Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
ORIGINAL PAPER
Polypharmacy and Decreased Cognitive Abilities in Elderly
Patients
Alma Alic1, Nurka Pranjic2, Enisa Ramic3
Educational Center of Family Medicine, Primary Health Care Center Zenica, Bosnia and Herzegovina1
Department of Occupational Medicine, Medical Faculty, University of Tuzla, Tuzla, Bosnia and Herzegovina2
Educational Center of Family Medicine, Primary Health Care Center Tuzla, Bosnia and Herzegovina3
G
oal: To estimate the prevalence of poly pharmacy and poly pharmacy
effect on decline in cognitive abilities of randomly selected group of
people over 65. Methodology: A preliminary pilot study was based
on the results of other researchers. 54 patients over 65 were randomly interviewed. Poly pharmacy was defined as using ≥3 drugs. “A short portable
mental status questionnaire“ was used in estimating decline of cognitive abilities. Results: According to the study results it was concluded that prevalence
of poly pharmacy by the elderly is significant–48.1%. Most present drugs are
the ones treating cardiovascular disease, anti diabetic, anti-inflammatory
drugs, long acting benzodiazepines, antihistamines. Of the total respondents
33.3% of them live alone and do not have adequate supervision. We have
found that poly pharmacy resulted in decline of cognitive abilities in 23 of
54 patients tested in rapid mental status check. Conclusion: It is necessary
to conduct future research on this issue. Key words: poly pharmacy,
elderly patients, decreased cognitive abilities.
Corresponding author: Alma Alic, MD, Health center Zenica, Zenica, Talica brdo 8a, B&H. E-mail:[email protected]
1.
INTRODUCTION
Today there is a higher prevalence of
symptomatic treatment than the causative, and the clinical signs are atypical,
so poly therapy or polypharmacy is inevitable. Unfortunately, very often atypical symptoms that are complains of geriatric patients are signs of adverse reactions to medications. Polypharmacy in
patients is almost a regular occurrence,
adherence to guidelines on pharmacotherapy in difficult, often using complicated schemes, drug dosing intervals are different, thus further increasing the risk of inefficiencies and different side effects (1). In aging organism
certain bodily functions are reduced.
Therefore, a therapy that was preventa-
102
tive and rational can be obsolete in geriatric patients (>65 years) (2). Elderly
patients are often inadequately treated
even with the condition that they have
the correct diagnosis. Predisposing factors are psychological changes associated with aging, and multiple pathological conditions requiring complex drug
therapy (3). Geriatric patients generally
have a number of different diseases and
symptoms. They have prescribed different medications sometimes even for the
natural signs of aging. That is the reason that the symptoms and the disease
eventually do not respond to treatment.
For example, edema due to cardiovascular disease may not require medication if a person loses weight or is not
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tORIGINAL PAPER
subject to the same physical effort as
before (4, 5).
Polypharmacy (lat. polypragmasia)
is the administration of multiple medications together (2, 6, 7, 8, 9). The aging process affects the systemic effect
of drugs in humans: slows down the absorption, metabolism and elimination
of drugs which can delay the beginning
of effective action. Due to the decline of
renal function there is reduced elimination, and increased accumulation and
toxicity of the drug especially after taking repeated doses (4). There are more
and more new drugs and the spread
of unapproved indications. It’s getting
harder to know the toxicology of the
drug and/or drug-drug interactions (6).
Consumption of drugs in older patients is proportionally higher according to their proportion in the population. In Sweden on the total population,
the prevalence of elderly persons was
8%, and they use 25% of all prescribed
drugs (7, 8, 9). It turned out that 90% of
the elderly take at least one drug. Outpatients taking the average of three
drugs, and residents of homes for the
elderly even eighth most commonly
prescribed drugs for senior gastrointestinal diseases, cardiovascular diseases, analgesics, anti-rheumatic and
anti-depressants. The use of these drugs
increases with age (9, 10). There was a
statistically significant relationship between the number of drugs used by the
women and increased risk of side effects
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
(10). Approximately 10-14% of geriatric
patients are hospitalized because of adverse reactions (11). Sometimes there is
classic oversight so unrecognized side
effects impute disease and prescribe a
new drug. Because of unnecessary new
therapies patients are exposed to the
risk of new side effects. Sometimes it
is unfortunate that the patient suffers
from side effects for months, which
gradually leads to functional disability
(12). It is similar with drug interactions.
The number of interactions increases
with the number of drugs (13, 14).
