Polypharmacy (original) (raw)

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Use of five or more medications daily

Polypharmacy is often defined as taking 5 or more medicines.

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions.[1][2] The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time.[1][3][4] Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older.[5][6] In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population.[7][8] In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects.[9] Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.[9]

The prevalence of polypharmacy is estimated to be between 10% and 90% depending on the definition used, the age group studied, and the geographic location.[10] Polypharmacy continues to grow in importance because of aging populations. Many countries are experiencing a fast growth of the older population, 65 years and older.[11][12][13] This growth is a result of the baby-boomer generation getting older and an increased life expectancy as a result of ongoing improvement in health care services worldwide.[14][15] About 21% of adults with intellectual disability are also exposed to polypharmacy.[16] The level of polypharmacy has been increasing in the past decades. Research in the USA shows that the percentage of patients greater than 65 years-old using more than 5 medications increased from 24% to 39% between 1999 and 2012.[17] Similarly, research in the UK found that the number of older people taking 5 plus medication had quadrupled from 12% to nearly 50% between 1994 and 2011.[18]

Polypharmacy is not necessarily ill-advised, but in many instances can lead to negative outcomes or poor treatment effectiveness, often being more harmful than helpful or presenting too much risk for too little benefit. Therefore, health professionals consider it a situation that requires monitoring and review to validate whether all of the medications are still necessary. Concerns about polypharmacy include increased adverse drug reactions, drug interactions, prescribing cascade, and higher costs.[19] A prescribing cascade occurs when a person is prescribed a drug and experiences an adverse drug effect that is misinterpreted as a new medical condition, so the patient is prescribed another drug.[20] Polypharmacy also increases the burden of medication taking particularly in older people and is associated with medication non-adherence.[21]

Polypharmacy is often associated with a decreased quality of life, including decreased mobility and cognition.[22] Patient factors that influence the number of medications a patient is prescribed include a high number of chronic conditions requiring a complex drug regimen. Other systemic factors that impact the number of medications a patient is prescribed include a patient having multiple prescribers and multiple pharmacies that may not communicate.

Whether or not the advantages of polypharmacy (over taking single medications or monotherapy) outweigh the disadvantages or risks depends upon the particular combination and diagnosis involved in any given case.[23] The use of multiple drugs, even in fairly straightforward illnesses, is not an indicator of poor treatment and is not necessarily overmedication. Moreover, it is well accepted in pharmacology that it is impossible to accurately predict the side effects or clinical effects of a combination of drugs without studying that particular combination of drugs in test subjects. Knowledge of the pharmacologic profiles of the individual drugs in question does not assure accurate prediction of the side effects of combinations of those drugs; and effects also vary among individuals because of genome-specific pharmacokinetics. Therefore, deciding whether and how to reduce a list of medications (deprescribe) is often not simple and requires the experience and judgment of a practicing clinician, as the clinician must weigh the pros and cons of keeping the patient on the medication. However, such thoughtful and wise review is an ideal that too often does not happen, owing to problems such as poorly handled care transitions (poor continuity of care, usually because of siloed information), overworked physicians and other clinical staff, and interventionism.

Appropriate medical uses

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While polypharmacy is typically regarded as undesirable, prescription of multiple medications can be appropriate and therapeutically beneficial in some circumstances.[24] “Appropriate polypharmacy” is described as prescribing for complex or multiple conditions in such a way that necessary medicines are used based on the best available evidence at the time to preserve safety and well-being.[24] Polypharmacy is clinically indicated in some chronic conditions, for example in diabetes mellitus, but should be discontinued when evidence of benefit from the prescribed drugs no longer outweighs potential for harm (described below in Contraindications).[24]

Often certain medications can interact with others in a positive way specifically intended when prescribed together, to achieve a greater effect than any of the single agents alone. This is particularly prominent in the field of anesthesia and pain management – where atypical agents such as antiepileptics, antidepressants, muscle relaxants, NMDA antagonists, and other medications are combined with more typical analgesics such as opioids, prostaglandin inhibitors, NSAIDS and others. This practice of pain management drug synergy[25] is known as an analgesia sparing effect.

