The goal of this Atlas domain is to identify whether there is significant variation in the dispensing rates of long-term medications among people aged 65 and over, that may highlight areas that warrant further local investigation.
Polypharmacy refers to the concurrent use of multiple medicines by a person. It can be beneficial (appropriate polypharmacy) or harmful (inappropriate polypharmacy).[1]
Polypharmacy is associated with:
The risk of adverse drug events increases with the number of medications taken, with an inflexion point at five medications where the risk of side effects accelerates. Polypharmacy is consistently associated with higher rates of medication-related harm, including drug interactions, hospitalisations and poorer health outcomes [3,4].
Polypharmacy is more likely to be appropriate in those aged 65 to 74 while inappropriate polypharmacy is more likely to occur in those aged 85 and over. Hence a focus on the 85 years and over age group may be most appropriate, where the doses used may be as important as the number of medicines.
Impact of these changes are listed in the table below:
| Indicator | Method change | Impact of method changes |
|
1. People aged 65 years and over dispensed five or more unique long-term medicines |
Previously, the numerator was calculated as the quarterly sum of individuals who received medications in a given quarter and had also been dispensed the same medications in the preceding quarter. This was averaged across four quarters. This update counts the distinct number of individuals who received the same medications in two consecutive quarters in a year. Therefore, current figures are not directly comparable with those from the previous update. This change was made to better capture those who may not receive five or more medicines consistently throughout the entire year, and to ensure consistency with other Atlas indicators, where we report medication use on an annual basis rather than as an average. |
The dispensing rate of 5+ medications increased from 32.1% in 2019 to 44.4% with the method change. Since 2019, this has increased to 46.5% in 2023. |
| 2. People aged 65 years and over dispensed five, six or seven unique long-term medicines | The rate in 2019 has increased from 19.2% to 33.1% with the method change. Rates have remained steady since. | |
| 3. People aged 65 years and over dispensed eight, nine or ten unique long-term medicines | In the previous version the rate was 8.9% in 2019, this has increased to 16.5% with the method change. The rate in 2023 was 17.9%. | |
| 4. People aged 65 years and over dispensed 11 or more unique long-term medicines | Reported at 4.0% in 2019, this increased to 6.8% with the method change, and to 8.1% in 2023. | |
| 5. People aged 65 years and over who received the ‘triple whammy’ | No change to numerator calculation. | The reported rate in 2019 was previously 3.2%, it is now 3.4%. In 2023, the rate has reduced to 2.7%. |
| 6. PHO-enrolled population aged 65 years and over who received an antipsychotic during the year | The earlier method used a quarterly average of individuals dispensed medications. This update instead counts the distinct number of individuals who received medications in at least one quarter of the calendar year. This is consistent with our usual methodology. | Antipsychotic use was 2.9% in 2019, rising to 4.3% with the method change. In 2023, the rate was 4.9%. |
| 7. PHO-enrolled population aged 65 years and over who received a benzodiazepine or zopiclone | The rate reported in 2019 was 10.4%, increasing to 17.1% with the method change. The rate in 2023 was reduced slightly to 16.2%. | |
| 8. People aged 65 years and over who received both a benzodiazepine or zopiclone and an antipsychotic in the same quarter during the calendar year | Reported rates were between 1–1.3% from 2012 to 2019, increasing slightly to 1.8% with the method change. Rates have remained unchanged since. |
The methodology report has more information on the indicators, data sources, definitions and rationale we used to gather this data.
Atlas of Healthcare Variation: Methodology for polypharmacy (PDF 535KB)
Atlas of Healthcare Variation: Methodology for polypharmacy (DOCX 330KB)
Selected findings from the Atlas are summarised below. For all indicators and detailed commentary, see the Atlas dashboards, where you can search by age, ethnic group, year, and health district.
Table 1 shows the percentage and count by age group and ethnic group of those dispensed five or more long-term medicines.
| Ethnic Group | Age group (years) | |||||
|---|---|---|---|---|---|---|
| 65–74 | 75–84 | 85+ | ||||
| % | count | % | count | % | count | |
| Māori | 47.2 | 39,497 | 63.4 | 8,831 | 69.6 | 1,971 |
| Pacific peoples | 55.2 | 18,277 | 65.5 | 4,910 | 64.0 | 1049 |
| Asian | 35.7 | 47,063 | 55.5 | 9,961 | 64.9 | 3,394 |
| European/Other | 34.7 | 353,581 | 54.5 | 125,523 | 69.6 | 56,732 |
| Age % | ||||
| 65–74 | 75–84 | 85 and over | Total | |
| Dispensed five or more long-term medicines | 36.7 | 55.3 | 69.2 | 46.5 |
| 5–7 long-term medicines | 27.5 | 38.8 | 46.7 | 33.3 |
| 8–10 long-term medicines | 12.8 | 22.1 | 30.9 | 17.9 |
| 11 or more long-term medicines | 5.7 | 10.3 | 13.9 | 8.1 |
| Note: these groups are not mutually exclusive. | ||||
| Long-term medicines dispensed (%) | ||||
| Ethnic group | Five or more | 5–7 | 8–10 | 11 or more |
| Māori | 52.3 | 35.5 | 21.9 | 10.5 |
| Pacific peoples | 58.5 | 37.8 | 25.5 | 12.2 |
| Asian | 42.9 | 29.6 | 16.6 | 7.9 |
| European/Other | 45.8 | 33.4 | 17.3 | 7.7 |
The triple whammy is the combination of an angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), a diuretic and a non-steroidal anti-inflammatory drug (NSAID).
