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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 7-13

Assessment of patterns and associated aspects of polypharmacy among the geriatric population of Kangra (Himachal Pradesh)


1 Center for Public Health and Healthcare Administration, Eternal University, Himachal Pradesh, India
2 Department of Psychology, Eternal University, Baru Sahib, Himachal Pradesh, India

Date of Submission16-Aug-2019
Date of Decision14-Sep-2019
Date of Acceptance18-Sep-2019
Date of Web Publication13-Jan-2020

Correspondence Address:
Dr. Priya Sharma
Center for Public Health and Healthcare Administration, Eternal University, Baru Sahib, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_62_19

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  Abstract 


INTRODUCTION: Polypharmacy, defined by the World Health Organization as “the administration of many drugs at the same time or the administration of an excessive number of drugs,” is frequent among the elderly as they often suffer from chronic diseases with concomitant pathologies. Polypharmacy is a debated concept. Various definitions have ranged from two medications at a time to 18 or to more medications than clinically necessary. Five or more concurrent regular medications appear to be the most common definition. Despite the uncertainty around a definition, experts generally agree on the magnitude, potential for harm, and potential for the reduction in medication regimens for elderly people.
AIM: The study aimed to assess the patterns of polypharmacy and its associated aspects among the elderly outpatient department (OPD) patients.
OBJECTIVES: (1) The objectives of this study were as follows: to study patterns of polypharmacy and its associated aspects and (2) to study general ailments and their association with polypharmacy.
MATERIALS AND METHODS: A cross-sectional study was conducted on 371 elderly patients of ≥60 years old with concomitant use of 4 or more medications, defined as polypharmacy.
RESULTS: The results of the present study regarding drug use pattern revealed that majority, i.e., 50.9% were questioned most of the times for medicines before prescribing new set of medicines, 41.0% mostly preferred self-medication, 53.1% had no knowledge about the use of medication, 89.2% had no knowledge of the clinical purpose of the medicine they were using, 51.8% mostly forgot the dose and time of medicines, 18.6% had faced intolerable consequences of discontinuing medicine use, and 13.7% had encountered serious problem due to stocking up of the medicines. Majority, i.e., 84.6% experienced side effects of taking medication. The association reveals that polypharmacy was affected significantly by knowledge about the use of medication (P = 0.01), remembering the doses and timing of the medicines (P = 0.01), and encountering serious problem due to stocking up of the medicines (0.01), nasal problems (P = 0.001), and throat problems (P = 0.001).
CONCLUSION: There is a pattern of polypharmacy that combines the factors such as aging and the risk of polypharmacy.
RECOMMENDATION: The application of specific criteria before prescribing drugs, appropriate monitoring of drug therapy, and careful periodic review of the patient's list of medicines will assist with preventing the lethal complications of polypharmacy. The results indicate the need for additional research into many other aspects of polypharmacy.

Keywords: Aging, concomitant, elderly, patterns, polypharmacy


How to cite this article:
Sharma P, Gupta N L. Assessment of patterns and associated aspects of polypharmacy among the geriatric population of Kangra (Himachal Pradesh). Int J Health Allied Sci 2020;9:7-13

How to cite this URL:
Sharma P, Gupta N L. Assessment of patterns and associated aspects of polypharmacy among the geriatric population of Kangra (Himachal Pradesh). Int J Health Allied Sci [serial online] 2020 [cited 2020 Jan 18];9:7-13. Available from: http://www.ijhas.in/text.asp?2020/9/1/7/275650




  Introduction Top


Currently, Asia has the largest number of world's elderly people. This pressure of increasing the number of elderly is expected to intensify in the next 50 years. In India, as per the 2011 census, the population of senior citizens is 104 million constituting 8.6% of the total population. By the year 2026, the population of senior citizens is expected to reach 173 million constituting 12.4% of the total population.

