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Analysis of Various Effects of Polypharmacy in Geriatrics in the

Department of General Medicine at Tertiary Care Teaching Hospital

S.Ahmed Hussaini1, *Sameera Gouher1, Shawana Nazim1, Marya Fairdous1,

Syeda Kareema Sobia1, Musa Khan2 1 MESCO College of Pharmacy, Mustaidpura, Karwan Road, Hyderabad.

2 Department of General Medicine, Osmania General Hospital (OGH), Afzal Gunj, Hyderabad,T.S,

Email: [email protected]

Corresponding author: *Sameera Gouher

ABSTRACT: The principle aim of our study was to analyze prevalence and the effects of Polypharmacy in

geriatric patients in a tertiary care setup. This study was carried out for duration of 6months at the Inpatient

department of General medicine in Osmania general hospital, Afzalgunj, Hyderabad.

The data of 150 patients was collected by using prepared forms and was examined to explore the relationship

between polypharmacy in geriatrics and adverse clinical outcomes through drug interactions and adverse drug

reactions. The effects of polypharmacy on patient’s awareness level and prescription adherence had also been

analysed.

In the data collected the following out comes were recorded of 150 patients among which the most common

subject of our study lies in between 60 – 65 yrs of age group. Out of 150 patients more than 102 patients were

given more than 7 – 8 and more than 8 medications. Very few patients received less than 3 - 4 medications.

Majority of adverse drug reactions were observed in patients given 7 – 8 and more than 8 medications. There

was more number of moderate drug interactions with an increase in medications. A total of 140 patients were

found to be satisfied with the treatment given.

On analyzing the results it was noted that polypharmacy is very common in old patients of above 60years and

observed that number of medications was factor associated with adverse drug reactions, drug interactions,

patient adherence and awareness of medications.

INTRODUCTION

POLYPHARMACY

Polypharmacy is the use of four or more medications by a patient, generally adults aged over 60years.

Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes.

the prevalence of many diseases increases with age. Therefore elderly people often suffer from multiple

coexisting health problems. Many of this are chronic problems which required long term drug therapy and

sometimes combination drug therapy; so older people are frequently prescribed multiple medications

(polypharmacy). Studies have consistently reported a positive association between the number of medication

and the risk of adverse drug reactions (ADR’S), drug interactions, unplanned hospital admissions and

medication non-compliance therefore although the use of multiple medications may be unavoidable in patients

with multiple co-existing medical conditions, care must be taken to avoid unnecessary polypharmacy.

International Journal of Research

Volume 7, Issue IX, September/2018

ISSN NO: 2236-6124

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GERIATRICS

Geriatrics is the branch of medicines that is concerned with the medical and social aspects of health and illness

in the elderly. The term “elderly” generally refers to people aged 65years and above. However, the

physiological changes associated with ageing occur gradually over a lifetime, with significant patient-to-patient

variability, so the choice of 65years is arbitrary, and sometimes the definition is extended to include people

aged 60years and above.

The use of multiple medications is recognized as an increasingly serious problem in the current healthcare

system. Older people have higher rates of chronic illness and are more likely to be taking multiple medications.

Polypharmacy increases the risk of adverse drug events such as falls,

Confusion and functional decline.

Changes in physiology and social and physical circumstances contribute to the risk of adverse drug events.

Older people are more likely to experience poor vision, hearing and memory loss and have altered metabolic

rates, such as declining renal function. Adverse reactions may go undetected because symptoms may mimic

problems associated with older age such as forgetfulness, weakness or tremor. Adverse reactions may also be

misinterpreted as a medical condition and lead to the prescription of additional drugs.

Concerns about polypharmacy include increased adverse drug reactions, drug interactions, prescribing

cascade and higher costs. Polypharmacy is often associated with a decreased quality of life, decreased mobility

and cognition.

It is well accepted in pharmacology that it is impossible to accurately predict the side effects or clinical effects

of a combination of drugs without studying that particular combination of drugs in test subjects. Knowledge of

the pharmacologic profiles of the individual drugs in question does not assure accurate prediction of the side

effects of combinations of those drugs.

Whether or not the advantages of polypharmacy (over monotherapy) outweigh the disadvantages or a risk

depends upon the particular combination and diagnosis involved in any given case.The use of multiple drugs,

even in fairly straightforward illnesses, is not an indicator of poor treatment. A perfectly legitimate treatment

regimen could include, for example, the following: a statin, an ACE inhibitor, a beta-

blocker, aspirin, paracetamol and an antidepressant in the first year after a myocardial infarction.



