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The “iatrogenic triad”: polypharmacy, drug–drug interactions, and potentially inappropriate medications in older adults

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Abstract

Background The elderly population is often in continuous use of several medications and is more subject to the “iatrogenic triad” of polypharmacy, potentially inappropriate medication use and drug–drug interactions. However, few studies have investigated these three factors concomitantly. Purpose To assess the prevalence and inter-relationship of potentially inappropriate medication (PIM) use, polypharmacy and drug–drug interactions in older adults, together with their associated factors. Setting city of Juiz de Fora, Brazil. Methods a cross-sectional, observational and door-to-door epidemiologic study in community-dwelling older adults was conducted. Main outcome measure The primary outcomes were polypharmacy, inappropriate medication use (2012 Beers and 2015 STOPP criteria) and drug–drug interactions. Associated factors were also investigated using bivariate and multivariate analyses. Results a total of 368 (92%) older adults were in continuous use of at least one drug. There was a high prevalence of polypharmacy (44.6%), drug–drug interaction (72.3%) and PIMs by Beers (42.1%) and PIMs by STOPP (46.2%). Analysis of the inter-relationship of the criteria (polypharmacy, PIMs STOPP and drug–drug interactions) revealed that 108 (29.3%) of the older adults had all three criteria concomitantly and multivariate analysis showed that frailty and having a caregiver were associated with this “iatrogenic triad”. Conclusion A high prevalence of iatrogenic effects from drugs was found in the older adults assessed. One in every three elderly participants of the study had all three iatrogenic criteria concomitantly, highlighting the major public health impact of this problem. The results of this study can serve to inform new preventive and educational strategies for health professionals.

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References

  1. World Health Organization. Mental health and older adults. http://www.who.int/mediacentre/factsheets/fs381/en/. Accessed 12 Jan 2015.

  2. da Silva AF, de Oliveira Abreu CR, Barbosa EMS, Raposo NRB, Chicourel EL. Problemas relacionados aos medicamentos em idosos fragilizados da Zona da Mata Mineira. Brasil. Rev bras geriatr gerontol. 2013;16(4):691–704.

    Article  Google Scholar 

  3. Rozenfeld S. Prevalência, fatores associados e mau uso de medicamentos entre os idosos: uma revisão Prevalence, associated factors, and misuse of medication in the elderly: a review. Cad Saúde Pública. 2003;19(3):717–24.

    Article  PubMed  Google Scholar 

  4. Shi S, Morike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol. 2008;64(2):183–99. doi:10.1007/s00228-007-0422-1.

    Article  PubMed  Google Scholar 

  5. Patel RB. Polypharmacy and the elderly. J Infus Nurs Off Publ Infus Nurs Soc. 2003;26(3):166–9.

    Article  Google Scholar 

  6. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.

    Article  Google Scholar 

  7. Fick DM, Mion LC, Beers MH, Waller JL. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health. 2008;31(1):42–51.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007;370(9582):185–91. doi:10.1016/s0140-6736(07)61092-7.

    Article  CAS  PubMed  Google Scholar 

  9. Fulton MM, Riley Allen E. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract. 2005;17(4):123–32.

    Article  PubMed  Google Scholar 

  10. Secoli SR. Polypharmacy: interaction and adverse reactions in the use of drugs by elderly people. Revista Bras Enferm. 2010;63(1):136–40.

    Article  Google Scholar 

  11. Opondo D, Eslami S, Visscher S, de Rooij SE, Verheij R, Korevaar JC, et al. Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. PLoS ONE. 2012;7(8):e43617. doi:10.1371/journal.pone.0043617.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Sistema IBGE de Recuperação Eletrônica (SIDRA). População residente por sexo, situação e grupos de idade - Amostra - Características Gerais da População: Tabela 200. http://www.sidra.ibge.gov.br/bda/tabela/listabl.asp?z=t&c=200. Accessed 13 Feb 2014.

