Problematic aspects of polypragmasia in the development of multimorbidity in elderly and senile patients

10.18137/cardiometry.2022.25.1924; Available from: http://www.

In most countries of the world today, there is an increase in people whose age is 60 years and older, and the forecast of an increase in the age limits of survival is quite favorable [1]. This has become possible thanks to the introduction of new medical technologies and public health, which enable elderly people to live with one or more chronic diseases. The positive aspect of the above invariably entails a problem associated with demographic changes of this magnitude, which results in a change in approaches to providing medical and social care taking into account the age of patients.

Multimorbidity is a fairly common phenomenon among elderly and senile patients, which results in their use of several medications simultaneously [2]. In addition to medications prescribed by medical specialists, elderly patients also use other medications under the influence of numerous recommendations from the media and “reputable” acquaintances and friends. Accordingly, in this case there is a phenomenon that is designated by the medical term “polypragmasia”.

To date, there is no consensus on the definition of this term, but attempts are continuing to improve its definition and shift the focus from a simple number of drugs to their expediency, effects and, ultimately, to appropriate clinical outcomes in elderly patients. However, in this context, it is very important to understand the following: age-related changes significantly transform pharmacokinetics and pharmacodynamics, and quite often taking certain medications may not only fail to achieve the desired result, but also cause irreparable harm to the body of an elderly person. In this regard, clinical testing of individual drugs or their combinations can play a very important role, but elderly people are often excluded from such trials. For this reason, there is a lack of evidence of the safety and efficacy of many drugs in the population under consideration [3].

It is for the above reasons that the expediency of using a significant number of medications in comor-bid patients remains unclear. This entails the inadequacy of drug treatment and causes adverse clinical outcomes. The scale of the problem is growing from year to year, for this reason, the identification of problems and clinical consequences of polypragmasia for elderly and senile patients with comorbidity is becoming an increasingly relevant and significant approach in the light of the provision of specialized medical and social services to age-related patients.

Materials and methods

The problem of polypragmasia in the development of comorbidity in age-related patients every year becomes the focus of research by an increasing number of specialists from different countries. Both review studies and generalized clinical cases are devoted to its consideration. To study the presented problem, we carried out a generalization and analysis of the selected information array devoted to the research topic; in the process of writing the work, general scientific and private research methods were used.

Results

Elderly and senile patients, taking into account the state of the body, are known to be susceptible to the development of various diseases, while one patient may develop two or more diseases at the same time. Experts call this condition multimorbidity [4]. Diseases can cover both physical and psychosocial spheres and include conditions such as cardiovascular, metabolic, musculoskeletal diseases, mental illnesses, chronic pain, sensory deprivation and substance abuse.

It must be said that multimorbidity can develop not only in elderly patients, but it is among people who are over 60 years old and older that this condition is most common due to age-related disorders in the work of various organs.

Experts note that people living with multimorbidity are at greater risk of incidents, as well as deterioration of pre-existing mental health problems, unplanned hospitalization, higher levels of polypragmasia and adverse drug reactions (ADR), as well as a decrease in quality of life [5].

The consequences of multimorbidity affect both individuals and health systems, as multimorbidity is associated with lower quality of life and mental health, impaired functionality and increased health care costs, which are associated, among other things, with increased use of primary health care and, especially, inpatient care.

Patients with multimorbidity have an increased risk of mortality. Thus, according to the researchers, in 20 | Cardiometry | Issue 25. December 2022

adults over 60 years of age with ≥2 or ≥3 diseases, the risk of death was higher by 1.73 (95% CI: 1.41; 2.13) and 2.72 (95% CI: 1.81; 4.08), respectively, compared with those who were not multimorbid [6]. Understanding the trends of a constant increase in the number of age-related patients with polypragmasia brings to life the need to comprehend the problems arising in this regard and find solutions to them.

Researchers note the multifactorial relationship between multiple morbidity and poor outcome for patients. So, there is an opinion that health conditions tend to combine and interact with other related diseases and can aggravate the severity of each disease or lead to the development of another potentially more serious condition. In particular, the metabolic syndrome is based on visceral obesity and insulin resistance and can be combined with hypertension and hyperlipidemia. The interaction between these diseases causes the deterioration of each individual condition, while increasing the risk of cardiovascular events, such as stroke or myocardial infarction.

Among other similar examples, congestive heart failure and dementia should be cited, when patients often have several coexisting long-term conditions, such as diabetes and hypertension, while their daily activity and physical functions are disrupted [7].

The literature notes that in clinical practice, the healthcare infrastructure is not optimized for the simultaneous treatment of several diseases, which results in disorganized treatment of patients with multiple diseases. Most doctors specialize in the treatment of a certain group of diseases, and often isolated treatment of diseases can lead to duplication of medical efforts, as well as fragmented, poorly coordinated medical assessments without proper responsibility, accountability and follow-up [8].

The so-called “isolated” treatment eliminates the need to study the dynamics of clusters of diseases. It should also be taken into account that clinical trials of new drugs often exclude participants who have an additional health problem in addition to the studied one, and often exclude elderly people from experimental and control groups [9]. At the same time, it is known that several groups of drugs are used to treat various diseases in such patients and, accordingly, polypragmasia takes place.

