Polypharmacy single map

Consumer summary

Polypharmacy

Polypharmacy refers to the concurrent use of multiple medicines by a person. It can be beneficial (‘appropriate polypharmacy’) or harmful (‘problematic polypharmacy’).[1]

  • Appropriate polypharmacy has been described as ‘prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence’.[1]
  • Problematic polypharmacy is the prescribing of many medicines inappropriately (five or more medicines is often quoted) or adding an inappropriate medicine to an existing regime.[2]

The goal of this Atlas domain is to identify whether there is wide variation in rates that may highlight areas for further local investigation. 

Domain update 2017

Updated with data 2014–16 data and two new indicators

This update contains two new indicators looking at the ‘triple whammy’ (see below) and the dispensing of a benzodiazepines or zopiclone and a strong opioid on discharge from a public hospital. It is not possible to infer appropriateness or otherwise of treatment from these data. See the method for more detail.

22,000 people 65 and over received the triple whammy in 2016.

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 those with risk factors for renal failure and in older adults. [3] It is recommended that this combination should be avoided if possible.

  • Of those 65 and over, 3.2 percent of those 65 and over were dispensed the triple whammy these three medications in the same quarter. 
  • This equates to 22,000 people in 2016. 
  • Rates were significantly higher in younger Māori and Pacific peoples than those from Asian or European or other groups. Rates reduced significantly with age for all populations.
  • This indicator does not include those who bought an NSAID over the counter or had a prescription in a previous period. It is unknown whether people actually took this combination.

Table 1: Age and ethnicity of those dispensed the triple whammy in a quarter, 2016

Ethnicity   Age
65–74 75–84 85+
% count % count % count
Māori 4.4
(4.2–4.7)
1310  2.9
(2.6–3.3)
 341 1.9
(1.4–2.6)
46
Pacific peoples 4.7
(4.3–5.0)
 583 3.2
(2.7–3.7) 
 164  0.9
(0.4–1.7)
10
Asian  2.0
(1.8–2.1)
 553  1.7
(1.5–2.0)
 204  1.2
(0.9–1.8)
32 
European/Other 3.4
(3.3–3.4)
 11260  3.3
(3.2–3.4)
 6045  2.1
(2.0–2.2)
1638 
Total 3.4  13706  3.2  6754  2.1 1726

Note: Ninety-five percent confidence intervals are shown in brackets.

Four thousand people were dispensed the combination of a benzodiazepine or zopiclone and a strong opioid following a public hospital event.

The combination of a benzodiazepine or zopiclone and a strong opioid carries an increased risk of over-sedation. The Federal Drug Agency in the USA issued an alert in 2017 warning against prescribing this combination due to the risk of serious side effects, including slowed or difficult breathing and deaths. They recommend using the combination only in patients for whom alternative treatment options are inadequate: https://www.fda.gov/Drugs/DrugSafety/ucm518473.htm.

  • Around 4,000 older people were dispensed the combination of a benzodiazepine or zopiclone and a strong opioid following a public hospital event in 2016. 
  • This included only those who had not had a dispensing for benzodiazepine or zopiclone in the previous three months, suggesting the combination was started in hospital.
  • The rate increased significantly with age, from 0.35 percent of those aged 65 – 74 years up to 1.6 percent in the 85 and over age group. 
  • The opioids Atlas domain contains data on this indicator for all age groups.

Table 2: People aged 65 and over receiving a benzodiazepine or zopiclone and a strong opioid following a public hospital event, by age, 2016 

  Age (%)
65–74 75–84 85+ Total
Dispensed a benzodiazepine/ zopiclone and a strong opioid following a public hospital event 0.35
(0.33–0.37)
0.69
(0.66–0.73)
1.6
(1.55–1.7)
0.61

 

Note: Ninety-five percent confidence intervals are shown in brackets.

Polypharmacy is associated with:

  • reduced adherence to therapies
  • significant costs to patients and health services
  • poor health outcomes, such as adverse drug events, drug interactions, admissions to hospital and death. 

Older people (defined here as those aged 65+) are more susceptible to medicine-related morbidity and mortality, especially those who are frail or have multiple comorbid conditions.

