Advertisement

Polypharmacy in Nursing Home Residents: What Is the Way Forward?

Published:August 17, 2015DOI:https://doi.org/10.1016/j.jamda.2015.07.008
      Polypharmacy is the use of multiple drugs by a patient, although there is not a universally accepted definition. According to several authors, the use of greater than or equal to 5 drugs corresponds to polypharmacy, whereas others consider polypharmacy to be the use of as few as 3 or more drugs, up to 10 or more drugs.
      • Hajjar E.R.
      • Cafiero A.C.
      • Hanlon J.T.
      Polypharmacy in elderly patients.
      From another perspective, polypharmacy is defined as the use of unnecessary drugs by a patient.
      • Shah B.M.
      • Hajjar E.R.
      Polypharmacy, adverse drug reactions, and geriatric syndromes.
      Independent of the specific definition, polypharmacy is a hot topic in medicine today, particularly in older patients. Epidemiologic data demonstrate that polypharmacy is widespread in the older population,
      • Kaufman D.W.
      • Kelly J.P.
      • Lynn R.
      • et al.
      Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States.
      • Onder G.
      • Bonassi S.
      • Abbatecola A.M.
      • et al.
      High prevalence of poor drug prescribing in older individuals: A nationwide report from the Italian Medicines Agency (AIFA).
      • Charlesworth C.J.
      • Smit E.
      • Lee D.S.
      • et al.
      Polypharmacy among adults aged 65 years and older in the United States: 1988–2010.
      with increasing prevalence in the last decade.
      • Franchi C.
      • Tettamanti M.
      • Pasina L.
      • et al.
      Changes in drug prescribing to Italian community-dwelling elderly people: The EPIFARM-Elderly Project 2000–2010.
      Polypharmacy is caused by essentially 2 factors: (1) the increasing availability of drugs to treat or prevent specific diseases (eg, hypertension, diabetes, heart failure, chronic obstructive pulmonary disease) implies that recommended therapies often require multiple drugs; and (2) the frequent occurrence of multiple diseases in the same person (multimorbidity).
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hajjar E.R.
        • Cafiero A.C.
        • Hanlon J.T.
        Polypharmacy in elderly patients.
        Am J Geriatr Pharmacother. 2007; 5: 345-351
        • Shah B.M.
        • Hajjar E.R.
        Polypharmacy, adverse drug reactions, and geriatric syndromes.
        Clin Geriatr Med. 2012; 28: 173-186
        • Kaufman D.W.
        • Kelly J.P.
        • Lynn R.
        • et al.
        Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States.
        J Am Med Dir Assoc. 2002; 287: 337-344
        • Onder G.
        • Bonassi S.
        • Abbatecola A.M.
        • et al.
        High prevalence of poor drug prescribing in older individuals: A nationwide report from the Italian Medicines Agency (AIFA).
        J Gerontol A Biol Sci Med Sci. 2014; 69: 430-437
        • Charlesworth C.J.
        • Smit E.
        • Lee D.S.
        • et al.
        Polypharmacy among adults aged 65 years and older in the United States: 1988–2010.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 989-995
        • Franchi C.
        • Tettamanti M.
        • Pasina L.
        • et al.
        Changes in drug prescribing to Italian community-dwelling elderly people: The EPIFARM-Elderly Project 2000–2010.
        Eur J Clin Pharmacol. 2014; 70: 437-443
        • Rolland Y.
        • Abellan van Kan G.
        • Hermabessiere S.
        • et al.
        Descriptive study of nursing home residents from the REHPA network.
        J Nutr Health Aging. 2009; 13: 679-683
        • Lattanzio F.
        • Mussi C.
        • Scafato E.
        • et al.
        Health care for older people in Italy: The U.L.I.S.S.E. Project (Un Link Informatico sui Servizi Sanitari Esistenti per l'anziano—A computerized network on health care services for older people).
        J Nutr Health Aging. 2010; 14: 238-242
        • Dwyer L.L.
        • Han B.
        • Woodwell D.A.
        • Rechtsteiner E.A.
        Polypharmacy in nursing home residents in the United States: Results of the 2004 National Nursing Home Survey.
        Am J Geriatr Pharmacother. 2010; 8: 63-72
        • Elseviers M.M.
        • Vander Stichele R.R.
        • Van Bortel L.
        Drug utilization in Belgian nursing homes: Impact of residents' and institutional characteristics.
        Pharmacoepidemiol Drug Saf. 2010; 19: 1041-1048
        • Onder G.
