; (v) monitoring and follow-up: strategies in care planning, self-management and medication-related aspects, communication with patients including safety instructions and adherence, coordination of care regarding referral and discharge management, medication appropriateness and safety concerns. The spectrum of clinical and self-management issues varied from guiding principles to specific recommendations and tools providing actionable support. The limited availability of reliable risk prediction models, feasible interventions of proven effectiveness and decision aids, and limited consensus on appropriate outcomes of care highlight major research deficits. An integrated approach to both multimorbidity and polypharmacy should be considered in future guidelines.

Abstract: Polypharmacy and potentially inappropriate medications (PIMs) are prevalent in older adults in hospital, and are associated with negative outcomes including adverse drug reactions, falls, confusion, hospitalisation and death. Deprescribing may reduce inappropriate polypharmacy and use of inappropriate medications. The aim of this systematic review was to investigate the efficacy of deprescribing interventions in older inpatients to reduce PIMs and impact on clinical outcomes. Ovid MEDLINE, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL were searched for randomised controlled trials (RCTs) from 1996 to April 2017. RCTs reporting on deprescribing interventions to reduce PIMs in older hospitalised adults were eligible. Data were extracted, and study quality assessed. The primary outcome was reduction in PIMs. Where available, clinically relevant outcomes were assessed. Nine RCTs (n = 2522 subjects) met the inclusion criteria. Deprescribing interventions were either pharmacist-led (n = 4), physician-led (n = 4) or multidisciplinary team-led (n = 1). Seven of the nine studies reported a statistically significant reduction in PIMs in the intervention group. There was no change in one study where there were zero PIMs on admission and discharge, and in the other study a reduction in PIMs that was not statistically significant was observed. There was significant heterogeneity in outcome measures and reporting. Few studies reported on the impact of deprescribing interventions on clinical outcomes. Reported clinical outcomes included drug-related problems (n = 3), quality of life (n = 2), mortality (n = 3), hospital readmissions (n = 4), falls (n = 3) and functional status (n = 2). Most studies reported a benefit in the intervention group that was not statistically significant. No notable harm was observed in the intervention group. There was a high risk of bias in the included studies. The evidence available suggests that deprescribing interventions in hospital are feasible, generally effective at reducing PIMs and safe. However, the current evidence is limited, of low quality and the impact on clinical outcomes is unclear.

Abstract: Introduction: Statins reduce the risk of cardiovascular morbidity and mortality in patients with or at risk for cardiovascular disease and their use is expanding, especially in elderly. Statins are prescribed on a long-term basis and may undergo drug–drug interactions (DDIs) with other drugs. Statins have different safety and tolerability, and this might affect the possibility of DDIs with other cardiovascular drugs, increasing the risk of statin-associated myopathy and hepatotoxicity. Polypharmacy and pharmacogenetic variability are potential causes of statin DDIs. Thus, the safety and adverse effects of statins, particularly in patients receiving multiple medications at risk of DDIs, are a matter of special concern.Areas covered: The purpose of this manuscript is to give an update on the potential statin DDIs and related adverse drug reactions (myopathy and hepatotoxicity), with special considerations on polypharmacy in elderly population, HIV patients, cardiovascular drugs and liver toxicities....

