To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community-dwelling persons.
Systematic review of MEDLINE (OvidSP 1946 to May, Week 3, 2014).
Observational studies examining health outcomes according to number of prescription medications taken.
Association between number of medications and health outcomes. Because of the importance of comorbidity as a potential confounder of the relationship between polypharmacy and health outcomes, articles were assessed regarding the quality of their adjustment for confounding.
Of the 50 studies identified, the majority that were rated good in terms of their adjustment for comorbidity demonstrated relationships between polypharmacy and a range of outcomes, including falls, fall outcomes, fall risk factors, adverse drug events, hospitalization, mortality, and measures of function and cognition. However, a number of these studies failed to demonstrate associations, as did a substantial proportion of studies rated fair or poor.
Data are mixed regarding the relationship between polypharmacy, considered in terms of number of medications, and adverse outcomes in community-dwelling older persons. Because of the challenge of confounding, randomized controlled trials of medication discontinuation may provide more-definitive evidence regarding this relationship than observational studies can provide.
- 1. Multimorbidity in older adults. Epidemiol Rev 2013; 35: 75–83.
- 2, , et al. Prescription drug coverage and seniors: Findings from a 2003 national survey. Health Aff (Millwood) 2005; (Suppl Web Exclusives): W5–152–W5–166.
- 3. Health outcomes and polypharmacy in elderly individuals: An integrated literature review. J Gerontol Nurs 2005; 31: 4–11.
- 4, , et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA 2005; 294: 716–724.
- 5, , . Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351: 2870–2874.
- 6, , . Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007; 5: 345–351.
- 7, . Polypharmacy in the elderly: A literature review. J Am Acad Nurse Pract 2005; 17: 123–132.
- 8, , et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. PLoS Med 2009; 6: e1000100.
- 9, , . The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc 2004; 52: 1719–1723.
- 10, , et al. Quality use of medicines and health outcomes among a cohort of community dwelling older men: An observational study. Br J Clin Pharmacol 2011; 71: 592–599.
- 11, , . Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol A Biol Sci Med Sci 1989; 44A: M112–M117.
- 12, , et al. Multidimensional geriatric assessment: Back to the future preclinical disability as a risk factor for falls in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2008; 63A: 314–320.
- 13, , et al. Risk factors for falling among community-based seniors. J Patient Saf 2009; 5: 61–66.
- 14, . Dizziness in an older community dwelling population: A multifactorial syndrome. J Nutr Health Aging 2009; 13: 278–282.
- 15, , et al. Polypharmacy cutoff and outcomes: Five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol 2012; 65: 989–995.
- 16, , . Dizziness as a geriatric condition among rural community-dwelling older adults. J Nutr Health Aging 2011; 15: 490–497.
- 17, , et al. The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: The Diabetes and Aging Study. J Gen Intern Med 2009; 25: 141–146.
- 18, , . Association between falls in elderly women and chronic diseases and drug use: Cross sectional study. BMJ 2003; 327: 712–717.
- 19, , . Characteristics associated with fear of falling and activity restriction in community-living older persons. J Am Geriatr Soc 2002; 50: 516–520.
- 20, , . Dizziness among older adults: A possible geriatric syndrome. Ann Intern Med 2000; 132: 337–344.
- 21, , et al. A two-year longitudinal study of falls in 482 community-dwelling elderly adults. J Gerontol A Biol Sci Med Sci 1998; 53A: M264–M274.
- 22, , et al. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol 2006; 61: 218–223.
- 23, , . Activity restriction related to fear of falling among older people in the Colombian Andes mountains: Are functional or psychosocial risk factors more important? J Aging Health 2009; 21: 460–479.
- 24. Risk factors for fractures in the elderly. Epidemiology 1998; 9: 417.
- 25, , et al. Validation of dizziness as a possible geriatric syndrome. J Am Geriatr Soc 2001; 49: 72–75.