        • Vetrano D.L.
        • Cherubini A.
        • et al.
        Prescription drug use among older adults in Italy: A country-wide perspective.
        J Am Med Dir Assoc. 2014; 15: 531.e11-531.e15
        • Bronskill S.E.
        • Gill S.S.
        • Paterson J.M.
        • et al.
        Exploring variation in rates of polypharmacy across long term care homes.
        J Am Med Dir Assoc. 2012; 13: 309.e15-309.e21
        • Guthrie B.
        • Makubate B.
        • Hernandez-Santiago V.
        • Dreischulte T.
        The rising tide of polypharmacy and drug-drug interactions: Population database analysis 1995–2010.
        BMC Med. 2015; 13: 74
        • Jokanovitch N.
        • Tan E.C.
        • Dooley M.J.
        • et al.
        Prevalence and factors associated with polypharmacy in long-term care facilities: A systematic review.
        J am Med Dir Assoc. 2015; 16: 535.e1-535.e12
        • Cherubini A.
        • Corsonello A.
        • Lattanzio F.
        Underprescription of beneficial medicines in older people: causes, consequences and prevention.
        Drugs Aging. 2012; 29: 463-475
        • Avorn J.
        A new paradigm for quality drug therapy in the elderly?.
        Arch Intern Med. 2004; 164: 1957-1959
        • Morley J.E.
        Polypharmacy in the nursing home.
        J Am Med Dir Assoc. 2009; 10: 289-291
        • Morley J.E.
        Inappropriate drug prescribing and polypharmacy are major causes of poor outcomes in long-term care.
        J Am Med Dir Assoc. 2014; 15: 780-782
        • Cherubini A.
        • Oristrell J.
        • Pla X.
        • et al.
        The persistent exclusion of older subjects from ongoing trials on heart failure.
        Arch Intern Med. 2011; 171: 550-556
        • Crome P.
        • Cherubini A.
        • Oristrell J.
        The PREDICT (increasing the participation of the elderly in clinical trials) study: The charter and beyond.
        Expert Rev Clin Pharmacol. 2014; 7: 457-468
        • Avorn J.
        • Gurwitz J.H.
        Drug use in the nursing home.
        Ann Intern Med. 1995; 123: 195-204
        • Morley J.E.
        • Caplan G.
        • Cesari M.
        • et al.
        International survey of nursing home research priorities.
        J Am Med Dir Assoc. 2014; 15: 309-312
        • Rolland Y.
        • de Souto Barreto P.
        Research can improve care in the nursing home.
        J Am Med Dir Assoc. 2013; 14: 233-235
        • Rolland Y.
        • Resnick B.
        • Katz P.R.
        • et al.
        Nursing home research: The first International Association of Gerontology and Geriatrics (IAGG) research conference.
        J Am Med Dir Assoc. 2014; 15: 313-325
        • de Souto Barreto P.
        • Vellas B.
        • Morley J.E.
        • Rolland Y.
        The nursing home population: An opportunity to make advances on research on multimorbidity and polypharmacy.
        J Nutr Health Aging. 2013; 17: 399-400
        • Cestac P.
        • Tavassoli N.
        • Vellas B.
        • Rolland Y.
        Improving medication use in the nursing homes: A European perspective.
        J Am Med Dir Assoc. 2013; 14: 6-9
        • Landi F.
        • Dell'Aquila G.
        • Collamati A.
        • et al.
        Anticholinergic drug use and negative outcomes among the frail elderly population living in a nursing home.
        J Am Med Dir Assoc. 2014; 15: 825-829
        • Morley J.E.
        End-of-life care in the nursing home.
        J Am Med Dir Assoc. 2011; 12: 77-83
        • Van der Cammen T.J.
        • Rajkumar C.
        • Onder G.
        • et al.
        Drug cessation in complex older adults: Time for action.
        Age Ageing. 2014; 43: 20-25
        • Tija J.
        • Givens J.
        Ethical framework for medication discontinuation in nursing home residents with limited life expectancy.
        Clin Geriatr Med. 2012; 28: 255-272
        • Tjia J.
        • Rothman M.R.
        • Kiely D.K.
        • et al.
        Daily medication use in nursing home residents with advanced dementia.
        J Am Geriatr Soc. 2010; 58: 880-888
        • Cool C.
        Potentially inappropriate drug prescribing and associated factors in nursing homes.
        J Am Med Dir Assoc. 2014; 15: 850.e1-850.e9
        • Smeets C.