Special populations

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People who are at greatest risk for negative polypharmacy consequences include elderly people, people with psychiatric conditions, patients with intellectual or developmental disabilities,[28] people taking five or more drugs at the same time, those with multiple physicians and pharmacies, people who have been recently hospitalized, people who have concurrent comorbidities,[29] people who live in rural communities, people with inadequate access to education,[30] and those with impaired vision or dexterity. Marginalized populations may have a greater degrees of polypharmacy, which can occur more frequently in younger age groups.[31]

It is not uncommon for people who are dependent or addicted to substances to enter or remain in a state of polypharmacy misuse.[32] About 84% of prescription drug misusers reported using multiple drugs.[32] Note, however, that the term polypharmacy and its variants generally refer to legal drug use as-prescribed, even when used in a negative or critical context.

Measures can be taken to limit polypharmacy to its truly legitimate and appropriate needs. This is an emerging area of research, frequently called deprescribing.[33] Reducing the number of medications, as part of a clinical review, can be an effective healthcare intervention.[34] Clinical pharmacists can perform drug therapy reviews and teach physicians and their patients about drug safety and polypharmacy, as well as collaborating with physicians and patients to correct polypharmacy problems. Similar programs are likely to reduce the potentially deleterious consequences of polypharmacy such as adverse drug events, non-adherence, hospital admissions, drug-drug interactions, geriatric syndromes, and mortality.[35] Such programs hinge upon patients and doctors informing pharmacists of other medications being prescribed, as well as herbal, over-the-counter substances and supplements that occasionally interfere with prescription-only medication. Staff at residential aged care facilities have a range of views and attitudes towards polypharmacy that, in some cases, may contribute to an increase in medication use.[36]

Risks of polypharmacy

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The risk of polypharmacy increases with age, although there is some evidence that it may decrease slightly after age 90 years.[2] Poorer health is a strong predictor of polypharmacy at any age, although it is unclear whether the polypharmacy causes the poorer health or if polypharmacy is used because of the poorer health.[2] It appears possible that the risk factors for polypharmacy may be different for younger and middle-aged people compared to older people.[2]

The use of polypharmacy is correlated to the use of potentially inappropriate medications. Potentially inappropriate medications are generally taken to mean those that have been agreed upon by expert consensus, such as by the Beers Criteria. These medications are generally inappropriate for older adults because the risks outweigh the benefits.[37] Examples of these include urinary anticholinergics used to treat incontinence; the associated risks, with anticholinergics, include constipation, blurred vision, dry mouth, impaired cognition, and falls.[38] Many older people living in long term care facilities experience polypharmacy, and under-prescribing of potentially indicated medicines and use of high risk medicines can also occur.[37] Medicine use rises from 6.0 ± 3.8 regular medicines on average when people enter long term care to 8.9 ± 4.1 regular medicines after two years.[39]

Polypharmacy is associated with an increased risk of falls in elderly people.[40][41] Certain medications are well known to be associated with the risk of falls, including cardiovascular and psychoactive medications.[42][43] There is some evidence that the risk of falls increases cumulatively with the number of medications.[44][45] Although often not practical to achieve, withdrawing all medicines associated with falls risk can halve an individual's risk of future falls.

Every medication has potential adverse side-effects. With every drug added, there is an additive risk of side-effects. Also, some medications have interactions with other substances, including foods, other medications, and herbal supplements.[46] 15% of older adults are potentially at risk for a major drug-drug interaction.[47] Older adults are at a higher risk for a drug-drug interaction due to the increased number of medications prescribed and metabolic changes that occur with aging.[48] When a new drug is prescribed, the risk of interactions increases exponentially. Doctors and pharmacists aim to avoid prescribing medications that interact; often, adjustments in the dose of medications need to be made to avoid interactions. For example, warfarin interacts with many medications and supplements that can cause it to lose its effect.[48][49]

Pill burden is the number of pills (tablets or capsules, the most common dosage forms) that a person takes on a regular basis, along with all associated efforts that increase with that number - like storing, organizing, consuming, and understanding the various medications in one's regimen. The use of individual medications is growing faster than pill burden.[50] A recent study found that older adults in long term care are taking an average of 14 to 15 tablets every day.[51]

Poor medical adherence is a common challenge among individuals who have increased pill burden and are subject to polypharmacy.[52] It also increases the possibility of adverse medication reactions (side effects) and drug-drug interactions. High pill burden has also been associated with an increased risk of hospitalization, medication errors, and increased costs for both the pharmaceuticals themselves and for the treatment of adverse events. Finally, pill burden is a source of dissatisfaction for many patients and family carers.[21]

