Polypharmacy Among Older Adults in Tehran Tehran University of Medical Sciences, School of Public Health, Islamic Republic of Iran Ahmadi, Batoul, Pharm D., M. P. H., Ph.D, Dpt. Health Management & Economics Alimohamadian, Masoumeh, M.S., Dpt. Ecology; Mahmoodi, Mahmood, Ph.D, Dpt. Epidemiology and biostatistics Tehran University of Medical Sciences ICIUM 2011

Problem Statement The older adults usually suffer from chronic conditions and have multiple medical problems, requiring prescription drugs to treat diseases and to prevent the arising complications. Moreover complex medical conditions are frequent and often involve multiple drug therapy. The elderly people consume about four times as many daily doses as the rest of the populations. The older population in Iran is increasing and they likely use more drugs than any other age groups. The figure for population more than 60 years old in Iran is estimated to be 6.6%, more than 4 millions, and is estimated to reach up to 10 millions in 2020.

Problem Statement Multiple concurrent illnesses that may benefit from drug treatment are the rule, not the exception, in this group. Multiple drug use is frequently considered to be hazardous for older people, because of their grater vulnerability to the complications. The likelihood of adverse drug reactions increases markedly as the number of concurrently administered drugs increases. This combined with the age-related decline in physiological functions (decreased cardiac reserve, decreased immunological response, decreased renal function) that in younger patients may be protective from severity of an adverse drug reaction make the older patient particularly at risk for polypharmacy related adverse drug reaction.

Polypharmacy The term polypharmacy refers to the group of medications one person may be taking. It is generally used when that one person is taking too many medications, or when the drugs have been prescribed by many doctors, and may not have been coordinated well. Also, it's possible that new symptoms will occur based on one drug, and be treated by taking another drug instead of exploring the root cause for the symptoms - the original drug. Over time patients may be prescribed many drugs that just compound problematic symptoms, masking the roots of their original medical problem.

Problem Statement Polypharmacy is the unwanted duplication of drugs and often results when patients visit multiple physicians or purchase prescription and nonprescription medicines from pharmacies. Polypharmacy is problematic for older persons. It causes drug interaction, reduced compliance, adverse drug reactions, emergency room visits and hospitalizations.

Objectives The purpose of this study was to determine the prevalence of polypharmacy in older adults in Tehran and to assess the relative medical and demographic characteristics of patients.

Design and Setting In a cross-sectional descriptive study, the selective patients were interviewed to answer a questionnaire at home and their current using drugs were observed. The Information on all medications used was collected. The questionnaire also contained questions regarding personal, social, and medical factors. Polypharmacy was defined as daily intake of three or more drugs. Study Population: Four hundred cases of patients aged 55 and older by cluster sampling were randomly selected from community residents in Tehran.

Results Cases personal characteristics: 54% of cases were female, 58.2% aged 55 to 64 years old, 71% were retired 50% were housewife Mostly (67%) belonged to the middle class income of the society. More than 80% of cases had kinds of insurance coverage.

Results Mediam number of drugs used was 3.4 ± 1.9 in studied cases and 39.6% of cases were exposed to polypharmacy. The prevalence of physician prescribed drugs was observed to be increased by increasing number of total used drugs in each case (P<0.002). The most commonly used drugs were: – acetylsalicylic acid – atenolol – propranolol These drugs were prescribed by physician in over 90% of cases.

Results Most frequently used drug categories : Cardio vascular (35.3%) Central nervous system (25%) Hormones (9.2%) Vitamins (8.4%) Gastrointestinal (7.9%) They mostly were prescribed by physicians.

Results: In this study 39.6% of cases were exposed to polypharmacy, of which 60% were female. The median number of daily drug usage for age groups was: – 3.2 for years – 3.6 for years – 3.5 for 75 years and older

Results: It was observed that as the number of daily drug usage was increased the prescribed drugs usage was also increased (p<0.002) Polypharmacy was more prevalent in: – the age group of 65–75 years (P<0.04) – lower levels of education (P<0.004) Polypharmacy was less prevalent in the group with moderate income (P<0.001). There were positive correlations between polypharmacy and: – visiting multiple physicians (OR=1.96, CI 95%, ) (P<0.002) – reported adverse drug reactions (OR=2.44, CI 95%, ) (P<0.001)

The correlation between polypharmacy and socio- demographic characteristics

Results patient’s sources of information about drugs: – physicians as the most common source of drug information for all cases (86%), – family and friends (27%), – media (22%), – pharmacists (11%) – drug brochures (10%) had a less important role; There were no meaningful relation with the patient's characteristics. In polypharmacy group the figures were: – 54% for physicians, – 10% for pharmacists, – 6% for drug brochures. There was correlation between polypharmacy and patient’s source of information only for pharmacists (p<0.005).

Polypharmacy relation with Visiting Multiple Physicians (VMP), and Adverse Drug Reactions (ADR) in patients

Polypharmacy prevalence for prescribed drugs (PD) and non prescribed drugs (NPD)

Conclusion Polypharmacy is common among adults aged55 years and older in Tehran and is affected by age, education level, and economic status. Physicians have played an essential role in providing needed information and explanation on drug consumption, and pharmacists have had a poor performance in this regard Polypharmacy should be reduced as it has many potential adverse effects.

Lessons learned The use of prescribed drugs and the mean number of medications being used is growing among older adults. This study finding indicates that the pattern of drug consumption among the older adults living in Tehran was not satisfactory. That means polypharmacy is common among community old people and is affected by age, educational level, and economic status. Considering the fact that physicians have played an essential role in providing needed information and explanation on drug consumption, and pharmacists have had a poor performance in this regard; it seems that more attention should be paid to this issue.

Policy Implications and Conclusion: Factors such as longer life, multiple health problems, chronic conditions, long term medical treatment, increased use of health services, visiting multiple physicians, and development of new medications contribute to this problem It seems that more attention should be paid to this issue by taking the following strategies: – Adequate training and education programmes for physicians and pharmacists; paying more attention to their prescribing role and skills in improving the pattern of drug consumption among the elderly. – Establishing appropriate relations to convey the required information between physicians and pharmacists, and with the elderly patients. – Improving technical and diagnostic skills of Physicians to prevent symptom therapy. – Paying more attention by physicians to being informed about the number of drugs given to the elderly and prescribing the minimum required drugs. An appropriate diagnosis should be recorded for each medication prescribed.

Policy Implications and Conclusion: – Electronic patient’s record and physicians computer systems can be helpful in reviewing prescriptions and avoiding duplication of drug in patient at higher risk of medication errors. – Regular medication review by physician or nurses in each visit for elderly patients. – Repeat prescribing systems need improvement, emphasizing on more attention by pharmacists to repeated prescriptions and possible interactions of prescribed drugs for the elderly. – Regulatory intervention, assessments and closer monitoring on drug prescriptions and controlling drug orders of Physicians by health authorities. – Patient consultation and education especially for the elderly and their family in this regard through health care services and health education programs.

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