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Table of Contents
PERSPECTIVE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 4-9

Prevalence of polypharmacy: Comparing the status of Indian states


1 Centre for Public Health and Healthcare Administration, Eternal University, Baru Sahib, Himachal Pradesh, India
2 Department of Psychology, Eternal University, Baru Sahib, Himachal Pradesh, India

Date of Web Publication4-Jul-2019

Correspondence Address:
Priya Sharma
Centre for Public Health and Healthcare Administration, Eternal University, Baru Sahib, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_10_19

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  Abstract 

Introduction: The word “poly” is Greek and means many or much. However, the term polypharmacy has been given definitions connected both to the use of more than a certain number of drugs concomitantly and to the clinical appropriateness of drug use. Polypharmacy is the use of multiple medications by a patient, generally older adults (those aged 60 or over 65 years). More specifically, it is often defined as the use of 5 or more regular medications. It sometimes alternatively refers to purportedly excessive or unnecessary prescriptions. The term polypharmacy lacks a universally consistent definition with an increasing share of population in this age group, it is natural to expect an increase in the problems associated with them as well. Health problems are supposed to be the major concern of this section of the society, and it is reported that use of medications has increased significantly among the elderly in the last decade.
Objective: The objective of this study is to assess the prevalence of polypharmacy among elderly patients in different Indian states, to make a comparison, and also to study the patterns of polypharmacy and its associated aspects.
Materials and Methods: Literature review comprising of original articles, reviews, and case studies was studied to identify articles which correspond to research done on polypharmacy in various different ways published between the years 2010 and 2018. As the review focuses on the geriatric population, so considerable data were searched and collected for the use of medication in geriatrics to assess what makes them prone to polypharmacy, what pattern of polypharmacy they follow, and how they are affected by the consequences.
Results: Uttaranchal, Karnataka, and Telangana reported a higher level of polypharmacy with 93.14%, 84.6%, and 82.8%, respectively, whereas Andaman and Nicobar Islands (2%) and West Bengal (5.82%) showed the lowest polypharmacy.
Conclusion: Overall comparisons made show that there are more studies needed to assess the level of polypharmacy and ways and measures should be incorporated by the government in states showing high polypharmacy.

Keywords: Cascade, elderly, India, polytherapy, states


How to cite this article:
Sharma P, Gupta N L, Chauhan H S. Prevalence of polypharmacy: Comparing the status of Indian states. Indian J Community Fam Med 2019;5:4-9

How to cite this URL:
Sharma P, Gupta N L, Chauhan H S. Prevalence of polypharmacy: Comparing the status of Indian states. Indian J Community Fam Med [serial online] 2019 [cited 2019 Jul 20];5:4-9. Available from: http://www.ijcfm.org/text.asp?2019/5/1/4/262114


  Introduction Top


Elderly population is increasing worldwide. In India, the size of elderly population is fast growing; from 5.6% in 1961, it is projected to rise to 12.4% of the population by the year 2026.[1] India has witnessed a remarkable growth in the life expectancy in the last century. In the early 1930s, the average life expectancy of an Indian adult was only 32 years. Against a global average life expectancy of 75 years, currently, the life expectancy in India is about 67 years. The life expectancy in India is expected to reach 75 years by 2025. Further, the United Nations projections indicate that elderly Indian population will rise to 21.2% of the total by 2055 (from 7.2% estimated in 2005). This increase in life expectancy may be one of the most significant achievements of Indian health-care system. At the same time, it also poses a major public health issue. With the increase in the aging population, the drug-related problems have also increased. The health-care needs of this growing population are based on the presence of age-related diseases, increase in the chances of hospital admissions, longer hospital stays, and more extensive drug therapies.[2] In India, an estimated 50% of elderly people suffer from at least one chronic disease that requires lifelong medication.[3] The term “elderly” or “geriatrics” refers to a population with a chronological age of >65 years in most of the developed nations, while this does not adapt very well to the underdeveloped or developing nations. The United Nations thus recommends no standard numerical criterion but agreed a cutoff of >60 years as elderly population. In January 1999, the Government of India adopted the “National Policy on Older Persons” by which “senior citizen” or “elderly” is defined as persons who are of the chronological age of 60 years or above. Based on the 2011 census, the number of the elderly living in India is 103.8 million (10.38 crores), which corresponds to 8.6% of the total population. Polypharmacy as such has no standard definition but is generally referred as taking multiple medications together usually 5 or more per day and/or administration of more medications than that are clinically warranted, indicating unnecessary or unwanted drug use. High level of polypharmacy is defined as intake of 10 or more drugs.[4] Although polypharmacy is practiced quite often, there is a lack of consensus definition for polypharmacy. It is also not known as to the concurrent use of how many medications are considered as polypharmacy. Different thresholds have been used to assess polypharmacy. Some of the authors use thresholds of 3, 4, 5, or 10 medications to evaluate polypharmacy. This definition is solely based on the count of medications irrespective of clinical indications and conditions suffered by the patient.[5]

Rationale

Elderly population constitute nearly 8% of the total Indian population. However, this segment of population is neglected in almost all the aspects of life. They are social sufferers and are major victims of compromised health. With this review, we will be able to assess the level of polypharmacy that is prevalent among elderly population in different states as the comparison will help the respective states to improve their insights and focus on this segment of population. The generated data of this study can then be utilized in various programs to take adequate measures to reduce adverse effects of polypharmacy. There should be concern given to the optimal use of medication and to improve the good communication among elderly patients and health providers.