High pill burden was commonly associated with antiretroviral drug regimens to control HIV,[53] and is also seen in other patient populations.[52] For instance, adults with multiple common chronic conditions such as diabetes, hypertension, lymphedema, hypercholesterolemia, osteoporosis, constipation, inflammatory bowel disease, and clinical depression may be prescribed more than a dozen different medications daily.[54] The combination of multiple drugs has been associated with an increased risk of adverse drug events.[55]

Reducing pill burden is recognized as a way to improve medication compliance, also referred to as adherence. This is done through "deprescribing", where the risks and benefits are weighed when considering whether to continue a medication.[56] This includes drugs such as bisphosphonates (for osteoporosis), which are often taken indefinitely although there is only evidence to use it for five to ten years.[56] Patient educational programs, reminder messages, medication packaging, and the use of memory tricks has also been seen to improve adherence and reduce pill burden in several countries.[48] These include associating medications with mealtimes, recording the dosage on the box, storing the medication in a special place, leaving it in plain sight in the living room, or putting the prescription sheet on the refrigerator.[48] The development of applications has also shown some benefit in this regard.[48] The use of a polypill regimen, such as combination pill for HIV treatment, as opposed to a multi-pill regimen, also alleviates pill burden and increases adherence.[52]

The selection of long-acting active ingredients over short-acting ones may also reduce pill burden. For instance, ACE inhibitors are used in the management of hypertension.[_medical citation needed_] Both captopril and lisinopril are examples of ACE inhibitors. However, lisinopril is dosed once a day, whereas captopril may be dosed 2-3 times a day. Assuming that there are no contraindications or potential for drug interactions, using lisinopril instead of captopril may be an appropriate way to limit pill burden.[_medical citation needed_]

The most common intervention to help people who are struggling with polypharmacy is deprescribing.[57] Deprescribing can be confused with medication simplification, which does not attempt to reduce the number of medicines but rather reduce the number of dose forms and administration times.[58] Deprescribing refers to reducing the number of medications that a person is prescribed and includes the identification and discontinuance of medications when the benefit no longer outweighs the harm.[59] In elderly patients, this can commonly be done as a patient becomes more frail and treatment focus needs to shift from preventative to palliative.[59] Deprescribing is feasible and effective in many settings including residential care, communities and hospitals.[57] This preventative measure should be considered for anyone who exhibits one of the following: (1) a new symptom or adverse event arises, (2) when the person develops an end-stage disease, (3) if the combination of drugs is risky, or (4) if stopping the drug does not alter the disease trajectory.[9]

Several tools exist to help physicians decide when to deprescribe and what medications can be added to a pharmaceutical regimen. The Beers Criteria and the STOPP/START criteria help identify medications that have the highest risk of adverse drug events (ADE) and drug-drug interactions.[60][61][62] The Medication appropriateness tool for comorbid health conditions during dementia (MATCH-D) is the only tool available specifically for people with dementia, and also cautions against polypharmacy and complex medication regimens.[63][64]

Barriers faced by both physicians and people taking the medications have made it challenging to apply deprescribing strategies in practice.[65] For physicians, these include fear of consequences of deprescribing, the prescriber's own confidence in their skills and knowledge to deprescribe, reluctance to alter medications that are prescribed by specialists, the feasibility of deprescribing, lack of access to all of patients' clinical notes, and the complexity of having multiple providers.[65][66][67] For patients who are prescribed or require the medication, barriers include attitudes or beliefs about the medications, inability to communicate with physicians, fears and uncertainties surrounding deprescribing, and influence of physicians, family, and the media.[65] Barriers can include other health professionals or carers, such as in residential care, believing that the medicines are required.[68]

In people with multiple long-term conditions (multimorbidity) and polypharmacy deprescribing represents a complex challenge as clinical guidelines are usually developed for single conditions. In these cases tools and guidelines like the Beers Criteria and STOPP/START could be used safely by clinicians but not all patients might benefit from stopping their medication. There is a need for clarity about how much clinicians can do beyond the guidelines and the responsibility they need to take could help them prescribing and deprescribing for complex cases. Further factors that can help clinicians tailor their decisions to the individual are: access to detailed data on the people in their care (including their backgrounds and personal medical goals), discussing plans to stop a medicine already when it is first prescribed, and a good relationship that involves mutual trust and regular discussions on progress. Furthermore, longer appointments for prescribing and deprescribing would allow time explain the process of deprescribing, explore related concerns, and support making the right decisions.[69][70]

