Journal of Gerontological Nursing

The articles prior to January 2011 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

Geropharmacology 

Health Outcomes and Polypharmacy in Elderly Individuals

Susan C Frazier, MS, NP-C

Abstract

An Integrated Literature Review

The purpose of this integrated literature review was to determine the extent of research available related to polypharmacy and its effect on the health outcomes of the elderly population. A search of the Cumulative Index of Nursing and Allied Health Literature and Medline was conducted for studies published between 1995 and 2003 that linked polypharmacy and outcomes in the elderly population. The 16 studies in this integrative literature review were conducted in the United States, Canada, Australia, and Europe. Polypharmacy was shown to be a statistically significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition. The effect of polypharmacy on elderly individuals is significant as demonstrated by this literature review. Nurses are in a unique position to monitor and potentially eliminate adverse effects of a complex medication regimen. Nursing research on polypharmacy and its effects on nursing-sensitive outcomes will help define guidelines for prevention and intervention.

Abstract

An Integrated Literature Review

The purpose of this integrated literature review was to determine the extent of research available related to polypharmacy and its effect on the health outcomes of the elderly population. A search of the Cumulative Index of Nursing and Allied Health Literature and Medline was conducted for studies published between 1995 and 2003 that linked polypharmacy and outcomes in the elderly population. The 16 studies in this integrative literature review were conducted in the United States, Canada, Australia, and Europe. Polypharmacy was shown to be a statistically significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition. The effect of polypharmacy on elderly individuals is significant as demonstrated by this literature review. Nurses are in a unique position to monitor and potentially eliminate adverse effects of a complex medication regimen. Nursing research on polypharmacy and its effects on nursing-sensitive outcomes will help define guidelines for prevention and intervention.

The use of multiple medications (i.e., polypharmacy) is common in the elderly population (Kaufman, Kelly, Rosenberg, Anderson, & Mitchell, 2002; Neary & White, 2001). Although they comprise less than 15% of the population, adults older than 65 use one-third of prescription drugs and 40% of all nonprescription medications (U.S. Department of Health and Human Services, 2000a). Twenty-three percent of women and 19% of men older than 65 take at least five prescription drugs. Fifty-seven percent of women take more than five medications when over-the-counter (OTC) products are included. Older adults are also likely to take herbal, vitamin, and mineral supplements (Kaufman et al., 2002).

The prevalence of polypharmacy in elderly individuals is caused by many factors, including the co-existence of chronic conditions, multiple prescribing providers, the use of more than one pharmacy, and the recent OTC availability of previous prescription drugs (Conry, 2000; Larsen & Martin, 1999). An elderly individual leaves an office visit with a new prescription for medication 75% of the time (Neary & White, 2001). The reduction of polypharmacy in elderly individuals is one of the goals of Healthy People 2010 (U.S. Department of Health and Human Services, 2002b), making it a national priority.

The safety and efficacy of individuals using multiple medications has not been well investigated (Neary & White, 2001). An increase in the number of medications dramatically increases the number of drug combinations, thereby increasing the risk of adverse drug reactions (ADRs) and drug-drug interactions (Jones, 1997). According to a study by Goldberg (as cited in Ebbesen et al., 2001), the probability of an ADR increases from 13% for two drugs to 82% for more than seven drugs. Nolan and O'Mally (as cited in Flaherty, Perry, Lynchard, & Morley, 2000) report that the potential of an ADR nears 100% when 10 medications are used.

Elderly individuals are especially at risk of complications from polypharmacy. As individuals age, they are less able to effectively metabolize and excrete multiple medications (Conry, 2000; Larsen & Martin, 1999). Approximately 70% to 80% of elderly patients experience side effects of medications, and they experience them two to three times more frequently than younger adults (Neary & White, 2001). Older adults are also more likely to suffer from cognitive and sensory impairments, which increase the risk of medication errors (Neary & White, 2001). Medication errors are a major cause of morbidity and mortality (Bedell et al., 2000).

Nurses are the health care providers most involved in administering medications, providing medication instruction, and assessing patient response to medications. This puts nurses in a unique position to address the problem of polypharmacy in elderly individuals. The American Nurses Association (1997), recognizing this position, advocates a reduction in the number of medications whenever possible. Although the association between polypharmacy and health outcomes in elderly individuals has been investigated by other disciplines, it has not been studied from a nursing perspective.

The purpose of this integrated literature review is to identify specific health outcomes empirically associated with polypharmacy in elderly individuals. The research questions are:

* How is polypharmacy defined in the literature?