- 26, , et al. Polypharmacy as a risk for fall occurrence in geriatric outpatients. Geriatr Gerontol Int 2012; 12: 425–430.
- 27, , et al. An epidemiological study of falls in older community-dwelling women: The Randwick Falls and Fractures Study. Aust J Public Health 1993; 17: 240–245.
- 28, , et al. Factors associated with falls among community-dwelling older people in Taiwan. Ann Acad Med Singapore 2012; 42: 320–327.
- 29, , et al. A simple clinical scale to stratify risk of recurrent falls in community-dwelling adults aged 65 years and older. Phys Ther 2010; 90: 550–560.
- 30, , et al. Falls among older people: Relationship to medication use and orthostatic hypotension. J Am Geriatr Soc 1995; 43: 1141–1145.
- 31, , et al. Multimorbidity, polypharmacy, referrals, and adverse drug events: Are we doing things well? Br J Gen Pract 2012; 62: e821–e826.
- 32, , et al. Risk factors for adverse drug events in older adults with mobility limitations in the community setting. J Am Geriatr Soc 2007; 55: 29–34.
- 33, , et al. Risk factors for adverse drug events among older adults in the ambulatory setting. J Am Geriatr Soc 2004; 52: 1349–1354.
- 34, , et al. Adverse drug events resulting from patient errors in older adults. J Am Geriatr Soc 2007; 55: 271–276.
- 35, , et al. Drug complications in outpatients. J Gen Intern Med 2000; 15: 149–154.
- 36, , . Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother 2007; 5: 31–39.
- 37, , et al. Frequency, severity and risk factors for adverse drug reactions in adult out-patients: A prospective study. J Chronic Dis 1986; 39: 533–542.
- 38, , et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res 2011; 46: 1517–1533.
- 39, , . Self-reported adverse drug reactions and related resource use. A study of community-dwelling persons 65 years of age and older. Ann Intern Med 1992; 117: 634–640.
- 40, , . Adverse drug reactions in an elderly outpatient population. Am J Hosp Pharm 1992; 49: 90–96.
- 41, , et al. Adverse drug events in the outpatient setting: An 11-year national analysis. Pharmacoepidemiol Drug Saf 2010; 19: 901–910.
- 42, , et al. Adverse drug events in ambulatory care. N Engl J Med 2003; 348: 1556–1564.
- 43, , et al. The impact of polypharmacy on the health of Canadian seniors. Fam Pract 2012; 29: 427–432.
- 44, , et al. Adverse drug reactions and polypharmacy in the elderly in general practice. Eur J Clin Pharmacol 1999; 55: 533–536.
- 45, , et al. Variation over time in the association between polypharmacy and mortality in the older population. Drugs Aging 2011; 28: 547–560.
- 46, , et al. Suboptimal medication use and mortality in an older adult community-based cohort: Results from the Hispanic EPESE Study. J Gerontol A Biol Sci Med Sci 2006; 61A: 170–175.
- 47, , et al. Screening for hospitalization and nutritional risks among community-dwelling older persons. Am J Clin Nutr 2001; 74: 201–205.
- 48, , et al. Polypharmacy status as an indicator of mortality in an elderly population. Drugs Aging 2009; 26: 1039–1048.
- 49, , et al. Is suboptimal prescribing a risk factor for poor health outcomes in community-dwelling elders? The ICARe Dicomano study. Pharmacoepidemiol Drug Saf 2010; 19: 954–960.
- 50, , et al. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med 1997; 157: 1681–1686.
- 51, , et al. Drug utilization in the old old and how it relates to self-perceived health and all-cause mortality: Results from the Bronx Aging Study. J Am Geriatr Soc 1995; 43: 356–360.
- 52, , . Inappropriate medication use and health outcomes in the elderly. J Am Geriatr Soc 2004; 52: 1934–1939.
- 53, , et al. High-risk prescribing and incidence of frailty among older community-dwelling men. Clin Pharmacol Ther 2012; 91: 521–528.
