Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences

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Key summary points

Aim

This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy.

Findings

Numerous definitions of polypharmacy and associated terms were found. The prevalence of polypharmacy greatly varies, and numerous adverse clinical outcomes were associated with polypharmacy.

Message

The clinically oriented definitions of polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.

Abstract

Background

The number of older adults has been constantly growing around the globe. Consequently, multimorbidity and related polypharmacy have become an increasing problem. In the absence of an accepted agreement on the definition of polypharmacy, data on its prevalence in various studies are not easily comparable. Besides, the evidence on the potential adverse clinical outcomes related to polypharmacy is limited though polypharmacy has been linked to numerous adverse clinical outcomes. This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy.

Methods

The MEDLINE database was used to identify recent publications on the definition, prevalence and clinical consequences of polypharmacy using their respective common terms and their variations. Systematic reviews and original studies published between 2015 and 2020 were included.

Results

One hundred and forty-three definitions of polypharmacy and associated terms were found. Most of them are numerical definitions. Its prevalence ranges from 4% among community-dwelling older people to over 96.5% in hospitalized patients. In addition, numerous adverse clinical outcomes were associated with polypharmacy.

Conclusion

The term polypharmacy is imprecise, and its definition is yet subject to an ongoing debate. The clinically oriented definitions of polypharmacy found in this review such as appropriate or necessary polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults, particularly in nursing home residents and hospitalized patients. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.

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Most cited references 86

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What is polypharmacy? A systematic review of definitions

Nashwa Masnoon, Sepehr Shakib, Lisa Kalisch-Ellett … (2017)

Background Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. Methods The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). Results A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. Conclusions Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.

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STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

Denis O’Mahony, David O'Sullivan, Stephen Byrne … (2014)

Purpose: screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.

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The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010

Bruce Guthrie, Boikanyo Makubate, Virginia Hernandez Santiago … (2015)

Background The escalating use of prescribed drugs has increasingly raised concerns about polypharmacy. This study aims to examine changes in rates of polypharmacy and potentially serious drug-drug interactions in a stable geographical population between 1995 and 2010. Methods This is a repeated cross-sectional analysis of community-dispensed prescribing data for all 310,000 adults resident in the Tayside region of Scotland in 1995 and 2010. The number of drug classes dispensed and the number of potentially serious drug-drug interactions (DDIs) in the previous 84 days were calculated, and age-sex standardised rates in 1995 and 2010 compared. Patient characteristics associated with receipt of ≥10 drugs and with the presence of one or more DDIs were examined using multilevel logistic regression to account for clustering of patients within primary care practices. Results Between 1995 and 2010, the proportion of adults dispensed ≥5 drugs doubled to 20.8%, and the proportion dispensed ≥10 tripled to 5.8%. Receipt of ≥10 drugs was strongly associated with increasing age (20–29 years, 0.3%; ≥80 years, 24.0%; adjusted OR, 118.3; 95% CI, 99.5–140.7) but was also independently more common in people living in more deprived areas (adjusted OR most vs. least deprived quintile, 2.36; 95% CI, 2.22–2.51), and in people resident in a care home (adjusted OR, 2.88; 95% CI, 2.65–3.13). The proportion with potentially serious drug-drug interactions more than doubled to 13% of adults in 2010, and the number of drugs dispensed was the characteristic most strongly associated with this (10.9% if dispensed 2–4 drugs vs. 80.8% if dispensed ≥15 drugs; adjusted OR, 26.8; 95% CI 24.5–29.3). Conclusions Drug regimens are increasingly complex and potentially harmful, and people with polypharmacy need regular review and prescribing optimisation. Research is needed to better understand the impact of multiple interacting drugs as used in real-world practice and to evaluate the effect of medicine optimisation interventions on quality of life and mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0322-7) contains supplementary material, which is available to authorized users.

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Author and article information

Contributors

Martin Wehling: martin.wehling@medma.uni-heidelberg.de

Journal

Journal ID (nlm-ta): Eur Geriatr Med

Journal ID (iso-abbrev): Eur Geriatr Med

Title: European Geriatric Medicine

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1878-7649

ISSN (Electronic): 1878-7657

Publication date (Electronic): 10 March 2021

Publication date PMC-release: 10 March 2021

Publication date (Print): 2021

Volume: 12

Issue: 3

Pages: 443-452

Affiliations

GRID grid.7700.0, ISNI 0000 0001 2190 4373, Clinical Pharmacology Mannheim, Medical Faculty Mannheim, , Ruprecht-Karls-Heidelberg University, ; Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany

Article

Publisher ID: 479

DOI: 10.1007/s41999-021-00479-3

PMC ID: 8149355

PubMed ID: 33694123

SO-VID: d9da1210-22e0-4f16-be92-fab03b8b8ec8

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 14 November 2020

Date accepted : 25 February 2021

Funding

Funded by: Medizinische Fakultät Mannheim der Universität Heidelberg (8990)

Open Access :

Open Access funding enabled and organized by Projekt DEAL.

Custom metadata

Keywords: polypharmacy,multimorbidity,older adults,health outcomes,inappropriate prescribing

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Keywords: polypharmacy, multimorbidity, older adults, health outcomes, inappropriate prescribing

Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences

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Special Issue: Colleges as Anchor Institutions in their Local Community

Most cited references 86

What is polypharmacy? A systematic review of definitions

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995–2010

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