* Is polypharmacy associated with adverse drug events?

* Is polypharmacy a predictor of adverse health outcomes?

* What health outcomes are associated with polypharmacy in elderly individuals?

METHOD OF REVIEW

A literature search was conducted using the Cumulative Index of Nursing and Allied Health Literature (CINAHL Information Systems, Glendale, CA), Medline (Medline Industries Inc., Mundelein, IL), and PubMed (U.S. National Institutes of Health, Bethesda, MD) to identify studies of health outcomes published between 1995 and 2003 related to polypharmacy in elderly individuals and reported in English. The keywords "polypharmacy OR multiple medications" and "elderly OR elders" and "outcomes OR effects" guided the retrieval of current research studies. These searches yielded 85 reference citations of published peer-reviewed articles.

A hand search of these citations was then conducted to determine which articles met the criteria for review. Studies were included if they were original investigations of the relationship between polypharmacy and a health outcome. These studies also had to describe the health outcome in the elderly population specifically. Two articles reported results from the same investigation, so one was excluded as a duplicate. Reference lists were also checked for additional relevant studies. Of the 16 studies that met the inclusion criteria, were published in gerontology journals, 5 were published in medical journals, 3 appeared in pharmacy journals, and 1 was published in a nutrition journal. These studies were reviewed for their investigation of the relationships between polypharmacy and elderly health outcomes.

FINDINGS

The 16 studies exploring polypharmacy were conducted in a variety of international health care settings in the United States, Canada, Australia, and Europe. Participants studied were:

* Living at home independently (Cohen, Rogers, Burke, & Beilin, 1998; Incalzi et al., 2001; Jacqmin-Gadda, Fourrier, Commenges, & Dartigues, 1998; Jensen, Friedmann, Coleman, & Smiciklas -Wright, 2001; Mitchell, Mathews, Hunt, Cobb, & Watson, 2001; Shorr, Ray, Daugherty, & Griffin, 1997; Veehof, Stewart, Meyboom-de Jong, & HaaijerRuskamp, 1999).

* Hospitalized (Alarcon, Barcena, Gonzalez-Montalvo, Penalosa, & Salgado, 1999; Buajordet, Ebbesen, Erikssen, Brors, & HiIberg, 2001; Courtman & Stallings, 1995; Onder et al., 2002; Satish, Winograd, Chavez, & Bloch, 1996).

* With home care (Flaherty et al., 2000), or in retirement homes (Griep, Mets, Collys, PonjaertKristoffersen, & Massart, 2000; Lord & Menz, 2002).

* In a combination of settings (Langmore et al., 1998).

Sample sizes varied from 81 to 28,411 participants. Twelve studies had between 100 and 1,000 participants and three had more than 2000. In seven studies, participants were 65 or older. The youngest participants were 60 (Cohen et al., 1998; Langmore et al., 1998). The two studies conducted in a Veterans Administration setting excluded women; all of the others had fairly even distributions of men and women participating.

All 16 studies were quantitative correlational studies. Eleven studies had a cross-sectional design and four were longitudinal, measuring outcomes from 6 months to 5 years. Of the seven studies that defined polypharmacy, four defined it as more than five simultaneous medications (Alarcon et al, 1999; Flaherty et al., 2000; Satish et al., 1996; Shorr et al., 1997). Polypharmacy has also been described as more than three drugs (Jensen et al., 2001) or three or more respiratory drugs (Incalzi et al., 2001). Veehof et al. (1999) distinguished minor (2 to 3 drugs), moderate (4 to 5 drugs), and major (> 5 drugs) polypharmacy. The remaining studies did not define polypharmacy explicitly.

The purpose of the research for 15 of the 16 studies was to determine independent predictors or risk factors for certain health outcomes in the elderly population. Only one (Veehof et al., 1999) examined polypharmacy specifically as a predictor of a particular outcome (i.e., ADR) at the onset of the study. The result of the study was that the incidence of ADRs increased non-significantly with the number of drugs used. However, the investigators defined polypharmacy as "the long-term simultaneous use of two or more drugs; long term is 480 days or more in 2 years" (Veehof et al., 1999, p. 534). Because most ADRs occur within 4 days after taking a new drug (Veehof et al., 1999), this definition affects the internal validity of the study. Another limitation of this study was that ADRs were measured only if they were recognized and reported by the general practitioner. This may have led to under-reporting of ADRs.

As shown in the Table, health outcomes examined in the 16 studies were:

* Mobility.

* Mortality.

* Fractures.

* Hypotension.

* Hypoglycemia.