Two of the common mental status
changes in geriatric patients are dementia or cognitive decline and depression. Today it is estimated that more
and more different types of neuropsychiatric disorders exist among the elderly. Changes in mental status may
have long-lasting effect on elderly patients and their families (15). The term
dementia, namely dementia syndrome
denotes a complex disorder of different
cognitive activities to reflect changes
in the normal function of the human
brain. Dementia is characterized by
deterioration of previously acquired
mental functions, which lead to reduction of or inability to perform daily activities. This is one of the most serious
disorders that affect people of third age
(16). It is characterized by weakening of
memory and reducing the functionality
usually in two or more areas of cognition. There may be various changes in
behavior, indifference, inaction, or irritability. Mood swings are often present, sometimes as apathy or depression or inappropriately elevated mood.
It should be said that the emergence
of mild forgetfulness do not automatically mean dementia. Forgetfulness is
not always a sign of illness, so if it over
6 months does not worsen is not on the
initial degree of dementia (16, 17). Lack
of cognitive function due to dementia is
important to the extent that affects the
physical and social function of the patient and its relations with others (18).
Elderly people often suffer from depression, and that their environment
does not notice because they do not
connect their symptoms with a mental
illness. Most often complain of physical problems such as problems with
digestion, headaches, joint pain, mus-
cle and back pain. Detailed examination and questions about sleep disturbance, loss of appetite, concentration,
memory, and to a lesser extent due to
previous activity is detected by reduced
motivation and depression. Depression
is more common in the elderly with
a prevalence of 20%. There is greater
number of complications including inability to care for themselves and their
own health. More common is the development of psychotic symptoms and
the number of completed suicides (15).
The effect of any medication on the
patient’s electrolyte profile may contribute to changes in mental status (19-21).
Elderly patients are more susceptible to
common therapeutic concentrations of
benzodiazepines. Barbiturates, phenytoin, and benzodiazepines are the cause
of deterioration of some basic human
abilities: concentration, mental energy,
mood and memory. For benzodiazepines was confirmed causality of anterograde amnesia (22). After cimetidine was first used in the treatment of
peptic ulcer treatment have been published reports about the effects of a drug
to change the cognitive status when the
drug is used in large doses (23). It was
confirmed that the adverse reaction of
beta-blockers is mental depression, and
barbiturates can cause confusion and
decrease cognitive abilities (21, 22, 23)
(Table 1). Ever since the introduction
of reserpine in 1950 it was clear that
it empty the depot of catecholamine
and serotonin and can cause depression (4,19).
This study was undertaken as a research of this complex public health
problem of polypharmacy that can if
preventive actions are not taken, to
significantly reduce the quality of life
of geriatric patients and their families.
Polypharmacy can be a major cause of
irreparable damage and lead to diminishing functional ability and independence of elderly patients. This is because
the polypharmacy resulting in decline
of cognitive ability and depression. A
special task of this study was to assess
the current situation.
2. METHODS
Randomly were interviewed 54 patients-respondents, age >65 years, of
both sexes in the family medicine clinic
“Potok” in the Primary Health Care
Center Zenica in the period from April
1st 2010 until May 1st 2010. The subjects
are regularly treated in the above clinic
and were using a different number and
types of medications. Factor in the selection and comparability among the
respondents was polypharmacy. Polypharmacy (lat.polypragmasia) is the
administration of multiple medications together. It means unjustified,
often found prescription drugs more
safely without present indications and
the likelihood that the patient will often have unwanted and toxic effects in
the interaction of these drugs (1). It is
estimated that older patients were subjected to polypharmacy to a greater extent than necessary, so we wanted to
verify this hypothesis (2).
Design and research instruments
In the design of the research task
was to create and record lists of the
most commonly used drugs from 1-10
for each patient, record their preparations, body mass index-BMI, dose of
drugs used and the signature of the used
drugs. In the design of the research is
used a survey that contained additional
questions about living conditions (alone
or in a family environment), on the
use of vitamins and other products for
self medication, alcohol consumption,
smoking, morbidity, disease history and
content of everyday activities. The sample was distributed to collect relevant
data on polypharmacy (the use of ≥ 3
drugs in tested population), treatment
and other relevant factors of importance for the study of medical records
in family medicine teams. Finally made
are two groups (those who use less than
three drugs and a group of patients with
three or more regularly used drugs) in
both groups was carried out Short Portable Mental Status Questionnaire. The
Short Portable Mental Status Questionnaire-SPMSQ for the assessment of the
reduction of mental capacity in elderly
patients (25). The questionnaire was
completed by a health worker team selected doctor, and does not require the
patient to fill out the questionnaire so it
can be applied to patients with physical
defects or for patients of limited mobility. Data on population and mental disorders in geriatric patients have been
used by the projections of the Federal
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tORIGINAL PAPER
103
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
Bureau of Statistics of B&H. Registering of the disease was made according
to the tenth revision of International
Classification of Diseases, Injuries and
Causes of Death (ICD-10). Statistical analysis is done by the standard
tests of descriptive statistics with measures of central tendency and dispersion. Quantitative variables are tested
by Student t-test if they were normally
distributed or Mann-Whitney-test if
they were distributed asymmetrically.
