Polypharmacy as a risk factor for hospital admission among ambulance-transported old-old patients

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Abstract

<div class="section"> <a class="named-anchor" id="ams2153-sec-0001">  </a> <h5 class="section-title" id="d2898793e218">Aim</h5> <p id="d2898793e220">The aim of this study was to analyze the relationship between polypharmacy and hospital admission in ambulance‐transported old‐old patients. </p> </div><div class="section"> <a class="named-anchor" id="ams2153-sec-0002">  </a> <h5 class="section-title" id="d2898793e223">Methods</h5> <p id="d2898793e225">A retrospective cohort study was conducted of consecutive old‐old patients (aged ≥ 85 years) transported by ambulance to a community teaching hospital between <span style="fixed-case">A</span>pril and <span style="fixed-case">D</span>ecember of 2013. Patients with out‐of‐hospital cardiopulmonary arrest were excluded. Data were collected from the computerized records on the demographics, chief complaints, vital signs, and level of consciousness at arrival, final diagnoses at discharge, and polypharmacy (≥5 medications). The primary outcome was requirement of hospital admission. We also analyzed symptomatic adverse drug events ( <span style="fixed-case">ADEs</span>). </p> </div><div class="section"> <a class="named-anchor" id="ams2153-sec-0003">  </a> <h5 class="section-title" id="d2898793e237">Results</h5> <p id="d2898793e239">Of the 3,084 adults (aged ≥ 18 years) transported to the hospital during the study period, 381 (13%) were old‐old patients. Of those, 233 (61%) were women, and 261 (69%) were admitted to the hospital. The mean number of their baseline medications was 6.8 ± 3.9, and 250/347 patients (72%) were suffering from polypharmacy. Twenty‐seven of the patients (7%) had symptomatic <span style="fixed-case">ADEs</span>. Although the <span style="fixed-case">ADEs</span> were not related to polypharmacy ( <i>P</i> = 0.437), logistic regression adjustments for age, sex, and vital signs at arrival showed that patients with polypharmacy were more likely to be admitted to the hospital than were patients without (odds ratio: 2.12 [95% <span style="fixed-case">CI</span>, 1.03–4.43]; <i>P</i> = 0.042). </p> </div><div class="section"> <a class="named-anchor" id="ams2153-sec-0004">  </a> <h5 class="section-title" id="d2898793e257">Conclusions</h5> <p id="d2898793e259">Symptomatic <span style="fixed-case">ADEs</span> due to polypharmacy were one of the most preventable causative factors leading to hospital admission of old‐old patients. Polypharmacy could be a major risk for emergency admission to hospital. </p> </div>

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Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Donna M Fick, James W. Cooper, William Wade … (2003)

Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

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Potentially inappropriate medication use among elderly home care patients in Europe.

Daniela Fialova, Eva Topinkova, Giovanni Gambassi … (2005)

Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

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Medication use leading to emergency department visits for adverse drug events in older adults.

Daniel S Budnitz, Scott Kegler, Alexander L. Richards … (2007)

The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System, 2004-2005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. Persons 65 years of age or older seeking emergency department and outpatient care. Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. Among U.S. patients 65 years of age or older, an estimated 177,504 emergency department visits (95% CI, 100,155 to 254,854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. Adverse events were identified only in emergency departments. Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events.