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ALTERED DRUG RESPONSE:

Elderly patients, especially the very old (over 75years) and the frail, tend to be more sensitive to the effects of

medications compared to younger adults. This is a result of physiological changes that occur with aging

resulting in altered Pharmacokinetics and Pharmacodynamics, Older patients are therefore more prone to

adverse effects and often require low doses. Moreover the elderly patients have higher rates of co morbidities

and conditions that can alter drug metabolism and excretions therefore there may be increased incidences of

adverse events found in them.

ADR’S may present insidiously without typical symptoms in the elderly and therefore they can be difficult to

distinguish from new onset of illness. This can result in misdiagnosis and the introduction of an additional drug

to treat the symptoms there by contributing to Polypharmacy.

INAPPROPRIATE PRISCRIBING

Inappropriate prescribing by the physicians is one of the problems apart from this inappropriate drug selection,

under prescribing and over prescribing is also common.

PATIENTS’ NON-COMPLAINCE

Compliance is defined as the extent to which the behavior of the patients coincides with the prescribe drug

regimen. Non-compliance with the drug therapy is most common among geriatrics due to the following…

a) Multiple drug prescriptions

b) Polypharmacy

c) Complex drug regimen

d) Cognitive impairment

e) Lack of proper adequate patient counseling

f) Poverty and illiteracy.

ADVERSE DRUG REACTION

Incidence of ADR’S among the elderly is relatively higher in India due to self medications and lack of proper

patient counseling. polypharmacy coupled with multiple diseases and inappropriate in elderly may also

increases the risk of ADR’S.

BASIC PRINCIPLES OF DRUG THERAPY IN GERIATRICS:

1) Saftey and efficacy

Providing safe and effective treatment is the primary objective of drug therapy in elderly to fulfill this

objectives through the knowledge of pharmacokinetics and pharmacodynamic aspects is essential in order to

select an appropriate drug therapy which can prove to be safe, beneficial and efficacious.

2) Choice of an appropriate drug

Various pharmacokinetics and pharmacodynamic parameters should be taken into consideration while

choosing the drugs in elderly. As geriatrics are at an increased risk of ADR’s, the drugs chosen should be safe,

effective and posses less risk of drug related adverse effect.



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Drugs effecting multiple organs should be avoided the prescriber should also consider other coexisting diseases

or disorder while prescribing the medication

3) Dose adjustment

Since geriatrics require less doses of drugs therefore the prescriber should start with a low dose while

prescribing, the prescriber should always abide by the golden rules go low and go slow.i.e.,start with a low dose

and titrate upwards slowly as tolerated by the patients.

Table 1: Dosage adjustment in Geriatrics

4) Drug history

Drug history of elderly patients should be taken into consideration to avoid adverse effects and potential drug

interactions.

5) Concomitant medical illness

As elderly people suffer from multiple disorders such as cardiac failure, renal failure etc., concomitant disease

should be taken into consideration while prescribing drugs so as to minimize the risk of adverse effects.

6) Packaging and labeling

Majority of elderly patients with arthritis find it difficult to open containers and blister packs while those with

visual impairment are unable to read and follow the written instructions on labels. Hence, for geriatric patients

medicines shouled be dispensed in easy-to-open containers that are clearly labeled using large prints and colour

coders.

7) Choice of suitable dosage forms

Since it is quite difficult geriatric patients swallow tablets and capsules therefore, syrups, suspensions and

effervescent tablets should be prescribed.

DRUG

NORMAL DOSE IN

ADULTS

DOSE ADJUSTMENTS IN

GERIATRICS

Cimetidine 300 mg q.i.d Plasma clearance is drastically decrease

the oral dose should be reduced by 1/3

to 1/2

Allopurinol 800 mg /day Dose is decreased in renally impaired

patients

Diazepam 2 to 10 mg b.i.d to q.i.d Dose is reduced to 2 to 2.5 mg O.D or

b.i.d



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Table 2: Prescription Risk in Geriatrics

Class Drug Prescription risks in elderly

Analgesics Indomethacin Produces CNS adverse effects.

Antidepressants

___ Produces severe anticholinergic and sedative effects.

Antihistamines ___ Produces anticholinergic effects, hence should be avoided.

Cardiovascular

drugs

Digoxin

Dipyridamole

Methyldopa

Decreases renal clearance in elderly.

Produces orthostatic hypotension in elderly. May cause

bradycardia and aggravate depression in geriatric patients.

8) Avoiding polypharmacy

Avoiding polypharmacy and drug prescribing cascade keeps a check on adverse effects, drug interactions and

nocomplaince.