The frequency of adverse drug events increases with the number of medicines taken: from 13 percent with two medicines and 58 percent with five medicines to 82 percent when seven or more medicines are taken.[4]

Polypharmacy is more likely to be appropriate in the robust 'young elderly' while problematic polypharmacy is more likely to occur in the frail 'old elderly'. Hence a focus on the 85+ age group may be most appropriate, where the doses used may be as important as the number of medicines.

Overall, the rate of long-term medicines has reduced since 2012 but rates continue to be high in those aged 85 and over.

  • On average, 35 percent of people aged 65 and over received five or more long-term medicines (five or more of the same chemicals dispensed over two consecutive quarters). There was a 2 percent reduction between 2012 and 2016. These findings are in the context of an ageing population and an international trend towards increased prescribing over time.[1] 
  • Of concern however is that the number of long-term medicines dispensed is significantly higher with older age, from 25 percent of those aged 65–74 to 59 percent of those aged 85 and over.
  • Around four percent of older people received 11 or more long-term medicines. The rate increased sharply with age with people aged 85 and over three times more likely to receive 11 or more medicines than those aged 65–74. 

Table 3: People aged 65 and over receiving five or more long-term medicines, by age, 2016

  Age (%)
65–74 75–84 85+
Dispensed 5 or more long-term medicines 25.1 43.1 58.8
5–7 long-term medicines 16.2 25.3 32.3
8–10 long-term medicines 6.3 12.3 18.8
11 or more long-term medicines 2.6 5.5 7.8

Dispensed 11 or more long-term medicines: 

 
2012 2.6 5.6 8.0
2013 2.6 5.5 7.9
2014 2.7 5.8 9.0
2015 2.7 5.7 8.5
2016 2.6 5.5 7.8

Age and ethnicity

Māori and Pacific peoples received more medicines at a younger age compared with those identifying as Asian or European/Other.

Table 4 shows the percentage and count by age and ethnicity of those dispensed five or more long-term medicines. 

Table 4: People dispensed five or more long-term medicines, by age and ethnicity, 2016

Ethnicity Age
  65–74 75–84 85+
  % count % count % count
Māori 31.7 9,349 41.7 4,850 38.3 903
Pacific peoples 44.6 5,589 52.9 2,699 45.5 503
Asian  20.7 5,849 33.5 4,002 39.1 1,002
European/Other 24.2 80,706 42.3 77,796 54.7 42,371

Antipsychotic and benzodiazepine or zopiclone dispensing increases significantly with age.

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 benzodiazepines 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.

  • The use of psychotropic agents increased with age; of people aged 85 and over on average 6.8 percent received an antipsychotic and 20 percent received a benzodiazepine or zopiclone.
  • The rates for a combination of antipsychotics and a benzodiazepines or zopiclone were low but increased with age from 0.7 percent of those aged 65-74 up to 3.1 percent of those aged 85 and over. 
  • Rates of antipsychotic use have increased since 2012; benzodiazepine or zopiclone use has fluctuated since 2012.

Table 5: People dispensed an antipsychotic, by age and ethnicity, 2016

Ethnicity Age (%) (2016)
65–74 75–84 85+ Total
Māori 2.0 3.2 4.8 2.5
Pacific peoples 1.6 3.3 6.6 2.3
Asian  0.9 1.7 4.6 1.4
European/Other 1.9 3.0 7.0 2.9
Total 1.8 3.0 6.8 2.8

Table 6: People dispensed a benzodiazepine or zopiclone, by age and ethnicity, 2016

Ethnicity Age (%)
65–74 75–84 85+ Total
Māori 4.8 6.1 8.3 5.3
Pacific peoples 2.4 4.1 7.0 3.1
Asian  4.6 8.5 11.6 6.1
European/Other 9.4 13.7 21.3 12.3
Total 8.5 12.8 20.4 11.2

Psychotropic medication increases the risk of falling[5] 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] The falls Atlas domain shows that, in 2015, 26 percent of people aged 85 and over made at least one ACC claim for a fall, and hip fractures following a fall were most common in that age group, at a rate of 23.1 per 1,000.

What questions might the data prompt?

