Authored by SM Alqallaf*
Abstract
Multiple drug use is considered to be hazardous generally and in specific for the elderly because of their greater vulnerability to complications. The aim of this study is to determine the satisfaction and knowledge of elderly patients in Bahrain towards their multiple medications usage and to discover the prevalence of inappropriate polypharmacy among elderly patients in Bahrain. In a cross-sectional study, 100 participants age more than 55 years were interviewed to determine the prevalence of polypharmacy. The participants were randomly selected and asked to answer a questionnaire. The questionnaire consisted of questions regarding drugs taken, pattern of using each drug and patients’ personal, social and medical history in addition to their satisfaction with their treatment regimen. The data collected were analyzed using Microsoft Excel. Participants were found to consume an average of 8.14 ± 1.22 of drugs and the average number of tablets / capsules were 9.88 ± 1.21. The most commonly used drugs were aspirin, atorvastatin, metformin, and beta-blockers. Those were prescribed by physicians in 82 % of cases. Participants using herbal products / nutritional supplements were found to be 34%. The desire of participants to reduce the number of their medications was found to be high (83%) as many believed that at least one of them is causing side effects. Polypharmacy is common among elderly population in Bahrain and is affected by age, education level and medical factors. Different measures need to be implemented to minimize this problem to ensure better health for the elderly population.
Keywords: Polypharmacy; Multiple medications; Satisfaction
Background and Aims
Although multiple drug use or polypharmacy might be considered appropriate as in cases of concomitant diseases or in complex medical conditions, the inappropriate polypharmacy or major polypharmacy is a very common problem around the globe [1-4]. An example of that is a German study which reported the use of more than 5 medications in 26.7% of elderly patients and this doubles (54%) when including over the counter medications [1]. Nevertheless, the number of medications that constitutes polypharmacy is not fully agreed. However, WHO (2004) defined Polypharmacy as “the administration of many drugs at the same time or the administration of an excessive number of drugs “WHO 2004. Hence, polypharmacy term has been used to describe a patient’s use of multiple drugs and is used also more generally to describe unnecessary drug prescription [3,5].
The main reason for the problem of inappropriate polypharmacy is the growing elderly population with its accompanying pathophysiological changes and the advancement in healthcare services [6-8]. Age-related changes involves all body organs / systems and necessitates special considerations in drug prescribing in the elderly [9]. These changes might affect drugs’ pharmacokinetics parameters and might result in potential drugdrug interactions [9,10]. Other causes for the polypharmacy include visiting multiple physicians, the use of complex drug treatment and the occurrence of drugs’ side effects which might be interpreted as a newly existing disease [6,11,12]. Another genuine reason is the psychosocial factor such as the use of traditional remedies or herbs which was reported in 30 % of German adults [6,8].
The evidence for the negative impact of polypharmacy on the patients’ health is well established, even with the intake of as few as four medications at any given time [5,13]. One main complication is the exposure to potentially inappropriate medications with what it carries of an increase in the incidence of serious adverse drug reactions and interactions [2,6,13-16]. In Sweden, fatal adverse drug reactions represented approximately 3 % of all deaths in elderly patients [15]. Non-fatal adverse drug reactions secondary to polypharmacy represents a significant cause of emergency department visits and hospital admission in the elderly [7,14-16]. A study indicated that 12 % of hospital admissions in elderly are related to adverse drug reactions [14]. These patients were found to be at increased risk of rehospitalization [17]. Another complication of polypharmacy is the under-prescribing of recommended drugs; which is known as ‘‘treatment risk paradox’’ [6]. Polypharmacy is also associated with an increase in the risk of geriatric syndromes such as delirium, falls, incontinence and behavioral disturbances [14-16]. Other consequences of polypharmacy are higher mortality rate, greater health-care cost and increased medication errors [6, 14-18]. Additionally, multiple medication use carries the risk of poor adherence which is a multi-factorial problem [14]. Factors that might worsen the problem of poor adherence in patients with multiple medications include dosing schedule confusion, inadequate medication education / counselling, poor patient’s memory, poor hand dexterity with difficult to open packages and it might intentional trying to avoid adverse drug reactions [6].
The aim of this study is to determine the satisfaction and knowledge of elderly patients in Bahrain towards their multiple medication’s usage. Another aim is to discover the prevalence of inappropriate polypharmacy among elderly patients in Bahrain.
Methods
A systematic review of the literature was performed using several medical engines including the National Library of Medicine’s PubMed database, Science Direct and Google Scholars (limited to English language). The terms used in the search were polypharmacy, multiple medication use, polypharmacy and elderly, inappropriate medication frequency, medication errors with polypharmacy. The search profile included comprehensive lists of various clinical studies that were conducted in different world areas for statistically relevant information about polypharmacy. Data of these studies were eventually compared with the analysis of the current study. A cross sectional survey was carried out aiming at exploring the prevalence of the problem of inappropriate polypharmacy. Using a standardized questionnaire, 100 Bahraini patients aged 55 to more than 75 years were interviewed in different. Because of the limited time available for completing the study being part of an educational course, convenience sampling was used and therefore the study may not be sufficiently representative of the entire population. The Inclusion criteria were patients aged more than 55 years. No exclusion criteria were put. Both genders were enrolled, in which fifty-five males and forty-five females were interviewed. Participants answered 14 questions regarding drugs taken, pattern of using each drug and patients’ personal, social and medical history in addition to their satisfaction with their treatment regimen. The survey was pilot tested on 10 subjects to improve questions, clarity and quality of data collection. Full demographic data was collected for all subjects, including age, gender, and education Table 1.
A summary score of percentage correct answers was finally created. The data was analyzed using Microsoft Excel program for statistical analysis. Since the study is cross-sectional, descriptive statistical analysis was conducted. This study was approved by the Pharmacy Program Ethics Committees. Data was collected from participants who provided verbal consent.
Results
Demographic data
Demographical data of the participants are shown in Table 1. The male patients were 55 %, while the rest were female. The majority (49 %) of patients were 55 - 64 years age, 31 % were 65- 75 years and the rest (20%) were more than 75 years. Illiterate patients were 15 %, patients with elementary, intermediate and secondary school certificates were 18%, 16% and 33% respectively, while patients with university degrees were 18%. The results showed that the majority of participants suffered from diabetes (87%), hypertension (84%) and hyperlipidemia (83%). Furthermore, some of the participants suffered from heart disease (38 %), thyroid gland disorders (32%) and other chronic disease such as gout, glaucoma, depression, asthma and rheumatoid arthritis (Figure 1).
The number of medications that patients take daily ranged from 4 to 26 with an average of 8.14±1.22. The most commonly used drugs were acetylsalicylic acid, atorvastatin, metformin, atenolol and propranolol. These drugs were prescribed by physicians in over 82 % of patients. The number of tablets or capsules used daily ranged from 6 to 27 with an average of 9.88 ± 1.21 (data not shown). It was found that 90 % of participants felt that all their regular medications were necessary; while 5% felt that they were taking a medication they no longer need (Figure 2). The desire of the participants to reduce the number of medications they were taking currently was found to be high (83%); while 3% felt comfortable with the number of medications they were taking (Figure 3).
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