Abstract: Geriatric Patients Living with HIV/AIDS (GEPPO) is a new prospective observational multicentre cohort consisting of all the HIV-positive geriatric patients being treated at 10 clinics in Italy, and HIV-negative controls attending a single geriatric clinic. The aim of this analysis of the GEPPO cohort was to compare prevalence and risk factors of individual non-communicable diseases (NCD), multi-morbidity (MM) and polypharmacy (PP) amongst HIV positive and HIV negative controls at enrolment into the GEPPO cohort. This cross-sectional study was conducted between June 2015 and May 2016. The duration of HIV infection was subdivided into three intervals: 20 years. The NCD diagnoses were based on guidelines defined criteria, including cardiovascular disease, hypertension, type 2 diabetes, chronic kidney disease, dyslipidaemia, chronic obstructive pulmonary disease. MM was classified as the presence of two or more co-morbidities. The medications prescribed for the treatment of comorbidities were collected in both HIV positive and HIV negative group from patient files and were categorized using the Anatomical Therapeutic Chemical (ATC) classification. PP was defined as the presence of five or more drug components other than anti-retroviral agents. The study involved a total of 1573 patient: 1258 HIV positive and 315 HIV negative). The prevalence of individual comorbidities was similar in the two groups with the exception of dyslipidaemia, which was more frequent in the HIV-positive patients (p < 0.01). When the HIV-positive group was stratified based on the duration of HIV infection, most of the co-morbidities were significantly more frequent than in control patients, except for hypertension and cardiovascular disease, while COPD was more prevalent in the control group. MM and PP were both more prevalent in the HIV-positive group, respectively 64% and 37%. MM and PP burden in geriatric HIV positive patients are related to longer duration of HIV-infection rather than older age per se.

Abstract: Importance Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years;P Conclusions and Relevance Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Abstract: The aim of this review was to identify factors that influence patients’ adherence to anti-osteoporotic therapy. Factors identified that were associated with poorer medication adherence included polypharmacy, older age, and misconceptions about osteoporosis. Physicians need to be aware of these factors so as to optimize therapeutic outcomes for patients. To identify factors that influence patients’ adherence to anti-osteoporotic therapy. A systematic review of literature was performed for articles published up till January 2018 using PubMed®, PsychINFO®, Embase®, and CINAHL®. Peer-reviewed articles which examined factors associated with anti-osteoporotic medication adherence were included. Classes of anti-osteoporotic therapy included bisphosphonates, parathyroid hormone-related analogue, denosumab, selective estrogen receptor modulators, estrogen/progestin therapy, calcitonin, and strontium ranelate. Meta-analyses, case reports/series, and other systematic reviews were excluded. Identified factors were classified using the World Health Organization’s five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains). Of 2404 articles reviewed, 124 relevant articles were identified. The prevalence of medication adherence ranged from 12.9 to 95.4%. Twenty-four factors with 139 sub-factors were identified. Bisphosphonates were the most well-studied class of medication (n = 59, 48%). Condition-related factors that were associated with poorer medication adherence included polypharmacy, and history of falls was associated with higher medication adherence. Patient-related factors which were associated with poorer medication adherence included older age and misconceptions about osteoporosis while therapy-related factors included higher dosing frequency and medication side effects. Health system-based factors associated with poorer medication adherence included care under different medical specialties and lack of patient education. Socio-economic-related factors associated with poorer medication adherence included current smoker and lack of medical insurance coverage. This review identified factors associated with poor medication adherence among osteoporotic patients. To optimize therapeutic outcomes for patients, clinicians need to be aware of the complexity of factors affecting medication adherence.

Abstract: Background Geriatric syndromes are complex clinical manifestations that are not an isolated disease in older adults and have common risk factors within themselves. The syndromes are significant causes of mortality, morbidity, and increased health care costs. Objective To determine the frequency of geriatric syndromes such as malnutrition, dementia, depression, falls, polypharmacy, urinary incontinence, pressure ulcer, sarcopenia, and frailty in community-dwelling older adults. Methods A total of 2,816 patients, who applied to geriatric outpatient clinic and were evaluated by comprehensive geriatric assessment, were included in this cross-sectional retrospective study. Falls in the last year and urinary incontinence were recorded. Polypharmacy was accepted as concurrent use of more than four drugs. Diagnosis of dementia and depression was defined according to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition diagnostic criteria. In addition, frailty and sarcopenia were evaluated according to Fried's physical frailty scale and European Working Group on Sarcopenia criteria, respectively. Results The frequency of polypharmacy was 54.5%, urinary incontinence 47.6%, malnutrition 9.6%, depression 35.1%, dementia 21.6%, falls 33.6%, sarcopenia 31.7%, and frailty 28.3%. When all the participants were divided into three groups (60-69, 70-79, ≥80 years), all syndromes were significantly increased with age, except for depression. While 20% of cases in 60-69 years age group did not have any syndromes, 48% of cases in ≥80 years had more than four syndromes simultaneously. Conclusion The frequency and coincidence of geriatric syndromes, except for depression, increases with age. Therefore, clinicians other than geriatricians taking care of older people should be aware of these syndromes as well as their treatment mechanisms.