- 54, , et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf 2011; 20: 514–522.
- 55, , et al. Medication use and functional decline among community-dwelling older women. J Aging Health 1989; 1: 470–484.
- 56, , et al. Association of suboptimal prescribing and change in lower extremity physical function over time. Gerontology 2007; 53: 445–453.
- 57, , et al. Geriatric syndromes and incident disability in older women: Results from the Women's Health Initiative Observational Study. J Am Geriatr Soc 2013; 61: 371–379.
- 58, , et al. Life long changes in cognitive ability are associated with prescribed medications in old age. Int J Geriatr Psychiatry 2004; 19: 327–332.
- 59, , et al. Heterogeneity in risk factors for cognitive impairment, no dementia: Population-based longitudinal study from the Kungsholmen Project. Am J Geriatr Psychiatry 2007; 15: 60–69.
- 60, , et al. Predictors of medication use, compliance and symptoms of hypotension in a community-based sample of elderly men and women. J Clin Pharm Ther 1998; 23: 423–432.
- 61. Potential health impacts of multiple drug prescribing for older people: A case-control study. Br J Gen Pract 2011; 61: 128–130.
- 62, , et al. Drug use by the elderly in general practice: Effects on upper gastrointestinal symptoms. Eur J Clin Pharmacol 2006; 62: 65–73.
- 63, , et al. Polypharmacy correlates with increased risk for hip fracture in the elderly: A population-based study. Medicine (Baltimore) 2010; 89: 295–299.
- 64, , et al. Polypharmacy increases the risk of Parkinson's disease in older people in Taiwan: A population-based study. Psychogeriatrics 2011; 11: 150–156.
- 65, , et al. Prognostic factors for influenza-associated hospitalization and death during an epidemic. Epidemiol Infect 2001; 126: 261–268.
- 66, , et al. Association between polypharmacy and dementia in older people: A population-based case-control study in Taiwan. Geriatr Gerontol Int 2012; 12: 491–498.
- 67, , et al. Paradoxical relations of drug treatment with mortality in older persons. Epidemiology 2001; 12: 682–689.
- 68, . Reducing polypharmacy in the elderly. A controlled trial of physician feedback. J Am Geriatr Soc 1990; 38: 31.
- 69, . Strategies for reducing polypharmacy in older adults. J Gerontol Nurs 2010; 36: 8–12.
- 70, , et al. Reducing medication regimen complexity: A controlled trial. J Gen Intern Med 2001; 16: 77–82.
- 71, , . Medication review by GPs reduces polypharmacy in the elderly: A quality use of medicines program. Aust J Prim Health 2004; 10: 78–82.
- 72, , . Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic Drugs. J Am Geriatr Soc 1999; 47: 30–39.
- 73, , . Medication as a risk factor for falls: Critical systematic review. J Gerontol A Biol Sci Med Sci 2007; 62A: 1172–1181.
- 74, . Benzodiazepines and risk of hip fractures in older people. CNS Drugs 2003; 17: 825.
- 75, , et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts. Arch Intern Med 2003; 163: 2716–2724.
- 76, , et al. STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46: 72–83.
- 77, , et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006; 54: 1516–1523.
- 78. Polypharmacy: A new paradigm for quality drug therapy in the elderly? Arch Intern Med 2004; 164: 1957–1959.
- 79, , et al. Interpreting treatment effects from clinical trials in the context of real-world risk information: End-stage renal disease prevention in older adults. JAMA Intern Med 2014; 174: 391–397.
- 80, , et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med 1996; 100: 428–437.
- 81, , et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 2004; 116: 394–401.
- 82, , et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331: 821–827.
- 83, , . Does multiple risk factor reduction explain the reduction in fall rate in the Yale FICSIT trial? Am J Epidemiol 1996; 144: 389–399.
- 84, . Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy. Arch Intern Med 2010; 170: 1648–1654.