* Institutionalization.

* Hospital admissions.

* Risk of malnutrition.

* Aspiration pneumonia.

* Length of hospital stay.

* Fatal adverse drug events.

* General drug-related problems.

* Emergency department visits.

* Quality of life in severely compromised respiratory patients.

Polypharmacy was found to have a statistically significant association with drug-related problems, which is defined as inappropriate drug doses, ADRs, drug interactions, noncompliance, and omission of drug therapy (Courtman & Stallings, 1995). Veehof et al. (1999) found a non-significant positive association between longterm polypharmacy and ADRs. However, the under-reporting of ADRs is possibly responsible for the non-significance. Two studies conducted in the United States found polypharmacy to be associated with hospital admission (Flaherty et al., 2000; Jensen et al., 2001). A study conducted in Spain (Alarcon et al., 1999) found association with hospital readmission within 6 months of discharge. An Italian study (Onder et al., 2002) reported an association between polypharmacy and ADR-related hospitalizations. Other significant positive associations were found with fatal adverse drug events (Buajordet et al., 2001), emergency room visits (Alarcon et al., 1999), postprandial hypotension (Cohen et al., 1998), risk of fractures (Jacqmin-Gadda et al., 1998), dysphagia (Langmore et al., 1998), malnutrition (Griep et al., 2000), a poor quality of life in patients with chronic respiratory disease (Incalzi et al., 2001), impaired mobility (Lord & Menz, 2002), and serious hypoglycemia in insulin-dependent diabetics (Shorr et al., 1997).

Some associations with health outcomes warrant further research. Although a study conducted in Spain (Alarcon et al., 1999) found polypharmacy to be associated with hospital mortality and mortality 6 months after hospital discharge, a study of male veterans in the United States did not find an association with mortality (Satish et al., 1996). The American study found polypharmacy to have a statistically significant association with nursing home placement, but when patients who came from a nursing home were excluded from the analysis, the association was no longer significant. Polypharmacy was not found to be a predictor of nursing home placement in the Spanish study (Alarcon et al., 1999). Neither study found polypharmacy to be a predictor of prolonged hospital length of stay.

Table

TABLERESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

Table

TABLERESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

Table

TABLERESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

Two studies differed in whether polypharmacy is associated with medication mismanagement. An Australian study (Cohen et al., 1998) found that omission of medications showed an independent positive association with taking more than two drugs daily or taking drugs more than twice daily. A study conducted in North Carolina that purported to examine medication mismanagement (Mitchell et al., 2001) did not find an association between polypharmacy and medication mismanagement. However, it is arguable if the behaviors described as "noncompliance strategies" in the North Carolina study are mismanagement strategies at all. Instead, the described strategies of using credit at the pharmacy, borrowing money, or asking a family member to buy medications, as well as asking for free samples, may be interpreted as creative ways to remain in compliance.

DISCUSSION

The reviewed studies support other research that polypharmacy is prevalent in elderly individuals. Non-institutionalized elderly individuals were found to use an average of 4 drugs (Mitchell et al., 2001), and 41% to 65% of elderly individuals used more than 4 drugs daily (Cohen et al., 1998; Jensen et al., 2001). Elderly individuals receiving home care were found to use an average of 5.5 medications (Flaherty et al., 2000). On admission to a hospital, older patients were found to use an average of 4 (Courtman & Stallings, 1995) to 5.7 medications (Buajordet et al., 2001). One study (Satish et al., 1996) found that 42% of their participants used 5 or more drugs.

Results from 14 of the 16 studies reviewed demonstrated a significant positive correlation between polypharmacy and adverse health outcomes in elderly individuals, although two studies had contradictory findings (Alarcon et al., 1999; Satish et al., 1996). Results from the other two studies (Mitchell et al., 2001; Veehof et al., 1999) did not support the positive correlations with negative health outcomes. However, the internal validity of those two studies is problematic.

One limitation of this integrated literature review is the wide variation in the operationalization of polypharmacy. Monane, Monane, and Semla (1997) suggest defining polymedicine as the use of medications for the treatment of multiple comorbidities and polypharmacy as a negative state with duplicative or inappropriate medications and likely drug-drug interactions. However, these definitions are not universally accepted.

Alternative explanations for findings affect the internal validity of a study (Polit & Hungler, 1999). It may be that polypharmacy as op era - tionalized in the reviewed studies is merely a marker for those with more severe illness or more comorbidities instead of a true independent correlate. The coexistence of many disease states often requires multiple medications (Dunn, 2002; Monane et al., 1997). Some argue that polypharmacy is even essential in the treatment of elderly individuals (Dunn, 2002; Larsen & Martin, 1999).