Abstract: The aims of this study were to compare the application of three geriatric medication screening tools to the Beers Criteria alone for potentially inappropriate medication quantification and to determine feasibility of a pharmacist-led polypharmacy assessment in a geriatric oncology clinic. Adult patients with cancer aged 65 and older underwent a comprehensive geriatric assessment. A polypharmacy assessment was completed by a pharmacist and included a review of all drug therapies. Potentially inappropriate medications were screened using the Beers Criteria, Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons’ Prescriptions, and the Medication Appropriateness Index. Deprescribing occurred after discussion with the pharmacist, geriatric oncologist, patient, and caregiver. Data were collected for 26 patients. The mean number of medications was 12. The Beers Criteria alone identified 38 potentially inappropriate medications compared to 119 potentially inappropriate medications with the three-tool assessment; a mean of 5 potentially inappropriate medications were identified per patient. After the application of the three-tool assessment, 73% of potentially inappropriate medications identified were deprescribed, resulting in a mean of 3 medications deprescribed per patient. Approximately two thirds of patients reported a reduction in symptoms after the deprescribing intervention. Healthcare expenditures of $4282.27 per patient were potentially avoided as a result of deprescribing. Our three-tool assessment identified three times more potentially inappropriate medications than the Beers Criteria alone. Pharmacist-led deprescribing interventions are feasible and may lead to improved patient outcomes and cost savings. This three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.

Abstract: Objectives To investigate longitudinal associations between polypharmacy and cognitive and physical capability and to determine whether these associations differ with cumulative exposure to polypharmacy. Design Prospective birth cohort study. Setting England, Scotland, and Wales. Participants An eligible sample of men and women from the Medical Research Council National Survey of Health and Development with medication data at age 69 (N=2,122, 79%). Measurements Cognitive capability was assessed using a word learning test, visual search speed task, and the Addenbrooke's Cognitive Examination, Third Edition (ACE‐III). Physical capability was measured using chair rise speed, standing balance time, walking speed, and grip strength. Results Polypharmacy (5–8 prescribed medications) was present in 18.2% of participants at age 69 and excessive polypharmacy (≥9 prescribed medications) in 4.7%. Both were associated with poorer cognitive and physical capability in models adjusted for sex, education, and disease burden. Stronger associations were found for excessive polypharmacy (e.g., difference in mean ACE‐III scores comparing polypharmacy=−2.0, 95% CI=−2.8 to −1.1 and excessive polypharmacy=−2.9, 95% CI=−4.4 to −1.4 with no polypharmacy). Participants with polypharmacy at age 60 to 64 and at age 69 showed stronger Negative associations with cognitive and physical capability were stronger still in participants with polypharmacy at both age 60 to 64 and at age 69 (e.g. difference in mean chair rise speed, comparing polypharmacy with no polypharmacy at both ages=−3.9, 95% CI=−5.2 to −2.6 and at age 60–64 only=−2.5, 95% CI=−4.1 to −0.9). Conclusion Polypharmacy at age 60 to 64 and age 69 was associated with poorer physical and cognitive capability, even after adjusting for disease burden. Stronger negative associations were seen in participants with longstanding polypharmacy, suggesting a cumulative, dose‐dependent relationship (where dose is the number of prescribed medications). Future research aiming to improve cognitive and physical capability should consider interventions to reduce the duration and level of polypharmacy at younger ages, in addition to optimizing disease control with appropriate medications.