Qualitative variables are tested by chisquare test with continuity correction.
All tests were leveled with the level of
statistical significance of 95% (p<0.05).
3. RESULTS
The population of B&H is an older
society, which is confirmed by the demographics of increasing the participation of elderly in total population since
1961 until 2003 (3.5%, 15.4%). Participation of elderly in the total population was 15.4% (Table 2). Leading mental disorders of the elderly people in the
FB&H are shown in Table 3. The most
common disorders are depression and
neurotic disorders, stress related (39%),
affective disorders (27%), dementia (5%)
and others. In the sample of randomly
selected 54 patients who regularly
come into the family medicine clinic
for check-ups, age >65 years (according to their regular therapy), and possibly as patients with some new problems, there were 36 female and 18 male
patients (Table 4). There was a statistically significant difference in participation of women compared to men
(P=0.001). Within polypharmacy (with
three or more drugs used) were 26 patients, of which with 3 regularly taken
drugs were 17 patients, and 9 were using more than 3 drugs (Table 5). Of the
total number of patients who received
polypharmacy 19 of them used 2 drugs,
five were using 1 medication and only
4 patients were not generally used any
regularly used therapy.
From the most commonly used
drugs were drugs for treatment of cardiovascular diseases, antidiabetic, longacting benzodiazepines, anti-inflammatory drugs (results not shown but are
comparable with Table 1). Out of the total number of respondents 36 living in
the family environment (house or flat),
104
Illness or health
disorder
Drugs
Effect
Cognitive
disorder
Barbiturates, anticholinergics (Atropine, Benytropine,
Benzhexol) Antihistamines, anticonvulsants (Phenitoin,
Carbamazepine, Clonazepam, Valproate, Vigabatrin),
Antiparkinsonics (Amanatadine, L-dopa, bromocriptine),
drugs for heart diseases (beta-blockers, Digoxin,
Theophzlline, diuretics, hypotension medications), antiINÞAMMATORYÙDRUGSÙ.3!)$ÙSTEROIDS
sympathomimetics (Ephedrine, amphetamine),
antispasmoic medications, Muscle relaxants, Antibiotics,
Antineoplastic agents, cimetidine, ranitidine, lithium,
stimulants of the central nervous system (CNS):
dextroamphetamine (Adderall), methylphenidate (Ritalin),
methamphetamine, pemolin
Causes a
change in the
effects on CNS
Depression
Long-acting benzodiazepines, simphatolitic agents:
methyldopa (Aldomet), reserpine, guanethidine (Ismelin),
hormones, cytostatics, steroid anti-rheumatics, drugs for
arthritis
Can initiate the
development
of depression
or facilitate
recurrent
depression
Table 1 Drugs that may have an adverse reaction to a high degree of risk in mental status and decline in
cognitive abilities in geriatric patients
Year
1961
2003
percent of elderly in the population
3.5%
15.4%
Table 2 Population aged over 65 years in Bosnia
and Herzegovina in the period 1961-2003.
Percent
of mental
disorders
Mental disorders
depression and neurotic
disorders related to stress
affective disorders
dementia
39%
27%
5%
Table 3. Leading mental disorders in FB&H in
2008.
Gender
M
F
No.
18
36
Percent
33.4%
66.6%
Table 4 Distribution of respondents by gender
Patients in poly pharmacy (> or No. of
= 3 drugs)
patients
3 regularly taken medications
17
> 3 drugs taken
9
Patients who are not in poly
pharmacy (<3 drugs)
2 regularly taken medications
19
1 regularly taken medication
5
Do not use drugs
4
Table 5. Distribution of respondents by number of
drugs used daily
and 18 of them living alone (Table 6).
After analysis of results from Short
Portable Mental Status Questionnaire,
we found a significant decline in cog-
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tORIGINAL PAPER
nitive abilities in patients with polypharmacy. Decline in cognitive abilities is observed in 23 of 54 patients. In
tested group median functional dementia scale was 30 with interquartile ranging from 26 to 40, while in the control
group was 28 with interquartile range
of 24 to 37. This difference was not statistically significant (Mann-Whitney
Patient lives
Alone
In family
Number of patients
18
36
Table 6 Distribution of respondents by way of
living: alone or in family
test, Z=1.67, p=0.010) between groups.
