Main Article Content
Polypharmacy, Prevalence, Multimorbidity, Socioeconomic Factors, Age Factors, Race Factors, Sex Factors, Health Services Accessibility, Multivariate Analysis, Cross-Sectional Studies, Brazil
Background: Polypharmacy has become an increasingly public health issue as population age and novel drugs are developed. Yet, evidence on low- and middle-income countries (LMIC) is still scarce.
Objective: This work aims to estimate the prevalence of polypharmacy among Brazilians aged 50 and over, and investigate associated factors.
Methods: A cross-sectional study was conducted using data from the baseline assessment of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n=9,412). Univariate and bivariate analyses described the sample. Robust Poisson regression was used to estimate prevalence ratios and predict probabilities of polypharmacy.
Results: Prevalence of polypharmacy was estimated at 13.5% among older adults in Brazil. Important disparities were observed in regard to gender (16.1% among women and 10.5% among men), race (16.0% among whites and 10.1% among blacks) and geographic region (ranging from 5.1% in the North to 18.7% in the South). The multivariate analysis showed that polypharmacy is associated with various sociodemographic/individual factors (age, gender, race, education, region, health status, body mass index) as well as with several variables of healthcare access/utilization (number of visits, same physician, provider’s knowledge of patient’s medications, gate-keeper, and difficulty managing own medication). Overall, the more utilization of health services, the higher the probability of polypharmacy, after adjusting for all other model covariates.
Conclusions: Polypharmacy prevalence is relatively low in Brazil, compared to European countries. After controlling for variables of healthcare need and demographic characteristics, there is still substantial residual variance in polypharmacy prevalence. Policies to identify inappropriate prescribing and reduce regional discrepancies are necessary.
2. Cadogan CA, Ryan C, Hughes CM. Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many. Drug Saf. 2016;39(2):109-116. https://doi.org/10.1007/s40264-015-0378-5
3. Stewart RB. Polypharmacy in the elderly: a fait accompli?. DICP. 1990;24(3):321-323. https://doi.org/10.1177/106002809002400320
4. Montamat SC, Cusack B. Overcoming problems with polypharmacy and drug misuse in the elderly. Clin Geriatr Med. 1992;8(1):143-158.
5. Rankin A, Cadogan CA, Patterson SM, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;9(9):CD008165. https://doi.org/10.1002/14651858.cd008165.pub4
6. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230. https://doi.org/10.1186/s12877-017-0621-2
7. Cadogan CA, Ryan C, Francis JJ, et al. Development of an intervention to improve appropriate polypharmacy in older people in primary care using a theory-based method. BMC Health Serv Res. 2016;16(1):661. https://doi.org/10.1186/s12913-016-1907-3
8. Hughes LD, McMurdo ME, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. 2013;42(1):62-69. https://doi.org/10.1093/ageing/afs100
9. Davies EA, O'Mahony MS. Adverse drug reactions in special populations - the elderly. Br J Clin Pharmacol. 2015;80(4):796-807. https://doi.org/10.1111/bcp.12596
10. Lucchetti G, Lucchetti AL. Inappropriate prescribing in older persons: A systematic review of medications available in different criteria. Arch Gerontol Geriatr. 2017;68:55-61. https://doi.org/10.1016/j.archger.2016.09.003
11. Gutiérrez-Valencia M, Izquierdo M, Cesari M, Casas-Herrero Á, Inzitari M, Martínez-Velilla N. The relationship between frailty and polypharmacy in older people: A systematic review. Br J Clin Pharmacol. 2018;84(7):1432-1444. https://doi.org/10.1111/bcp.13590
12. Aguiar JP, Brito AM, Martins AP, Leufkens HGM, Alves da Costa F. Potentially inappropriate medications with risk of cardiovascular adverse events in the elderly: A systematic review of tools addressing inappropriate prescribing. J Clin Pharm Ther. 2019;44(3):349-360. https://doi.org/10.1111/jcpt.12811
13. Salvi F, Rossi L, Lattanzio F, Cherubini A. Is polypharmacy an independent risk factor for adverse outcomes after an emergency department visit?. Intern Emerg Med. 2017;12(2):213-220. https://doi.org/10.1007/s11739-016-1451-5
14. Smaje A, Weston-Clark M, Raj R, Orlu M, Davis D, Rawle M. Factors associated with medication adherence in older patients: A systematic review. Aging Med (Milton). 2018;1(3):254-266. https://doi.org/10.1002/agm2.12045
15. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev. 2002;(2):CD000011. https://doi.org/10.1002/14651858.cd000011