Abstract: AIMS: Polypharmacy is increasingly common in older adults, placing them at risk of medication-related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes, and poor information transfer between hospital and primary care. The aim of this study was to investigate the incidence, severity, preventability and cost of medication-related harm (MRH) in older adults in England post-discharge. METHODS: An observational multicentre prospective cohort study recruited 1280 older adults (median age 82 years) from five teaching hospitals in Southern England, UK. Participants were followed up for eight weeks by senior pharmacists, using 3 data sources (hospital readmission review, participant telephone interview and primary care records), to identify MRH and associated health service utilisation. RESULTS: Four hundred and thirteen participants (37%) experienced MRH (556 MRH events per 1000 discharges). Three hundred and thirty-six (81%) cases were serious, and 214 (52%) potentially preventable. Four participants experienced fatal MRH. The most common MRH events were gastrointestinal (n=158, 25%) and neurological (n=111, 18%). Medicine classes associated with the highest risk of MRH were opiates, antibiotics, and benzodiazepines. Three hundred and twenty-eight (79%) participants with MRH sought healthcare over the eight-week follow-up. The incidence of MRH associated hospital readmission was 78 per 1000 discharges. Post-discharge MRH in older adults is estimated to cost the National Health Service £396 million annually, of which £243 million is potentially preventable. CONCLUSIONS: MRH is common in older adults following hospital discharge, and results in substantial use of healthcare resources.

Abstract: Objectives: A systematic literature review was conducted comparing different approaches estimating persistence and adherence in chronic diseases with polypharmacy of oral and subcutaneous treatments.Methods: This work followed published guidance on performing systematic reviews. Twelve electronic databases and grey literature sources were used to identify studies and guidelines for persistence and adherence of oral and subcutaneous therapies in hypercholesterolemia, type 2 diabetes, hypertension, osteoporosis and rheumatoid arthritis. Outcomes of interest of each persistence and adherence data collection and calculation method included pros: accurate, easy to use, inexpensive; and cons: inaccurate, difficult to use, expensive.Results: A total of 4158 records were retrieved up to March 2017. We included 16 observational studies, 5 systematic reviews and 7 guidelines, in patients with hypercholesterolemia (n = 8), type 2 diabetes (n = 4), hypertension (n = 2), rheumatoid arthritis (n = 1) and mixed ...

Abstract: Background Polypharmacy and inappropriate drug use cause numerous complications, such as cognitive impairment, frailty, falls, and functional dependence. The present study aimed to determine the effect of the comprehensive geriatric assessment (CGA) on polypharmacy, potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the economic reflections of medication changes. Methods One thousand five hundred and seventy-nine older patients, who had undergone CGA, were retrospectively evaluated. The drugs, drug groups, and number of drugs that the patients used were recorded. Appropriate drug therapy was identified by both CGA and STOPP/START criteria. Based on these criteria, PIMs were discontinued and PPOs were started. The monthly cost of these drugs was calculated separately for PIMs and PPOs by using the drugstore records. Results After CGA, while the prevalence of non-polypharmacy was increased from 43.3% to 65.6%, the prevalence of polypharmacy and hyperpolypharmacy was decreased from 56.7% to 34.4% and 12.0% to 3.6%, respectively. The three most common PIMs discontinued were proton pump inhibitors, anti-dementia drugs, and antipsychotics, respectively. However, the most common PPOs started were vitamin D and B12 supplements, and anti-depressants. After CGA, monthly saved total per capita cost of PIMs was US$12.8 and monthly increased total per capita cost of PPOs was $5.6. Conclusion It was demonstrated that prevalence of polypharmacy, PIM, and PPO could be decreased by CGA including START/STOPP criteria in older adults. Furthermore, this will have beneficial effects on economical parameters due to decreasing drug-related health care costs.