Example: piroxicam (NSAID) indicates in inflammation and pain is associated with edema and hypertension.

misconstruction of these adverse effects as a new medical conditions and prescribing another drug such as

chlorthalidone (diuretic) to relieve the oedema may results in newer adverse effects like low serum k+ levels,

dizziness, cramps etc. these adverse effects may further be misinterpreted requiring medical intervention with

another drug.

9) Record keeping

Maintenance of the past and presented drug record of patients is very important as this helps the physician to

know about the patients response to prevent medications, presence of allergies, complications etc.

10) Cost effectiveness

Generally, most of the geriatric populations either have fixed incomes or are dependent on their families.

Therefore, while prescribing drug, physicians should also take the cost factor into account. A drug which is

cheaper and effective should be preferred while prescribing.

11) Monitoring of drug therapy

Close and careful monitoring of drugs therapy and periodic review of the prescriptions helps to avoid

undesirable drug effects and would provide better results.

PRECAUTIONS IN DRUG USAGE IN GERIATRICS

Precautions to be taken by health professionals

1) Prescribing two or more drugs for a single disorder should be avoided without avoiding the drug with known

clinical benefits.

2) Drugs whose potential benefits are less when compared to their adverse effects should be avoided.

3) Drugs that commonly produce harmful effects in elderly should be avoided.



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4) Selection and adjustment of dosage should be based on the age, weight, liver or renal function and other

conditions of the patients.

5) Non-pharmacological or non-drug approaches should be used for symptoms like anxiety, chronic pain

insomnia and in conditions which can be treated by modifications in lifestyle.

Example: Reduction in sodium intake and loss of weight can reduce the use of antihypertensive drugs in about

40% individuals with high B.P.

6) Safest possible drug should be chosen and the drug dosge should be low especially when administered a new

drug so as to reduce the adverse effects associated with it.

Example: CNS active drug used in low doses resulted in leser adverse effects when compared to high doses.

7) patient’s drug regimen should be evaluated periodically for,

a) Simplifications of drug dosage regimen.

b) Determining the interaction between the drug and minimizing side effects.

8) Usage of drugs with limited therapeutic benefit and high risk of adverse effects should be avoided.

Example: Digoxin with its low therapeutic benefit may cause toxic effects in patients with renal impairment or

temporary dehydration.

Precautions to be taken by patients

1) patients should follow the directions for taking medications and seek help from care givers, doctors, family

members or pharmacists especially when they are,

a) Taking three or more drugs, non-prescription drugs, herbal drugs and dietary supplements.

b) Visiting several different health care professionals or clinics for care.

c) Living alone.

d) Using both community and online pharmacies.

e) Having short term memory or memory problems.

2) They should always read the label of the medicine carefully.

3) The medicines’ name and direction for use said by the physician should be checked at the pharmacist after the

prescription is filled.

4) They should strictly adhere to the prescribed regimen.

5) Concomitant use f dietary supplements, herbal products, non-prescriptions drugs that may significantly interact

with prescribed drug should be avoided.



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6) Intake of foods and beverages that have potential to interact with drugs should be avoided.

Examples:

i. Grape juice – Antihypertensive drugs

ii. Milk and milk products – Antibiotics and antifungal drugs

Table 3: Drugs Contraindicated in Elderly

DRUGS ADVERSE EFFECTS PRODUCED

Tetracycline Increase in blood urea levels in case of renally impaired patients.

Reserpine Depression

Cabenoxolone CHF and oedema

Barbiturates Dilemma

Streptomycine Ototoxicity

Guanethidine Postural hypotension

Pentazocine Dilemma

Chlorthalidone Incontinence, prolonged dieresis

Bethanidine Severe postural hypotension

Debrisoquine Postural hypotension

NEED OF STUDY

Geriatric patients are compounded multiple complications and co morbid conditions due their altered

physiological changes, they may highly require the use of multiple drugs for their conditions but their capacity

to metabolise and eliminate the given drugs also get altered. So treatment in these patients gets complicated

therefore should be done highly through the evidence gathered through different researches.

During our review and search for articles on this subject we found that there is lack of comprehensive research

done covering different aspects and effects of polypharmacy in geriatrics, so we found that there was an

absolute need to carry out a study to assist in practicing geriatrics.

This study had analysed the prevalence of polypharmacy in a tertiary care hospital (Osmania General Hospital)

and its effects in increasing patient’s mortality and morbidity. As previous studies also suggested patient’s

medication compliance and prescription adherence is low in polypharmacy practice that was also analysed.