16. Pantuzza LL, Ceccato MDGB, Silveira MR, Junqueira LMR, Reis AMM. Association between medication regimen complexity and pharmacotherapy adherence: a systematic review. Eur J Clin Pharmacol. 2017;73(11):1475-1489. https://doi.org/10.1007/s00228-017-2315-2
17. Midão L, Giardini A, Menditto E, Kardas P, Costa E. Polypharmacy prevalence among older adults based on the survey of health, ageing and retirement in Europe. Arch Gerontol Geriatr. 2018;78:213-220. https://doi.org/10.1016/j.archger.2018.06.018
18. Slater N, White S, Venables R, Frisher M. Factors associated with polypharmacy in primary care: a cross-sectional analysis of data from The English Longitudinal Study of Ageing (ELSA). BMJ Open. 2018;8(3):e020270. https://doi.org/10.1136/bmjopen-2017-020270
19. Lima-Costa MF, de Andrade FB, de Souza PRB Jr, et al. The Brazilian Longitudinal Study of Aging (ELSI-Brazil): Objectives and Design. Am J Epidemiol. 2018;187(7):1345-1353. https://doi.org/10.1093/aje/kwx387
20. Heeringa SG, West BT, Berglund PA. Applied Survey Data Analysis. Boca Raton: Chapman and Hall/CRC; 2010. ISBN: 978-1420080667
21. Sterne JA, White IR, Carlin JB, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ. 2009;338:b2393. https://doi.org/10.1136/bmj.b2393
22. He Y, Zaslavsky AM, Landrum MB, Harrington DP, Catalano P. Multiple imputation in a large-scale complex survey: a practical guide. Stat Methods Med Res. 2010;19(6):653-670. https://doi.org/10.1177/0962280208101273
23. O'Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ Open. 2016;6(4):e010505. https://doi.org/10.1136/bmjopen-2015-010505
24. Almeida NA de, Reiners AA, Azevedo RC et al. Prevalence of and factors associated with polypharmacy among elderly persons resident in the community. Rev Br,as Geriatr Gerontol. 2017;20(1):138-148. https://doi.org/10.1590/1981-22562017020.160086
25. Dal Pizzol Tda S, Pons Eda S, Hugo FN, Bozzetti MC, Sousa Mda L, Hilgert JB. Uso de medicamentos entre idosos residentes em áreas urbanas e rurais de município no Sul do Brasil: um estudo de base populacional [Use of medication by the elderly in urban and rural areas in southern Brazil: a population-based study]. Cad Saude Publica. 2012;28(1):104-114. https://doi.org/10.1590/s0102-311x2012000100011
26. Rozenfeld S, Fonseca MJ, Acurcio FA. Drug utilization and polypharmacy among the elderly: a survey in Rio de Janeiro City, Brazil. Rev Panam Salud Publica. 2008;23(1):34-43. https://doi.org/10.1590/s1020-49892008000100005
27. Hosseini SR, Zabihi A, Jafarian Amiri SR, Bijani A. Polypharmacy among the Elderly. J Midlife Health. 2018;9(2):97-103. https://doi.org/10.4103/jmh.jmh_87_17
28. Walckiers D, Van der Heyden J, Tafforeau J. Factors associated with excessive polypharmacy in older people. Arch Public Health. 2015;73:50. https://doi.org/10.1186/s13690-015-0095-7
29. Junius-Walker U, Theile G, Hummers-Pradier E. Prevalence and predictors of polypharmacy among older primary care patients in Germany. Fam Pract. 2007;24(1):14-19. https://doi.org/10.1093/fampra/cml067
30. Charalampopoulou E, Kontogiorgis C, Nena E, Constantinides T, Kolios G. The complex phenomenon of polypharmacy in older age people of Greece: data from the new era of e-prescribing. Drugs & Therapy Perspectives. 2017;33(12):580-584. https://doi.org/10.1007/s40267-017-0449-z
31. Herr M, Sirven N, Grondin H, Pichetti S, Sermet C. Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population. Eur J Clin Pharmacol. 2017;73(9):1165-1172. https://doi.org/10.1007/s00228-017-2276-5
32. Varas-Doval R, Gastelurrutia MA, Benrimoj SI, García-Cárdenas V, Sáez-Benito L, Martinez-Martínez F. Clinical impact of a pharmacist-led medication review with follow up for aged polypharmacy patients: A cluster randomized controlled trial. Pharm Pract (Granada). 2020;18(4):2133. https://doi.org/10.18549/pharmpract.2020.4.2133
33. Brandt M, Hallas J, Graabæk T, Pottegård A. Description of a practice model for pharmacist medication review in a general practice setting. Pharm Pract (Granada). 2014;12(3):420. https://doi.org/10.4321/s1886-36552014000300005
34. Wang Y, Singh S, Bajorek B. Old age, high risk medication, polypharmacy: a 'trilogy' of risks in older patients with atrial fibrillation. Pharm Pract (Granada). 2016;14(2):706. https://doi.org/10.18549/pharmpract.2016.02.706
35. Pednekar PP, Ágh T, Malmenäs M, et al. Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group. Value Health. 2019;22(2):139-156. https://doi.org/10.1016/j.jval.2018.08.006
36. Thomas RE, Thomas BC. A Systematic Review of Studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years. Curr Aging Sci. 2019;12(2):121-154. https://doi.org/10.2174/1874609812666190516093742