The effectiveness of specific interventions to improve the appropriate use of polypharmacy such as pharmaceutical care and computerised decision support is unclear.[9] This is due to low quality of current evidence surrounding these interventions.[9] High quality evidence is needed to make any conclusions about the effects of such interventions in any environment, including in care homes.[71] Deprescribing is not influenced by whether medicines are prescribed through a paper-based or an electronic system.[72] Deprescribing rounds has been proposed as a potentially successful methodology in reducing polypharmacy.[73] Sharing of positive outcomes from physicians who have implemented deprescribing, increased communication between all practitioners involved in patient care, higher compensation for time spent deprescribing, and clear deprescribing guidelines can help enable the practice of deprescribing.[67] Despite the difficulties, a recent blinded study of deprescribing reported that participants used an average of two fewer medicines each after 12 months showing again that deprescribing is feasible.[74]

  1. ^ a b Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE (October 2017). "What is polypharmacy? A systematic review of definitions". BMC Geriatrics. 17 (1): 230. doi:10.1186/s12877-017-0621-2. PMC 5635569. PMID 29017448.
  2. ^ a b c d Lee GB, Etherton-Beer C, Hosking SM, Pasco JA, Page AT (January 2022). "The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review". Therapeutic Advances in Drug Safety. 13: 20420986221100117. doi:10.1177/20420986221100117. PMC 9260603. PMID 35814333.
  3. ^ Taghy N, Cambon L, Cohen JM, Dussart C (2020). "Failure to Reach a Consensus in Polypharmacy Definition: An Obstacle to Measuring Risks and Impacts-Results of a Literature Review". Therapeutics and Clinical Risk Management. 16: 57–73. doi:10.2147/TCRM.S214187. PMC 7023902. PMID 32103967.
  4. ^ Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S (June 2017). "Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy". Pharmacology Research & Perspectives. 5 (3): e00321. doi:10.1002/prp2.321. PMC 5464348. PMID 28603638.
  5. ^ "Multiple long-term conditions (multimorbidity): making sense of the evidence". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2021-03-30. doi:10.3310/collection_45881. S2CID 243406561.
  6. ^ Schneider J, Algharably EA, Budnick A, Wenzel A, Dräger D, Kreutz R (2021-06-08). "High Prevalence of Multimorbidity and Polypharmacy in Elderly Patients With Chronic Pain Receiving Home Care are Associated With Multiple Medication-Related Problems". Frontiers in Pharmacology. 12: 686990. doi:10.3389/fphar.2021.686990. PMC 8217758. PMID 34168565.
  7. ^ "polypharmacy". Oxford English Dictionary. 2022. The use of multiple drugs or medicines for several concurrent disorders (now esp. by elderly patients), often with the suggestion of indiscriminate, unscientific, or excessive prescription.
  8. ^ "A Glossary of Terms for Community Health Care and Services for Older Persons" (PDF). World Health Organization. 2004. p. 45. Retrieved September 6, 2022. 1 The administration of many drugs at the same time. 2 The administration of an excessive number of drugs.
  9. ^ a b c d e Cole, Judith A; Gonçalves-Bradley, Daniela C; Alqahtani, Mubarak; Barry, Heather E; Cadogan, Cathal; Rankin, Audrey; Patterson, Susan M; Kerse, Ngaire; Cardwell, Chris R; Ryan, Cristin; Hughes, Carmel (2023-10-11). Cochrane Effective Practice and Organisation of Care Group (ed.). "Interventions to improve the appropriate use of polypharmacy for older people". Cochrane Database of Systematic Reviews. 2023 (10): CD008165. doi:10.1002/14651858.CD008165.pub5. PMC 10565901. PMID 37818791.
  10. ^ Khezrian M, McNeil CJ, Murray AD, Myint PK (2020). "An overview of prevalence, determinants and health outcomes of polypharmacy". Therapeutic Advances in Drug Safety. 11: 2042098620933741. doi:10.1177/2042098620933741. PMC 7294476. PMID 32587680.