This shows that the older population is increasing and with it, the risk of polypharmacy is also on rise. Multiple treatments given to one patient by a physician, increasing comorbidities, and an increase in the variety of drugs available contribute to the adversity of the polypharmacy scenario.[1] It is more frequent among elderly people than among middle-aged adults. It is potentially problematic because it can lead to serious adverse events. Previous studies have shown that, on average, polypharmacy affects between 40% and 50% of all older adults.[2] Moreover, polypharmacy increases the incidence of fall, number and rate of hospital stay, length of stay, frequent hospitalizations, and the death rate in elderly population. The proper medications for aged people are prescribed according to the history of disease, drug resistance, physical and mental health, physical ability, memory, and family support. Inattention to different metabolic changes of medications such as their absorption, distribution, and excretion in elderly people's body compared to middle-aged people is regarded as an important factor in the incidence of unwanted side effects in elderly people. Different factors affect polypharmacy in elderly people, including age, gender, level of education, frequent visit to doctors, and types and number of diseases. Low levels of literacy and information in patients are one of the most common causes of polypharmacy.[3] Multimorbidity is defined as suffering from coexistent chronic conditions. Multimorbid patients demand highly complex patient-centered care which often includes polypharmacy.[4] The specific number of drugs taken is not itself indicative of polypharmacy, as all of the drugs may be clinically necessary and appropriate for the patient. It is generally used when one person is taking too many medications or when the drugs have been prescribed by many doctors and may not have been coordinated well.[5] Polypharmacy in a managed care setting presents a unique set of challenges and opportunities. Intervention to reduce polypharmacy must address several issues such as appropriate medication usage in the elderly, including the appropriateness indication, drug–drug duplication in the same class of therapeutics, inappropriate and complex dosing, drug–drug interaction, drug-disease interaction, drug-food interaction, coordination of the medication between primary care provider and specialists, and education of member regarding adverse drug effects and other issues related to compliance. Polypharmacy increases the risk of hospitalizations and medication errors. These factors eventually lead to increased patient costs, nonadherence to treatment, and increased rate of patient morbidity and mortality. Polypharmacy may be responsible for unnecessary health expenditures not only directly due to the cost of superfluous medication but also indirectly due to the increased number of hospitalizations caused by drug-related complications. The beneficial effect of reducing the occurrence of polypharmacy in the population has been addressed to cut down on expenditures for both physician and hospital services.[6]


  Materials and Methods Top


A cross-sectional descriptive design was adopted to carry out the study. The study population constituted of patients >60 years of age in Dr. Rajendra Prasad Government Medical College, Tanda, District Kangra, Himachal Pradesh, India. The following finite population formula was used since the population of the area was <50,000.

n = NZ2 p (1 − p)/d2 (N − 1) + Z2 p (1 − p)

n = 4258 (1.96)2 0.5 (1 − 0.5)/(0.05)2 4257 + (1.96) 2 0.5 (1 − 0.5)

= 353 (adding 5% nonresponse rate) = 371.

Proportionate sampling technique was used. Sampling was done based on the records obtained from the record section of Dr. RPGMC, Tanda. The study sample was chosen using proportionate sampling from eight departments of the hospital that concerned with the treatment of geriatrics patient. These departments include general medicine, surgery, orthopedics and physiotherapy, dental, psychiatry, ear, nose, and throat, ophthalmology, gynecology, and obstetrics. Elderly aged above 60 years who were willing to participate in the study and the elderly present in the OPD at the time of the study were included in the study, whereas the elderly suffering from cancers and other traumatic disorders and IPD patients were excluded from the study.