Abstract: Polypharmacy is common in older people and associated with potential harms. The aim of this study was to analyse the characteristics of an older multimorbid population with polypharmacy and to identify factors contributing to excessive polypharmacy in these patients. This cross-sectional analysis is based on the PRIMA-eDS trial, a large randomised controlled multicentre study of polypharmacy in primary care. Patients’ baseline data were used for analysis. A number of socioeconomic and medical data as well as SF-12-scores were entered into a generalized linear mixed model to identify variables associated with excessive polypharmacy (taking ≥10 substances daily). Three thousand nine hundred four participants were recruited. Risk factors significantly associated with excessive polypharmacy were frailty (OR 1.45; 95% CI 1.22–1.71), > 8 diagnoses (OR 2.64; 95% CI 2.24–3.11), BMI ≥30 (OR 1.18; 95% CI 1.02–1.38), a lower SF-12 physical health composite score (OR 1.47; 95% CI 1.26–1.72), and a lower SF-12 mental health composite score (OR 1.33; 95% CI 1.17–1.59) than the median of the study population (≤36.6 and ≤ 48.7, respectively). Age ≥ 85 years (OR 0.83; 95% CI 0.70–0.99) led to a significantly lower risk for excessive polypharmacy. No association with excessive polypharmacy could be found for female sex, low educational level, and smoking. Regarding the study centres, being recruited in the UK led to a significantly higher risk for excessive polypharmacy compared to being recruited in Germany 1/Rostock (OR 1.71; 95% CI 1.27–2.30). Being recruited in Germany 2/Witten led to a slightly significant lower risk for excessive polypharmacy compared to Germany 1/Rostock (OR 0.74; 95% CI 0.56–0.97). Frailty, multimorbidity, obesity, and decreased physical as well as mental health status are risk factors for excessive polypharmacy. Sex, educational level, and smoking apparently do not seem to be related to excessive polypharmacy. Physicians should especially pay attention to their frail, obese patients who have multiple diagnoses and a decreased health-related quality of life, to check carefully whether all the drugs prescribed are evidence-based, safe, and do not interact in an unfavourable way. This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559).

Abstract: In the present study, we aimed to identify multimorbidity patterns in a Japanese population and investigate whether these patterns have differing effects on polypharmacy and dosage frequency. Data was collected on 17 chronic health conditions via nationwide cross-sectional survey of 3,256 adult Japanese residents. Factor analysis was performed to identify multimorbidity patterns, and associations were determined with excessive polypharmacy [concurrent use of ≥ 10 prescription or over-the-counter (OTC) medications] and higher dosage frequency ( ≥ 3 doses per day). Secondary outcomes were the number of concurrent prescription medications and the number of concurrent OTC medications. We used a generalized linear model to adjust for individual sociodemographic characteristics. Five multimorbidity patterns were identified: cardiovascular/renal/metabolic, neuropsychiatric, skeletal/articular/digestive, respiratory/dermal, and malignant/digestive/urologic. Among these patterns, malignant/digestive/urologic and cardiovascular/renal/metabolic patterns showed the strongest associations with excessive polypharmacy and the number of concurrent OTC medications. Malignant/digestive/urologic, respiratory/dermal, and skeletal/articular/digestive patterns were also associated with higher dosage frequency. Multimorbidity patterns have differing effects on excessive polypharmacy and dosage frequency. Malignant/digestive/urologic pattern may be at higher risk of impaired medication safety and increased treatment burden, than other patterns. Continued study is warranted to determine how to incorporate multimorbidity patterns into risk assessments of polypharmacy and overall treatment burden.

Abstract: Background: medical practice has changed over the last decades reflecting the ageing population, when multi-morbidity requiring multiple medications is more common. Objective: describe and quantify self-reported medicine use including both prescription and over the counter medicines in two comparable population-based studies of older people (65+) in England and to assess the nature and scale of polypharmacy. Methods: data used were from two separate population-based studies; the Cognitive Function Ageing Study I and II. Descriptive analyses were performed to summarise and quantify general medicine use. Negative binomial regression models were fitted to determine factors associated with the number of medicines used. Results: medication use, including both prescribed medicines and over the counter products has increased dramatically over the last 2 decades. The number of people taking five or more items quadrupled from 12 to 49%, while the proportion of people who did not take any medication has decreased from around 1 in 5 to 1 in 13. Cardiovascular drugs were the most frequently taken medication. Polypharmacy is associated with increases in the number of diagnosed long-term conditions. Conclusions: comparison between CFAS I and II reveals marked increases in medication usage and polypharmacy in the older population. The influence of healthcare organisation, introduction of new guidelines and technology changes leading to diagnosis of earlier, milder chronic diseases and treatment may be contributing to this changing pattern. Further research is needed to develop practical solutions to optimise medication management in older people, reducing the harming associated with medication.