  11. ^ Cruz LP, Miranda PM, Vedana KG, Miasso AI (2011). "Medication therapy: adherence, knowledge and difficulties of elderly people from bipolar disorder". Revista Latino-Americana de Enfermagem. 19 (4): 944–952. doi:10.1590/S0104-11692011000400013. PMID 21876947.
  12. ^ Gellad WF, Grenard JL, Marcum ZA (February 2011). "A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity". The American Journal of Geriatric Pharmacotherapy. 9 (1): 11–23. doi:10.1016/j.amjopharm.2011.02.004. PMC 3084587. PMID 21459305.
  13. ^ Page AT, Falster MO, Litchfield M, Pearson SA, Etherton-Beer C (July 2019). "Polypharmacy among older Australians, 2006-2017: a population-based study". The Medical Journal of Australia. 211 (2): 71–75. doi:10.5694/mja2.50244. PMID 31219179.
  14. ^ Cline CM, Björck-Linné AK, Israelsson BY, Willenheimer RB, Erhardt LR (June 1999). "Non-compliance and knowledge of prescribed medication in elderly patients with heart failure". European Journal of Heart Failure. 1 (2): 145–149. doi:10.1016/S1388-9842(99)00014-8. PMID 10937924. S2CID 32043403.
  15. ^ Yasein NA, Barghouti FF, Irshaid YM, Suleiman AA (March 2013). "Discrepancies between elderly patient's self-reported and prescribed medications: a social investigation". Scandinavian Journal of Caring Sciences. 27 (1): 131–138. doi:10.1111/j.1471-6712.2012.01012.x. PMID 22616831.
  16. ^ Haider SI, Ansari Z, Vaughan L, Matters H, Emerson E (November 2014). "Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability". Research in Developmental Disabilities. 35 (11): 3071–3080. doi:10.1016/j.ridd.2014.07.060. PMID 25129201.
  17. ^ Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL (November 2015). "Trends in Prescription Drug Use Among Adults in the United States From 1999-2012". JAMA. 314 (17): 1818–1831. doi:10.1001/jama.2015.13766. PMC 4752169. PMID 26529160.
  18. ^ Gao L, Maidment I, Matthews FE, Robinson L, Brayne C (March 2018). "Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II". Age and Ageing. 47 (2): 220–225. doi:10.1093/ageing/afx158. PMC 6037294. PMID 29036509.
  19. ^ Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J (January 2009). "The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people". Journal of the American Geriatrics Society. 57 (1): 62–69. doi:10.1111/j.1532-5415.2008.02040.x. PMID 19054196. S2CID 205703844.
  20. ^ Ponte ML, Wachs L, Wachs A, Serra HA (2017). "Prescribing cascade. A proposed new way to evaluate it". Medicina. 77 (1): 13–16. PMID 28140305.
  21. ^ a b Maidment ID, Lawson S, Wong G, Booth A, Watson A, McKeown J, et al. (June 2020). "Medication management in older people: the MEMORABLE realist synthesis". Health Services and Delivery Research. 8 (26): 1–128. doi:10.3310/hsdr08260. PMID 32579319. S2CID 225671789.
  22. ^ "Polypharmacy in Elderly Patients" (PDF). Vumc.nl. Archived from the original (PDF) on 22 January 2016. Retrieved 16 January 2015.
  23. ^ Tamminga CA (July 2011). "When is polypharmacy an advantage?". The American Journal of Psychiatry. 168 (7): 663. doi:10.1176/appi.ajp.2011.11050695. PMID 21724668.
  24. ^ a b c Duerden M, Avery T, Payne R (November 2013). Polypharmacy and medicines optimisation : making it safe and sound. London. ISBN 978-1-909029-18-7. OCLC 864790728.{{[cite book](/wiki/Template:Cite%5Fbook "Template:Cite book")}}: CS1 maint: location missing publisher (link)
  25. ^ Tallarida RJ (November 2011). "Quantitative methods for assessing drug synergism". Genes & Cancer. 2 (11): 1003–1008. doi:10.1177/1947601912440575. PMC 3379564. PMID 22737266.
  26. ^ Sergi G, De Rui M, Sarti S, Manzato E (July 2011). "Polypharmacy in the elderly: can comprehensive geriatric assessment reduce inappropriate medication use?". Drugs & Aging. 28 (7): 509–518. doi:10.2165/11592010-000000000-00000. PMID 21721596. S2CID 28551158.
  27. ^ Torpy JM, Lynm C, Golub RM (March 2011). "JAMA patient page. General anesthesia". JAMA. 305 (10): 1050. doi:10.1001/jama.305.10.1050. PMID 21386084.