  13. Plano de Desenvolvimento Local - Regiões administrativas – dados comparativos. Juiz de Fora 2004 p 20.

  14. INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Sistema IBGE de Recuperação Eletrônica (SIDRA). População residente, por cor ou raça, segundo a situação do domicílio, o sexo e a idade: Tabela 3175. http://www.sidra.ibge.gov.br/bda/tabela/listabl.asp?z=t&c=3175. Accessed 13 Feb 2014.

  15. MINAS GERAIS. Secretaria de Estado de Saúde. Manual do Prontuário de Saúde da Família. Belo Horizonte: SES/MG; 2008.

  16. Cruz DT, Ribeiro LC, Vieira Mde T, Teixeira MT, Bastos RR, Leite IC. Prevalence of falls and associated factors in elderly individuals. Rev Saude Publica. 2012;46(1):138–46.

    Article  PubMed  Google Scholar 

  17. Fabrício-Wehbe SCC, Schiaveto FV, Vendrusculo TRP, Haas VJ, Dantas RAS, Rodrigues RAP. Cross-cultural adaptation and validity of the” Edmonton Frail Scale-EFS” in a Brazilian elderly sample. Rev Lat Am Enferm. 2009;17(6):1043–9.

    Article  Google Scholar 

  18. Kocalevent R-D, Finck C, Jimenez-Leal W, Sautier L, Hinz A. Standardization of the Colombian version of the PHQ-4 in the general population. BMC Psychiatry. 2014;14(1):205.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–86.

    Article  CAS  PubMed  Google Scholar 

  20. Hovstadius B, Petersson G. Factors leading to excessive polypharmacy. Clin Geriatr Med. 2012;28(2):159–72. doi:10.1016/j.cger.2012.01.001.

    Article  PubMed  Google Scholar 

  21. Moura CS, Acurcio FA, Belo NO. Drug–drug interactions associated with length of stay and cost of hospitalization. J Pharm Pharm Sci Publ Can Soc Pharm Sci. 2009;12(3):266–72.

    Article  CAS  Google Scholar 

  22. Costa SC. Avaliação da prescrição de medicamentos para idosos internados em serviço de clínica médica do sistema único de saúde em um hospital público universitário brasileiro. Belo Horizonte. Belo Horizonte Universidade Federal de Minas Gerais Dissertação apresentada ao Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical. 2009.

  23. Gotardelo DR, Fonseca LS, Masson ER, Lopes LN, Toledo VN, Faioli MA, et al. Prevalência e fatores associados a potenciais interações medicamentosas entre idosos em um estudo de base populacional. Revista Brasileira de Medicina de Família e Comunidade. 2014;9(31):111–8.

    Article  Google Scholar 

  24. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults, Fick D, Semla T, Beizer J, Brandt N, Dombrowski R, DuBeau CE, Flanagan N, Hanlon J, Hollmann P, Linnebur S, Nau D, Rehm B, Sandhu S, Steinman M. J Am Geriatr Soc. 2012;60(4):616–31. doi:10.1111/j.1532-5415.2012.03923.x.

  25. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213–8. doi:10.1093/ageing/afu145.

    Article  PubMed  Google Scholar 

  26. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.

    Article  CAS  PubMed  Google Scholar 

  27. Bao Y, Shao H, Bishop TF, Schackman BR, Bruce ML. Inappropriate medication in a national sample of US elderly patients receiving home health care. J Gen Intern Med. 2012;27(3):304–10. doi:10.1007/s11606-011-1905-4.

    Article  PubMed  Google Scholar 

  28. Lao CK, Chan KK, Tou CF, Tong HHY, Chan A. Potentially inappropriate prescribing and drug–drug interactions among elderly Chinese nursing home residents in Macao. Int J Clin Pharm. 2013;35(5):805–12.

    Article  PubMed  Google Scholar 

  29. Hosia-Randell HM, Muurinen SM, Pitkälä KH. Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland. Drugs Aging. 2008;25(8):683–92.

