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ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 1-5

Pattern of poly pharmacy among geriatric patients in a tertiary care teaching hospital: A cross-sectional study


1 Department of Community Medicine, Rangaraya Medical College, Pithapuram Road, Kakinada, Andhra Pradesh, India
2 Department of Community Medicine, NRI Institute of Medical Sciences, Besides ANITS Engineering College, Sangivalasa, Visakhapatnam, Andhra Pradesh, India
3 Medical Student, NRI Institute of Medical Science, Besides ANITS Engineering College, Sangivalasa, Visakhapatnam, Andhra Pradesh, India
4 Department of Community Medicine, GVP Institute of Health Care and Medical Technology, Marikavalsa, Visakhapatnam, Andhra Pradesh, India

Date of Submission14-Aug-2020
Date of Acceptance23-Mar-2021
Date of Web Publication23-May-2022

Correspondence Address:
Dr. K Vijaya
Department of Community Medicine, NRI Institute of Medical Sciences, Besides ANITS Engineering College, Sangivalasa, Visakhapatnam - 531 162, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_133_20

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  Abstract 


Background: In older adults multimorbidity increases with age and this increases the consumption of medications and the risk of Polypharmacy (PP). Along with this, the use of Potentially Inappropriate Medications (PIMs) among the elderly patients is a very common public concern.
Objectives: The primary objective is to assess the pattern of PP and estimate the proportion of PP and PIMs among the geriatric in-patients. The secondary objective is to find out the association between serum creatinine and PP.
Methods: A cross-sectional observational study was conducted among the geriatric in-patients aged ≥65 years admitted in medical wards by reviewing the case sheets. PIMs use was identified using Beer's criteria. Descriptive statistics like mean, range, standard deviation and proportions were used for Polypharmacy and PIMS. Inferential statistics like Pearson's Chi-squared test was used to find out association between serum creatinine and PP.
Results: A total of 84 geriatric in-patients were enrolled as study subjects. Mean number of drugs prescribed was 6.9 (±3.2) and range 2-18. Proportion of PP was 73.8% and that of PIMs was found in 33.3% in the patients. There was significant association between an increase in serum creatinine levels with an increase in consumption of drugs. (p = 0.009)
Conclusion: The proportion of PP and PIM and was found to be high among the geriatric patients. There was an increase in serum creatinine levels with increased consumption of drugs.

Keywords: Geriatric in-patients, polypharmacy, potentially inappropriate medication, serum creatinine


How to cite this article:
Surya Prabha K J, Vijaya K, Sai Shri P, Ravi Kiran E. Pattern of poly pharmacy among geriatric patients in a tertiary care teaching hospital: A cross-sectional study. J NTR Univ Health Sci 2022;11:1-5

How to cite this URL:
Surya Prabha K J, Vijaya K, Sai Shri P, Ravi Kiran E. Pattern of poly pharmacy among geriatric patients in a tertiary care teaching hospital: A cross-sectional study. J NTR Univ Health Sci [serial online] 2022 [cited 2022 Jul 2];11:1-5. Available from: https://www.jdrntruhs.org/text.asp?2022/11/1/1/345800




  Introduction Top


In this modern era, with the increase in life span of individuals as a result of increased healthcare facilities, the elderly population is also increasing. Geriatric population (of age 65+) share of the global population increased from 5% in 1960 to 9% in 2018 and is projected to rise to 16% by 2050. By 2050, 82 countries are projected to have at least 20% of their population ageing 65 and over, up from 13 countries today. This trend poses challenges for many countries.[1] In older adults, multi morbidity (which increases with age) increases the consumption of medications and the risk of Polypharmacy (PP), which is defined by the World Health Organization (WHO) as “the administration of many drugs at the same time or the administration of an excessive number of drugs.”[2] Although WHO has suggested a threshold of ≥5 per day, quantification of PP remains controversial.[3],[4] PP can be defined as the use of multiple medications by a patient, generally, ranging between 5 to 10.[5]

This PP in a patient can lead to many problems like drug interactions, adverse drug reactions, decrease in compliance amongst the drugs and altogether leading to poor quality of life for the patient.[6],[7] Therefore, writing a drug prescription to an elderly patient should be considered as a challenge considering the age-related changes in pharmacodynamics and pharmacokinetics, many medications are needed to be used cautiously.

