An investigation of inappropriate medication use and dangerous drug combinations in elderly patients with polypharmacy

Abstract

Objective:  Polypharmacy is common among the elderly patients. The aim of this study was to determine drugs used inappropriately in elderly with polypharmacy or causing a dangerous drug combination (DDC) and to investigate the relation between drug interaction and emergency department (ED) presentation symptoms. Methods: This prospective study was performed with elderly patients aged over 65. Patients’ demographic characteristics, presentation symptoms, comorbid diseases, and the names, numbers, dosages and side-effect of drugs used were recorded. Results: DDC was present in 94.6% of patients, and 24.3% presented to the ED with drug interaction-related symptoms. The mean age of the patients with DDCs was 72.4±6.7 years, 68.3±5.5 years among those without DDC(p=0.016).The most common comorbid disease was hypertension(75.1%), the most commonly used drug group was anti arrhythmics (15.4%),and the most commonly used medication was aspirin(6.5%). The relation was observed between drug interaction-related presentation symptoms and coronary artery disease (CAD) (p=0.044). Correlation was determined between DDC and the anti-hypertensive drug group (p<0.001).Correlation was determined between drug interaction and subjects with presentation symptoms of dyspnea and bleeding (p<0.001 and p<0.001, respectively). Numbers of drugs used and frequency of presentation to hospital were higher in patients with DDCs (p<0.001; 0.040 respectively).Positive correlation was determined between frequency of presentation and number of drugs used(r: 0.514; p <0.001). Conclusion: DDCs are more common as age increases in elderly. This situation especially remarkable in subjects with CAD and antihypertensive drugs users. Presentations to hospital caused by drug-drug interactions most commonly involve dyspnea and bleeding, and a higher number of drugs increase rates of DDC development and numbers of hospital presentations.

Keywords

• Emergency department,medicine,elderly,polypharmacy

References

1. 1. Yerli G. Yaşlılık dönemi özellikleri ve yaşlılara yönelik sosyal hizmetler Journal of International Social Research. 2017;10(52):1278-87.
2. 2. Mandiracioglu A. Demographic characteristics of the elderly population in Turkey and the world Ege Journal of Medicine. 2010;49(3):39-45.
3. 3. Organization WH. World report on ageing and health. Geneva: WHO World Health Organization; 2015.
4. 4. Midlöv P, Eriksson T, Kragh A. Drug-related Problems in the Elderly: Springer Science & Business Media; 2009.
5. 5. Veehof L, Stewart R, Haaijer-Ruskamp F, Jong BM-d. The development of polypharmacy. A longitudinal study. Family practice. 2000;17(3):261-7.
6. 6. Gurwitz JH. Polypharmacy: a new paradigm for quality drug therapy in the elderly? Archives of internal medicine. 2004;164(18):1957-9.
7. 7. Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, et al. Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. Journal of hospital medicine. 2016;11(10):694-700.
8. 8. MacKinnon NJ, Helper CD. Indicators of preventable drug-related morbidity in older adults. Journal of Managed Care Pharmacy. 2003;9(2):134-41.

