Polypharmacy Among Elderly Diabetic
Patients in Home Health Care
Eunjeong Kang, MPH
Ibrahim Awad Ibrahim, MD, PhD. Assistant Professor
Kathryn Dansky, PhD., Associate Professor
Department of Health Policy & Administration,
College of Health and Human Development
The Pennsylvania State University
116 Henderson Bldg., University Park, PA 16802
TEL (814)865-1472 FAX (814)863-0846
E- mail: iai2@psu.edu
FOR MORE INFO...
Contact Mrs. Eunjeong Kang e-mail: exk192@psu.edu
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Objectives

To assess the possibility of occurrence of
polypharmacy in a home health diabetes
elderly population.
 To identify combinations of drugs that can
possibly result in serious health
consequences.
 To examine the correlates of
polypharmacy in this population.
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Introduction

Polypharmacy has been defined as:
– Regimens with unnecessary drugs
– Use of 2 more drugs for >240 days
– Simultaneous use of 5 or more drugs

Why is it important?
– Drug-drug Interaction (DDI)
– Drug Food Interaction (DFI)
– Adverse Drug Events (ADE)

Who is at risk?
– Patients with multiple diseases, complicated
prolonged diseases, multiple providers
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Drug-Drug Interaction

Possible mechanisms of action of
DDI:
– Synergy
– Antagonism
– Adverse effects
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Methodology
Subjects
 Data
 Identification of possible interaction
 Inclusion criteria
 Statistical analysis

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Subjects
Elderly diabetic patients who were
discharged from hospital to home
health care provided by a large MidAtlantic home health agency.
 These patients received skilled
nursing visits at home through either
telehomecare or through traditional
home visits.

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Data
Medication sheets for these patients
were examined for possible drugdrug interaction
 We analyzed medication sheets for
139 patients
 There were another 37 patients for
whom medication sheets could not
be obtained.

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Data collection

Data collection spanned 18 month
period from 3/1998 through 9/1999
JF MAM JJASO ND JF MAMJJASO ND
1998
1999
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Drugs considered
 Prescription
systemic drugs for
diabetes and other conditions
– Different types of insulin were considered as
one drug and collapsed into one category.
 Drugs
not considered
– Optic and topical drugs.
– Over-the-counter medications.
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Drug checker
We used an automated
DrugChecker available through
Dr.Koop’s Website: www.drkoop.com
 This drug checker is designed and
compiled by Multum Information
Service, Inc.® who used medical
literature references to support the
results of possible DDI and enhance
their reliability.

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Statistical Analysis
Descriptive statistics
 t-test comparison (comparing
participants and non-participants)
 Pearson correlation for correlates of
polypharmacy

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Results
Sample demographic description
 Prevalence of comorbidities
 Polypharmacy rates
 Sample drug-drug interactions
 Correlates of drug-drug interactions

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Table 1. Comparisons between the study
sample and the non-participants
Study Sample
(N=139)
Excluded Sample
(N=37)
Age**
73.6 (SD=9.50)
78.0 (SD=6.76)
Male
Female
39 (28.7%)
97 (71.3%)
9 (20.0%)
27 (80.0%)
Black/non-white
White, non-hispanic
90 (67.2%)
44 (32.8%)
24 (75.0%)
6 (25.0%)
Years of Education
10.5 SD=2.8)
10.9 (SD=3.4)
Number of Co-morbidities
3.0
3.1
Diabetes Severity*
2.4
2.0
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* p<.05 ** p<.01
Table 2. Prevalence of diabetes-related
complications
Complication
Frequency (%)
Ischemic heart disease
34 (25.8)
Cerebrovascular
25 (18.9)
Congestive heart failure
24 (18.2)
Infectious
21 (15.9)
Renal
11 (8.3)
Neurological
6 (4.5)
Peripheral vascular
5 (3.8)
Amputations
5 (3.8)
Retinal
1 (0.8)
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Prevalence of other comorbid
conditions
• The most common comorbid conditions were
hypertension, rheumatic arthritis, and neurological
disorders 40.5%, 9.2%, and 6.4%, respectively.
• Other conditions were urological conditions,
wounds, respiratory diseases, and gastrointestinal
conditions.
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Comorbid complications and
conditions

137 patients (98.6%) had at least one diabetic
complication or other co-morbidities.
 The most common diabetes-related
complications were ischemic heart disease
(25.8%), cerebrovascular disease (18.9%), and
congestive heart failure (18.2%).
 hypertension was most prevalent comorbid
condition (40.5%) followed by rheumatoid
arthritis was (9.2%).
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Polypharmacy

We found that 88% of the patients
reviewed were at risk for polypharmacy
(5+ drugs simultaneously)
 The average number of medications taken
by these diabetic patients was 8.9 (SD=3.4)
[range 2 – 19]
 Patients took 6.3 oral drugs per episode of
care (mean 48 days, SD 14 days).
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Possible Drug-Drug Interactions






38.8% of patients at risk for least one severe DDI.
92.8% of patients at risk for at least one moderate DDI
70.5% of patients at risk for at least one mild DDI.
Mild:clinically insignificant effects and neutral or even
favorable effects have been reported for these interactions.
Moderate: serious, but non-lethal and non-life-threatening
injuries have been reported
Severe: death and/or life-threatening injuries have been
reported.
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Table 4. Examples of Potential Severe Drug-Drug
Interactions and their Frequency in our study sample
Example
Frequency (%)
Diuretic-NSAID
furosemide-aspirin,
37 (39.4)
DiureticAntihypertentive
AnticoagulantNSAID
Cardiac agentAntihypertensive
CNS agent-CNS
agent
CNS agent-Analgesic
Furosemide-digoxin, furosemideamiodarone, bumetanide-digoxin
Coumadin-aspirin
18 (19.1)
Other
Captopril-allopurinol, vasotec-allopurinol,
coumadin-tamoxifen, coumadin-ampicillin,
coumadin-synthroid, coumadin-amiodarone,
coumadin-cyclosporin, cyclosporin-pravachol
Total
14 (14.9)
Verapamil-digoxin, atenolol-verapamil
8 (8.5)
Fluoxetine-imipramin, haloperidolsinemet, elavil-fluoxetine
Carbamazepine-tramadol, norpramintramadol
3 (3.2)
2 (2.1)
12 (12.8)
94 (100.0)
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Table 5. Pearson correlation coefficients
of factors associated with polypharmacy
Coefficients
p-value
Age*
-0.187
0.014
Gender (female)*
0.163
0.030
Race (white)*
0.173
0.022
Co-morbidity
0.007
0.936
Diabetes Co-morbidity
-0.084
0.308
Diabetes Severity*
0.208
0.013
* p<0.05
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Service implications

Need for
– Medication monitoring
– Prescription coordination
– Case management
• Community pharmacy
• Patients
• Home nurse
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Policy implications

What can we do to prevent or reduce
the occurrence of polypharmacy and
its possible ill effects?
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Future research
Did it really happen?
 To what extent?
 How can we prevent or reduce it?

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Thank you
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