PP among older adults is common and consequently older patients are at higher risk of Potentially Inappropriate Medications (PIMs) use.[8] PIMS are defined as “medications that should be avoided due to the risk which outweighs their benefit and when there are equally or more effective but lower risk alternatives are available.[9] They are considered one of the commonly encountered medication-related problems among the elderly population. So, PP among the elderly needs to be addressed urgently as it can affect the quality of health being provided to them.[10]

Therefore, the present study was done to know the pattern of polypharmacy amongst the elderly population.


  Aim and objectives Top


Primary objective is to assess the pattern of PP and estimate the proportion of PP and PIMs among the geriatric in-patients. Secondary objective is to find out the association between serum creatinine and PP.


  Subjects and Methods Top


An observational descriptive cross-sectional study was conducted among all the geriatric inpatients aged ≥65, both the sexes who were admitted in medical wards of the teaching hospital during the study period of 2 months, from 1st July 2019 to 31st August 2019. The study subjects were given information about the study. Written informed consent was taken and the patients who were not willing to participate, with incomplete case sheets, severe illnesses, malignancies and major complications were excluded from the study. Ethical clearance from the Institutional Ethics Committee was taken prior to the conduct of the study.

Beers criteria-2015[11] was used to find PIMs usage. It was first developed in 1991 and consequently updated with the latest update in 2015. The case sheets of inpatients were reviewed every day by the investigator. Each case sheet was reviewed only once for each patient during one single admission. If any patient got admitted more than once during study period, each admission case sheet was considered as a separate admission. The information regarding demographic details of the patients, diagnosis, co-morbid illnesses, details about the medications and serum creatinine levels was noted. Patients were also interviewed personally about any other concomitant drug intake which was not mentioned in the case sheet. The data was entered in Microsoft Excel sheet and the analysis was done using Statistical Package for Social Sciences (SPSS) v21.0. Descriptive statistics like mean, range, standard deviation for categorical and continuous variables and proportions were used for PP and PIMS. Pearson's Chi-squared test was used to find out association between serum creatinine and PP.


  Results Top


A total of 84 geriatric inpatients admitted in medicine department were enrolled for the study. They were divided into five age groups of 65-70, 71-75, 76-80, 81-85 and >85 years. Most of the elderly patients admitted during the study period were of the age group 65–70 years (85.7%), followed by the age group of 71–75 years (9.5%). The minimum age of elderly patients admitted in medicine department was 65 years and the maximum was 88 years. The mean age of patients was 66.4 ± 3.1 years. Among the study group 44 (52.4%) were male and 40 (47.6%) were female [Table 1].
Table 1: Distribution of Study Group Patients According to Age And Sex

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Mean number of drugs prescribed to the study population was 6.9 ± 3.2 and range was 2-18. Out of this ≤4 number of drugs were prescribed to 26.2%, 5–9 number of drugs were prescribed to 51.2% and 10–14 number of drugs were prescribed to 20.2% of the population. The proportion of PP was found to be 73.8% in the geriatric patients. [Figure 1]
Figure 1: Distribution of Study Group Patients According to Average Drug Consumption Per Day

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Average number of medications per day in geriatric in-patients was high among 81-85 years age group (10.5), followed by 65-70 years,[7] 71-75 years (6.1) and >85 years[5] [Table 2]. The average number of medications per day was high among males (7.25) when compared to female inpatients (6.6). Most common associated clinical condition among the elderly patients was hypertension (45.2%), followed by diabetes (35.7%) and others like epilepsy, cirrhosis of liver (38%).
Table 2: Age Wise Distribution of The Patients According to Average No. of Medications Per Day