9. 9. Counsell SR. 2015 updated AGS Beers Criteria offer guide for safer medication use among older adults. Journal of gerontological nursing. 2015;41(11):60-1.
10. 10. Imatani RJ. Fractures of the scapula: a review of 53 fractures. J Trauma. 1975;15(6):473-8.
11. 11. Lu WH, Wen YW, Chen LK, Hsiao FY. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. Canadian Medical Association Journal. 2015;187(4):E130-E7.
12. 12. Chen YC, Huang HH, Fan JS, Chen MH, Hsu TF, Yen DHT, et al. Comparing characteristics of adverse drug events between older and younger adults presenting to a Taiwan emergency department. Medicine. 2015;94(7):1-6.
13. 13. Sayir CT, Toprak DE, Karaoglu SA. Evaluation of polypharmacy and complementary therapy use in patients>= 65 years, attending to Family Medicine Outpatient Clinic of Şişli Etfal Training and Research Hospital. Turkish Journal of Family Practice. 2014;18(1):35-41.
14. 14. Sonmez Y, Ucku R, Kitay S, Korkut H, Surucu S, Sezer M, et al. Quality of life and the factors affecting it among people aged 75 years and over living in a health center region in Izmir. Dokuz Eylul Universitesi Tip Fakultesi Dergisi. 2007;21(3):145-53.
15. 15. Topbas M, Yaris F, Can G. Do the elderly have adequate information about the drugs they use ?: Results of a study conducted in a primary health care in Trabzon. Ege Tip Dergisi. 2003;42(2):85-90.
16. 16. Arslan S, Atalay A, Gokce-Kutsal Y. Drug use in elderly. Turk Geriatri Dergisi. 2000;3(2):56-60.
17. 17. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. The American journal of geriatric pharmacotherapy. 2007;5(4):345-51.
18. 18. Unsal A, Demir G, Ozkan AC, Arslan GG. The Prevalance of Chronic disease and Drug Use of the Olders Living in Nursing Home ADU Tip Fakultesi Dergisi. 2011;12(3):5-10.
19. 19. Chiovenda P, Vincentelli GM, Alegiani F. Cognitive impairment in elderly ED patients: need for multidimensional assessment for better management after discharge. The American journal of emergency medicine. 2002;20(4):332-5.
20. 20. Banerjee A, Mbamalu D, Ebrahimi S, Khan AA, Chan TF. The prevalence of polypharmacy in elderly attenders to an emergency department-a problem with a need for an effective solution. International journal of emergency medicine. 2011;4(1):22.
21. 21. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Annals of emergency medicine. 2001;38(6):666-71.
22. 22. Seckin U, Bodur H, Gokce-Kutsal Y. Yaslilarda ilac tuketimi. Turk J Geriatr. 1998;1(1):36-8.
23. 23. Sanson TG, O'Keefe KP. Evaluation of abdominal pain in the elderly. Emergency medicine clinics of North America. 1996;14(3):615-27.
24. 24. Cahir C, Bennett K, Teljeur C, Fahey T. Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. British journal of clinical pharmacology. 2014;77(1):201-10.
25. 25. Burak U, Turkay C, Bavbek N, Ayse I, Erbayrak M, Uyar ME. Evaluation of patients with constipation. Akademik Gastroenteroloji Dergisi. 2006;5(1):56-9.
26. 26. Marcum ZA, Amuan ME, Hanlon JT, Aspinall SL, Handler SM, Ruby CM, et al. Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans. Journal of the American Geriatrics Society. 2012;60(1):34-41.
27. 27. Feldstein AC, Smith DH, Perrin N, Yang X, Simon SR, Krall M, et al. Reducing warfarin medication interactions: an interrupted time series evaluation. Archives of Internal Medicine. 2006;166(9):1009-15.
28. 28. Webster J. Interactions of NSAIDs with diuretics and β-blockers. Drugs. 1985;30(1):32-41.
29. 29. Sari O, Tanoglu A, Inal V, Turkoglu HI, Ozturk B, Saglam K. GATA Acil Dahiliye Kliniğinde üst gastrointestinal sistem kanaması nedeniyle 1998-2005 yılları arasında takip edilen hastaların sosyodemografik özelliklerinin incelenmesi. Gülhane Tıp Dergisi. 2007;49:226-31.
30. 30. Hilmer S, Gnjidic D. The effects of polypharmacy in older adults. Clinical Pharmacology & Therapeutics. 2009;85(1):86-8.
31. 31. Steinman MA, Seth Landefeld C, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ. Polypharmacy and prescribing quality in older people. Journal of the American Geriatrics Society. 2006;54(10):1516-23.
32. 32. Field TS, Gurwitz JH, Avorn J, McCormick D, Jain S, Eckler M, et al. Risk factors for adverse drug events among nursing home residents. Archives of internal medicine. 2001;161(13):1629-34.
33. 33. Björkman IK, Fastbom J, Schmidt IK, Bernsten CB, Group PCotEiER. Drug—Drug Interactions in the Elderly. Annals of Pharmacotherapy. 2002;36(11):1675-81.
34. 34. Pozzi C, Lapi F, Mazzaglia G, Inzitari M, Boncinelli M, Geppetti P, et al. Is suboptimal prescribing a risk factor for poor health outcomes in community‐dwelling elders? The ICARe Dicomano study. Pharmacoepidemiology and drug safety. 2010;19(9):954-60.
35. 35. Unsal A, Ayranci U, Cevik AA, Metintas S, Arslantas D, Unluoglu I. Use of emergency departments by elderly patients in a city of Western Turkey. European Journal of Emergency Medicine. 2007;14(3):125-9.
36. 36. Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. Jama. 2003;289(13):1652-8.
37. 37. Chrischilles EA, Segar ET, Wallace RB. Self-reported adverse drug reactions and related resource use: a study of community-dwelling persons 65 years of age and older. Annals of internal medicine. 1992;117(8):634-40.
38. 38. Reason B, Terner M, Moses McKeag A, Tipper B, Webster G. The impact of polypharmacy on the health of Canadian seniors. Family practice. 2012;29(4):427-32.
39. 39. Sehgal V, Bajwa SJS, Sehgal R, Bajaj A, Khaira U, Kresse V. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. Journal of family medicine and primary care. 2013;2(2):194-9.