Original Study
Adverse Outcomes in Relation to Polypharmacy in Robust and Frail Older Hospital Patients

https://doi.org/10.1016/j.jamda.2016.05.017Get rights and content

Abstract

Objective

To explore the relationship between polypharmacy and adverse outcomes among older hospital inpatients stratified according to their frailty status.

Design and setting

A prospective study of 1418 patients, aged 70 and older, admitted to 11 hospitals across Australia.

Measurements

The interRAI Acute Care (AC) assessment tool was used for all data collection, including the derivation of a frailty index calculated using the deficit accumulation method. Polypharmacy was categorized into 3 groups based on the number of regular drugs prescribed. Recorded adverse health outcomes were falls, delirium, functional and cognitive decline, discharge to a higher level of care and in-hospital mortality.

Results

Patients had a mean (SD) age of 81 (6.8) years and 55% were women. Polypharmacy (5–9 drugs per day) was observed in 48.2% (n = 684) and hyper-polypharmacy (≥10 drugs) in 35.0% (n = 497). Severe cognitive impairment was significantly associated with nonpolypharmacy compared with polypharmacy and hyper-polypharmacy groups combined (P = .004). In total, 591 (42.5%) patients experienced at least 1 adverse outcome. The only adverse outcome associated with polypharmacy was delirium. Within each polypharmacy category, frailty was associated with adverse outcomes and the lowest overall incidence was among robust patients prescribed 10 or more drugs.

Conclusion

While polypharmacy may be a useful signal for medication review, in this study it was not an independent predictor of adverse outcomes for older inpatients. Assessing the frailty status of patients better appraised risk. Extensive de-prescribing in all older inpatients may not be an intervention that directly improves outcomes.

Section snippets

Study Sample and Setting

This was a secondary analysis of 3 cohorts of older patients (n = 1418), aged 70 and older, admitted to 11 acute care hospitals in Queensland and Victoria, Australia, between 2005 and 2010, for whom data were collected prospectively. Most (n = 1220) were admitted to general medical units, with 71 in orthopedic wards and 127 in surgical wards. The study sites were diverse, from small secondary care centers with 120 to 160 beds to major tertiary referral centers with more than 650 beds.

Results

Patients’ mean age was 81 (SD 6.8) years, and 55% were women. Before admission, 86% were living independently in the community and 36% were living alone. Sociodemographic and clinical characteristics of the study population by polypharmacy categories are shown in Table 1. Polypharmacy was observed in almost half of the study population (n = 684, 48.2%) and hyper-polypharmacy in 497 (35.0%) patients. Patients with severe cognitive impairment were significantly more likely to be in the

Discussion

In this large and well-characterized cohort of older inpatients, we found no significant association between polypharmacy and a range of clinically relevant adverse outcomes. Within each polypharmacy category, the incidence of adverse outcomes increased with increasing frailty, and the most robust patients taking 10 or more drugs had the lowest incidence compared with other polypharmacy/frailty categories.

Here, the only significant association between polypharmacy and an adverse outcome was an

References (38)

  • A.A. Mangoni

    Predicting and detecting adverse drug reactions in old age: Challenges and opportunities

    Expert Opin Drug Metab Toxicol

    (2012)
  • M.H. Chiu et al.

    Medication use and fall-risk assessment for falls in an acute care hospital

    Geriatr Gerontol Int

    (2015)
  • G.J. McAvay et al.

    Older adults discharged from the hospital with delirium: 1-year outcomes

    J Am Geriatr Soc

    (2006)
  • D.A. Cadilhac et al.

    Organized blood pressure control programs to prevent stroke in Australia: Would they be cost-effective?

    Stroke

    (2012)
  • A. Cherubini et al.

    Underprescription of beneficial medicines in older people: Causes, consequences and prevention

    Drugs Aging

    (2012)
  • S.M. Patterson et al.

    Interventions to improve the appropriate use of polypharmacy for older people

    Cochrane Database Syst Rev

    (2014)
  • M. Christensen et al.

    Medication review in hospitalised patients to reduce morbidity and mortality

    Cochrane Database Syst Rev

    (2013)
  • A. Bennett et al.

    Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: A prospective cohort study

    Drugs Aging

    (2014)
  • C.A. Brand et al.

    Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: Study protocol

    BMC Health Serv Res

    (2011)
  • Cited by (61)

    • The Prevalence of Frailty Among Older Adults Living With Dementia: A Systematic Review

      2022, Journal of the American Medical Directors Association
    • The prevalence of frailty and pre-frailty among geriatric hospital inpatients and its association with economic prosperity and healthcare expenditure: A systematic review and meta-analysis of 467,779 geriatric hospital inpatients

      2022, Ageing Research Reviews
      Citation Excerpt :

      Differences in the pooled prevalence estimates of frailty were also statistically significant between these alternative age group classifications based on the mean age of study samples (p < 0.001) (Supplementary Figure D). Fifty-three studies were included in pooled analysis of the prevalence of frailty stratified by ward type (Amblàs-Novellas et al., 2018; Andela et al., 2010; Baldwin et al., 2014; Bo et al., 2016; Cheung et al., 2017; Chew et al., 2017; Chia et al., 2016; Chong et al., 2017; Coleman et al., 2012; Dent et al., 2014; Dutzi et al., 2017; Eeles et al., 2012; Guidet et al., 2018; Gullón et al., 2018; Hartley et al., 2017; Heppenstall et al., 2011; Hewitt et al., 2015; Hewitt et al., 2016; Hii et al., 2014; Ibrahim et al., 2019; Induruwa et al., 2017; Jokar et al., 2016; Joosten et al., 2014; Joseph et al., 2014; Joseph et al., 2016; Juma et al., 2016; Karlekar et al., 2017; Khan et al., 2019; Kobe et al., 2016; Koyama et al., 2018; Lee et al., 2018; Le Maguet et al., 2014; Martín et al., 2018; Muessig et al., 2018; Müller et al., 2017; Myint et al., 2018; Nolan, Öztürk et al., 2016, 2017; Papageorgiou et al., 2018; Papakonstantinou et al., 2018; Pasqualetti et al., 2018; Peel et al., 2017; Pollack et al., 2017; Poudel et al., 2016; Purser et al., 2006; Ritt et al., 2015; Rose et al., 2014; Sánchez et al., 2011; Sanchis et al., 2015; Sündermann et al., 2014; Ticinesi et al., 2016; Vidán et al., 2014; Wou et al., 2013). Fifteen of the included studies were specifically conducted on geriatric wards (Amblàs-Novellas et al., 2018; Andela et al., 2010; Bo et al., 2016; Chew et al., 2017; Chong et al., 2017; Dent et al., 2014; Hartley et al., 2017; Joosten et al., 2014; Martín et al., 2018; Müller et al., 2017; Pasqualetti et al., 2018; Peel et al., 2017; Ritt et al., 2015; Ticinesi et al., 2016; Vidán et al., 2014); twelve on general internal medicine wards (Andela et al., 2010; Eeles et al., 2012; Gullón et al., 2018; Heppenstall et al., 2011; Induruwa et al., 2017; Juma et al., 2016; Koyama, Öztürk et al., 2018, 2017; Papakonstantinou et al., 2018; Peel et al., 2017; Rose et al., 2014; Vidán et al., 2014); seven acute wards (Amblàs-Novellas et al., 2018; Bo et al., 2016; Ibrahim et al., 2019; Joosten et al., 2014; Poudel et al., 2016; Ticinesi et al., 2016; Wou et al., 2013), seven cardiology wards (Hii et al., 2014; Kobe et al., 2016; Purser et al., 2006; Sánchez et al., 2011; Sanchis et al., 2015; Sündermann et al., 2014; Vidán et al., 2014); seven surgical wards (Andela et al., 2010; Cheung et al., 2017; Chia et al., 2016; Hewitt et al., 2015; Hewitt et al., 2016; Jokar et al., 2016; Myint et al., 2018); six intensive care wards (Baldwin et al., 2014; Guidet et al., 2018; Le Maguet et al., 2014; Muessig et al., 2018; Papageorgiou et al., 2018; Pollack et al., 2017); six traumatology wards (Andela et al., 2010; Joseph et al., 2014; Joseph et al., 2016; Karlekar et al., 2017; Khan et al., 2019; Lee et al., 2018); and, three on rehabilitation wards (Coleman et al., 2012; Dutzi et al., 2017; Nolan et al., 2016).

    View all citing articles on Scopus

    The authors declare no conflicts of interest.

    View full text