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A total of 583 drugs were prescribed to the study group, of which the number of PIMs found were 14 in number, i.e., 2.4%. Out of the total of 84 in-patients, 28 patients (33.3%) were found to be prescribed with PIMs as listed in Beers criteria. [Figure 2] Most common PIMs prescribed was Diclofenac, followed by Scopolamine, then Chlorpheniramine, Nifedipine and Naproxen in the study population [Table 3].
Figure 2: Distribution of Study Group Patients According to Percentage of PIMs

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Table 3: Distribution of Pims Prescribed in The Study Population

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Serum creatinine level was raised among 30 (35.7%) in-patients of the study group. [Figure 3] Among the study group, those consuming 5-9 drugs per day, there was a raise in serum creatinine levels among 28% whereas those taking >10 drugs per day, the raise in serum creatinine levels was noted in 38.7% of them. The association of consumption of drugs with serum creatinine levels was found to be statistically highly significant. (p = 0.009) [Table 4].
Figure 3: Distribution of The Study Group Patients According to Serum Creatinine Level

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Table 4: Distribution of Study Group Patients According to Daily Drug Consumption and Serum Creatinine Level

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  Discussion Top


In our study the predominant age group among the geriatric in-patients was 65-70 years with a mean age of 66.4 ± 3.1 years. Similar observations (67.3 ± 7.05 years) were made in a study on PP and drug interactions among elderly hypertensive patients admitted to tertiary care hospital in Central Delhi by Agrawal RK, et al.[12] In study by Subeesh VK, et al.[13] among the geriatric patients at a private corporate hospital in Coimbatore, the mean age was 72.9 ± 6.5 years. It was seen in our study that males (52.4%) were more when compared to females which was similar to that of the findings of the study by Subeesh VK, et al.[13] which was 61% males and 39% females whereas in the study by Agrawal RK, et al.[12] female patients (61%) were more than the males (39%).

In the present study it was noted that the mean number of drugs prescribed to the study population was 6.9 ± 3.2, which was more than reported by Agrawal RK, et al.[12] (4.03 ± 1.80) and comparatively less (9.68) than the observations made by Subeesh VK, et al.[13] in their study. It was seen in our study that PP was observed in 73.8% of patients which was high compared to National Health and Nutrition Examination Survey (NHANES-III) (12%)[14] and other studies by Agrawal RK, et al.[12] (26%), Gupta R, et al.[15] (53.13%) and Subeesh VK,[13] et al. (60%). Average number of drug consumption per day was high among 81-85 years age group (10.5) and it was higher among males (7.25) compared to females (6.6). Most common associated clinical condition among the patients was hypertension (45.2%), followed by diabetes (35.7%) and others like epilepsy, cirrhosis of liver (38%). This was similar to the observations reported in the study by Gupta R, et al.[15] in a tertiary care teaching hospital in Jammu and Kashmir where hypertension was found in 57.8%, followed by gastritis (42.2%), diabetes (29.7%) and chronic obstructive pulmonary disease (COPD) (20.3%) among the elderly patients. Subeesh VK, et al.[13] reported in his study that 43% of the study population had DM (Diabetes Mellitus), followed by hypertension (29%) and CVD (Cardio Vascular Diseases-18%).