  Materials and Methods Top


Literature review comprising of original articles, reviews, and case studies was studied to identify articles which correspond to research done on polypharmacy in various different ways published between the years 2010 and 2018 to give priority to the freshness of the article as the most recent data will provide the best results. Furthermore, the focus was laid on the work and data pertaining to research done on this subject in the elderly. Effort was put in to at least have data of one study from each state, but some states were found to be having no work on polypharmacy. Literature review was also done to understand the general concept of polypharmacy and the associated causes. Reference lists of the most relevant articles were separated from the gray literature and were sorted to identify other relevant articles. The search strategy was developed in consultation with the coauthors with a predetermined protocol for methods to search and select relevant articles. The studies done specifically showing the prevalence of polypharmacy were chosen and analyzed, and useful material was then extracted from the collected material according to the need of this review.

Data extraction

Data items extracted included the definition of polypharmacy and associated causes and the prevalence of polypharmacy in different states. The studies conducted in different states were searched and compiled individually. Later, these articles were studied and screened, and then, the most similar articles were considered for final inclusion in the review. Once the primary data extraction was complete, all authors reviewed the content for each of the extracted studies, and later, the data were further summarized in [Table 1].
Table 1: Comparison among the states in reference to polypharmacy prevalence

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Causes of polypharmacy

  • An aging population with comorbidities requiring several different medications and an increasing availability of newer medications
  • Patients self-medicating with over-the-counter medications and herbal preparations without a clear understanding of the adverse reactions and interactive effects
  • A “prescribing cascade” which occurs when patients take a medication and exhibit side effects that are misinterpreted by the health-care practitioner as symptoms of a disease and requiring additional medication
  • The patient sees several physicians and fills prescriptions at different pharmacies, but there is a failure to keep all parties informed about each other's actions
  • Ineffective communication and coordination between health-care practitioners result in redundancy.[18]



  Results Top


The data above in the tabulation form shows the prevalence of polypharmacy in various Indian states. It reveals the range of medicines taken by the individuals mostly above four which further goes upto the range of ten and in some states even more than 10.


  Discussion Top


Although it is stated in literature that the use of even one medicine which is not indicated by a practitioner is also considered polypharmacy, most of the studies have taken the use of >5 medicines as polypharmacy. Thus, this review takes into account the use of 5 or more medications as the base for defining polypharmacy. However, the criteria for polypharmacy differed in all the studies with respect to demographic variables. There was a considerable amount of difference in prevalence rates depending on the type of study, institution-based study, or community-based study, but to maintain homogeneity of this review, the most matching relevant available material was included to understand the general prevalence and trend of polypharmacy in Indian states. It was understood from the literature that maximum studies related to the prevalence of polypharmacy were done in southern states of India. Thus, in states such as Bihar, Chhattisgarh, Haryana, Meghalaya, Mizoram, Nagaland, Orissa, Rajasthan, Sikkim, Jharkhand, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, and Delhi, Lakshadweep showed no relevant data in relation to the prevalence of polypharmacy in the literature studied.

The study done by Pandey and Saharan shows that the prevalence of polypharmacy is 4.2% among the elderly in India. Saldanha et al. revealed that the prevalence of polypharmacy was 84.6% and the prevalence of high-level polypharmacy was 11.1%.[12],[25]

The study done by Kumar et al., 2015, revealed that the prevalence of polypharmacy was 73.93%; among this, minor polypharmacy (2–4 drugs) accounted for 81.15% and major polypharmacy (≥5 drugs) for 18.85%. Mean (±standard deviation SD) number of medication taken was 2.57 (±1.47), while the study done by Dhanapal et al. revealed that out of 502 prescriptions, 61 (11.73%) prescriptions were minor polypharmacy and 457 (88.26%) prescriptions were major polypharmacy. Furthermore, Radhika et al. revealed that polypharmacy was observed in 82.8% and 5–8 drugs were prescribed for most of the patients (42.6), followed by >8 drugs (40.2%). These studies showed dissimilarity to the study conducted by Mohammad et al. which shows that of 1003 prescriptions, 403 (40.18%) prescriptions were found to be of minor polypharmacy and 600 (59.82%) prescriptions were of major polypharmacy.[3],[4],[18],[26]

The study done by Raut et al., 2013, revealed that polypharmacy was observed in almost all cases, wherein 45% were prescribed 11–15 drugs and 32% patients were with 6–10 drugs per prescription. Romana et al. study showed that 18% of the patients received six drugs, 24% of the patients received seven drugs, 20% of the patients received eight drugs, and 38% of the patients received nine drugs or >9 drugs.[27],[28]