According to Alarcon et al. (1999), although polypharmacy was a predictor of adverse health outcomes, neither main diagnosis nor number of diagnoses on hospital admission was a predictor of outcomes. Buajordet et al. (2001) found comorbidity was significantly higher among patients with fatal adverse drug events versus those without them. Cohen et al. (1998) found that the number of drugs increased with the number of diagnoses. Whether comorbidity is an extraneous variable needs more research. Severity of illness was not controlled for, nor examined as, a possible independent correlate. More studies are necessary to clarify this area.

Realizing that multiple medications are often necessary, the U.S. Department of Health and Human Services (2000a) recommends that health care providers, pharmacists, pharmaceutical companies, and patients work together using an integrated, computerized system to maximize benefits and minimize risks associated with medications. Although the technology to integrate the different components of health care is available, it is rarely used.

Because nurses are involved heavily in medication administration, teaching, and assessment, they can play a role in reducing the ill effects of polypharmacy in elderly individuals by practicing the following (Dunn, 2002):

* Keeping current in the latest drug information.

* Providing thorough patient and family education.

* Accurately reporting the number and types of medications to the prescribing provider.

* Using available technology to review medications for interactions, contraindications, and side effects.

Advanced practice nurses who prescribe medications must follow the Healthy People 2010 recommendations and review medications regularly to eliminate unnecessary or inappropriate medications (U.S. Department of Health and Human Services, 2000b). Neary and White (2001) recommend that agencies adopt a policy of performing automatic chart audits any time a patient is prescribed more than five drugs. At the least, polypharmacy should be considered a predictor of adverse health outcomes for older patients. Patients taking multiple medications warrant more intense nursing observation and possibly earlier intervention.

CONCLUSION

Further research is needed in which comorbidities and severity of illness are controlled to determine if polypharmacy itself is an independent risk factor for adverse health outcomes. Research from a nursing perspective is needed to explore the association between polypharmacy and other health outcomes and to describe nursing interventions that can prevent the associated adverse health outcomes in elderly individuals.