    Article  CAS  PubMed  Google Scholar 

  30. Greene M, Steinman MA, McNicholl IR, Valcour V. Polypharmacy, drug–drug interactions, and potentially inappropriate medications in older adults with human immunodeficiency virus infection. J Am Geriatr Soc. 2014;62(3):447–53. doi:10.1111/jgs.12695.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mamun K, Lien CT, Goh-Tan CY, Ang WS. Polypharmacy and inappropriate medication use in Singapore nursing homes. Ann Acad Med Singapore. 2004;33(1):49–52.

    CAS  PubMed  Google Scholar 

  32. Johnell K, Fastbom J, Rosen M, Leimanis A. Inappropriate drug use in the elderly: a nationwide register-based study. Ann Pharmacother. 2007;41(7):1243–8. doi:10.1345/aph.1K154.

    Article  PubMed  Google Scholar 

  33. Hanlon JT, Artz MB, Pieper CF, Lindblad CI, Sloane RJ, Ruby CM, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother. 2004;38(1):9–14.

    Article  PubMed  Google Scholar 

  34. Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol. 2013;69(3):319–26.

    Article  PubMed  Google Scholar 

  35. Poudel A, Hubbard RE, Nissen L, Mitchell C. Frailty: a key indicator to minimize inappropriate medication in older people. QJM Mon J Assoc Phys. 2013;106(10):969–75. doi:10.1093/qjmed/hct146.

    CAS  Google Scholar 

  36. Thorpe JM, Thorpe CT, Kennelty KA, Gellad WF, Schulz R. The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia. Am J Geriatr Pharmacother. 2012;10(4):230–41. doi:10.1016/j.amjopharm.2012.05.001.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Nishio S, Watanabe H, Kosuge K, Uchida S, Hayashi H, Ohashi K. Interaction between amlodipine and simvastatin in patients with hypercholesterolemia and hypertension. Hypertens Res Off J Jpn Soc Hypertens. 2005;28(3):223–7. doi:10.1291/hypres.28.223.

    Article  CAS  Google Scholar 

  38. Haueis P, Russmann S, Zorina OI, Grohmann R, Kullak-Ublick GA, Jaquenoud Sirot E, et al. Coprescription of levodopa with antipsychotics in a population of 84,596 psychiatric inpatients from 1994 to 2008. Pharmacopsychiatry. 2012;45(4):127–32. doi:10.1055/s-0031-1291348.

    Article  CAS  PubMed  Google Scholar 

  39. Kiley CA, Cragin DJ, Roth BJ. Omeprazole-associated digoxin toxicity. South Med J. 2007;100(4):400–3.

    Article  PubMed  Google Scholar 

  40. Lima-Costa MF, Barreto SM, Giatti L. Condições de saúde, capacidade funcional, uso de serviços de saúde e gastos com medicamentos da população idosa brasileira: um estudo descritivo baseado na Pesquisa Nacional por Amostra de Domicílios. Cad Saúde Pública. 2003;19(3):735–43.

    Article  PubMed  Google Scholar 

  41. Lucchetti G, Lucchetti ALG, Pires SL, Gorzoni ML. “Farmácia Dose Certa” program and Beers-Fick criteria: general versus specific analysis. Sao Paulo Med J. 2012;130(4):268.

    Article  Google Scholar 

  42. Kaur S, Mitchell G, Vitetta L, Roberts MS. Interventions that can reduce inappropriate prescribing in the elderly. Drugs Aging. 2009;26(12):1013–28.

    Article  PubMed  Google Scholar 

  43. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, Fick DM, Semla TP, Beizer J, Brandt N, Dombrowski R, DuBeau CE, Eisenberg W, Epplin JJ, Flanagan N, Giovannetti E, Hanlon J, Hollmann P, Laird R, Linnebur S, Sandhu S, Steinman M. J Am Geriatr Soc 2015;63(11):2227–46. doi:10.1111/jgs.13702.

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Novaes, P.H., da Cruz, D.T., Lucchetti, A.L.G. et al. The “iatrogenic triad”: polypharmacy, drug–drug interactions, and potentially inappropriate medications in older adults. Int J Clin Pharm 39, 818–825 (2017). https://doi.org/10.1007/s11096-017-0470-2

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