  28. ^ Raj R, Owen D, Kannan L, Syeda U (February 2022). "Polypharmacy in a Patient With Intellectual and Developmental Disabilities". Cureus. 14 (2): e22019. doi:10.7759/cureus.22019. PMC 8908801. PMID 35282537.
  29. ^ Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW (August 2005). "Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance". JAMA. 294 (6): 716–724. doi:10.1001/jama.294.6.716. PMID 16091574. S2CID 28090181.
  30. ^ Haider SI, Johnell K, Thorslund M, Fastbom J (February 2008). "Analysis of the association between polypharmacy and socioeconomic position among elderly aged > or =77 years in Sweden". Clinical Therapeutics. 30 (2): 419–427. doi:10.1016/j.clinthera.2008.02.010. PMID 18343279.
  31. ^ Page A, Hyde Z, Smith K, Etherton-Beer C, Atkinson DN, Flicker L, et al. (August 2019). "Potentially suboptimal prescribing of medicines for older Aboriginal Australians in remote areas". The Medical Journal of Australia. 211 (3): 119–125. doi:10.5694/mja2.50226. hdl:11343/285988. PMID 31187902. S2CID 186205805.
  32. ^ a b Omenka I, Greene MS (2017-08-01). Polypharmacy Among Prescription Drug Users. Indiana University Center for Bioethics, Indiana State Department of Health, The Association of State and Territorial Health Officials (ASTHO) (Report).
  33. ^ Quek, Hui Wen (2024). "The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis". British Journal of Clinical Pharmacology. 90 (10): 2409–2482. doi:10.1111/bcp.16200. PMID 39164070.
  34. ^ Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD (September 2016). "The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis". British Journal of Clinical Pharmacology. 82 (3): 583–623. doi:10.1111/bcp.12975. PMC 5338123. PMID 27077231.
  35. ^ Hajjar ER, Cafiero AC, Hanlon JT (December 2007). "Polypharmacy in elderly patients". The American Journal of Geriatric Pharmacotherapy. 5 (4): 345–351. doi:10.1016/j.amjopharm.2007.12.002. PMID 18179993.
  36. ^ Lo SY, Reeve E, Page AT, Zaidi ST, Hilmer SN, Etherton-Beer C, et al. (August 2021). "Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff". Drugs & Aging. 38 (8): 697–711. doi:10.1007/s40266-021-00874-2. PMID 34169458. S2CID 235630612.
  37. ^ a b Page AT, Potter K, Naganathan V, Hilmer S, McLachlan AJ, Lindley RI, et al. (February 2023). "Polypharmacy and medicine regimens in older adults in residential aged care". Archives of Gerontology and Geriatrics. 105: 104849. doi:10.1016/j.archger.2022.104849. PMID 36399891. S2CID 253363170.
  38. ^ Taylor-Rowan M, Edwards S, Noel-Storr AH, McCleery J, Myint PK, Soiza R, et al. (Cochrane Dementia and Cognitive Improvement Group) (May 2021). "Anticholinergic burden (prognostic factor) for prediction of dementia or cognitive decline in older adults with no known cognitive syndrome". The Cochrane Database of Systematic Reviews. 2021 (5): CD013540. doi:10.1002/14651858.CD013540.pub2. PMC 8169439. PMID 34097766.
  39. ^ Page, A; Potter, Kathleen; Lee, Georgie; Almutairi, Hend; Lee, Kenneth; Wang, Kate; Ailabouni, Nagham; Etherton-Beer, Christopher (2024-02-28). "Medicines Regimens Charted for Older People Living in Residential Aged Care: A Repeated Cross-Sectional Study Describing the Number of Medicines, Regimen Complexity, High-Risk Prescribing, and Potential Underprescribing". Journal of the American Medical Directors Association. 25 (6). doi:10.1016/j.jamda.2024.01.013. ISSN 1525-8610. PMID 38428832.
  40. ^ WHO global report on falls prevention in older age. Geneva, Switzerland: World Health Organization. 2008. ISBN 978-92-4-156353-6. OCLC 226291980.
  41. ^ Seniors' falls in Canada. Second report. Ottawa, ON: Public Health Agency of Canada. 2014. ISBN 978-1-100-23261-4. OCLC 1031268452.
  42. ^ Park H, Satoh H, Miki A, Urushihara H, Sawada Y (December 2015). "Medications associated with falls in older people: systematic review of publications from a recent 5-year period". European Journal of Clinical Pharmacology. 71 (12): 1429–1440. doi:10.1007/s00228-015-1955-3. PMID 26407688. S2CID 44942.