Data were collected using structured survey questionnaire by the researcher. Hospital visits were conducted to interview and fill the questionnaire from the elderly who had come to the hospital to visit the doctor. For the elderly who could not answer or were not in a good condition, then questions were asked from the relatives or the caregivers accompanying them. The questionnaire comprised two parts. Part A comprised the demographic profile of elderly patients, whereas part B comprised the health profile of the patients. The study period allotted for the completion of research work was from January 2018 to July 2018. The data collection particularly was done in January 2018–February 2018. Data analysis software SPSS (IBM crop., SPSS Statistics for Windows, Version 23.0. Armonk, NY, USA) was used for data entry, processing, and analysis. The research was conducted after obtaining approval from the Institutional Review Committee of Eternal University and Government Medical College and Hospital, Tanda (Himachal Pradesh), India. Verbal and written consent were obtained from the participants. Privacy of the information was maintained and used for research objective only.

Following descriptive and inferential statistics were performed for data analyses:

Frequencies and percentages of different variables were used to check the prevalence of polypharmacy. The Chi-square test was used to examine the significant statistics of polypharmacy with sociodemographic variables.


  Results Top


Tables and figures describe the profile of respondents regarding various aspects of polypharmacy in geriatrics. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] represent variables like side effects of taking medication. The various side effects noted were headache and nausea, constipation, vomiting and dehydration, general weakness and other problems and memory change.
Figure 1: Experienced any side effects of taking medication

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Figure 2: Experienced any headache and nausea

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Figure 3: Have you faced constipation

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Figure 4: Have you faced vomiting and dehydration

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Figure 5: Have you faced general weakness and other problems

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Figure 6: Have you noticed any memory change

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Respondents were questioned for medicines before prescribing new medicines, which refers to the fact that do they ask or tell the physician regarding what medicines they are already taking or informing them of the medicines that they have used before. The respondents were also enquired about the particular aspects like if they knew the use of drugs, their timing, dosage, and frequency of medication and the also if the respondents were aware about the proper clinical use of medicines and also about dependency on others to take medication. They are themselves not aware, but they continue taking them even if the complaint is sorted because of negligence on the caregiver's side. They were also questioned if they faced any consequences due to stocking up of medicines referring to the problems such as not knowing exactly which drug is for what use making it complicated for them to know and remember what to take when they face problem. This has increased chances of wrong medication leading to complications. The special information was taken for nasal and throat problems since the study was conducted in the month of January and February. Most of the elderly at the peak winter season in Himachal Pradesh suffer from respiratory tract infections. Nasal infections and throat infections are common findings in daily OPD, leading to addition of more drugs in their regular prescription. [Table 1], [Table 2], [Table 3], [Table 4] represent profile of respondents regarding drug use pattern, general ailments, association between polypharmacy and drug use behavior and their side effects and association between polypharmacy and other general ailments.
Table 1: Profile of respondents regarding drug use pattern

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Table 2: Profile of respondents regarding general ailments

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Table 3: Association between polypharmacy and drug use behavior and their side effects

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Table 4: Association between polypharmacy and other general ailments

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  Discussion Top


Polypharmacy, a phenomenon less considered and emerging public health concern in elderly persons, has become very common nowadays. This study was conducted for the assessment of patterns and associated aspects of polypharmacy among the geriatric population visiting the Government Medical College and Hospital, Tanda, Himachal Pradesh, India. For the purpose of this study, polypharmacy was considered as the use of four or more drugs by an individual for their morbid or comorbid conditions. The results obtained from the study have been discussed herein.

The study reveals that the highest number of respondents were in the age group of 60–65 years (29.5%) and minimum (7.5%) were aged above 86 years. The mean age of the respondents was 71.14 ± 8.196 years, which differed from the mean age of other studies like the prospective study conducted at the emergency department of General and Oncological Hospital of Kifissia by Vrettos et al. in 2017 revealed 80.24 years and 60.4 ± 14.1 years in an observational, cross-sectional, and descriptive study of patients in Internal Medicine Outpatient clinics at Riyadh, Saudi Arabia by Salih et al. in 2013.[7],[8]