Medsafe notes an increased risk of acute kidney injury with this combination, especially in people with risk factors for renal failure and in older adults.[5] The combination should be avoided if possible.
In older people, certain classes of medicines carry a substantially higher risk of adverse effects. Two examples presented in this Atlas domain are antipsychotics and a benzodiazepine or zopiclone. Common adverse effects include impaired functional ability, agitation, confusion, blurred vision, urinary retention, constipation, postural hypotension and falls. These increase if both classes of medicine are taken together. This indicator cannot assess inappropriate use of these medicines; however, high rates of prescribing may indicate misuse or overuse.
Psychotropic medication increases the risk of falling [6] and there is evidence that reducing psychotropic medication can result in no or limited worsening of key outcomes such as sleep quality or behavioural problems.[6, 7] The most recent Australian and New Zealand Hip Fracture Registry (ANZHFR report) shows that in 2023, the rate remains high at around 22 per 1,000 in this age group, confirming that hip fractures continue to be a major burden among older adults [8].
Our analysis showed significant differences in the dispensing of multiple medications between people who lived in aged residential care (ARC) and those who didn’t, in 2023:
For age-specific rates, please refer to Figure 1.
Figure 1: Polypharmacy rates in people living in aged residential care and those not living in aged residential care, by age group (percent), 2023
It is pleasing to see the reduction in ‘triple whammy’ dispensing since 2019. Key findings from this update include high dispensing rates of 11 or more medications – particularly among those aged 85 years and over – and notable differences between people living in aged residential care and those who are not. These findings warrant further investigation.
Table 1 shows the percentage and count by age group and ethnic group of those dispensed five or more long-term medicines.
| Ethnic Group | Age group (years) | |||||
|---|---|---|---|---|---|---|
| 65–74 | 75–84 | 85+ | ||||
| % | count | % | count | % | count | |
| Māori | 47.2 | 39,497 | 63.4 | 8,831 | 69.6 | 1,971 |
| Pacific peoples | 55.2 | 18,277 | 65.5 | 4,910 | 64.0 | 1049 |
| Asian | 35.7 | 47,063 | 55.5 | 9,961 | 64.9 | 3,394 |
| European/Other | 34.7 | 353,581 | 54.5 | 125,523 | 69.6 | 56,732 |
| Age % | ||||
| 65–74 | 75–84 | 85 and over | Total | |
| Dispensed five or more long-term medicines | 36.7 | 55.3 | 69.2 | 46.5 |
| 5–7 long-term medicines | 27.5 | 38.8 | 46.7 | 33.3 |
| 8–10 long-term medicines | 12.8 | 22.1 | 30.9 | 17.9 |
| 11 or more long-term medicines | 5.7 | 10.3 | 13.9 | 8.1 |
| Note: these groups are not mutually exclusive. | ||||
| Long-term medicines dispensed (%) | ||||
| Ethnic group | Five or more | 5–7 | 8–10 | 11 or more |
| Māori | 52.3 | 35.5 | 21.9 | 10.5 |
| Pacific peoples | 58.5 | 37.8 | 25.5 | 12.2 |
| Asian | 42.9 | 29.6 | 16.6 | 7.9 |
| European/Other | 45.8 | 33.4 | 17.3 | 7.7 |
The triple whammy is the combination of an angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), a diuretic and a non-steroidal anti-inflammatory drug (NSAID).
Medsafe notes an increased risk of acute kidney injury with this combination, especially in people with risk factors for renal failure and in older adults.[5] The combination should be avoided if possible.
In older people, certain classes of medicines carry a substantially higher risk of adverse effects. Two examples presented in this Atlas domain are antipsychotics and a benzodiazepine or zopiclone. Common adverse effects include impaired functional ability, agitation, confusion, blurred vision, urinary retention, constipation, postural hypotension and falls. These increase if both classes of medicine are taken together. This indicator cannot assess inappropriate use of these medicines; however, high rates of prescribing may indicate misuse or overuse.
Psychotropic medication increases the risk of falling [6] and there is evidence that reducing psychotropic medication can result in no or limited worsening of key outcomes such as sleep quality or behavioural problems.[6, 7] The most recent Australian and New Zealand Hip Fracture Registry (ANZHFR report) shows that in 2023, the rate remains high at around 22 per 1,000 in this age group, confirming that hip fractures continue to be a major burden among older adults [8].
Our analysis showed significant differences in the dispensing of multiple medications between people who lived in aged residential care (ARC) and those who didn’t, in 2023:
For age-specific rates, please refer to Figure 1.
Figure 1: Polypharmacy rates in people living in aged residential care and those not living in aged residential care, by age group (percent), 2023
It is pleasing to see the reduction in ‘triple whammy’ dispensing since 2019. Key findings from this update include high dispensing rates of 11 or more medications – particularly among those aged 85 years and over – and notable differences between people living in aged residential care and those who are not. These findings warrant further investigation.
Data for this Atlas domain was drawn from the Pharmaceutical Collection, which contains claim and payment information from community pharmacists for subsidised dispensing.
The data presented does not allow for analysis of patients’ condition or the effectiveness of dose provided. This means it was not possible to assess the appropriateness or otherwise of prescribing. Instead, proxy markers were employed, beginning with a simple count of the number of long-term medicines taken by older people. Unsubsidised or over-the-counter medicines are not included. Data also does not indicate whether people took the medicine.