  43. ^ de Vries M, Seppala LJ, Daams JG, van de Glind EM, Masud T, van der Velde N (April 2018). "Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: I. Cardiovascular Drugs". Journal of the American Medical Directors Association. 19 (4): 371.e1–371.e9. doi:10.1016/j.jamda.2017.12.013. PMID 29396189.
  44. ^ Zia A, Kamaruzzaman SB, Tan MP (April 2015). "Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk". Postgraduate Medicine. 127 (3): 330–337. doi:10.1080/00325481.2014.996112. PMID 25539567. S2CID 23910834.
  45. ^ Fried TR, O'Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK (December 2014). "Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review". Journal of the American Geriatrics Society. 62 (12): 2261–2272. doi:10.1111/jgs.13153. PMC 4270076. PMID 25516023.
  46. ^ "Drug Interactions: What You Should Know". Center for Drug Evaluation and Research. U.S. Food and Drug Administration. 2020-03-17.
  47. ^ Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC (April 2016). "Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011". JAMA Internal Medicine. 176 (4): 473–482. doi:10.1001/jamainternmed.2015.8581. PMC 5024734. PMID 26998708.
  48. ^ a b c d e Merel SE, Paauw DS (July 2017). "Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care". Journal of the American Geriatrics Society. 65 (7): 1578–1585. doi:10.1111/jgs.14870. PMID 28326532. S2CID 6621392.
  49. ^ Stewart D, Mair A, Wilson M, Kardas P, Lewek P, Alonso A, et al. (February 2017). "Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments". Expert Opinion on Drug Safety. 16 (2): 203–213. doi:10.1080/14740338.2017.1265503. hdl:10059/2071. PMID 27885844. S2CID 205825132.
  50. ^ Page AT, Falster MO, Litchfield M, Pearson SA, Etherton-Beer C (July 2019). "Polypharmacy among older Australians, 2006-2017: a population-based study". The Medical Journal of Australia. 211 (2): 71–75. doi:10.5694/mja2.50244. PMID 31219179.
  51. ^ Page AT, Potter K, Naganathan V, Hilmer S, McLachlan AJ, Lindley RI, et al. (February 2023). "Polypharmacy and medicine regimens in older adults in residential aged care". Archives of Gerontology and Geriatrics. 105: 104849. doi:10.1016/j.archger.2022.104849. PMID 36399891. S2CID 253363170.
  52. ^ a b c Baumgartner A, Drame K, Geutjens S, Airaksinen M (February 2020). "Does the Polypill Improve Patient Adherence Compared to Its Individual Formulations? A Systematic Review". Pharmaceutics. 12 (2): 190. doi:10.3390/pharmaceutics12020190. PMC 7076630. PMID 32098393.
  53. ^ Paramesha AE, Chacko LK (2019). "Predictors of adherence to antiretroviral therapy among PLHIV". Indian Journal of Public Health. 63 (4): 367–376. doi:10.4103/ijph.IJPH_376_18. PMID 32189660. S2CID 209445305.
  54. ^ Ha CY (February 2014). "Medical management of inflammatory bowel disease in the elderly: balancing safety and efficacy". Clinics in Geriatric Medicine. 30 (1): 67–78. doi:10.1016/j.cger.2013.10.007. PMID 24267603.
  55. ^ Maher RL, Hanlon J, Hajjar ER (January 2014). "Clinical consequences of polypharmacy in elderly". Expert Opinion on Drug Safety. 13 (1): 57–65. doi:10.1517/14740338.2013.827660. PMC 3864987. PMID 24073682.
  56. ^ a b Hilmer SN, Gnjidic D, Le Couteur DG (December 2012). "Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients". Australian Family Physician. 41 (12): 924–928. PMID 23210113.
  57. ^ a b Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD (September 2016). "The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis". British Journal of Clinical Pharmacology. 82 (3): 583–623. doi:10.1111/bcp.12975. PMC 5338123. PMID 27077231.