The present study presents the profile of respondents regarding drug use pattern such as majority (50.9%) were questioned most of the times for medicines other than the prescribed ones, 41.0% mostly preferred self-medication (SM), 53.1% had no knowledge about the use of medication, 89.2% had no knowledge of the clinical purpose of the medicine they were using, 51.8% mostly forgot the dose and time of medicines, 18.6% had faced intolerable consequences of discontinuing medicine use, and 13.7% had encountered serious problem due to stocking up of the medicines. These results were compared to the cross-sectional study conducted in Eastern Ethiopia and revealed more than half (57.8%) of the study participants declared that they were practicing SM due to prior experience and seeking less expensive service; two-fifths of them (40.3%) reported pharmacy professionals as source of information, whereas 18.9% of respondents were advised by neighbors, friends, or relatives. About one-third (31.9%) of them did not have any source of information for SM practice.[9]

Another cross-sectional study conducted during December 2012–January 2013 in Puducherry revealed that the prevalence of SM was found to be 11.9%. Fever (31%), headache (19%), and abdominal pain (16.7%) are the most common illnesses where SM is being used. Telling the symptoms to pharmacist (38.1%) was the most common method adopted to procure drugs by the users. Majority of the SM users expressed that SM is harmless (66.6%) and they are going to use 90% and advice others also, i.e. 73.8% to use SM drugs. About 30.9% had used SM not getting relieved even after 2 days of use. People opted for SM mainly due to nature of mild illness and lack of time. Majority of the respondents had the intention to use in future for them and to recommend for others.[10] Further, a SM survey conducted in Wuhan City, China, revealed that the main reasons of opting for SM reported by the respondents include the following: that the severity of the illness did not warrant a visit to the doctor (45.4%); that the trouble of seeing a doctor was not worth the effort (22.5%); that there was no time to see a doctor (11.6%); and that medical costs were too high (15.1%). The sources of drug information for SM were from past experience (51.2%), a friend's recommendation/peer advice (27.7%), the Internet (19.1%), and newspapers and magazines (2%).[11]

The present study revealed the profile of respondents regarding general ailments such as 57.4% faced problems of the eyes, 41.5% ears, 7.8% skin, 29.6% bowel or GI problems, 23.5% dementia, 15.4% obesity/overweight, 15.9% nose, and 13.2% throat which showed slight similarity to the problems such as cold and cough (55.1%), cardiovascular and cerebrovascular diseases (18.2%), gastrointestinal (GI) diseases (15.7%), and bruises (5.5%).[11] The study carried out by O'Dwyer et al. also revealed that GI disease was significantly associated with excessive polypharmacy only.[12] Malignant/digestive/urologic and cardiovascular/renal/metabolic patterns had the strongest association with excessive polypharmacy, and these results could be explained by the increase in over the counter (OTC) medications.[13]

The profile of respondents regarding any side effects revealed that majority (84.6%) experienced side effects of taking medication, 37.5% faced headache and nausea, 47.4% faced constipation, 27.5% vomiting and dehydration, 42.0% faced general weakness, and other problems 40.4% had noticed change in their memory.

Polypharmacy was affected significantly by knowledge about the use of medication (P = 0.01), remembering the doses and timing of the medicines (P = 0.01), and encountering serious problem due to stocking up of the medicines (0.01), whereas no statistically significant relationships between polypharmacy and other factors, SM (P = 0.80), knowledge of clinical purpose of medicines (P = 0.86), facing intolerable consequences of discontinuing medicine use (P = 0.20), facing side effects (P = 0.39), memory change (P = 0.74), headache and nausea (P = 0.79), constipation (P = 0.94), vomiting and dehydration (P = 0.18), and general weakness and other problems (P = 0.58) were found.

It was also revealed that polypharmacy was found significantly related with nasal problems (P = 0.001) and throat problems (P = 0.001), whereas no statistically significant relationship between polypharmacy and other ailments (eyes and ears (P = 0.84), skin (P = 0.18), bowel and other GI problems (P = 0.98), dementia (P = 0.54), and overweight (P = 0.14) was found.[14]

Limitations

  1. The study could have been a community-based study
  2. Only one tertiary health-care hospital was included in the study, the total being two in the state.