Through the process counselling the patient’s adherence was improved and the adverse effects and drug

interactions were reported or reduced with consultation with the physicians.

This study can be helpful for medical professionals in understanding the consequences of polypharmacy

practices so that it could reduce poor effects and improve management of disease among geriatrics.

AIMS AND OBJECTIVES

The aim of our study is to analyze prevalence and the effects of polypharmacy in geriatric patients.

The purpose of this study was to explore the relationship between polypharmacy and adverse clinical

outcomes through drug interactions and adverse drug effects.

The effects of polypharmacy on patients awareness level and prescription adherence were also analysed.



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Study Design: An Observational prospective study.

Sample Size: Patient size selected for the study is 150.

Site of Study: The study was conducted in the General medicine department Osmania

General Hospital (Afzalgunj, Hyderabad, Telangana,) which is

Study Duration: The study was carried out for the period of 6 Months.

Plan of Work:

During the study researchers had collected data on suitable data collecting form from hospital case sheets and

questionnaire prepared to achieve objectives required to accomplish aim of the study.

To estimate prevalence of polypharmacy and summaris

geriatric patients.

Data was collected based on number of patients receiving polypharmacy, their gender, prescription pattern of

drugs will be derived.

As the increase in number of medications prescribe

adherence to their medications, so through questionnaire data is collected and analysed to asses the patient

awareness and adherence.

To count the number of adverse effects or complications developed wh

relation with the increase of number of medication administered.

With the use polypharmacy there may be chances of Drug interactions so

and its relation with increase in number of medica

Table 4: Tabular description showing the Age Groups of Subjects enrolled in the Study

Table 5: Tabular description showing

MALE

116

77.3%

METHODOLOGY

An Observational prospective study.

Patient size selected for the study is 150.

The study was conducted in the General medicine department Osmania

General Hospital (Afzalgunj, Hyderabad, Telangana,) which is a tertiary care hospital.

The study was carried out for the period of 6 Months.



To estimate prevalence of polypharmacy and summarise prescription pattern of drugs


As the increase in number of medications prescribed to patients may effect on the patient awareness and


To count the number of adverse effects or complications developed which were than analysed for their

relation with the increase of number of medication administered.

With the use polypharmacy there may be chances of Drug interactions so the prevalence

and its relation with increase in number of medications prescribed to the patient is analysed.


Tabular description showing the gender of Subjects enrolled in the Study

FEMALE

34

22.6%

The study was conducted in the General medicine department Osmania

tertiary care hospital.



e prescription pattern of drugs prescribed in


d to patients may effect on the patient awareness and


ich were than analysed for their

the prevalence of such interactions

tions prescribed to the patient is analysed.


enrolled in the Study

FEMALE

22.6%



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Table 6: Tabular description showing

Fig 2: Graphical Presentation showing the no. of medications of Subjects enrolled in the study

Table 7: Tabular description showing the

Fig 2: Graphical Presentation showing the

0

10

20

30

40

50

60

3 to 4

NO. OF PATIENTS

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

3 to 4

No. ofpatients

Tabular description showing the no. of medications of Subjects


Table 7: Tabular description showing the awareness and adherence of Subjects

Fig 2: Graphical Presentation showing the awareness & adherence of Subjects enrolled in the study

3 to 4 5 t0 6 7 to 8

NO. OF MEDICATIONS

5 to 6 7 to 8 >8

Awareness for doses % of Pts

Awareness for frequency % of Pts

Awareness for instructions % of Pts

Reported missing dose % of Pts

enrolled in the Study


awareness and adherence of Subjects enrolled in the study

of Subjects enrolled in the study

>8

Awareness for doses % of Pts

Awareness for frequency % of Pts

Awareness for instructions % of Pts

Reported missing dose % of Pts



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study


study


0

10

20

30

40

50

60

No issue of compliance

No. of patients

Table 7: Tabular description showing the Compliance and Satisfaction of Subjects

: Graphical Presentation showing the Compliance and Satisfaction of Subjects enrolled in the

Tabular description showing the Adverse Drug Reactions of Subjects

No issue of compliance

Satisfied with the current treatment

issue of compliance Not satiesfied with the treatment

of Subjects enrolled in the

of Subjects enrolled in the


Not satiesfied with the treatment

3 to 4

5 to 6

7 to 8

>8



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0

5

10

15

20

03 to 04

No. of patient

0

10

20

30

40

50

60

70

03 to 04

No. of patients

Presentation showing the Adverse Drug Reactions of Subjects enrolled in the study

Tabular description showing the Drug Interactions of Subjects enrolled in the study

