|Date:||20 April 2015|
Ruth E Hubbard, Nancye M Peel, Ian A Scott, Jennifer H Martin, Alesha Smith, Peter I Pillans, Arjun Poudel and Leonard C Gray
Med J Aust 2015; 202 (7): 373-377. doi: 10.5694/mja13.00172
Objectives: To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy.
Design: Prospective cohort study.
Participants and setting: Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010. All patients were assessed using the interRAI assessment system for acute care.
Main outcome measures: Measures of physical, cognitive and psychosocial functioning; and number of regular prescribed medications categorised into three groups: non-polypharmacy (0–4 drugs), polypharmacy (5–9 drugs) and hyperpolypharmacy (≥ 10 drugs).
Results: Of 1220 patients who were recruited for the study, medication records at admission were available for 1216. Mean age was 81.3 years (SD, 6.8 years), and 659 patients (54.2%) were women. For the 1187 patients with complete medication records on admission and discharge, there was a small but statistically significant increase in mean number of regular medications per day between admission and discharge (7.1 v 7.6), while the prevalence of medications such as statins (459 [38.7%] v 457 [38.5%] patients), opioid analgesics (155 [13.1%] v 166 [14.0%] patients), antipsychotics (59 [5.0%] v 65 [5.5%] patients) and benzodiazepines (122 [10.3%] v 135 [11.4%] patients) did not change significantly. Being in a higher polypharmacy category was significantly associated with increase in comorbidities (odds ratio [OR], 1.27; 95% CI, 1.20–1.34), presence of pain (OR, 1.31; 1.05–1.64), dyspnoea (OR, 1.64; 1.30–2.07) and dependence in terms of instrumental activities of daily living (OR, 1.70; 1.20–2.41). Hyperpolypharmacy was observed in 290/1216 patients (23.8%) at admission and 336/1187 patients (28.3%) on discharge, and the proportion of preventive medication in the hyperpolypharmacy category at both points in time remained high (1209/3371 [35.9%] at admission v 1508/4117 [36.6%] at discharge).
Conclusions: Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.
Received 3 Dec 2013, accepted 22 Oct 2014
Media release: The medical Journal of Australia (MJA)
EMBARGOED UNTIL 12.01am, Monday 20 April 2015
Hospital wards ideal for deprescribing in older people
THE opportunity to safely reduce the number of medications being prescribed to older patients is being missed by Australian hospitals, which may be the ideal setting for such complex assessments, according to research published in the Medical Journal of Australia.
Polypharmacy, defined as five or more regular prescription medicines, has been shown to have adverse outcomes for older people living in the community. A study led by Associate Professor Ruth Hubbard and her coauthors, from the University of Queensland, Princess Alexandra Hospital in Brisbane and the University of Newcastle, was designed to explore the same phenomenon in older patients admitted to hospital.
“Individualisation of therapy should underpin prescribing, weighing up the potential benefits and risks of medication with reference to the patient’s own goals of care”, the researchers wrote.
“Hospitalisation presents an opportunity for physicians to undertake such a process and to rationalise prescribing for older people.”
The study involved the data from 1216 patients aged 70 years or older (mean age of 81 years) admitted to general medical units of 11 acute care hospitals in Queensland and Victoria between July 2005 and May 2010.
Measures of physical, cognitive and psychosocial functioning were recorded; and the regularly prescribed medications were categorised into three groups: non-polypharmacy (0–4 drugs), polypharmacy (5–9 drugs) and hyperpolypharmacy (≥ 10 drugs).
Three-quarters (925/1216 [76.1%]) of the assessed patients received five or more drugs at admission. In more than one-fifth of them (290/1216 [23.8%]), hyperpolypharmacy was observed.
For the 1187 patients with complete records on admission and discharge, “most patients (875/1187 [73.7%]) did not change polypharmacy category from admission to discharge.” There were 200 patients (16.8%) who changed to a higher polypharmacy category and 112 patients (9.4%) who moved to a lower polypharmacy category.
The researchers found that there was a small but statistically significant increase in the mean number of regular medications per day between admission and discharge (7.1 versus 7.6).
“This may suggest that active attempts were not made to deprescribe when appropriate,” the authors wrote.
“With increasing age, prolonging life often becomes a less feasible therapeutic goal”, the authors wrote.
“Older patients themselves prioritise improvements in mobility and functional status over longer survival.”
“Our study found that among patients taking 10 or more drugs, more than one in four of these medications were classified as purely preventive, according to mean numbers of drugs per patient, which may constitute an unnecessary treatment burden if clinical benefits are not realised in the short term.”
Although community medication reviews by pharmacists have been touted as an attractive option for reducing polypharmacy in older patients, research had shown “no positive effect on clinical outcomes or quality of life”, the authors wrote.
“Perhaps only a medication review underpinned by careful consideration of the health status of the patient concerned, including estimation of life expectancy and exploration of individual goals of care, is likely to result in clinically meaningful outcomes.
“The acute care hospital ward under the care of physicians is a setting in which these complex decisions could be considered and actions initiated in discontinuing inappropriate medications.”
Please acknowledge the Medical Journal of Australia (MJA) as the source of this article
The Medical Journal of Australia is a publication of the Australian Medical Association.
The statements or opinions that are expressed in the MJA reflect the views of the authors and do not represent the official policy of the AMA or the MJA unless that is so stated.
CONTACTS: A/Prof Ruth Hubbard, 0400 530 193