Recommendations

  1. The prevalence of polypharmacy was found to be 33.7% among elderly population and joint disorders were the highest. The present study concluded that polypharmacy was affecting the elderly to a very high extent and cannot be ignored. Thus, appropriate measures are needed to check on polypharmacy
  2. Since the only focus of this article was drug use pattern among the elderly, so more aspects of the elderly health should be explored
  3. Further studies should be conducted to explore general practitioners' opinions on the acquisition of the skills of health professionals to support medical care and monitoring of patients receiving multiple medications.


The plan of prevention and implication of the study to the elderly/society

Polypharmacy has potential negative complications because of the fact that most of this segment of population, i.e., geriatrics is often left neglected. This neglection leads to stigmatization of this population. The government should put forth the initiative to launch policies and programs specifically keeping the aspect of polypharmacy in mind. Information, education, and counseling of caregivers are very important as most of this population is dependent on their families and offsprings for care and treatment.


  Conclusion Top


There is a pattern of polypharmacy that combines the factors such as aging and the risk of polypharmacy. The major factors like seeking multiple physicians, over the counter drugs and duplication of medication are important findings. It may also be noted that because the geriatric age group lacks knowledge and clarity about the positive and negative aspects of medication which is often overlooked. Such dimensions of geriatric age group draw them to a typical unhealthy pattern of medication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Sachin D, Nair A, Bilawad S, Mohan SR, Hurakadli S. Drug box: A novel stratergic tool to minimize pill burden and polypharmacy in geriatric population. Indian J Forensic Community Med 2018;5:71-2.  Back to cited text no. 1
    
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Morin L, Johnell K, Laroche ML, Fastbom J, Wastesson JW. The epidemiology of polypharmacy in older adults: Register-based prospective cohort study. Clin Epidemiol 2018;10:289-98.  Back to cited text no. 2
    
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Rambhade S, Chakarborty A, Shrivastava A, Patil UK, Rambhade A. A survey on polypharmacy and use of inappropriate medications. Toxicol Int 2012;19:68-73.  Back to cited text no. 5
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Mohammed SS, Sreenath MK, Vishnu VG, Jose F, Siraj ST, Anand VP. The prevalence of polypharmacy in South Indian patients: A pharmaco-epidemiological approach. Indian J Pharm Pract 2012;5:40.  Back to cited text no. 6
    
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Vrettos I, Voukelatou P, Katsoras A, Theotoka D, Kalliakmanis A. Diseases linked to polypharmacy in elderly patients. Curr Gerontol Geriatr Res 2017;2017:4276047.  Back to cited text no. 7
    
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Salih SB, Yousuf M, Durihim H, Almodaimegh H, Tamim H. Prevalence and associated factors of polypharmacy among adult Saudi medical outpatients at a tertiary care center. J Family Community Med 2013;20:162-7.  Back to cited text no. 8
    
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Mamo S, Ayele Y, Dechasa M. Self-medication practices among community of Harar city and its surroundings, Eastern Ethiopia. J Pharm 2018;2018.  Back to cited text no. 9
    
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Selvaraj K, Kumar SG, Ramalingam A. Prevalence of self-medication practices and its associated factors in urban Puducherry, India. Perspect Clin Res 2014;5:32-6.  Back to cited text no. 10
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O'Dwyer M, Peklar J, McCallion P, McCarron M, Henman MC. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: A cross-sectional observational nationwide study. BMJ Open 2016;6:e010505.  Back to cited text no. 12
    
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Aoki T, Yamamoto Y, Ikenoue T, Onishi Y, Fukuhara S. Multimorbidity patterns in relation to polypharmacy and dosage frequency: A nationwide, cross-sectional study in a Japanese population. Sci Rep 2018;8:3806.  Back to cited text no. 13
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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