        • Smalbrugge M.
        • Zuidema S.
        • et al.
        Factors related to psychotropic drug prescription for neuropsychiatric symptoms in nursing home residents with dementia.
        J Am Med Dir Assoc. 2014; 15: 835-840
        • de Souto Barreto P.
        • Lapeyre-Mestre M.
        • Mathieu C.
        • et al.
        Prevalence and associations of the use of proton-pump inhibitors in nursing homes: A cross-sectional study.
        J Am Med Dir Assoc. 2013; 14: 265-269
        • Briesacher B.A.
        • Limcangco M.R.
        • Simoni-Wastila L.
        • et al.
        The quality of antipsychotic drug prescribing in nursing homes.
        Arch Intern Med. 2005; 165: 1280-1285
        • Barker K.N.
        • Flynn E.A.
        • Pepper G.A.
        • et al.
        Medication errors observed in 36 health care facilities.
        Arch Intern Med. 2002; 162: 1897-1903
        • Desai R.J.
        • Williams C.E.
        • Greene S.B.
        • et al.
        Exploratory evaluation of medication classes most commonly involved in nursing home errors.
        J Am Med Dir Assoc. 2013; 14: 403-408
        • Sinvani L.D.
        • Beizer J.
        • Akerman M.
        • et al.
        Medication reconciliation in continuum of care transitions: A moving target.
        J Am Med Dir Assoc. 2013; 14: 668-672
        • Lane S.J.
        • Troyer J.L.
        • Dienemann J.A.
        • et al.
        Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.
        Health Care Manage Rev. 2014; 39: 340-351
        • Field T.S.
        • Gurwitz J.H.
        • Avorn J.
        • et al.
        Risk factors for adverse drug events among nursing home residents.
        Arch Intern Med. 2001; 161: 1629-1634
        • Nguyen J.K.
        • Fouts M.M.
        • Kotabe S.E.
        • Lo E.
        Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents.
        Am J Geriatr Pharmacother. 2006; 4: 36-41
        • Ruggiero C.
        • Dell'Aquila G.
        • Gasperini B.
        • et al.
        Potentially inappropriate drug prescriptions and risk of hospitalization among Italian older nursing home residents: The U.L.I.S.S.E. project on behalf of the Ulisse study group.
        Drugs Aging. 2010; 27: 747-758
        • Tamura B.K.
        • Bell C.L.
        • Inaba M.
        • Masaki K.H.
        Outcomes of polypharmacy in nursing home residents.
        Clin Geriatr Med. 2012; 28: 217-236
        • Cherubini A.
        • Eusebi P.
        • Dell'aquila G.
        • et al.
        Predictors of hospitalization in Italian nursing home residents: the U.L.I.S.S.E. Project.
        J Am Med Dir Assoc. 2012; 13: 84.e5-84.e10
        • Loganathan M.
        • Singh S.
        • Franklin B.D.
        • et al.
        Interventions to optimise prescribing in care homes: Systematic review.
        Age Ageing. 2011; 40: 150-162
        • Onder G.
        • Liperoti R.
        • Foebel A.
        • et al.
        Polypharmacy and mortality among nursing home residents with advanced cognitive impairment: Results from the SHELTER study.
        J Am Med Dir Assoc. 2013; 14: 450.e7-450.e12
        • Marasinghe K.M.
        Computerised clinical decision support systems to improve medication safety in long-term care homes: A systematic review.
        BMJ Open. 2015; 5: e006539
        • Alldred D.P.
        • Raynor D.K.
        • Hughes C.
        • et al.
        Interventions to optimise prescribing for older people in care homes.
        Cochrane Database Syst Rev. 2013; : CD009095
        • Wallerstedt S.M.
        • Kindblom J.M.
        • Nylén K.
        • et al.
        Medication reviews for nursing home residents to reduce mortality and hospitalization: Systematic review and meta-analysis.
        Br J Clin Pharmacol. 2014; 78: 488-497
        • Tamura B.K.
        • Bell C.L.
        • Lubimir K.
        • et al.
        Physician intervention for medication reduction in a nursing home: The polypharmacy outcomes project.
        J Am Med Dir Assoc. 2011; 12: 326-330
        • Dilles T.
        • Vander Stichele R.H.
        • Van Bortel L.M.
        • Elseviers M.M.
        The development and test of an intervention to improve ADR screening in nursing homes.
        J Am Med Dir Assoc. 2013; 14: 379.e1-379.e6