  58. ^ Sluggett JK, Page AT, Chen EY, Ilomäki J, Corlis M, Van Emden J, et al. (July 2019). "Protocol for a non-randomised pilot and feasibility study evaluating a multicomponent intervention to simplify medication regimens for people receiving community-based home care services". BMJ Open. 9 (7): e025345. doi:10.1136/bmjopen-2018-025345. PMC 6661559. PMID 31326924.
  59. ^ a b Cadogan CA, Ryan C, Hughes CM (February 2016). "Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many". Drug Safety. 39 (2): 109–116. doi:10.1007/s40264-015-0378-5. PMC 4735229. PMID 26692396.
  60. ^ By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel (May 2023). "American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults". Journal of the American Geriatrics Society. 71 (7): 2052–2081. doi:10.1111/jgs.18372. PMID 37139824. S2CID 258486318.{{[cite journal](/wiki/Template:Cite%5Fjournal "Template:Cite journal")}}: CS1 maint: numeric names: authors list (link)
  61. ^ O'Mahony D (January 2020). "STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress". Expert Review of Clinical Pharmacology. 13 (1): 15–22. doi:10.1080/17512433.2020.1697676. PMID 31790317. S2CID 208611400.
  62. ^ "STOPP-START - CGA Toolkit Plus". cgakit. Retrieved 2023-05-06.
  63. ^ "MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia".
  64. ^ Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C (October 2016). "Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel". Internal Medicine Journal. 46 (10): 1189–1197. doi:10.1111/imj.13215. PMC 5129475. PMID 27527376.
  65. ^ a b c Reeve E, Thompson W, Farrell B (March 2017). "Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action". European Journal of Internal Medicine. 38: 3–11. doi:10.1016/j.ejim.2016.12.021. PMID 28063660.
  66. ^ Anderson K, Stowasser D, Freeman C, Scott I (December 2014). "Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis". BMJ Open. 4 (12): e006544. doi:10.1136/bmjopen-2014-006544. PMC 4265124. PMID 25488097.
  67. ^ a b Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM (2016-04-19). "Challenges and Enablers of Deprescribing: A General Practitioner Perspective". PLOS ONE. 11 (4): e0151066. Bibcode:2016PLoSO..1151066A. doi:10.1371/journal.pone.0151066. PMC 4836702. PMID 27093289.
  68. ^ Lo SY, Reeve E, Page AT, Zaidi ST, Hilmer SN, Etherton-Beer C, et al. (August 2021). "Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff". Drugs & Aging. 38 (8): 697–711. doi:10.1007/s40266-021-00874-2. PMID 34169458. S2CID 235630612.
  69. ^ "How to reduce medications for people with multiple long-term conditions". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2023-05-18. doi:10.3310/nihrevidence_57904. S2CID 258801327.
  70. ^ Reeve J, Maden M, Hill R, Turk A, Mahtani K, Wong G, et al. (July 2022). "Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis". Health Technology Assessment. 26 (32): 1–148. doi:10.3310/AAFO2475. PMC 9376985. PMID 35894932.
  71. ^ Alldred DP, Kennedy MC, Hughes C, Chen TF, Miller P (February 2016). "Interventions to optimise prescribing for older people in care homes". The Cochrane Database of Systematic Reviews. 2016 (2): CD009095. arXiv:1510.02343. doi:10.1002/14651858.CD009095.pub3. PMC 7111425. PMID 26866421.
  72. ^ Winata S, Liacos M, Crabtree A, Page A, Moran C (January 2021). "Electronic Medication Management System Introduction and Deprescribing Practice in Post-Acute Care". Journal of the American Medical Directors Association. 22 (1): 90–95. doi:10.1016/j.jamda.2020.10.015. PMID 33234446. S2CID 227167464.
  73. ^ Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D (February 2019). "Impact of deprescribing rounds on discharge prescriptions: an interventional trial". International Journal of Clinical Pharmacy. 41 (1): 159–166. doi:10.1007/s11096-018-0753-2. PMID 30478496. S2CID 53730423.
  74. ^ Quek HW, Etherton-Beer C, Page A, McLachlan AJ, Lo SY, Naganathan V, et al. (April 2023). "Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation". Archives of Gerontology and Geriatrics. 107: 104910. doi:10.1016/j.archger.2022.104910. PMID 36565605. S2CID 254917543.