  • How do similar DHBs compare? Why, for example, is the prescribing pattern in Tairāwhiti different to that in Northland?
  • Why is there a difference between the North and South Islands in the use of antipsychotics and a benzodiazepines or zopiclone?
  • What role might secondary clinicians have in influencing prescribing patterns in their community?

More information on medication review and managing polypharmacy

  • BPAC. 2014. Polypharmacy in primary care: Managing a clinical conundrum. Best Practice Journal 64. URL: www.bpac.org.nz/BPJ/2014/October/polypharmacy.aspx external link (accessed August 2015).
  • BPAC. 2012. Managing medicines in older people. Best Practice Journal 47. URL: www.bpac.org.nz/BPJ/2012/october/elderlyMedicines.aspx external link (accessed August 2015).  
  • Bohemian polypharmacy (video) – a parody of Queen's ‘Bohemian Rhapsody’, about taking more medicines than are clinically indicated. URL: www.youtube.com/watch?v=Lp3pFjKoZl8 external link (accessed August 2015).
  • Deprescribing guidelines to help practitioners and patients decide when to reduce or stop a medication: http://deprescribing.org/ external link (accessed October 2017).
  • The Geriatrician’s Scalpel: Pharmacological Debridement (video). MiniGEM providing an introduction to polypharmacy, prescribing cascades and rational prescribing in the elderly. URL: www.youtube.com/watch?v=jXcRHxl9qWw external link (accessed August 2015).
  • Royal Australian and New Zealand College of Psychiatrists. 2008. RANZCP Practice Guideline: The Use of Antipsychotics in Residential Aged Care. URL: www.bpac.org.nz/a4d/ranzcpGuide.asp external link (accessed August 2015).
  • Scott IA, Gray LC, Martin JH, et al. 2012. Minimizing Inappropriate Medications in Older Populations: A 10-step Conceptual Framework. AJM 125: 529–37.

This audit template, endorsed by the Royal New Zealand College of General Practitioners, entitles GPs to continuing professional development (MOPS) credits. Follow the instructions in the audit document to complete the activity and claim your credits.

Recommended reading

Corbett A, Burns A, Ballard C. 2014. Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia. BMJ 349. DOI: 10.1136/bmj.g6420. URL: www.bmj.com/archive/online/2014/11-03 (accessed August 2015).

Jackson G, Gerard C, Minko N, et al. 2014. Variation in benzodiazepine and antipsychotic use in people aged 65 years and over in New Zealand. NZMJ 127(1396): 67–78.

Consumer resources

Let’s plan for better care – a health literacy initiative to help consumers prepare well for their visit to the GP or other primary care health professional: www.open.hqsc.govt.nz/patient-safety-week/publications-and-resources/publication/1826/

Let’s plan pharmacy week – resources for helping people learn more about their medicines by talking to their pharmacist, or taking away information. The aim is to improve health literacy and reduce harm from high-risk medicines. www.open.hqsc.govt.nz/patient-safety-week/lets-plan/lets-plan-pharmacy-week/.

Method

For analysis, people were assigned to the district health board (DHB) where they normally live (DHB of domicile). 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. 

Detailed information on the indicators, data sources, definitions, ages and rationale can be found in the methodology.


References

  1. Duerden M, Avery T, Payne R. 2013. Polypharmacy and medicines optimisation. Making it safe and sound. London: The King's Fund. URL: www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation (accessed August 2015).
  2. Aronson J. 2004. In defence of polypharmacy. British Journal of Clinical Pharmacology 57(2): 119–20
  3. Medsafe: http://www.medsafe.govt.nz/profs/PUArticles/June2013NSAIDS.htm 
  4. Patterson S, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2012, Issue 5, Art. No. CD008165.
  5. Health Quality & Safety Commission. 2014. Topic 8: Medicines: balancing intended benefits and increased falls risks. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/publications-and-resources/publication/2879/ (accessed October 2017).
  6. Hill KD, Wee R. 2012. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem. Drugs Aging 29(1): 15–30. URL: www.ncbi.nlm.nih.gov/pubmed/22191720 (accessed August 2015).

Last updated 08/11/2017