REFERENCES

  • Alarcon, T., Barcena, A., Gonzalez-Montalvo, J.I., Penalosa, C, & Salgado, A. (1999). Factors predictive of outcome on admission to an acute geriatric ward. Age and Aging, 28(5), 429-432.
  • American Nurses Association. (1997). Position statement: Polypharmacy and the older adult. Retrieved February 27, 2002, from http://nursingworld.org/readroom/ position/drug/drpoly.htm
  • Bedell, S. E., Jabbour, S., Goldberg, R., Glaser, H., Gobble, S., Young-Xu, Y., Graboys, T.B., & Ravid, S. (2000). Discrepancies in the use of medications: Their extent and predictors in an outpatient practice. Archives of Internal Medicine, 760(4), 2129-2134.
  • Buajordet, L, Ebbesen, J., Erikssen, J., Brors, O., & Hilberg, T. (2001). Fatal adverse drug events: The paradox of drug treatment. Journal of Internal Medicine, 250(A), 327-341.
  • Cohen, I., Rogers, P., Burke, V., & Beilin, LJ. (1998). Predictors of medication use, compliance and symptoms of hypotension in a community-based sample of elderly men and women. Journal of Clinical Pharmacy and Therapeutics, 23, 423-432.
  • Conry, M. (2000). Polypharmacy: Pandora's medicine chest? Geriatric Times, 1(3). Retrieved June 21, 2005, from www. geriatrictimes.com/g001028.html
  • Courtman, B.J., & Stallings, S.B. (1995). Characterization of drug-related problems in elderly patients on admission to a medical ward. The Canadian Journal of Hospital Pharmacy, 48(3), 161-166.
  • Dunn, CM. (2002). Assessing and preventing medication interactions. Home Healthcare Nurse, 20(2), 105-111.
  • Ebbesen, J., Buajordet, L, Erikssen, J., Brors, O., Hilberg, T, Svaar, H., & Sandvik, L. (2001). Drug-related deaths in a department of internal medicine. Archives of Internal Medicine, 161(19), 2317-2323.
  • Flaherty, J.H., Perry, H.M., III, Lynchard, G.S., & Morley, J.E. (2000). Polypharmacy and hospitalization among older home care patients. Journal of Gerontology: Series A, Biological Sciences and Medical Sciences, 55(1 0), M554-M559.
  • Griep, M.I., Mets, TF, Collys, K., PonjaertKristoffersen, L, & Massart, D.L. (2000). Risk of malnutrition in retirement homes elderly persons measured by the "mini-nutritional assessment." Journal of Gerontology: Series A, Biological Sciences and Medical Sciences, 55(2), M57-M63.
  • Incalzi, R.A., Bellia, V., Catalano, F., Scichilone, N., Imperiale, C, Maggi, S., Rengo, F, Salute Respiratoria neh1- Anziano Study (2001). Evaluation of health outcomes in elderly patients with asthma and COPD using disease-specific and generic instruments: The Salute Respiratoria nell'Anziaone (Sa. RA.) study. Chest, 120(3), 734-742.
  • Jacqmin-Gadda, H, Fourrier, A, Commenges, D., & Dartigues, J.F. (1998). Risk factors for fractures in the elderly. Epidemiology, 9(4), 417-423.
  • Jensen, G. L., Friedmann, J.M., Coleman, CD., & Smiciklas-Wright, H. (2001). Screening for hospitalization and nutritional risks among community-dwelling older persons. American Journal of Clinical Nutrition, 74(2), 201-205.
  • Jones, B.A. (1997). Decreasing polypharmacy in clients most at risk. AACN Clinical Issues, 8(4), 627-634.
  • Kaufman, D.W., Kelly, J.P., Rosenberg, L., Anderson TE., & Mitchell, A.A. (2002). Recent patterns of medication use in the ambulatory adult population of the United States: The Slone survey. Journal of the American Medical Association, 287(3), 337-344.
  • Langmore, S.E., Terpenning, M.S., Schork, A., Chen, Y, Murray, JT., Lopatin, D., & Loesche, WJ. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69-81.
  • Larsen, P.D., & Martin, J.L.H. (1999). Elder care: Polypharmacy and elderly patients. Association of Operating Room Nurses Journal, 69(3), 619,621-622, 625.
  • Lord, S.R., & Menz, H.B. (2002). Physiologic, psychologic, and health predictors of 6minute walk performance in older people. Archives of Physical Medical Rehabilitation, 83(7), 907-911.
  • Mitchell, J., Mathews H.F., Hunt L.M., Cobb, K.H., & Watson, R. W (2001). Mismanaging prescription medications among rural elders: The effects of socioeconomic status, health status, and medication profile indicators. The Gerontologist, 41(3), 348-356.
  • Monane, M., Monane, S., & Semla, T (1997). Optimal medication use in elders: Key to successful aging. The Western Journal of Medicine, 167(4), 233-237.
  • Neary, S., & White, P (2001, November). Tutorial in polypharmacy. In MW. Edmunds, Mastering the basics in drug prescribing. National Conference for Nurse Practitioners, Baltimore, Maryland. Retrieved March 26, 2002, from www.medscape.com/viewarticle/420212
  • Onder, G., Pedone, C, Landi, F, Cesari, M., Vedova, CD., Bernabei, R., & Gambassi, G. (2002). Adverse drug reactions as cause of hospital admissions: Results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). Journal of the American Geriatrics Society, 50(12), 1962-1968.
  • PoHt, D.F., & Hungler, B.P. (1999). Nursing research: Principles and methods (6th ed.). Philadelphia: Lippincott.
  • Satish, S., Wnograd, CH., Chavez, C, & Bloch, DA. (1996). Geriatric targeting criteria as predictors of survival and health care utilization. Journal of the American Geriatric Society, 44(8), 914-921.
  • Shorr, R.I., Ray, W.A., Daugherty, J.R., & Griffin, M.R. (1997). Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Archives of Internal Medicine, 157(15), 1681-1686.
  • U.S. Department of Health and Human Services. (2000a). Healthy People 2010. Retrieved June 21, 2005, from www.healthypeople.gov/Document/ tableof contents . h tm#volume 1
  • U.S. Department of Health and Human Services. (2000b). Healthy People 2010 section 17: Medical product safety. Retrieved July 28, from www.healthypeople.gov/document/html/volume2/l 7Medical.htm
  • Veehof, L.J.G., Stewart, R.E., Meyboom-de Jong, B., & Haaijer-Ruskamp, F.M. (1999). Adverse drug reactions and polypharmacy in the elderly in general practice. European Journal of Clinical Pharmacology, 55(7), 533-536.

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

TABLE

RESULTS OF RESEARCH ON THE EFFECT OF POLYPHARMACY ON ELDERLY HEALTH OUTCOMES

10.3928/0098-9134-20050901-04

Sign up to receive

Journal E-contents