Abstract: Background Evidence remains limited on why diabetes and hypertensive patients admitted to long-term drug therapy miss doses or discontinue medication taking. We examined this phenomenon from the perspective of diabetes and hypertension patients at a Ghanaian teaching hospital. Methods Between July and December 2015, we conducted a qualitative study targeting caregivers and their patients with chronic diabetes and hypertensive on re-admission at the Korle Bu Teaching Hospital due to non-adherence to prescribed medication. Participants were sampled purposefully and taking through in-depth interviews using an interview guide. Notes and audio recordings of interviews were transcribed, managed and coded for themes guided by the thematic network analysis recommended by Attride-Stirling. Results Non-adherence was the result of perceptions that the medications are not effective for managing the conditions. Patients with these perceptions rejected the medications and turned to herbal medicines and spiritual healing as therapeutic alternatives, because of their easy accessibility, perceived efficacy and affordability. Other factors identified to influence non-adherence included polypharmacy practice; tight work schedules; social norms; poor prescription instruction by health providers; and knowledge and experience of medication. Conclusion Findings suggests the need for health providers to adopt therapeutic approaches that take into account patients’ beliefs, values and norms in administering medications. Sensitisation of patients and caregivers during admission on the implication of non-adherence, as well as interventions that monitor and provide feedback mechanisms on patients’ medication taking behaviour holds promise for maximising diabetes and hypertensive medication adherence.

Abstract: Background Polypharmacy is common among older adults, with increasing numbers also using prescription drugs with herbal medicinal products (HMPs) and dietary supplements. There is no reliable evidence from the UK on concurrent use of HMPs and dietary supplements with prescription drugs in older adults. Aim To establish prevalence of concurrent prescription drugs, HMPs, and dietary supplements among UK community-dwelling older adults and identify potential interactions. Design and setting Cross-sectional survey of older adults registered at two general practices in South East England. Method A questionnaire asking about prescription medications, HMPs, and sociodemographic information was posted to 400 older adults aged ≥65 years, identified as taking ≥1 prescription drug. Results In total 155 questionnaires were returned (response rate = 38.8%) and the prevalence of concurrent HMPs and dietary supplements with prescriptions was 33.6%. Females were more likely than males to be concurrent users (43.4% versus 22.5%; P = 0.009). The number of HMPs and dietary supplements ranged from 1 to 8, (mean = 3, median = 1; standard deviation = 1.65). The majority of concurrent users (78.0%) used dietary supplements with prescription drugs. The most commonly used dietary supplements were cod liver oil, glucosamine, multivitamins, and vitamin D. Others (20.0%) used only HMPs with prescription drugs. Common HMPs were evening primrose oil, valerian, and Nytol Herbal ® (a combination of hops, gentian, and passion flower). Sixteen participants (32.6%) were at risk of potential adverse drug interactions. Conclusion GPs should routinely ask questions regarding herbal and supplement use, to identify and manage older adults at potential risk of adverse drug interactions.

