MEETING REPORT
Polypharmacy and ageing
More than 450 participants gathered in Prague for the 50th European Society for Clinical Pharmacy Symposium . Topics included the challenges of managing multimorbidity and frailty , medication errors and appropriate medicines ’ use
Christine Clark PhD FRPharmS FCPP ( Hon ) Freelance medical writer
Polypharmacy and multimorbidity are closely interlinked , according to Graziano Onder ( Director of the Department of Cardiovascular , Endocrine-metabolic Diseases and Ageing , Italian National Institute of Health ). Polypharmacy is defined as taking five or more prescription drugs and multimorbidity as the co-occurrence of two or more chronic conditions . Multimorbidity is estimated to affect more than 60 % of older adults . It represents a challenge for health care systems because they tend to be focused on single conditions , he said .
The I-CARE4OLD network ( www . icare4old . eu ) has analysed data from more than 170,000 older adults ( 60 years or older ) and found that five common patterns or classes of disease predominate . They are : cardiopulmonary diseases , psychiatric conditions , stroke / hemiplegia , Alzheimer ’ s disease and ‘ other dementia ’.
Multimorbidity leads to polypharmacy and a report from Italy study showed that one third of over-65s were taking 10 or more medications . 1 Anti-hypertensive agents , PPIs and antibiotics were especially widely used . The risk of drug – drug interactions is high – for example , nearly one million Italians are estimated to be at risk of bleeding as a result of drug-drug interactions , explained Professor Onder .
Guidelines for management of multimorbidity and polypharmacy have been published by the National Institute for Health and Care Excellence ( NICE ) in the UK , the American Geriatric Society and an Italian group . All cover broadly similar ground and stress the importance of the patient ’ s own wishes and preferences . One important idea is the concept of ‘ inflammaging ’. This suggests that disease processes start years or decades before overt evidence of disease is apparent . It follows that early treatment is called for to ‘ switch off inflammation ’. This marks a paradigm shift from treating individual conditions to targeting ageing , as is being done in the TAME ( Targeting Aging with Metformin ) trial , 2 explained Professor Onder .
Frailty Frailty is a condition that affects about 30 % of the over-70s and it is important to realise that it is not the same as being chronologically old , Professor Eva Topinkova ( Department of Geriatrics , Charles University , Prague ) emphasised . It is defined as “ age-related alteration in physiology and pathology that leads to vulnerability with loss of organ system reserve , limited capacity to respond to internal and environmental stresses , unstable homeostasis and poor medical and functional outcomes ”. Thus , episodes of acute illness cause sharp declines in health and people do not recover to the same level as before .
The frailty phenotype is characterised by weight loss , weakness , fatigue and low level of physical activity ( e . g ., slow walking ). There can also be signs of osteopenia and sarcopenia ( loss of muscle mass and function ). “ Frailty and sarcopenia are two sides of the same coin ”, said Professor Topinkova . Adverse drug events and physical frailty are both associated with sarcopenia , she added .
A 2015 French study of frailty and polypharmacy concluded that frailty and excessive polypharmacy were independent predictors of mortality . 3 Moreover , frail people with excessive polypharmacy were six-times more likely to die during the follow-up period .
Some frailty indices are difficult to use in day-to-day clinical practice because they are time-consuming or require special instruments . A study comparing two frailty indices concluded that a simple , three-item instrument reliably predicts the risk of falls , disability , fracture , and death . 4 The Study of Osteoporotic Fractures ( SOF ) index uses only weight loss , inability to rise from a chair five times without using arms , and reduced energy level and is easy to use in routine daily practice , she said .
Pharmacists need key competencies to tackle frailty and polypharmacy . A recent article set out the measures required and recommended a structured review of prescribed medicines to enable rapid identification and management of potentially problematic medications . 5 Such medicines could include those which increased anticholinergic burden , benzodiazepines , and those likely to cause falls .
Drug-related problems and deprescribing In order to reduce the number of drug-related problems , much effort has been directed at identification of potentially inappropriate medicines ( PIMs ) and measures to reduce prescribing of high-risk drugs , said Professor Tobias Dreischulte ( Institute of Family Practice and General Medicine , LMU Hospital , Munich , Germany ). The most obvious route was to educate doctors but in practice this has not always resulted in reduced prescribing of high-risk drugs . The EMPOWER study , 6 in Canada , targeted deprescribing of benzodiazepines by educating patients via community pharmacies , rather than doctors . The results of this randomised study showed that 62 % of patients in the intervention group initiated a conversation with the physician or pharmacist and 27 % ( intervention ) vs 5 % ( control ) discontinued benzodiazepines .
Managing polypharmacy is complex and time-consuming , he said . Given that annual reviews are recommended and
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