Polypragmasia is defined as the simultaneous use of at least 4-5 drugs, which increases significantly as the number of health problems increases and the use of medical services increases [10]. The researchers point out that the absolute benefit of each additional medication will decrease if a person takes several medications, even if some of them are prescribed for preventive purposes. In addition, the risk of harm is likely to increase as a person takes more medications.

Although the addition of medication is usually of clinical significance and aimed at improving the patient’s health, it may expose the patient to an increased risk of potential drug interaction (PDI) and drug interaction with the disease. Clinically significant PDI are manifested by a decrease in the therapeutic effect of the drug, an increase in adverse reactions and a deterioration in treatment results. Severe potential PDI are those that are life-threatening and/or require medical treatment or intervention to minimize or prevent serious side effects.

As is known, polypragmasia does not only apply to the elderly, however, the greatest prevalence of this scenario falls on age-related patients. In particular, experts conducted studies of the spread of polypragmasia among people aged ≥65 years, which showed the following:

– in Sweden, the prevalence of polypragmasia reaches 44% [11] ;

– in the UK, 20.8% of people with two clinical conditions were prescribed from four to nine medications, while 10.1% of them – ten and more medicines [12] ;

– in Poland, polypragmasia is observed in 55.0% of citizens aged 80+ [13] ;

– in Scotland, about 35% of people aged 85 and older receive more than ten medications [14].

The high prevalence of polypragmasia in the elderly is also observed outside Europe, for example, in countries such as Brazil and the USA.

Thus, the burden of polypragmasia is a direct consequence of the demographic problem, which, although observed throughout the world, is especially pronounced in Europe. According to Eurostat, people aged 65 and over currently make up 19.2% of the European Union’s population, and this proportion is expected to rise to 29.1% by 2080, while the proportion of people aged over 80 is expected to increase. even more sharply – from the current 5.4–12.7% [15].

It should be noted that not every polypragmasia is unacceptable. Multiple prescriptions are appropriate in cases where medications have been optimized for complex conditions according to the best evidence. Problematic polypragmasia occurs when mul- tiple medications are prescribed, and the risk of harm outweighs the benefit, and the subsequent burden of taking pills leads to reduced adherence, undesirable medications, or the risk of potentially harmful interactions.

Turning to the disclosure of the essence of the concept of “polypragmasy”, as already mentioned above, it should be noted that there is no generally accepted definition of this scientific category. A report by the World Health Organization (WHO) noted that “polypragmasia is the simultaneous use of several medications. Although there is no standard definition, polypragmasia is often defined as the routine use of five or more medications. This includes over-the-counter, prescription and/or traditional and complementary medicines used by the patient” [16].

Approaches to the definition of the concept of polypragmasia have different grounds. So, some authors, using the number of medications taken by the patient, derive the concepts of mild, moderate, large and excessive polypragmasia. However, the threshold values of a particular type of polypragmasia vary in various sources from 2 or more to 11 drugs, so we can say that there are no developed criteria for accurately determining the degree of polypragmasia.

The researchers also introduce the following definitions of variants of polypragmasia:

– necessary polypragmasia, which provides for additional medication regimens that can optimize the functional state and prevent disability in the elderly. For elderly patients receiving regimens as part of the necessary polypragmasia, the benefits outweigh the risks;

high-quality polypragmasia involving the administration of five or more medications, including at least one drug that is considered potentially unsuitable for the elderly;

– psychotropic polypragmasia, which includes the simultaneous use of two or more psychotropic drugs by one person;

– proper polypragmasia, which is the optimization of drugs for patients with complex or multiple conditions, when the use of drugs is consistent with existing positive practices [17].

Polypragmasia and especially psychotropic and anticholinergic drugs have been associated with cognitive impairment in various studies [18]. Japanese experts have identified a link between polypragmasia and cognitive impairment [19]. According to a cross-sectional study of patients with newly diagnosed

Issue 25. December 2022 | Cardiometry | 21

Parkinson’s disease, participants with polypragmasia had significantly lower scores on the mental state brief examination scale compared to other patients without polypragmasia. It was also revealed that polypragmasia is associated with physical disorders in the elderly [20]. Accordingly, the risks of polypragmasia in relation to age-related patients are extremely high, which requires the development of various approaches to reduce the negative impact of polypragmasia on the health of such patients.

Discussion

The aging process is associated with changes in the physiological function of organs and changes in the body. In geriatric pharmacotherapy, the general recommendation is to reduce the dose of medications and slow titration based on pharmacokinetic considerations and concerns about adverse drug reactions, rather than on clinical trial data.

Due to the unprecedented increase in the proportion of elderly people in the population, understanding and studying geriatric pharmacology has become very important for drug therapy in elderly patients. Older patients experience many treatment-related problems compared to younger patients. Examples of such problems are a decrease in physiological function, a change in pharmacokinetics/pharmacodynamics, and susceptibility to adverse drug reactions, polypragmasia and low compliance. Understanding the various facts of factors influencing the results of reducing the level of drug dependence in the elderly requires knowledge of basic and clinical geriatric pharmacology.