Abstract: BACKGROUND The population of cancer survivors is rapidly growing in the United States. Long-term and late effects of cancer, combined with the ongoing management of other chronic conditions, make survivors particularly vulnerable to polypharmacy and its adverse effects. In the current study, the authors examined patterns of prescription medication use and polypharmacy in a population-based sample of cancer survivors. METHODS Using data from the Medical Expenditure Panel Survey (MEPS), the authors matched cancer survivors (5216 survivors) with noncancer controls (19,588 controls) by age, sex, and survey year. Polypharmacy was defined as ≥5 unique medications. The authors estimated the percentage of respondents prescribed medications within therapeutic classes and total prescription expenditures. RESULTS A higher percentage of cancer survivors were prescribed ≥5 unique medications (64.0%; 95% confidence interval [95% CI], 62.3%-65.8%) compared with noncancer controls (51.5%; 95% CI, 50.4%-52.6%), including drugs with abuse potential. Across all therapeutic classes, a higher percentage of newly (≤1 year since diagnosis) and previously (>1 years since diagnosis) diagnosed survivors were prescribed medications compared with controls, with large differences observed with regard to central nervous system agents (65.8% [95% CI, 62.3%-69.3%] vs 57.4% [95% CI, 55.3%-59.5%] vs 46.0% [95% CI, 45.0%-46.9%]). Specifically, nearly 10% of survivors were prescribed benzodiazepines and/or opioids compared with approximately 5% of controls. Survivors had more than double the prescription expenditures (median of $1633 vs $784 among controls). Findings persisted across age and comorbidity categories. CONCLUSIONS Cancer survivors were prescribed a higher number of unique medications, including drugs with abuse potential, thereby increasing their risk of adverse drug events, financial toxicity, poor adherence, and drug-drug interactions. Cancer 2018;124:2850-2857. © 2018 American Cancer Society.

Abstract: Background Although polypharmacy is associated with significant morbidity, deprescribing can be challenging. In particular, clinicians express difficulty with their ability to deprescribe (i.e. reduce or stop medications that are potentially inappropriate). Evidence-based deprescribing guidelines are designed to help clinicians take action on reducing or stopping medications that may be causing more harm than benefit. Objectives Determine if implementation of evidence-based guidelines increases self-efficacy for deprescribing proton pump inhibitor (PPI), benzodiazepine receptor agonist (BZRA) and antipsychotic (AP) drug classes. Methods A deprescribing self-efficacy survey was developed and administered to physicians, nurse practitioners and pharmacists at 3 long-term care (LTC) and 3 Family Health Teams in Ottawa, Canada at baseline and approximately 6 months after sequential implementation of each guideline. For each drug class, overall and domain-specific self-efficacy mean scores were calculated. The effects of implementation of each guideline on self-efficacy were tested by estimating the difference in scores using paired t -test. A linear mixed-effects model was used to investigate change over time and over practice sites. Results Of eligible clinicians, 25, 21, 18 and 13 completed the first, second, third and fourth survey respectively. Paired t-tests compared 14 participants for PPI and BZRA, and 9 for AP. Overall self-efficacy score increased for AP only (95% confidence intervals (CI) 0.32 to 19.79). Scores for domain 2 (develop a plan to deprescribe) increased for PPI (95% CI 0.52 to 24.12) and AP guidelines (95% CI 2.46 to 18.11); scores for domain 3 (implement the plan for deprescribing) increased for the PPI guideline (95% CI 0.55 to 14.24). Longitudinal analysis showed an increase in non-class specific scores, with a more profound effect for clinicians in LTC where guidelines were routinely used. Conclusion Implementation of evidence-based deprescribing guidelines appears to increase clinicians' self-efficacy in developing and implementing a deprescribing plan for specific drug classes.

Abstract: Background:The aim of this study was to evaluate efficacy and safety of poly-de-prescribing (PDP) based on the Garfinkel method in older people with polypharmacy.Methods:A longitudinal, prospective, nonrandomized study in Israel was carried out between 2009 and 2016. Comprehensive geriatric assessments were performed at home in people age ⩾66 years consuming ⩾6 prescription drugs. Exclusion criteria were life expectancy <6 months and a seeming unwillingness to cooperate (poor compliance). PDP of ⩾3 prescription drugs was recommended. Follow up was at ⩾3 years. Between April 2015 and April 2016 Likert scale questionnaires were filled by all participants/families to evaluate overall satisfaction and clinical outcomes. The outcome measures were change in functional, mental and cognitive status, sleep quality, appetite, continence; major complication, hospitalizations, mortality, and family doctor’s cooperation.Results:Poly-de-prescribing of ⩾3 drugs was eventually achieved by 122 participants (PDP group); ⩽2...