: Graphical Presentation showing the Drug Interactions of Subjects enrolled in the study

05 to 06 07 to 08 >8

05 to 06 07 to 08 >8


enrolled in the study

Subjects enrolled in the study

>8

No ADRS

1-2 ADRS

3-4 ADRS

5-6 ADRS

>6 ADRS

>8

No ADRS

1-2 ADRS

3-4 ADRS

5-6 ADRS

>6 ADRS



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Results and Discussion

Our study demonstrates that polypharmacy is very common in old patients (above 60 yrs) and we have

observed that number of medications was a factor associated with difference in clinical outcomes,

independently of the age. Type of medications prescribed and accompanied co-morbidities. As the number of

co-morbid conditions was increasing the number of prescription medications will also get increased but that

also led to increased frequency of Drug Interactions & Adverse drug reactions. Sometimes it might also be due

to the medications co-morbid conditions get evolved.

our study has shown that out of 150 subjects males (77.3%) were more in count when compaired to females

(22.6%). the age groupm of 60 – 65 years (79 ptns) was having more number of patients similar to the study

done by Maher RL, et al.-2014. On evaluatiojn of the collected samples it was found that categories like 7 – 8 (49 ptns) and more than 8 drugs

(55ptns) have more number of patients respectively. Which accounts for more number of moderate drug

interactions ( medscape drug interaction checker) which is similar to study conducted by Wang R – 2015. Numbers of

moderate reactions were found to be more in number (126 DI’s) rather than major (06) and minor (19).

Medscape Drug Interaction Checker

Mild – Minimally clinically significant minimize risk assess risk and considered on alternative drug.

Moderate – Moderately clinically significant usually avoid combinations use under special circumstances.

Major – Highly clinically significant avoid combinations.

A total number of 150 patients were assessed for their knowledge regarding the medication compliance and

prescription adherence out of which categories like 7 – 8 (83.6%) and more than 8 drugs (80%) have more

number of patient’s adherence respectively. which is incontrast with the survey done by Walid F. Gellad – 2012

Assessment was conducted to identify Adverse Drug Reaction in the recorded prescriptions and was observed

that, as the number of medications were increasing their were also an increase in number of Adverse Drug

Reactions generally under the category of 7 – 8 (44 ptns) and more than 8 drugs (57 ptns) have more number

of patients respectively which is similar to the study done by Stephen J. Evans- 2014 It was analyzed that as no. of co-morbid conditions were increasing there was an increase in number of

medications.Upon the assessment of the recorded data the category of dugs i.e., 7 – 8 and more than 8 drugs

were more prone to Adverse Drug Reactions and Drug Interactions.

CONCLUSION

This study provides an insight in analyzing the effects of polypharmacy in geriatrics which is very common in

old patients and observed that number of medications was a factor associated with difference in clinical

outcomes independently of age, type of medications prescribed and accompanied co morbidities. The

discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do

not aligns with the goals.



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The risks of adverse drug reaction and drug interactions can be minimize through identifying the prevalence of

this potential problem in high risk population and by increasing awareness among patients and healthcare

professionals. Physicians and clinical pharmacist have the potential to combating this problem through a

variety of interventions such as reducing number of medications taken, reducing number of doses taken,

increasing patient adherence, preventing adverse drug reactions, drug interactions and improving patient

quality of life.

When prescribing drugs for elderly general practitioner’s should to take into account the specificities of the

elderly, their biological and chronological framework and should always apply the principles of rational,

conservative and evidence based pharmacotherapy. Analyzing the results, we conclude that polypharmacy is

very common in old patients and observed that number of medications was a factor associated with adverse

drug reactions, drug interactions, patient adherence and awareness of medications.

References

1. Introduction from Text book of clinical pharmacy practice by G. parthasarthi/2nd edition/2013.

2. [Roger Walker] Clinical Pharmacy and Therapeutics/5th edition/2012.

3. clinical-pharmacy-in-general-practice-review-web/2012/Introduction https://www.midlandshn.health.nz/uploads/clinical-

pharmacy-in-general-practice-review-web.pdf

4. Comprehensive Pharmacy Review 7 by Leon shargel/2011.

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130196

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5078862/




10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000563 https://www.ncbi.nlm.nih.gov/pubmed/8656727

11. https://doi.org/10.1093/ageing/aft156

12. https://doi.org/10.1093/ageing/afm189


14. http://dx.doi.org/10.1016/j.amjmed.2017.02.028

15. http://dx.doi.org/10.1016/j.jpainsymman.2015.09.003



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