The total number of PIMs in the present study was 14 out of total 583 medications prescribed. The proportional PIM was 2.4%, whereas in the study by Agrawal RK, et al.[12] proportional PIMs was reported as 1.98% of total prescribed drugs in elderly patients. In our study, proportion of elderly patients prescribed with PIMs was 33.3% which was similar to the observations made by Subeesh VK, et al.[13] in their study. This differs with Harugeri et al.[16] who in their study noted that PIMs was only in 22.1% patients and Fialová D, et al.[17] who in the study noted that 19.8% of patients in the total sample used at least 1 inappropriate medication. The higher rate of PIMs showed that the healthcare professionals failed in monitoring the therapeutic regimen and adapting a disease-oriented approach. Most common PIMS noted in the in the study population in our study was Diclofenac, followed by Scopolamine, then Chlorpheniramine, Nifedipine and Naproxen whereas in study by Agrawal RK, et al.[12] most common PIMs used was Spironolactone followed by Diltiazem and Diclofenac.

In the present study, serum creatinine level was found raised among 35.7% of the study group and the association between daily drug consumption and serum creatinine levels was found to be statistically significant (p value = 0.009). Similar observations were made by Suleyman Ersoy and Velittin Selcuk Engin[18] in their study on risk factors for PP in older adults in a primary care setting Melekhatun, Turkey. Their study revealed that chronic renal failure (CRF) was significantly associated with increased daily drug consumption (DDC). To avoid collinearity, only serum creatinine level was added to regression analysis and it remained significant.


  Conclusion Top


There is a high proportion of PP and PIMs in the geriatric patients in the present study. The serum creatine level was also found to be raised in patients consuming a greater number of drugs. This is a matter of concern as it increases the safety problems in the elderly age and causes economic burden.

Recommendation

PP can be avoided by sharing treatment goals and plans. As PP results in PIMs, the healthcare professionals should adopt more of patient centric approach rather a disease-oriented approach. The clinical needs of the patient must be the sole determinant. To improve the drug safety in high-risk population, appropriate prescribing and evaluation is more important. Appropriate prescribing should promote evidence-based therapies while minimizing the use of medications for which there is no clinical requirement, questionable evidence or duplication.

Limitation of the study

Only a small population of elderly patients, short study duration and being restricted to a single department are some of the limiting factors. Large studies, involving a greater number of geriatric patients in various departments for a longer study duration are necessary to realize the impact of this serious problem of PP and PIMS and make an effort to rationalize the prescriptions.

Relevance of the study

The study brings into light the problem of PP and PIMS in geriatric patients in a tertiary care hospital setting and points out to the urgent need among doctor, the multidisciplinary continuum of care to share the responsibility, understand and adopt the safe and rational way of prescribing medicines taking into account the adverse effects they may have in the elderly population.

Financial support and sponsorship

ICMR.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Suehs BT, Davis C, Franks B, Yuran TE, Ng D, Bradt J, et al. Effect of potentially inappropriate use of antimuscarinic medications on healthcare use and cost in individuals with overactive bladder. J Am Geriatr Soc 2016;64:779-87.  Back to cited text no. 8
    
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A pocket guide to the AGS 2015 Beer's criteria. Available from: http://www.ospdocs.com/resources/uploads/files/Pocket%20Guide%20to%202015%20Beers%20Criteria.pdf. [Last cited on 2019 Jan 30].  Back to cited text no. 11
    
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Agrawal RK, Nagpure S. A study on polypharmacy and drug interactions among elderly hypertensive patients admitted in a tertiary care hospital. Int J Health Allied Sci 2018;7:222-7.  Back to cited text no. 12
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Dutta M, Prashad L. Prevalence and risk factors of polypharmacy among elderly in India: Evidence from SAGE Data. Int J Public Ment Health Neurosci 2015;2:11-6.  Back to cited text no. 14
    
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Harugeri A, Joseph J, Parthasarathi G, Ramesh M, Guido S. Prescribing patterns and predictors of high-level polypharmacy in the elderly population: A prospective surveillance study from two teaching hospitals in India. Am J Geriatr Pharmacother 2010;8:271-80.  Back to cited text no. 16
    
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Fialová D, Topinková E, Gambassi G, Finne-Soveri H, Jónsson PV, Carpenter I, et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 2005;293:1348-58.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
Aim and objectives
Subjects and Methods
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