4. DISCUSSION
In the treatment of elderly patients
should seek the correct diagnosis, from
which is derived a rational pharmacotherapy based on the guaranteed minimum number of effective drugs with
known side effects. Many of the diseases from which suffer patients of so
called elderly age cannot be treated
with medication. The same dose may
have due to individual characteristics
different effects in different patients.
Inter or even intra individual variations
are often much more pronounced. Doctors must be aware of the origin of these
variations to prescribe safe and effective
medicines. Variations can be caused by
different concentrations of the drug at
Polypharmacy and Decreased Cognitive Abilities in Elderly Patients
the site of action or different responses
to the same drug concentration. The
first type of variations is pharmacokinetic, which arise due to differences in
resorption, distribution, metabolism and
excretion. The second type is the pharmacodynamic (1, 2, 3, 4). Important factors responsible for variations in the effects of the drug were: ethnic origin, age,
pregnancy, genetic factors, idiosyncrasy
reactions, disease and interactions between drugs (4, 22, 26). The main reason that age influences the effect of the
drug is the fact that the elimination of
the drug is less effective in newborns
and the elderly, and drug causes longlasting and powerful effect in these age
groups (14). Some pathological factors
such as hypothermia, which is common
in older people, also change the effect of
the drug. The composition of body fluids vary with age, adipose tissue is in a
higher percentage of body mass, and all
this leads to changes in the volume of
drug distribution. The elderly take more
medications than younger people, so the
potential for drug taking is greater (23).
In the Federation of B&H since 1992
until 2008 the structure of the population has greatly changed because of war
casualties in these areas. Killed was 250
000 people, 17 000 are missing and 2.2
million people were running from their
homes. However, older adults showed
an increasing trend (27).
Irrational and inappropriate is the
provision of more therapeutic agents
for which there is no evidence of the
usefulness of the treatment. Rational
drug therapy reduces the number of
unwanted interactions, but the public pressure in terms of poly therapy,
polypharmacy in fact, is stronger. It is
not easy to resist therapeutic evangelism, which often comes from non-critical circles of experts. Using more than
three drugs pose a significant risk factor
for the occurrence of adverse reactions
in elderly people. To assess that risk a
family doctor (family doctor and nurse)
must pay special attention to drugs that
a patient is taking. Should always be
carefully evaluated, which drugs are
introduces in the last 4 weeks. Often
we forget to ask for drugs that are used
without prescription or herbal remedies
that can also cause adverse reactions:
sedatives, hypnotics, anxiolytics, espe-
cially long-acting benzodiazepines–diazepam (24).
As there is no justification to treat
every symptom of disease, so there is no
justification, for example, at the same
time to prescribe two drugs from the
same group. Older people usually take
4-5 medications daily. Sometimes it
comes to more than 6 different drugs
during the day, so the range is 3-12
drugs (3). It is necessary in the elderly
to seek the simplest possible application of medicines, because some conditions can have completely non-specific
symptoms. In particular, the patience
is necessary to communicate with patients, especially in older people who
have a fear that they will not understand and remember the most important (4). Nearly three quarters of elderly
people take on their own initiative medications that are not prescribed (5). Average number of prescribed drugs per
person increased from 67% in middleaged persons to 12.8% in those aged 65
and over (11). As a rule, older people
are more sensitive to the application
of conventional doses of drugs used in
middle age, but among them also unwanted drug reactions (side effects) and
drug poisoning is more frequent (4,28).
5. CONCLUSION
Health status, health needs and
functioning of the elderly population
varies considerably in relation to other
population groups. To estimate the risk
of adverse reactions that are harmful to
mental health by family practitioners
(doctors and nurses) need to pay special attention to drugs that a patient is
taking. Always be careful to evaluate
the drug included in treatment during
the last four weeks. Often we forget to
ask for drugs that are used without prescription or herbal remedies that can
also cause adverse reactions: sedatives,
hypnotics, anxiolytics especially longacting benzodiazepines-diazepam (24).
Overall, the treatment of older patients
is complex and rating of pharmacotherapy was not an easy task. For successful drug therapies, the key question is
in individual approach to every geriatric
patient. To successfully accomplish the
task, doctor prescribing the medication
must be well acquainted with all the
beneficial and harmful effects of each
drug (7-8). General Geriatric Questionnaire for future research should include
assessment of polypharmacy severity,
rapid questionnaire to assess cognitive
abilities decline, symptoms and signs of
geriatric depression, BMI records, and
questions about confounding variables,
smoking, alcohol and self-medication.
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