Battula et al. concluded that polypharmacy was observed based on the number of drugs prescribed in each participant and found that the average number of drugs for prescription was found to be 9.92 ± 0.53 (95% confidence interval). Polypharmacy was categorized into four types (no polypharmacy [0–2 drugs], minor polypharmacy [3–5 drugs], major polypharmacy [6–9 drugs], and excessive polypharmacy [≥10 days]). It was found that 48% (n = 101) of participants had excessive polypharmacy, 42% (n = 89%) had major polypharmacy, and 10% (n = 21) had minor polypharmacy. This showed similarity to the studies conducted by Harugeri et al. and Joy et al. which revealed that polypharmacy and high-level polypharmacy were prescribed in 366 (45.0%) and 370 (45.5%) patients and the prevalence of poly pharmacy and potentially inappropriate medication use was 41% (n = 51) and 51% (n = 63), respectively. Shah et al. revealed that polypharmacy and high polypharmacy were prevalent in 52% and 23.25% of patients, respectively. This showed similarity to the studies of Kashyap et al. and Gupta et al., with 57.9% and 53.13% of geriatrics, respectively.[9],[11],[16],[29],[30],[31]

Another study done by Agrawal and Nagpure revealed that ≤4 number of drugs were prescribed to 74% population, 5–9 number of drugs were prescribed to 25% population, and 10–14 number of drugs were prescribed to 1% population.[15]

Manjaly et al. revealed that 73.3% of patients were subject to polypharmacy. The mean number of medications consumed per day by the patients in the study group was 6.7 ± 3.1. This showed similarity to the study conducted by Rathnakar et al. in which polypharmacy of 4 or more drugs was found in 71.77% of prescriptions. Rakesh et al. revealed that around 66.19% of patients were receiving polypharmacy. A significant number of patients were receiving drugs which are to be avoided as well as overprescribed and underprescribed.[32],[33],[34]

The study done by Kanagasanthosh et al. revealed that a total of 1769 drugs were prescribed, giving an average of 2.98 drugs per person (range: 1–9). Polypharmacy (≥5 drugs) was observed in 99 patients. Sehgal et al. revealed that a total of 312 patients were on polypharmacy (5 or more medications at the time of admission). The study done by Khandeparkar and Rataboli revealed that the total number of drugs per prescription ranged from minimum of 5 to maximum of 16 drugs, with an average of 7.96 ± 1.75. A large number of 596 prescriptions contained 6–9 drugs per prescription. Chakraborty et al. revealed that 90.9% of patients were on <6 medications, while 6.81% and 2.27% of the patients were on 6–10 medications and >10 medications, respectively. Vardhan et al. revealed that the most number of prescriptions were containing 3 drugs accounting for 2360 (61%) prescriptions, followed by 1120 (29%) prescriptions with 4 drugs, followed by 300 (8%) prescriptions with 2 drugs and the least number were of prescriptions containing >4 drugs with 72 (2%) prescriptions, and all these prescriptions were containing at least 1.[8],[18],[23],[24],[35]

Nandagopal et al. revealed polypharmacy in geriatric patients, with an average number of drugs per prescription being 7.02. This deviates from the WHO standards of 1.6–4.8. Polypharmacy unfortunately is very common in India and some other countries. It results in increased cost of treatment, which may lead to nonadherence by patients as they have more medicines than they can cope with. It also increases the risk of significant adverse drug interaction.[36]


  Conclusion Top


Polytherapy is often mandatory in the management of most of the common ailments affecting geriatric patients. Drug prescription in the elderly is a serious challenge as there is an increased possibility of drug interaction resulting in toxicity, treatment failure, or loss of drug effect. Duplicative prescribing within the same drug class often occurs, and unrecognized drug side effects are treated with more drugs. To minimize polytherapy, periodic evaluation of patients' drug regimen is necessary. Prescribers need to know what other prescriptions patient is taking including herbs and teas. The small number of drugs in low doses with a simple regimen is good for drug therapy in the elderly. A significant proportion of hospitalized geriatric patients are exposed to substantial polypharmacy. Further researches are required to identify the risk of adverse drug effects following multiple drug administration and specific potential drug–drug interaction. It would be pertinent to develop country-specific list of medications inappropriate for the elderly and include this list in national drug formularies so as to reduce their prescription and use in this age group.[37],[38]

Recommendations

There are few studies in the predictors of polypharmacy among the elderly in India. With this review, the gross idea of the level of polypharmacy that is prevalent among the elderly population in India is assessed. The generated data of this review can be utilized in various programs to take adequate measures to reduce its adverse effects and misery to the elderly. There should be concern given to the optimal use of medication and to improve the good communication among elderly patients and health providers. Findings of the review will be helpful for the programs and policymakers, researchers, academician, and social workers who are working in the field of health and geriatrics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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