Aging is associated with changes in pharmacodynamics and the ability to maintain homeostasis in the body. A well-known example is the reduction of the reactivity of beta-adrenergic receptors in the elderly. The proximity and number of beta-adrenergic receptors decreases, and, on the contrary, sensitivity to neuropsychiatric drugs, including benzodiazepines, are usually increased in elderly patients, which leads to psychomotor dysfunction at lower drug doses compared to younger people.

The homeostatic response provides important information to explain the body’s overall response to the drug. In the elderly, the homeostatic regulation of the body is reduced. For example, the average blood pressure is elevated, but the possibility of orthostatic hypotension increases significantly. Blood glucose levels increase by about 1 mg/dl every year after up to 50 years.

Using this knowledge, attention should be paid to providing appropriate drug therapy. It is known that organ functions decrease, and pharmacokinetic processes differ in the elderly and young people. Simultaneous use of more than 5 medications is observed in 20-40% of elderly patients [21]. Thus, the risk of adverse events caused by medications is associated with drug interactions.

Prescribing medications to elderly patients requires an understanding of the effectiveness of medications in the elderly, an assessment of the risk of adverse events associated with taking medications, and careful monitoring of the patient’s response.

Clinicians should distinguish between appropriate and inappropriate polypragmasia and reduce inappropriate polypragmasia and severe PDI. The use of appropriate indicators can help in determining the appropriateness of polypragmasia.

The key points of management of elderly people living with multiple diseases and polypragmasia include early detection of people with multiple diseases, identification of weakness and patient-centered joint decision-making. These points are based on several principles of caring for the elderly:

• –    determining the priorities of treatment of an elderly patient;

• –    solving the psychosocial problems of an elderly patient;

• –    managing the process of drug prescriptions;

• –    control of thought processes to take into account cognitive awareness when making joint decisions;

• –    monitoring of the patient’s physical condition with an integrated approach to the treatment of various diseases.

Insufficient communication between medical specialists, as well as between clinicians and patients and their caregivers is the most common cause of adverse clinical events and complaints about treatment. In this regard, patient-centered or priority patient care that takes into account the preferences, needs and values of the patient ensures that patients will participate in clinical decision-making.

Optimization of medicine is defined as a human-centered, evidence-based approach to the safe and effective use of medicines to ensure that patients receive the best possible results from drug prescriptions. Drug optimization ensures that there is a specific and justifiable reason for each drug the patient takes, and that it is as optimal as it can be based on evidence. This includes stopping taking medications that are not beneficial or cause side effects, updating prescriptions for newer medications in accordance with current recommendations.

Given the heterogeneity of disease trajectories in the elderly, as well as the symptoms and individual preferences of patients, the treatment goals will vary from person to person. General practitioners are in an ideal position to make joint decisions with patients and their families about prescribing, canceling prescribing, rationalizing and optimizing medications. It should be taken into account that the influence of multiple pathology, weakness and polypragmasia extends to both primary and secondary care. Geriatricians and pharmacists can work closely with general practitioners to help set goals, implement the principles of comprehensive geriatric assessment and provide patient-centered care within this conditional division into primary and secondary care.

Patient orientation, elderly-friendly care and management of polypragmasia are embodied in the basic principles of a comprehensive geriatric assessment, where a holistic and balanced approach to individualization and prioritization of management opinions is central. The study of a person’s personal goals, health problems that have the greatest impact on his daily life, and the choice of medication regimen allows for an individual approach that can help improve the individual quality of life of elderly and senile patients.

Conclusions

The difficulties associated with the definition of the term “polypragmasia” are currently the reason for the lack of consideration of its consequences when prescribing medications to elderly and senile patients. In almost all studies, the prevalence of polypragmasia is directly correlated with age.

Inaccurate and heterogeneous definitions of polypragmasia complicate the analysis of its prevalence and impact on the corresponding health outcomes. As a rule, polypragmasia can only serve as an indicator of adverse clinical outcomes, a causal relationship with clinical outcomes has not been unequivocally proven, since prospective interventional studies of its clinical effects are mostly absent.

Polypragmasia, hyperpolypragmasia and severe potential drug interactions are very common in elderly people with cardiovascular diseases. Clinicians should closely monitor patients’ medical histories and adjust therapy accordingly to prevent adverse drug reactions and negative health consequences.

The best approaches to the study of polypragmasia should take into account both excessive and insufficient treatment of elderly patients. A number of approaches have been developed to improve the adequacy of drug therapy, but individualized and appropriate polypragmasia is not sufficiently considered in such approaches. It must be said that the multimorbidity of elderly and senile patients should be taken into account by specialists when prescribing medications not only from the standpoint of treating one particular disease, but also in combination with other medical prescriptions for a disease other than the one under study. In this regard, it is necessary to carry out integrated medical consultations for elderly patients with a history of several diseases. All this will reduce the risks of the negative impact of polypragmasia on the health of elderly and senile patients and will improve the quality and duration of their life.